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The generally accepted definition of an expanding stroke is an increase of either the National Institutes of Health Stroke Scale score of 1 point or 25% increase in the lesion volume on follow-up scan. This definition of an expanding stroke is similar to an increase in the sum of the National Institutes of Health Stroke Scale scores (ie, the cumulative NIH Stroke Scale score). The large sample size of the EAST trial allowed us to define a much broader group of patients with an expanding stroke. This includes patients with infarctions or brain swelling that expand but do not meet the criteria for a full hemorrhage. These patients will have a larger increase in lesion volume than those with pure infarctions (Table 6). This broader group of patients is at higher risk of undergoing an invasive procedure. In addition, only 28% of the patients in the EAST trial had cerebral microbleeds, and this group is unlikely to be selected for invasive procedures. Because the EAST trial included only a minority of patients with cerebral microbleeds, and the criteria for invasive procedures are generally based on a more homogeneous group of patients, it is not possible to estimate the impact of cerebral microbleeds on the observed association between infarct growth and procedure rates. Finally, the small increase in lesion growth observed in the EAST trial may be a reflection of the trialists’ intent to increase the sensitivity of the definition of an expanding stroke. Adding one point to the NIH Stroke Scale score could be considered adding a small amount of variance to the study. A larger trial to compare intervention in patients with expanding versus non-expanding stroke would be necessary to determine the best approach for managing patients with expanding stroke.


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