Indications and applications of arterial stents for stroke prevention in atherosclerotic intracranial stenosis.

PubMed

Fields, Jeremy D; Liu, Kenneth C; Barnwell, Stanley L; Clark, Wayne M; Lutsep, Helmi L

2010-01-01

Intracranial stenosis accounts for 8-10% of all ischemic strokes in North America, a frequency slightly less than that of extracranial carotid stenosis. Among patients presenting with transient ischemic attack or stroke due to intracranial stenosis, the risk of recurrent stroke in the first year after initial symptoms is about 14%. Those with high-risk features (recent stroke and severe stenosis) have up to a 23% rate of recurrent stroke in the year after their initial event. Angioplasty with stenting has emerged as a potential treatment strategy, particularly in high-risk patients, although evidence is currently limited to uncontrolled prospective trials and retrospective case series. In this article, we critically review the clinical results supporting the use of stenting and highlight some key considerations in the application of this technology, including patient selection, procedural management, technical issues, and risk factors for complications and in-stent restenosis.

Postthrombolysis hemorrhage risk is affected by stroke assessment bias between hemispheres

PubMed Central

Singer, O.C.; Gotzler, B.; Vatankhah, B.; Boy, S.; Fiehler, J.; Lansberg, M.G.; Albers, G.W.; Kastrup, A.; Rovira, A.; Gass, A.; Rosso, C.; Derex, L.; Kim, J.S.; Heuschmann, P.

2011-01-01

Objective: Stroke symptoms in right hemispheric stroke tend to be underestimated in clinical assessment scales, resulting in greater infarct volumes in right as compared to left hemispheric strokes despite similar clinical stroke severity. We hypothesized that patients with right hemispheric nonlacunar stroke are at higher risk for secondary intracerebral hemorrhage after thrombolysis despite similar stroke severity. Methods: We analyzed data of 2 stroke cohorts with CT-based and MRI-based imaging before thrombolysis. Initial stroke severity was measured with the NIH Stroke Scale (NIHSS). Lacunar strokes were excluded through either the presence of cortical symptoms (CT cohort) or restriction to patients with prestroke diffusion-weighted imaging (DWI) lesion size >3.75 mL (MRI cohort). Probabilities of having a parenchymal hematoma were determined using multivariate logistic regression. Results: A total of 392 patients in the CT cohort and 400 patients in the MRI cohort were evaluated. Although NIHSS scores were similar in strokes of both hemispheres (median NIHSS: CT: 15 vs 13, MRI: 14 vs 16), the frequencies of parenchymal hematoma were higher in right hemispheric compared to left hemispheric strokes (CT: 12.4% vs 5.7%, MRI: 10.4% vs 6.8%). After adjustment for potential confounders (but not pretreatment lesion volume), the probability of parenchymal hematoma was higher in right hemispheric nonlacunar strokes (CT: odds ratio [OR] 2.3; 95% confidence interval [CI] 1.08–4.89; p = 0.032) and showed a borderline significant effect in the MRI cohort (OR 2.1; 95% CI 0.98–4.49; p = 0.057). Adjustment for pretreatment DWI lesion size eliminated hemispheric differences in hemorrhage risk. Conclusions: Higher hemorrhage rates in right hemispheric nonlacunar strokes despite similar stroke severity may be caused by clinical underestimation of the proportion of tissue at bleeding risk. PMID:21248275

Atypical anticipatory postural adjustments during gait initiation among individuals with sub-acute stroke.

PubMed

Rajachandrakumar, Roshanth; Fraser, Julia E; Schinkel-Ivy, Alison; Inness, Elizabeth L; Biasin, Lou; Brunton, Karen; McIlroy, William E; Mansfield, Avril

2017-02-01

Anticipatory postural adjustments, executed prior to gait initiation, help preserve lateral stability when stepping. Atypical patterns of anticipatory activity prior to gait initiation may occur in individuals with unilateral impairment (e.g., stroke). This study aimed to determine the prevalence, correlates, and consequences of atypical anticipatory postural adjustment patterns prior to gait initiation in a sub-acute stroke population. Forty independently-ambulatory individuals with sub-acute stroke stood on two force plates and initiated gait at a self-selected speed. Medio-lateral centre of pressure displacement was calculated and used to define anticipatory postural adjustments (shift in medio-lateral centre of pressure >10mm from baseline). Stroke severity, motor recovery, and functional balance and mobility status were also obtained. Three patterns were identified: single (typical), absent (atypical), and multiple (atypical) anticipatory postural adjustments. Thirty-five percent of trials had atypical anticipatory postural adjustments (absent and multiple). Frequency of absent anticipatory postural adjustments was negatively correlated with walking speed. Multiple anticipatory postural adjustments were more prevalent when leading with the non-paretic than the paretic limb. Trials with multiple anticipatory postural adjustments had longer duration of anticipatory postural adjustment and time to foot-off, and shorter unloading time than trials with single anticipatory postural adjustments. A high prevalence of atypical anticipatory control prior to gait initiation was found in individuals with stroke. Temporal differences were identified with multiple anticipatory postural adjustments, indicating altered gait initiation. These findings provide insight into postural control during gait initiation in individuals with sub-acute stroke, and may inform interventions to improve ambulation in this population. Copyright © 2016 Elsevier B.V. All rights reserved.

Fatalism, optimism, spirituality, depressive symptoms and stroke outcome: A population-based analysis

PubMed Central

Morgenstern, Lewis B.; Sánchez, Brisa N.; Skolarus, Lesli E.; Garcia, Nelda; Risser, Jan M.H.; Wing, Jeffrey J.; Smith, Melinda A.; Zahuranec, Darin B.; Lisabeth, Lynda D.

2011-01-01

Background and Purpose We sought to describe the association of spirituality, optimism, fatalism and depressive symptoms with initial stroke severity, stroke recurrence and post-stroke mortality. Methods Stroke cases June 2004–December 2008 were ascertained in Nueces County, Texas. Patients without aphasia were queried on their recall of depressive symptoms, fatalism, optimism, and non-organizational spirituality before stroke using validated scales. The association between scales and stroke outcomes was studied using multiple linear regression with log-transformed NIHSS and Cox proportional hazards regression for recurrence and mortality. Results 669 patients participated, 48.7% were women. In fully adjusted models, an increase in fatalism from the first to third quartile was associated with all-cause mortality (HR=1.41, 95%CI: 1.06, 1.88), marginally associated with risk of recurrence (HR=1.35, 95%CI: 0.97, 1.88), but not stroke severity. Similarly, an increase in depressive symptoms was associated with increased mortality (HR=1.32, 95%CI: 1.02, 1.72), marginally associated with stroke recurrence (HR=1.22, CI: 0.93, 1.62), and with a 9.0% increase in stroke severity (95%CI: 0.01, 18.0). Depressive symptoms altered the fatalism-mortality association such that the association of fatalism and mortality was more pronounced for patients reporting no depressive symptoms. Neither spirituality nor optimism conferred a significant effect on stroke severity, recurrence or mortality. Conclusions Among patients who have already had a stroke, self-described pre-stroke depressive symptoms and fatalism, but not optimism or spirituality, are associated with increased risk of stroke recurrence and mortality. Unconventional risk factors may explain some of the variability in stroke outcomes observed in populations, and may be novel targets for intervention. PMID:21940963

Protocol for the Locomotor Experience Applied Post-stroke (LEAPS) trial: a randomized controlled trial

PubMed Central

Duncan, Pamela W; Sullivan, Katherine J; Behrman, Andrea L; Azen, Stanley P; Wu, Samuel S; Nadeau, Stephen E; Dobkin, Bruce H; Rose, Dorian K; Tilson, Julie K

