BACKGROUND AND PURPOSE: Improvement in the National Institutes of Health Stroke 
Scale (NIHSS) 24 hours after stroke has been associated with subsequent 
neurological deterioration. We hypothesized that a similar association would be 
apparent for events occurring after 7 days, when acute changes from edema and 
herniation are less common. We evaluated the degree of NIHSS improvement at 7 
days (recovery) as a predictor of subsequent neurological deterioration from day 
7 to day 90.
METHODS: We studied all patients of the Glycine Antagonist (gavestinel) In 
Neuroprotection (GAIN) International Trial with ischemic stroke alive at day 7, 
excluding patients with hemorrhagic events and deaths from nonstroke-related 
causes. The GAIN International Trial was a randomized, double-blind, 
placebo-controlled, and parallel-group trial; because the study drug had no 
effect on stroke outcome, treatment groups were combined for this analysis. 
Neurological deterioration was assessed by the combined measure, including: (1) 
stroke-related events recorded as "serious adverse events," (2) recurrent stroke 
recorded on a separate case report form, and (3) any NIHSS worsening.
RESULTS: Among 1187 patients included, 25% had >65% recovery. Deterioration was 
more prevalent in the group with >65% early recovery (15.5% versus 10.3%; 
P=0.01). Logistic regression modeling indicated that recovery was associated 
with subsequent neurological deterioration (odds ratio, 1.2; 95% CI, 1.1 to 1.3, 
per 10% recovery) after adjusting for age, NIHSS at 7 days, and stroke subtype.
CONCLUSIONS: Substantial neurological recovery at 7 days is associated with 
subsequent neurological deterioration.