What is recrudescence of a prior Cerebrovascular Accident (CVA)?

Recrudescence of Prior CVA: Definition and Management

Recrudescence of a prior cerebrovascular accident (CVA) refers to the temporary reappearance or worsening of neurological symptoms from a previous stroke, typically triggered by physiological stressors, without evidence of a new stroke on imaging.

Understanding Recrudescence

Recrudescence differs from a recurrent stroke in several important ways:

• Mechanism: Represents a temporary functional deterioration of previously damaged neural tissue rather than new ischemia or hemorrhage
• Imaging: No new lesions appear on neuroimaging
• Duration: Symptoms are typically transient and resolve when the triggering factor is addressed
• Prognosis: Generally better than a new stroke event

Common Triggers for Recrudescence

Several physiological stressors can precipitate recrudescence of prior stroke symptoms:

• Infections (particularly respiratory infections) 1
• Metabolic disturbances (hypoglycemia, electrolyte abnormalities)
• Fever/hyperthermia
• Dehydration
• Extreme fatigue
• Medications (particularly sedatives or those affecting cerebral perfusion)
• Psychological stress
• Vaccinations (rare but documented) 1

Diagnostic Approach

When a patient presents with apparent worsening of prior stroke symptoms:

1. Urgent neuroimaging (CT or MRI) to rule out new stroke 1, 2
2. Vascular imaging (CTA or MRA) to assess for new large vessel occlusion 2
3. Laboratory tests to identify metabolic triggers (glucose, electrolytes, CBC, etc.)
4. Infection workup if fever or other signs of infection are present
5. Medication review to identify potential pharmacological triggers

Management Principles

The management of recrudescence focuses on:

1. Identifying and treating the underlying trigger:

   • Antibiotics for infections
   • Correction of metabolic abnormalities
   • Fever control
   • Hydration

2. Supportive care:

   • Maintain adequate cerebral perfusion
   • Avoid hypotension
   • Ensure adequate oxygenation

3. Prevention of complications:

   • DVT prophylaxis
   • Early mobilization when appropriate
   • Swallowing assessment if needed

Prevention of Recrudescence

To prevent future episodes of recrudescence:

• Aggressive blood pressure control (target <140/90 mmHg, or <130/80 mmHg in patients with diabetes or chronic kidney disease) 1
• Infection prevention strategies, particularly during high-risk seasons
• Medication optimization to avoid drugs that may precipitate symptoms
• Patient education about recognizing and responding to early signs of recrudescence

Clinical Pitfalls to Avoid

1. Misdiagnosing recrudescence as a new stroke without appropriate imaging
2. Failing to identify the underlying trigger, leading to prolonged symptoms
3. Withholding appropriate stroke prevention therapies due to confusion with recurrent stroke
4. Overlooking the psychological impact of recrudescence, which can mimic new stroke symptoms

Distinguishing from Recurrent Stroke

It's crucial to differentiate recrudescence from a true recurrent stroke, as management differs significantly:

Feature	Recrudescence	Recurrent Stroke
Imaging	No new lesions	New infarct or hemorrhage
Symptoms	Similar to prior stroke	May be in same or different territory
Triggers	Identifiable physiological stressor	Often spontaneous
Treatment	Address underlying trigger	Acute stroke protocols
Prognosis	Usually temporary	May cause permanent new deficits

The risk of actual recurrent stroke is approximately 1-5% per year following an initial stroke 1, with the highest risk in the first year. This is distinct from recrudescence, which represents reemergence of prior symptoms rather than new damage.

Remember that while recrudescence typically resolves with treatment of the underlying trigger, it should still prompt reassessment of the patient's secondary stroke prevention regimen to ensure optimal protection against true recurrent events.