2007-01-01

Background Locomotor training using body weight support and a treadmill as a therapeutic modality for rehabilitation of walking post-stroke is being rapidly adopted into clinical practice. There is an urgent need for a well-designed trial to determine the effectiveness of this intervention. The objective of the Locomotor Experience Applied Post-Stroke (LEAPS) trial is to determine if there is a difference in the proportion of participants who recover walking ability at one year post-stroke when randomized to a specialized locomotor training program (LTP), conducted at 2- or 6-months post-stroke, or those randomized to a home based non-specific, low intensity exercise intervention (HEP) provided 2 months post-stroke. We will determine if the timing of LTP delivery affects gait speed at 1 year and whether initial impairment severity interacts with the timing of LTP. The effect of number of treatment sessions will be determined by changes in gait speed taken pre-treatment and post-12, -24, and -36 sessions. Methods/Design We will recruit 400 adults with moderate or severe walking limitations within 30 days of stroke onset. At two months post stroke, participants are stratified by locomotor impairment severity as determined by overground walking speed and randomly assigned to one of three groups: (a) LTP-Early; (b) LTP-Late or (c) Home Exercise Program -Early. The LTP program includes body weight support on a treadmill and overground training. The LTP and HEP interventions are delivered for 36 sessions over 12 weeks. Primary outcome measure include successful walking recovery defined as the achievement of a 0.4 m/s gait speed or greater by persons with initial severe gait impairment or the achievement of a 0.8 m/s gait speed or greater by persons with initial moderate gait impairment. LEAPS is powered to detect a 20% difference in the proportion of participants achieving successful locomotor recovery between the LTP groups and the HEP group, and a 0.1 m/s mean difference in gait speed change between the two LTP groups. Discussion The goal of this single-blinded, phase III randomized clinical trial is to provide evidence to guide post-stroke walking recovery programs. Trial registration NCT00243919. PMID:17996052

Worse stroke outcome in atrial fibrillation is explained by more severe hypoperfusion, infarct growth, and hemorrhagic transformation.

PubMed

Tu, Hans T H; Campbell, Bruce C V; Christensen, Soren; Desmond, Patricia M; De Silva, Deidre A; Parsons, Mark W; Churilov, Leonid; Lansberg, Maarten G; Mlynash, Michael; Olivot, Jean-Marc; Straka, Matus; Bammer, Roland; Albers, Gregory W; Donnan, Geoffrey A; Davis, Stephen M

2015-06-01

Atrial fibrillation is associated with greater baseline neurological impairment and worse outcomes following ischemic stroke. Previous studies suggest that greater volumes of more severe baseline hypoperfusion in patients with history of atrial fibrillation may explain this association. We further investigated this association by comparing patients with and without atrial fibrillation on initial examination following stroke using pooled multimodal magnetic resonance imaging and clinical data from the Echoplanar Imaging Thrombolytic Evaluation Trial and the Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution studies. Echoplanar Imaging Thrombolytic Evaluation Trial was a trial of 101 ischemic stroke patients randomized to intravenous tissue plasminogen activator or placebo, and Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution was a prospective cohort of 74 ischemic stroke patients treated with intravenous tissue plasminogen activator at three to six hours following symptom onset. Patients underwent multimodal magnetic resonance imaging before treatment, at three to five days and three-months after stroke in Echoplanar Imaging Thrombolytic Evaluation Trial; before treatment, three to six hours after treatment and one-month after stroke in Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution. Patients were assessed with the National Institutes of Health Stroke Scale and the modified Rankin scale before treatment and at three-months after stroke. Patients were categorized into definite atrial fibrillation (present on initial examination), probable atrial fibrillation (history but no atrial fibrillation on initial examination), and no atrial fibrillation. Perfusion data were reprocessed with automated magnetic resonance imaging analysis software (RAPID, Stanford University, Stanford, CA, USA). Hypoperfusion volumes were defined using time to maximum delays in two-second increments from >4 to >8 s. Hemorrhagic transformation was classified according to the European Cooperative Acute Stroke Studies criteria. Of the 175 patients, 28 had definite atrial fibrillation, 30 probable atrial fibrillation, 111 no atrial fibrillation, and six were excluded due to insufficient imaging data. At baseline, patients with definite atrial fibrillation had more severe hypoperfusion (median time to maximum >8 s, volume 48 vs. 29 ml, P = 0.02) compared with patients with no atrial fibrillation. At outcome, patients with definite atrial fibrillation had greater infarct growth (median volume 47 vs. 8 ml, P = 0.001), larger infarcts (median volume 75 vs. 23 ml, P = 0.001), more frequent parenchymal hematoma grade hemorrhagic transformation (30% vs. 10%, P = 0.03), worse functional outcomes (median modified Rankin scale score 4 vs. 3, P = 0.03), and higher mortality (36% vs. 16%, P = 0·.3) compared with patients with no atrial fibrillation. Definite atrial fibrillation was independently associated with increased parenchymal hematoma (odds ratio = 6.05, 95% confidence interval 1.60-22.83) but not poor functional outcome (modified Rankin scale 3-6, odds ratio = 0.99, 95% confidence interval 0.35-2.80) or mortality (odds ratio = 2.54, 95% confidence interval 0.86-7.49) three-months following stroke, after adjusting for other baseline imbalances. Atrial fibrillation is associated with greater volumes of more severe baseline hypoperfusion, leading to higher infarct growth, more frequent severe hemorrhagic transformation and worse stroke outcomes. © 2013 The Authors. International Journal of Stroke © 2013 World Stroke Organization.

Statistical analysis of electric field parameters for negative lightning in Malaysia

NASA Astrophysics Data System (ADS)

Wooi, Chin-Leong; Abdul-Malek, Zulkurnain; Ahmad, Noor-Azlinda; El Gayar, Ali I.

2016-08-01

This paper presents a comparative study on the electric field and its derivative parameters of negative lightning in Malaysia and other regions. This study is the first in Malaysia where the parameters of negative electric field and its derivative are thoroughly analyzed. 104 negative lightning flashes containing 277 negative return strokes occurring within 10-100 km from the measuring station and recorded during monsoon period in the state of Johor, Malaysia had been analyzed. It was found that 73% of the recorded flashes are multiple strokes with an average multiplicity of 2.6 strokes per flash. For first return strokes, the arithmetic mean (AM) of initial peak electric field and the AM of initial peak electric field derivative are 21.8 V/m and 11.3 V/m/μs, respectively. The initial peaks of electric field and its derivative for first return strokes are larger than those for the subsequent return strokes. Comparison of overall results with those obtained earlier in Sri Lanka, Germany, Sweden, Japan, Florida indicates that several electric field and its derivative parameters are affected by propagation media and geographical region. Similarity of results with other countries having the same climatic condition is also observed.

Relationship of initial hematocrit level to discharge destination and resource utilization after ischemic stroke: a pilot study.

PubMed

Diamond, Paul T; Gale, Shawn D; Evans, Brent A

2003-07-01

To examine the association between initial hematocrit level at the time of ischemic stroke, discharge destination, and resource utilization. Case series. University hospital. A total of 1012 consecutive patients with ischemic stroke admitted to a university health system between August 3, 1995, and June 24, 1999. Not applicable. Length of stay, hospital cost, and discharge disposition. Of 1012 patients presenting with ischemic stroke, 58% were discharged home, 10% were discharged home with home care services, 15% were discharged to a rehabilitation hospital, 11% were discharged to a skilled or intermediate care facility, and 6% died. After adjusting for age, sex, race, and comorbidities, a significant association (P=.009) existed between discharge outcome and initial hematocrit level. The probability of achieving an equivalent or less favorable outcome increased at both high and low hematocrit levels, with a minimum probability at a hematocrit level of approximately 45%. An association exists between hematocrit level at the time of ischemic stroke and discharge outcome. Midrange hematocrit levels appear to be associated with discharge to home rather than to an inpatient rehabilitation unit or to a nursing facility. Further study is indicated to examine the relationship among hematocrit level, stroke severity, and outcome.

