Background and Objectives: To determine the rate and predictors of early neurologic deterioration (END) in patients with lacunar strokes and its implications for management and outcome. Methods: We enrolled consecutive patients with MRI-defined lacunar stroke who presented within 12 hours after symptom onset from a prospective stroke database (2015-2019). END was defined as any persisting increase in NIH Stroke Scale (NIHSS) score of ≥2 points within 24 hours after admission and favorable outcome as modified Rankin Scale (mRS) score of 0 to 2 at 90 days. We assessed the association of END with clinical and imaging variables, acute treatment, and outcome using multivariable regression, calculating adjusted odds ratios (aORs). Results: Sixty-one of 365 (16.7%) patients with acute lacunar stroke (median age 71.8 years, 39.5% female, median NIHSS score on admission 3) had END. Lower NIHSS score on admission (per point, aOR 0.81, p = 0.006), capsular warning syndrome (aOR 7.00, p < 0.001), ventral pontine infarct (aOR 3.49, p = 0.008), and hypoperfusion lesion on imaging (aOR 2.13, p = 0.026) were associated with END. Acute dual antiplatelet therapy was associated with reduced risk of END (aOR 0.10, p = 0.04). Patients with END had less favorable outcome at 90 days (aOR0.13p < 0.001), but IV thrombolysis (IVT) was associated with favorable outcome at 90 days (aOR 3.95, p = 0.002). Discussion: One in 6 patients with lacunar stroke has END, and patients at high risk of END can be identified with radiologic and clinical variables. Targeted therapeutic trials for this population seem justified. Classification of Evidence: This study provides Class II evidence that early neurologic deterioration in patients with acute lacunar stroke predicts poorer functional outcome at 90 days as determined by the mRS.
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