# Early neurological rehabilitation management in a stroke patient with persistently and extremely elevated natriuretic peptides: a case report

## TL;DR

This case report shows how a stroke patient with very high natriuretic peptides and kidney disease successfully underwent early rehabilitation through careful monitoring and personalized care.

## Contribution

The paper introduces a novel interpretation of elevated NT-proBNP as cardiovascular reserve exhaustion in stroke patients, enabling safe early rehabilitation.

## Key findings

- Persistently high NT-proBNP in stroke patients may indicate cardiovascular reserve exhaustion rather than heart failure.
- Individualized stepwise rehabilitation is feasible and safe in such patients with rigorous monitoring.
- Neurological improvement was achieved without cardiovascular adverse events.

## Abstract

A marked elevation in N-terminal pro-B-type natriuretic peptide (NT-proBNP) typically suggests heart failure. However, its clinical significance in acute stroke patients without heart failure symptoms remains unclear, often complicating decisions regarding early rehabilitation. When combined with comorbidities such as renal insufficiency, the marked contrast between extremely high NT-proBNP levels and a stable clinical presentation poses a significant challenge for safely initiating rehabilitation.

This report describes a 65-year-old female admitted with an acute left basal ganglia and periventricular cerebral infarction. She had comorbid diabetic kidney disease (stage IV) and renal anemia. Following the stroke, her NT-proBNP level remained persistently elevated above 20,000 pg/mL, yet she was clinically stable with normal cardiac structure and function on resting echocardiography. We interpreted this condition as a state of “cardiovascular reserve exhaustion under multiple hits” and subsequently formulated an individualized rehabilitation strategy based on “cautious initiation and stepwise progression.” Through multidisciplinary collaboration, we optimized her volume status and corrected anemia, implementing a stepwise rehabilitation protocol under rigorous monitoring. The patient successfully completed rehabilitation without cardiovascular adverse events and demonstrated neurological improvement.

In stroke patients with complex comorbidities, persistently and markedly elevated NT-proBNP levels may reflect a state of “cardiovascular reserve exhaustion” rather than simple heart failure. Under the premise of rigorous multidisciplinary management, optimization of reversible factors, and close monitoring, individualized stepwise early rehabilitation may not necessarily require delay due to this isolated abnormality. This approach suggests that neurological recovery can be promoted while ensuring safety.