Which factors influence the resort to surrogate consent in stroke trials, and what are the patient outcomes in this context?

PubMed

Mendyk, Anne-Marie; Labreuche, Julien; Henon, Hilde; Girot, Marie; Cordonnier, Charlotte; Duhamel, Alain; Leys, Didier; Bordet, Régis

2015-04-24

The provision of informed consent is a prerequisite for inclusion of a patient in a clinical research project. In some countries, the legislation on clinical research authorizes a third person to provide informed consent if the patient is unable to do so directly (i.e. surrogate consent). This is the case during acute stroke, when the symptoms may prevent the patient from providing informed consent and thus require a third party to be approached. Identification of factors associated with the medical team's decision to resort to surrogate consent may (i) help the care team during the inclusion process and (ii) enable the patient's family circle to be better informed (and thus feel less guilty) about providing surrogate consent. Patients included in the BIOSTROKE cohort (initially dedicated to the analysis of factors influencing stroke severity) were divided into two groups: those having provided informed consent directly and those for whom a third party (such as a family member) had provided surrogate consent. We compared the groups in terms of the initial clinical characteristics (age, gender, type of stroke, severity on the National Institutes of Health Stroke Scale (NIHSS), pre-stroke cognitive status according to the Informant Questionnaire on Cognitive Decline in the Elderly, and the stroke's aetiology) and the functional and cognitive impairments (according to the NIHSS, the modified Rankin score (mRS) and the Mini Mental State Examination) on post-stroke days 8 and 90. Three hundred and ninety five patients were included (mean ± SD age: 67 ± 15 years; 53% males). Surrogate consent had been obtained in 228 cases, and 167 patients had provided consent themselves. The patients included with surrogate consent were likely to be older and more aphasic, with a pre-existing cognitive disorder and more severe stroke (relative to the patients having provided consent). In terms of recovery, the patients included with surrogate consent had a worse functional prognosis (day 90 mRS ≥3: 57.6%, compared with 16.8% in patients having provided consent themselves; p < 0.0001) and a worse cognitive prognosis (day 90 MMS < 24: 15.4% and 4.8%, respectively; p < 0.002). The mortality rate was significantly higher in the surrogate consent group. We found that in addition to age, aphasia and stroke severity, pre-stroke cognitive status is a factor that should prompt the care team to consider requesting surrogate consent for participation in a clinical study. Given that the unfavourable outcome in patients with surrogate consent is often due to their initial clinical state (rather than inclusion in a trial per se), the issue of the family's feelings of guilt (and how to avoid these feelings) should be further addressed.

Effects of sex difference on clinical features of acute ischemic stroke in Japan.

PubMed

Maeda, Koichiro; Toyoda, Kazunori; Minematsu, Kazuo; Kobayashi, Shotai

2013-10-01

Sex differences in stroke characteristics and outcomes have been inconsistent. The goal of this study was to determine the influence of sex on underlying patient characteristics, stroke subtypes and conditions, and outcomes after ischemic stroke from a nationwide registration study. A total of 33,953 patients with acute ischemic stroke, including 13,323 women, were registered in a multicenter, hospital-based registration study based on a computerized database from 162 Japanese institutes (the Japan Standard Stroke Registry Study) between January 2000 and November 2007. Women were significantly older than men at stroke onset (75.0 ± 11.7 v 69.3 ± 11.4 years; P < .0001). After age adjustment, women more frequently had cardioembolic events (odds ratio [OR] 1.090; 95% confidence interval [95% CI] 1.036-1.146; P = .0009) and other strokes (OR 1.177; 95% CI 1.079-1.284; P = .0003) and were more hypertensive (OR 1.056; 95% CI 1.006-1.108; P = .0267) and more dyslipidemic (OR 1.301; 95% CI 1.234-1.373; P < .0001) than men. After multivariate adjustment, onset-to-arrival time was longer (β = 0.0554; P = .026), the initial National Institutes of Health Stroke Scale score was higher (β = 0.1565; P < .001), and the duration of hospitalization was longer (β = 0.035; P = .010) in women than in men. At hospital discharge, women less commonly had a modified Rankin Scale (mRS) score of 0 to 1 (OR 0.802; 95% CI 0.741-0.868; P < .0001) and more commonly had a mRS score of 4 to 6 (OR 1.410; 95% CI 1.293-1.537; P < .0001) than men. Women developed more severe strokes than men in Japan. After multivariate adjustment for initial severity and other characteristics, acute care hospital stays were longer and stroke outcomes at discharge were worse in women than in men. Copyright © 2013 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Principles of proportional recovery after stroke generalize to neglect and aphasia.

PubMed

Marchi, N A; Ptak, R; Di Pietro, M; Schnider, A; Guggisberg, A G

2017-08-01

Motor recovery after stroke can be characterized into two different patterns. A majority of patients recover about 70% of initial impairment, whereas some patients with severe initial deficits show little or no improvement. Here, we investigated whether recovery from visuospatial neglect and aphasia is also separated into two different groups and whether similar proportions of recovery can be expected for the two cognitive functions. We assessed 35 patients with neglect and 14 patients with aphasia at 3 weeks and 3 months after stroke using standardized tests. Recovery patterns were classified with hierarchical clustering and the proportion of recovery was estimated from initial impairment using a linear regression analysis. Patients were reliably clustered into two different groups. For patients in the first cluster (n = 40), recovery followed a linear model where improvement was proportional to initial impairment and achieved 71% of maximal possible recovery for both cognitive deficits. Patients in the second cluster (n = 9) exhibited poor recovery (<25% of initial impairment). Our findings indicate that improvement from neglect or aphasia after stroke shows the same dichotomy and proportionality as observed in motor recovery. This is suggestive of common underlying principles of plasticity, which apply to motor and cognitive functions. © 2017 EAN.

Mortality Reduction for Fever, Hyperglycemia, and Swallowing Nurse-Initiated Stroke Intervention: QASC Trial (Quality in Acute Stroke Care) Follow-Up.

PubMed

Middleton, Sandy; Coughlan, Kelly; Mnatzaganian, George; Low Choy, Nancy; Dale, Simeon; Jammali-Blasi, Asmara; Levi, Chris; Grimshaw, Jeremy M; Ward, Jeanette; Cadilhac, Dominique A; McElduff, Patrick; Hiller, Janet E; D'Este, Catherine

2017-05-01

Implementation of nurse-initiated protocols to manage fever, hyperglycemia, and swallowing dysfunction decreased death and disability 90 days poststroke in the QASC trial (Quality in Acute Stroke Care) conducted in 19 Australian acute stroke units (2005-2010). We now examine long-term all-cause mortality. Mortality was ascertained using Australia's National Death Index. Cox proportional hazards regression compared time to death adjusting for correlation within stroke units using the cluster sandwich (Huber-White estimator) method. Primary analyses included treatment group only unadjusted for covariates. Secondary analysis adjusted for age, sex, marital status, education, and stroke severity using multiple imputation for missing covariates. One thousand and seventy-six participants (intervention n=600; control n=476) were followed for a median of 4.1 years (minimum 0.3 to maximum 70 months), of whom 264 (24.5%) had died. Baseline demographic and clinical characteristics were generally well balanced by group. The QASC intervention group had improved long-term survival (>20%), but this was only statistically significant in adjusted analyses (unadjusted hazard ratio [HR], 0.79; 95% confidence interval [CI], 0.58-1.07; P =0.13; adjusted HR, 0.77; 95% CI, 0.59-0.99; P =0.045). Older age (75-84 years; HR, 4.9; 95% CI, 2.8-8.7; P <0.001) and increasing stroke severity (HR, 1.5; 95% CI, 1.3-1.9; P <0.001) were associated with increased mortality, while being married (HR, 0.70; 95% CI, 0.49-0.99; P =0.042) was associated with increased likelihood of survival. Cardiovascular disease (including stroke) was listed either as the primary or secondary cause of death in 80% (211/264) of all deaths. Our results demonstrate the potential long-term and sustained benefit of nurse-initiated multidisciplinary protocols for management of fever, hyperglycemia, and swallowing dysfunction. These protocols should be a routine part of acute stroke care. URL: http://www.anzctr.org.au. Unique identifier: ACTRN12608000563369. © 2017 American Heart Association, Inc.

