{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,23]],"date-time":"2026-10-23T23:21:02Z","timestamp":1792797662270,"version":"4.5.0"},"reference-count":49,"publisher":"MDPI AG","issue":"5","license":[{"start":{"date-parts":[[2026,4,22]],"date-time":"2026-04-22T00:00:00Z","timestamp":1776816000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100004587","name":"Instituto de Salud Carlos III","doi-asserted-by":"crossref","award":["RD24\/0009\/0016"],"award-info":[{"award-number":["RD24\/0009\/0016"]}],"id":[{"id":"10.13039\/501100004587","id-type":"DOI","asserted-by":"crossref"}]},{"award":["RD24\/0009\/0016"],"award-info":[{"award-number":["RD24\/0009\/0016"]}],"id":[{"id":"https:\/\/ror.org\/00ca2c886","id-type":"ROR","asserted-by":"publisher"}]},{"name":"European Union\u2014NextGenerationEU"},{"id":[{"id":"https:\/\/ror.org\/019w4f821","id-type":"ROR","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Brain Sciences"],"abstract":"<jats:p>Background\/Objectives: Early neurological deterioration (END) is a frequent and clinically relevant complication in patients with a single small subcortical infarction (SSI), including lacunar infarction and branch atheromatous disease (BAD). Despite initially mild symptoms, END occurs in approximately 20\u201325% of cases and is strongly associated with poor functional outcomes. However, definitions, mechanisms, predictors, and therapeutic strategies remain heterogeneous. This review aims to synthesize current evidence regarding the incidence, pathophysiology, predictors, and management of END in SSI. Methods: We performed a narrative review of published studies addressing END in patients with lacunar stroke or SSI. We analyzed data on END definitions and incidence, imaging and clinical predictors, proposed pathophysiological mechanisms, and preventive and rescue therapeutic strategies. Results: END definitions vary across studies, most commonly defined as a \u22652-point increase in the National Institutes of Health Stroke Scale within 48\u201372 h. Hemodynamic compromise due to proximal perforator pathology, particularly in BAD, appears central to END development. Advanced imaging studies demonstrate perfusion abnormalities beyond the infarct core, supporting the concept of a \u201clacunar penumbra.\u201d Lesion topology, proximal infarct patterns, parent artery plaques, larger infarct size, and vertical extension are consistent imaging predictors. Clinical factors such as diabetes mellitus, higher baseline severity, systemic inflammation, and increased arterial stiffness further modulate risk. Preventive strategies, including early dual antiplatelet therapy and intensified antithrombotic regimens, show promising signals, while induced hypertension may benefit selected patients as a rescue therapy. However, evidence remains largely observational or derived from subgroup analyses. Conclusions: END in SSI is a multifactorial and potentially modifiable process driven by interactions between proximal vascular pathology, hemodynamic failure, and tissue vulnerability. Standardized definitions, MRI-based phenotyping, and mechanism-driven trials are needed to optimize risk stratification and develop targeted preventive and rescue strategies.<\/jats:p>","DOI":"10.3390\/brainsci16050437","type":"journal-article","created":{"date-parts":[[2026,4,22]],"date-time":"2026-04-22T10:38:14Z","timestamp":1776854294000},"page":"437","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Early Neurological Deterioration in Subcortical Infarcts: A Narrative Review"],"prefix":"10.3390","volume":"16","author":[{"given":"Juan","family":"Jos\u00e9 Mengual","sequence":"first","affiliation":[{"name":"Neurology Department, Complex Hospitalari Universitari Mois\u00e8s Broggi, Institut d\u2019Investigaci\u00f3 Biom\u00e8dica de Bellvitge (IDIBELL), Oriol Martorell 12, 08970 Sant Joan Desp\u00ed, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carmen","family":"Montalvo","sequence":"additional","affiliation":[{"name":"Neurology Department, Complex Hospitalari Universitari Mois\u00e8s Broggi, Institut d\u2019Investigaci\u00f3 Biom\u00e8dica de Bellvitge (IDIBELL), Oriol Martorell 12, 08970 Sant Joan Desp\u00ed, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sandra","family":"Boned","sequence":"additional","affiliation":[{"name":"Neurology Department, Complex Hospitalari Universitari Mois\u00e8s Broggi, Institut d\u2019Investigaci\u00f3 Biom\u00e8dica de Bellvitge (IDIBELL), Oriol Martorell 12, 08970 Sant Joan Desp\u00ed, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carla","family":"Avellaneda-G\u00f3mez","sequence":"additional","affiliation":[{"name":"Neurology Department, Complex Hospitalari Universitari Mois\u00e8s Broggi, Institut d\u2019Investigaci\u00f3 Biom\u00e8dica de Bellvitge (IDIBELL), Oriol Martorell 12, 08970 Sant Joan Desp\u00ed, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4191-7574","authenticated-orcid":false,"given":"Manuel","family":"G\u00f3mez-Choco","sequence":"additional","affiliation":[{"name":"Neurology Department, Complex Hospitalari Universitari Mois\u00e8s Broggi, Institut d\u2019Investigaci\u00f3 Biom\u00e8dica de Bellvitge (IDIBELL), Oriol Martorell 12, 08970 Sant Joan Desp\u00ed, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,4,22]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1521","DOI":"10.1016\/0140-6736(91)93206-O","article-title":"Classification and natural history of clinically identifiable subtypes of cerebral infarction","volume":"337","author":"Bamford","year":"1991","journal-title":"Lancet"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"822","DOI":"10.1016\/S1474-4422(13)70124-8","article-title":"Neuroimaging standards for research into small vessel disease and its contribution to ageing and neurodegeneration","volume":"12","author":"Wardlaw","year":"2013","journal-title":"Lancet Neurol."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1246","DOI":"10.1212\/WNL.39.9.1246","article-title":"Intracranial branch atheromatous disease: A neglected, understudied, and underused concept","volume":"39","author":"Caplan","year":"1989","journal-title":"Neurology"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"687","DOI":"10.1161\/STROKEAHA.114.007466","article-title":"Neuroimaging Markers for Early Neurologic Deterioration in Single Small Subcortical Infarction","volume":"46","author":"Jeong","year":"2015","journal-title":"Stroke"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1154","DOI":"10.1161\/01.STR.32.5.1154","article-title":"Neurological Deterioration in Acute Lacunar Infarctions","volume":"32","author":"Serena","year":"2001","journal-title":"Stroke"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"125","DOI":"10.1159\/000077012","article-title":"Progression in Lacunar Stroke Is Related to Elevated Acute Phase Parameters","volume":"51","author":"Audebert","year":"2004","journal-title":"Eur. 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