Observed Cost and Variations in Short Term Cost-Effectiveness of Therapy for Ischemic Stroke in Interventional Management of Stroke (IMS) III.

PubMed

Simpson, Kit N; Simpson, Annie N; Mauldin, Patrick D; Palesch, Yuko Y; Yeatts, Sharon D; Kleindorfer, Dawn; Tomsick, Thomas A; Foster, Lydia D; Demchuk, Andrew M; Khatri, Pooja; Hill, Michael D; Jauch, Edward C; Jovin, Tudor G; Yan, Bernard; von Kummer, Rüdiger; Molina, Carlos A; Goyal, Mayank; Schonewille, Wouter J; Mazighi, Mikael; Engelter, Stefan T; Anderson, Craig; Spilker, Judith; Carrozzella, Janice; Ryckborst, Karla J; Janis, L Scott; Broderick, Joseph P

2017-05-08

Examination of linked data on patient outcomes and cost of care may help identify areas where stroke care can be improved. We report on the association between variations in stroke severity, patient outcomes, cost, and treatment patterns observed over the acute hospital stay and through the 12-month follow-up for subjects receiving endovascular therapy compared to intravenous tissue plasminogen activator alone in the IMS (Interventional Management of Stroke) III Trial. Prospective data collected for a prespecified economic analysis of the trial were used. Data included hospital billing records for the initial stroke admission and subsequent detailed resource use after the acute hospitalization collected at 3, 6, 9, and 12 months. Cost of follow-up care varied 6-fold for patients in the lowest (0-1) and highest (20+) National Institutes of Health Stroke Scale category at 5 days, and by modified Rankin Scale at 3 months. The kind of resources used postdischarge also varied between treatment groups. Incremental short-term cost-effectiveness ratios varied greatly when treatments were compared for patient subgroups. Patient subgroups predefined by stroke severity had incremental cost-effectiveness ratios of $97 303/quality-adjusted life year (severe stroke) and $3 187 805/quality-adjusted life year (moderately severe stroke). Detailed economic and resource utilization data from IMS III provide powerful evidence for the large effect that patient outcome has on the economic value of medical and endovascular reperfusion therapies. These data can be used to inform process improvements for stroke care and to estimate the cost-effectiveness of endovascular therapy in the US health system for stroke intervention trials. URL: http://www.clinicaltrials.gov. Registration number: NCT00359424. © 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

Lack of repercussions of sleep apnea syndrome on recovery and attention disorders at the subacute stage after stroke: a study of 45 patients.

PubMed

Lefèvre-Dognin, C; Stana, L; Jousse, M; Lucas, C; Sportouch, P; Bradai, N; Guettard, E; Vicaut, E; Yelnik, A P

2014-12-01

Sleep apnea syndrome (SAS) frequently occurs after a stroke. Its association with a poor prognosis is open to discussion. To study, in a physical and rehabilitation medicine (PRM) unit, the possible repercussions of SAS on neurological and functional recovery as well as attentional abilities following a stroke. Forty-five patients, all of whom had recently had a stroke without previously documented SAS, were screened using the ApneaLink(®) system. An apnea-hypopnea index (AHI) score ≥10 was considered as indicative of SAS. The NIHSS, Fugl-Meyer (FM) and Functional Independence Measure (FIM) Scales were applied on admission and at two months as means of assessing neurological and functional recovery, which was expressed by the difference between the first and the second scores (delta FM, delta NIHSS, delta FIM). The Battery Attention William Lennox (BAWL) Test was given once in order to evaluate attention disorders. SAS severity was categorized according to the AHI. We compared the groups formed (mild, moderate and severe) using the same method. Twenty-eight patients (62.2%) presented AHI ≥ 10. Stroke characteristics were comparable in the SAS+ and the SAS- groups, with average post-stroke time lapse of 26 days, initial average FIM score of 71.2 points ± 26.3 and initial average NIHSS score of 8.9 ± 4.9. The demographic characteristics of the two groups were likewise comparable with the exception of age, as the SAS+ group was pronouncedly older (65.4 vs. 53.5 years). As for delta FIM, which evaluated functional recovery, it averaged 31.8 ± 20.6. Cases of SAS were found to be mild (37.1%), moderate (28.6%) or severe (34.3%). No significant difference was observed on admission or at 2 months as regards the clinical scales or the BAWL test between the two groups or according to severity, except for the NIHSS score at 2 months in the severe sub-group. This study did not demonstrate the supposed repercussions of SAS on the recovery or attentional abilities of post-stroke patients. The tests were maybe given too early; they should take place at a lengthier time interval after the stroke, and also to be more complete. Copyright © 2014 Elsevier Masson SAS. All rights reserved.

The frequency, characteristics and aetiology of stroke mimic presentations: a narrative review.

PubMed

McClelland, Graham; Rodgers, Helen; Flynn, Darren; Price, Christopher I

2018-05-01

A significant proportion of patients with acute stroke symptoms have an alternative 'mimic' diagnosis. A narrative review was carried out to explore the frequency, characteristics and aetiology of stroke mimics. Prehospital and thrombolysis-treated patients were described separately. Overall, 9972 studies were identified from the initial search and 79 studies were included with a median stroke mimic rate of 19% (range: 1-64%). The prehospital median was 27% (range: 4-43%) and the thrombolysis median 10% (range: 1-25%). Seizures, migraines and psychiatric disorders are the most frequently reported causes of stroke mimics. Several characteristics are consistently associated with stroke mimics; however, they do not fully exclude the possibility of stroke. Nineteen per cent of suspected stroke patients had a mimic condition. Stroke mimics were more common with younger age and female sex. The range of mimic diagnoses, a lack of clear differentiating characteristics and the short treatment window for ischaemic stroke create challenges for early identification.

Low cholesterol level associated with severity and outcome of spontaneous intracerebral hemorrhage: Results from Taiwan Stroke Registry

PubMed Central

Chen, Yu-Wei; Li, Chen-Hua; Yang, Chih-Dong; Liu, Chung-Hsiang; Chen, Chih-Hung; Sheu, Jau-Jiuan; Lin, Shinn-Kuang; Chen, An-Chih; Chen, Ping-Kun; Chen, Po-Lin; Yeh, Chung-Hsin; Chen, Jiunn-Rong; Hsiao, Yu-Jen; Lin, Ching-Huang; Hsu, Shih-Pin; Chen, Tsang-Shan; Sung, Sheng-Feng; Yu, Shih-Chieh; Muo, Chih-Hsin; Wen, Chi Pang; Sung, Fung-Chang; Jeng, Jiann-Shing; Hsu, Chung Y.

2017-01-01

The relationship between cholesterol level and hemorrhagic stroke is inconclusive. We hypothesized that low cholesterol levels may have association with intracerebral hemorrhage (ICH) severity at admission and 3-month outcomes. This study used data obtained from a multi-center stroke registry program in Taiwan. We categorized acute spontaneous ICH patients, based on their baseline levels of total cholesterol (TC) measured at admission, into 3 groups with <160, 160–200 and >200 mg/dL of TC. We evaluated risk of having initial stroke severity, with National Institutes of Health Stroke Scale (NIHSS) >15 and unfavorable outcomes (modified Rankin Scale [mRS] score >2, 3-month mortality) after ICH by the TC group. A total of 2444 ICH patients (mean age 62.5±14.2 years; 64.2% men) were included in this study and 854 (34.9%) of them had baseline TC <160 mg/dL. Patients with TC <160 mg/dL presented more often severe neurological deficit (NIHSS >15), with an adjusted odds ratio [aOR] of 1.80; 95% confidence interval [CI], 1.41–2.30), and 3-month mRS >2 (aOR, 1.41; 95% CI, 1.11–1.78) using patients with TC >200 mg/dL as reference. Those with TC >160 mg/dL and body mass index (BMI) <22 kg/m2 had higher risk of 3-month mortality (aOR 3.94, 95% CI 1.76–8.80). Prior use of lipid-lowering drugs (2.8% of the ICH population) was not associated with initial severity and 3-month outcomes. A total cholesterol level lower than 160 mg/dL was common in patients with acute ICH and was associated with greater neurological severity on presentation and poor 3-month outcomes, especially with lower BMI. PMID:28422955

Atrial fibrillation in patients with severe mental disorders and the risk of stroke, fatal thromboembolic events and bleeding: a nationwide cohort study

PubMed Central

Søgaard, Mette; Skjøth, Flemming; Kjældgaard, Jette Nordstrøm; Larsen, Torben Bjerregaard; Hjortshøj, Søren Pihlkjær; Riahi, Sam

2017-01-01

Objectives Outcomes of atrial fibrillation (AF) in patients with severe mental disorders are largely unknown. We compared rates of stroke, fatal thromboembolic events and bleeding in patients with AF with and without mental disorders. Design Nationwide registry-based cohort study. Setting Denmark (population 5.6 million), 2000–2015. Participants Patients with AF with schizophrenia (n=534), severe depression (n=400) or bipolar disease (n=569) matched 1:5 on age, sex and calendar time to patients with AF without mental disorders. Exposure Inpatient or hospital-based outpatient diagnosis of schizophrenia, severe depression or bipolar disease. Primary and secondary outcome measures HRs for stroke, fatal thromboembolic events and major bleeding comparing patients with and without mental disorders estimated by Cox regression with sequential adjustment for risk factors for stroke and bleeding, comorbidity and initiation of oral anticoagulant therapy (OAT). Results Compared with matched comparisons, crude 5-year HRs of ischaemic stroke were 1.37 (95% CI 0.88 to 2.14) for schizophrenia, 1.36 (95% CI 0.89 to 2.08) for depression and 1.04 (95% CI 0.69 to 1.56) for bipolar disease. After adjusting for risk factors, comorbidity and OAT, these HRs declined towards the null. Crude HRs of fatal thromboembolic events were 3.16 (95% CI 1.78 to 5.61) for schizophrenia, 1.31 (95% CI 0.67 to 2.56) for depression and 1.53 (95% CI 0.93 to 2.53) for bipolar disease. Rates of major bleeding were increased in patients with schizophrenia (crude HR 1.37, 95% CI 0.99 to 1.90) and severe depression (HR 1.25, 95% CI 0.87 to 1.78) but not bipolar disease (HR 0.82, 95% CI 0.58 to 1.15). Conclusion Patients with AF with schizophrenia or severe depression experienced increased rates of stroke and major bleeding compared with matched comparisons. This increase was largely explained by differences in the prevalence of risk factors for stroke and bleeding, comorbidity and initiation of OAT during follow-up. Patients with AF with schizophrenia further experienced higher mortality following thromboembolic events than matched comparisons without mental disorders. PMID:29217725

The Nottingham Fatigue After Stroke (NotFAST) study: results from follow-up six months after stroke.

PubMed

Hawkins, Louise; Lincoln, Nadina B; Sprigg, Nikola; Ward, Nick S; Mistri, Amit; Tyrrell, Pippa; Worthington, Esme; Drummond, Avril

2017-12-01

Background Post-stroke fatigue is common and disabling. Objectives The aim of NotFAST was to examine factors associated with fatigue in stroke survivors without depression, six months after stroke. Methods Participants were recruited from four UK stroke units. Those with high levels of depressive symptoms (score ≥7 on Brief Assessment Schedule Depression Cards) or aphasia were excluded. Follow-up assessment was conducted at six months after stroke. They were assessed on the Fatigue Severity Scale, Rivermead Mobility Index, Nottingham Extended Activities of Daily Living scale, Barthel Index, Beck Anxiety Index, Brief Assessment Schedule Depression Cards, Impact of Event Scale-Revised, and Sleep Hygiene Index. Results Of the 371 participants recruited, 263 (71%) were contacted at six months after stroke and 213 (57%) returned questionnaires. Approximately half (n = 109, 51%) reported fatigue at six months. Of those reporting fatigue initially (n = 88), 61 (69%) continued to report fatigue. 'De novo' (new) fatigue was reported by 48 (38%) of those not fatigued initially. Lower Nottingham Extended Activities of Daily Living scores and higher Beck Anxiety Index scores were independently associated with fatigue at six months. Conclusions Half the stroke survivors reported fatigue at six months post-stroke. Reduced independence in activities of daily living and higher anxiety levels were associated with the level of fatigue. Persistent and delayed onset fatigue may affect independence and participation in rehabilitation, and these findings should be used to inform the development of appropriate interventions.

Treatment of Fever After Stroke: Conflicting Evidence

PubMed Central

Wrotek, Sylwia E.; Kozak, Wieslaw E.; Hess, David C.; Fagan, Susan C.

2014-01-01

Approximately 50% of patients hospitalized for stroke develop fever. In fact, experimental evidence suggests that high body temperature is significantly correlated to initial stroke severity, lesion size, mortality, and neurologic outcome. Fever occurring after stroke is associated with poor outcomes. We investigated the etiology of fever after stroke and present evidence evaluating the efficacy and safety of interventions used to treat stroke-associated fever. Oral antipyretics are only marginally effective in lowering elevated body temperature in this population and may have unintended adverse consequences. Nonpharmacologic approaches to cooling have been more effective in achieving normothermia, but whether stroke outcomes can be improved remains unclear. We recommend using body temperature as a biomarker and a catalyst for aggressive investigation for an infectious etiology. Care must be taken not to exceed the new standard of a maximum acetaminophen does of 3 g/day to avoid patient harm. PMID:22026396

Patterns of stroke recurrence according to subtype of first stroke event: the North East Melbourne Stroke Incidence Study (NEMESIS).

PubMed

Azarpazhooh, Mahmoud Reza; Nicol, Marcus B; Donnan, Geoffrey A; Dewey, Helen M; Sturm, Jonathan W; Macdonell, Richard A L; Pearce, Dora C; Thrift, Amanda G

2008-08-01

Specific information about the nature of recurrent events that occur after each subtype of index stroke may be useful for refining preventive therapies. We aimed to determine whether stroke recurrence rates, the pattern of subtype recurrence, and prescription of secondary prevention agents differed according to initial stroke subtype. Multiple overlapping sources were used to recruit all first-ever stroke patients from a geographically defined region of Melbourne, Australia over a 3-year period from 1996 to 1999. Potential stroke recurrences (fatal and nonfatal) occurring within 2 years of the initial event were identified following patient interview and follow up of death records. Subjects were classified into the different Oxfordshire groups and the type of first-ever stroke was compared with recurrent stroke events. One thousand, three hundred and sixteen first-ever strokes were registered during the 3-year period (mean age 74.4 years). A total of 103 first recurrent stroke events (fatal and nonfatal) occurred among those with a first-ever ischemic stroke or intracerebral hemorrhage (ICH) during the 2-year follow-up period. The recurrent stroke subtype was different to the index stroke subtype in most (78%) patients. People with partial anterior circulation infarct had the greatest proportion of recurrences (13%), with a third of these being the more severe total anterior circulation infarct subgroup. The relative risk of ICH after an index lacunar infarct (LACI) compared with an index non-LACI was 4.06 (95% CI 1.10-14.97, P=0.038). Prescription of secondary prevention agents was greater at 2 years after stroke than at hospital discharge, and was similar between ischemic stroke subtypes. Approximately 9% of people with first-ever stroke suffered a recurrent event, despite many being prescribed secondary prevention agents. This has implications for the uptake of current preventive strategies and the development of new strategies. The possibility that ICH is greater among index LACI cases needs to be confirmed.

Small strokes causing severe vertigo: frequency of false-negative MRIs and nonlacunar mechanisms.

PubMed

Saber Tehrani, Ali S; Kattah, Jorge C; Mantokoudis, Georgios; Pula, John H; Nair, Deepak; Blitz, Ari; Ying, Sarah; Hanley, Daniel F; Zee, David S; Newman-Toker, David E

2014-07-08

Describe characteristics of small strokes causing acute vestibular syndrome (AVS). Ambispective cross-sectional study of patients with AVS (acute vertigo or dizziness, nystagmus, nausea/vomiting, head-motion intolerance, unsteady gait) with at least one stroke risk factor from 1999 to 2011 at a single stroke referral center. Patients underwent nonquantitative HINTS "plus" examination (head impulse, nystagmus, test-of-skew plus hearing), neuroimaging to confirm diagnoses (97% by MRI), and repeat MRI in those with initially normal imaging but clinical signs of a central lesion. We identified patients with diffusion-weighted imaging (DWI) strokes ≤10 mm in axial diameter. Of 190 high-risk AVS presentations (105 strokes), we found small strokes in 15 patients (median age 64 years, range 41-85). The most common vestibular structure infarcted was the inferior cerebellar peduncle (73%); the most common stroke location was the lateral medulla (60%). Focal neurologic signs were present in only 27%. The HINTS "plus" battery identified small strokes with greater sensitivity than early MRI-DWI (100% vs 47%, p < 0.001). False-negative initial MRIs (6-48 hours) were more common with small strokes than large strokes (53% [n = 8/15] vs 7.8% [n = 7/90], p < 0.001). Nonlacunar stroke mechanisms were responsible in 47%, including 6 vertebral artery occlusions or dissections. Small strokes affecting central vestibular projections can present with isolated AVS. The HINTS "plus" hearing battery identifies these patients with greater accuracy than early MRI-DWI, which is falsely negative in half, up to 48 hours after onset. We found nonlacunar mechanisms in half, suggesting greater risk than might otherwise be assumed for patients with such small infarctions. © 2014 American Academy of Neurology.

Statins in Acute Ischemic Stroke: A Systematic Review

PubMed Central

Hong, Keun-Sik; Lee, Ji Sung

2015-01-01

Background and Purpose Statins have pleiotropic effects of potential neuroprotection. However, because of lack of large randomized clinical trials, current guidelines do not provide specific recommendations on statin initiation in acute ischemic stroke (AIS). The current study aims to systematically review the statin effect in AIS. Methods From literature review, we identified articles exploring prestroke and immediate post-stroke statin effect on imaging surrogate markers, initial stroke severity, functional outcome, and short-term mortality in human AIS. We summarized descriptive overview. In addition, for subjects with available data from publications, we conducted meta-analysis to provide pooled estimates. Results In total, we identified 70 relevant articles including 6 meta-analyses. Surrogate imaging marker studies suggested that statin might enhance collaterals and reperfusion. Our updated meta-analysis indicated that prestroke statin use was associated with milder initial stroke severity (odds ratio [OR] [95% confidence interval], 1.24 [1.05-1.48]; P=0.013), good functional outcome (1.50 [1.29-1.75]; P<0.001), and lower mortality (0.42 [0.21-0.82]; P=0.0108). In-hospital statin use was associated with good functional outcome (1.31 [1.12-1.53]; P=0.001), and lower mortality (0.41 [0.29-0.58]; P<0.001). In contrast, statin withdrawal was associated with poor functional outcome (1.83 [1.01-3.30]; P=0.045). In patients treated with thrombolysis, statin was associated with good functional outcome (1.44 [1.10-1.89]; P=0.001), despite an increased risk of symptomatic hemorrhagic transformation (1.63 [1.04-2.56]; P=0.035). Conclusions The current study findings support the use of statin in AIS. However, the findings were mostly driven by observational studies at risk of bias, and thereby large randomized clinical trials would provide confirmatory evidence. PMID:26437994

Dose-response relationship of robot-assisted stroke motor rehabilitation: the impact of initial motor status.

PubMed

Hsieh, Yu-wei; Wu, Ching-yi; Lin, Keh-chung; Yao, Grace; Wu, Kuen-yuh; Chang, Ya-ju

2012-10-01

The increasing availability of robot-assisted therapy (RT), which provides quantifiable, reproducible, interactive, and intensive practice, holds promise for stroke rehabilitation, but data on its dose-response relation are scanty. This study used 2 different intensities of RT to examine the treatment effects of RT and the effect on outcomes of the severity of initial motor deficits. Fifty-four patients with stroke were randomized to a 4-week intervention of higher-intensity RT, lower-intensity RT, or control treatment. The primary outcome, the Fugl-Meyer Assessment, was administered at baseline, midterm, and posttreatment. Secondary outcomes included the Medical Research Council scale, the Motor Activity Log, and the physical domains of the Stroke Impact Scale. The higher-intensity RT group showed significantly greater improvements on the Fugl-Meyer Assessment than the lower-intensity RT and control treatment groups at midterm (P=0.003 and P=0.02) and at posttreatment (P=0.04 and P=0.02). Within-group gains on the secondary outcomes were significant, but the differences among the 3 groups did not reach significance. Recovery rates of the higher-intensity RT group were higher than those of the lower-intensity RT group, particularly on the Fugl-Meyer Assessment. Scatterplots with curve fitting showed that patients with moderate motor deficits gained more improvements than those with severe or mild deficits after the higher-intensity RT. This study demonstrated the higher treatment intensity provided by RT was associated with better motor outcome for patients with stroke, which may shape further stroke rehabilitation. Clinical Trial Registration- URL: http://clinicaltrials.gov. Unique identifier: NCT00917605.

[Stroke in paediatric patients with sickle-cell anaemia].

PubMed

Díaz-Díaz, Judit; Camacho-Salas, Ana; Núñez-Enamorado, Noemí; Carro-Rodríguez, Miguel A; Sánchez-Galán, Victoria; Martínez de Aragón, Ana; Simón-De Las Heras, Rogelio

2014-08-16

Sickle-cell anaemia is the severe homozygotic form of drepanocytosis, a genetic disorder that often occurs among black people and which is characterised by the production of haemoglobin S, chronic hemolytic anaemia and tissue ischaemia due to alterations in blood flow. A quarter of the patients presented neurological manifestations; 8-10% of children will have a stroke. AIM. To analyse the cases of stroke in children with sickle-cell anaemia in our centre. We conducted a retrospective descriptive study of children with sickle-cell anaemia and stroke. Five patients (two Dominicans and three Guineans) with sickle-cell anaemia and stroke; one patient suffered two episodes of stroke. The mean age was 27 months. Five of the episodes were ischaemic infarctions. Stroke was the initial form of presentation of drepanocytosis on three occasions. Two of the strokes occurred within a context of pneumococcal meningitis. Four of the patients had previously reported fever. The initial clinical picture was hemiparesis in four cases. Mean haemoglobin on diagnosing the stroke was 6.5 g/dL. Transcranial ultrasound imaging revealed alterations in three patients and, in all the patients, magnetic resonance imaging revealed lesions, which were bilateral in half the cases. Following the stroke, a hypertransfusion regimen protocol was established and only one patient presented a new stroke. This same patient went on to develop moya-moya disease and was submitted to an indirect revascularisation; the patient progressed well, without presenting any new ischaemic events. Drepanocytosis is a disease that is emerging in our setting as a result of immigration. It should be suspected in cases of paediatric strokes associated to anaemia, above all in black children under the age of five who were not submitted to neonatal screening.

Recovery-related indicators of motor network plasticity according to impairment severity after stroke.

PubMed

Lee, J; Park, E; Lee, A; Chang, W H; Kim, D-S; Kim, Y-H

2017-10-01

Brain connectivity analysis has been widely used to investigate brain plasticity and recovery-related indicators of patients with stroke. However, results remain controversial because of interindividual variability of initial impairment and subsequent recovery of function. In this study, we aimed to investigate the differences in network plasticity and motor recovery-related indicators according to initial severity. We divided participants (16 males and 14 females, aged 54.2 ± 12.0 years) into groups of different severity by Fugl-Mayer Assessment score, i.e. moderate (50-84), severe (20-49) and extremely severe (<20) impairment groups. Longitudinal resting-state functional magnetic resonance imaging data were acquired at 2 weeks and 3 months after onset. The differences in network plasticity and recovery-related indicators between groups were investigated using network distance and graph measurements. As the level of impairment increased, the network balance was more disrupted. Network balance, interhemispheric connectivity and network efficiency were recovered at 3 months only in the moderate impairment group. However, this was not the case in the extremely severe impairment group. A single connection strength between the ipsilesional primary motor cortex and ventral premotor cortex was implicated in the recovery of motor function for the extremely severe impairment group. The connections of the ipsilesional primary motor cortex-ventral premotor cortex were positively associated with motor recovery as the patients were more severely impaired. Differences in plasticity and recovery-related indicators of motor networks were noted according to impairment severity. Our results may suggest meaningful implications for recovery prediction and treatment strategies in future stroke research. © 2017 EAN.

The channel radius and energy of cloud-to-ground lightning discharge plasma with multiple return strokes

DOE Office of Scientific and Technical Information (OSTI.GOV)

Wang, Xuejuan; Yuan, Ping; Cen, Jianyong

2014-03-15

Using the spectra of a cloud-to-ground (CG) lightning flash with multiple return strokes and combining with the synchronous radiated electrical field information, the linear charge density, the channel radius, the energy per unit length, the thermal energy, and the energy of dissociation and ionization in discharge channel are calculated with the aid of an electrodynamic model of lightning. The conclusion that the initial radius of discharge channel is determined by the duration of the discharge current is confirmed. Moreover, the correlativity of several parameters has been analyzed first. The results indicate that the total intensity of spectra is positive correlatedmore » to the channel initial radius. The ionization and thermal energies have a linear relationship, and the dissociation energy is correlated positively to the ionization and thermal energies, the energy per unit length is in direct proportion to the square of initial radius in different strokes of one CG lightning.« less

Early Rehabilitation After Stroke: a Narrative Review

PubMed Central

Moudgal, Rohitha; Lang, Kathryn; Hyacinth, Hyacinth I.; Awosika, Oluwole O.; Kissela, Brett M.; Feng, Wuwei

2018-01-01

Purpose of Review Despite current rehabilitative strategies, stroke remains a leading cause of disability in the USA. There is a window of enhanced neuroplasticity early after stroke, during which the brain’s dynamic response to injury is heightened and rehabilitation might be particularly effective. This review summarizes the evidence of the existence of this plastic window, and the evidence regarding safety and efficacy of early rehabilitative strategies for several stroke domain-specific deficits. Recent Findings Overall, trials of rehabilitation in the first 2 weeks after stroke are scarce. In the realm of very early mobilization, one large and one small trial found potential harm from mobilizing patients within the first 24 h after stroke, and only one small trial found benefit in doing so. For the upper extremity, constraint-induced movement therapy appears to have benefit when started within 2 weeks of stroke. Evidence for non-invasive brain stimulation in the acute period remains scant and inconclusive. For aphasia, the evidence is mixed, but intensive early therapy might be of benefit for patients with severe aphasia. Mirror therapy begun early after stroke shows promise for the alleviation of neglect. Novel approaches to treating dysphagia early after stroke appear promising, but the high rate of spontaneous improvement makes their benefit difficult to gauge. Summary The optimal time to begin rehabilitation after a stroke remains unsettled, though the evidence is mounting that for at least some deficits, initiation of rehabilitative strategies within the first 2 weeks of stroke is beneficial. Commencing intensive therapy in the first 24 h may be harmful. PMID:29116473

Early Rehabilitation After Stroke: a Narrative Review.

PubMed

Coleman, Elisheva R; Moudgal, Rohitha; Lang, Kathryn; Hyacinth, Hyacinth I; Awosika, Oluwole O; Kissela, Brett M; Feng, Wuwei

2017-11-07

Despite current rehabilitative strategies, stroke remains a leading cause of disability in the USA. There is a window of enhanced neuroplasticity early after stroke, during which the brain's dynamic response to injury is heightened and rehabilitation might be particularly effective. This review summarizes the evidence of the existence of this plastic window, and the evidence regarding safety and efficacy of early rehabilitative strategies for several stroke domain-specific deficits. Overall, trials of rehabilitation in the first 2 weeks after stroke are scarce. In the realm of very early mobilization, one large and one small trial found potential harm from mobilizing patients within the first 24 h after stroke, and only one small trial found benefit in doing so. For the upper extremity, constraint-induced movement therapy appears to have benefit when started within 2 weeks of stroke. Evidence for non-invasive brain stimulation in the acute period remains scant and inconclusive. For aphasia, the evidence is mixed, but intensive early therapy might be of benefit for patients with severe aphasia. Mirror therapy begun early after stroke shows promise for the alleviation of neglect. Novel approaches to treating dysphagia early after stroke appear promising, but the high rate of spontaneous improvement makes their benefit difficult to gauge. The optimal time to begin rehabilitation after a stroke remains unsettled, though the evidence is mounting that for at least some deficits, initiation of rehabilitative strategies within the first 2 weeks of stroke is beneficial. Commencing intensive therapy in the first 24 h may be harmful.

Revised and updated recommendations for the establishment of primary stroke centers: a summary statement from the brain attack coalition.

PubMed

Alberts, Mark J; Latchaw, Richard E; Jagoda, Andy; Wechsler, Lawrence R; Crocco, Todd; George, Mary G; Connolly, E S; Mancini, Barbara; Prudhomme, Stephen; Gress, Daryl; Jensen, Mary E; Bass, Robert; Ruff, Robert; Foell, Kathy; Armonda, Rocco A; Emr, Marian; Warren, Margo; Baranski, Jim; Walker, Michael D

2011-09-01

The formation and certification of Primary Stroke Centers has progressed rapidly since the Brain Attack Coalition's original recommendations in 2000. The purpose of this article is to revise and update our recommendations for Primary Stroke Centers to reflect the latest data and experience. We conducted a literature review using MEDLINE and PubMed from March 2000 to January 2011. The review focused on studies that were relevant for acute stroke diagnosis, treatment, and care. Original references as well as meta-analyses and other care guidelines were also reviewed and included if found to be valid and relevant. Levels of evidence were added to reflect current guideline development practices. Based on the literature review and experience at Primary Stroke Centers, the importance of some elements has been further strengthened, and several new areas have been added. These include (1) the importance of acute stroke teams; (2) the importance of Stroke Units with telemetry monitoring; (3) performance of brain imaging with MRI and diffusion-weighted sequences; (4) assessment of cerebral vasculature with MR angiography or CT angiography; (5) cardiac imaging; (6) early initiation of rehabilitation therapies; and (7) certification by an independent body, including a site visit and disease performance measures. Based on the evidence, several elements of Primary Stroke Centers are particularly important for improving the care of patients with an acute stroke. Additional elements focus on imaging of the brain, the cerebral vasculature, and the heart. These new elements may improve the care and outcomes for patients with stroke cared for at a Primary Stroke Center.

Gesture Therapy: A Vision-Based System for Arm Rehabilitation after Stroke

NASA Astrophysics Data System (ADS)

Sucar, L. Enrique; Azcárate, Gildardo; Leder, Ron S.; Reinkensmeyer, David; Hernández, Jorge; Sanchez, Israel; Saucedo, Pedro

Each year millions of people in the world survive a stroke, in the U.S. alone the figure is over 600,000 people per year. Movement impairments after stroke are typically treated with intensive, hands-on physical and occupational therapy for several weeks after the initial injury. However, due to economic pressures, stroke patients are receiving less therapy and going home sooner, so the potential benefit of the therapy is not completely realized. Thus, it is important to develop rehabilitation technology that allows individuals who had suffered a stroke to practice intensive movement training without the expense of an always-present therapist. Current solutions are too expensive, as they require a robotic system for rehabilitation. We have developed a low-cost, computer vision system that allows individuals with stroke to practice arm movement exercises at home or at the clinic, with periodic interactions with a therapist. The system integrates a web based virtual environment for facilitating repetitive movement training, with state-of-the art computer vision algorithms that track the hand of a patient and obtain its 3-D coordinates, using two inexpensive cameras and a conventional personal computer. An initial prototype of the system has been evaluated in a pilot clinical study with promising results.

Factors for short-term outcomes in patients with a minor stroke: results from China National Stroke Registry.

PubMed

Wu, Lingyun; Wang, Anxin; Wang, Xianwei; Zhao, Xingquan; Wang, Chunxue; Liu, Liping; Zheng, Huaguang; Wang, Yongjun; Cao, Yibin; Wang, Yilong

2015-12-09

Stroke recurrence and disability in patients with a minor stroke is one of the most depressing medical situations. In this study, we aimed to identify which factors were associated with adverse outcomes of a minor stroke. The China National Stroke Registry (CNSR) is a nationwide prospective registry for patients presented to hospitals with acute cerebrovascular events between September 2007 and August 2008. The 3-month follow-up was completed in 4669 patients with a minor stroke defined as the initial neurological severity lower than 4 in the National Institutes of Health Stroke Scale (NIHSS). Multivariate model was used to determine the association between risk factors and clinical outcomes. Of 4669 patients with a minor stroke during 3-month follow-up, 459 (9.8 %) patients experienced recurrent stroke, 679 (14.5 %) had stroke disability and 168 (3.6 %) died. Multivariate model identified hypertension, diabetes mellitus, atrial fibrillation, coronary heart disease and previous stroke as independent predictors for the recurrent stroke. Age, diabetes mellitus, atrial fibrillation, previous stroke and time from onset to admission < 24 h were independent predictors for stroke disability. The independent predictors for the all-caused death were age, atrial fibrillation, and coronary heart disease. The short-term risk of poor clinical outcome in Chinese patients with a minor stroke was substantial. Therefore, patients with a minor stroke should be given expeditious assessment and urgent aggressive intervention.

Characteristics of the most intense lightning storm ever recorded at the CN Tower

NASA Astrophysics Data System (ADS)

Hussein, A. M.; Kazazi, S.; Anwar, M.; Yusouf, M.; Liatos, P.

2017-02-01

Lightning strikes to the CN Tower have been optically observed since 1978. In 1990, five independent systems started to operate to simultaneously record parameters of lightning strikes to the tower, including the time derivative of the current, the associated electric and magnetic fields, and the channel optical characteristics. On August 24, 2011, during an unusually severe lightning storm, video records showed that the CN Tower was struck with 52 lightning flashes within 84 min and 6.9 s. Thus, this storm produced, on average, a flash to the tower every 99 s. However, the CN Tower lightning current derivative measurement system only recorded 32 flashes, which were perfectly time-matched with 32 of the 52 video-recorded flashes. It is found that the current derivative measurement system recorded every video-recorded flash that contained at least one return stroke. Based on the analysis of video records, it is noted that each of the storm's 52 flashes contains an initial-stage current, proving that all flashes were upward initiated. This unique CN Tower storm - the most intense ever recorded at the tower - is here thoroughly analyzed, based on video and current records. The inter-flash time within the storm is found to vary between 10.6 s and 274 s, with an overall average of 98 s. It is also found that the inter-flash time between successive non-return-stroke flashes is on average 64% longer than that for successive flashes containing return strokes. Statistical analysis of video and current data clearly reveals that the time duration of flashes containing initial-stage currents and return strokes is on average 27% longer than that of flashes that only have initial-stage currents. Furthermore, it is important to note that the time duration of the initial-stage current in flashes containing no return strokes is on average 76% longer than that in flashes containing return strokes. Therefore, it is possible to conclude that if the time duration of the initial-stage current in a flash is long enough, resulting in large charge transfer, then there is less probability of having return strokes following it. The 32 current-recorded flashes contain a total of 156 return strokes, with an average multiplicity of 4.875. It is worth mentioning that during one decade, 1992-2001, the CN Tower current derivative measurement system only recorded 478 return strokes, demonstrating that the number of return strokes recorded at the tower within about 84 min is close to one third of those recorded at the tower during one decade. This finding clearly shows the great value and rarity of the presented extensive lightning current derivative data. Only one of the 32 current-recorded flashes is proved to be positive with a single return stroke. Based on current records, out of a total of 124 inter-stroke time intervals, 94% are found to be within 200 ms, with an overall inter-stroke time average of 68.1 ms. The maximum inter-stroke time recorded during this storm is 726.3 ms, the longest ever recorded at the CN Tower.

Fatigue after stroke: the development and evaluation of a case definition.

PubMed

Lynch, Joanna; Mead, Gillian; Greig, Carolyn; Young, Archie; Lewis, Susan; Sharpe, Michael

2007-11-01

While fatigue after stroke is a common problem, it has no generally accepted definition. Our aim was to develop a case definition for post-stroke fatigue and to test its psychometric properties. A case definition with face validity and an associated structured interview was constructed. After initial piloting, the feasibility, reliability (test-retest and inter-rater) and concurrent validity (in relation to four fatigue severity scales) were determined in 55 patients with stroke. All participating patients provided satisfactory answers to all the case definition probe questions demonstrating its feasibility For test-retest reliability, kappa was 0.78 (95% CI, 0.57-0.94, P<.01) and for inter-rater reliability kappa was 0.80 (95% CI, 0.62-0.99, P<.01). Patients fulfilling the case definition also had substantially higher fatigue scores on four fatigue severity scales (P<.001) indicating concurrent validity. The proposed case definition is feasible to administer and reliable in practice, and there is evidence of concurrent validity. It requires further evaluation in different settings.

Anomalous Lightning Behavior During the 26-27 August 2007 Northern Great Plains Severe Weather Event

NASA Astrophysics Data System (ADS)

Logan, Timothy

2018-02-01

Positive polarity lightning strokes can be useful indicators of thunderstorm behavior. A combination of National Lightning Detection Network and Next Generation Radar retrievals is used to analyze the anomalous positive cloud-to-ground (CG) lightning behavior of a rare, late summer severe weather event that occurred on 26-27 August 2007 in the Northern Great Plains region of the United States and southern Canada. Seven discrete supercells (SC1-SC7) exhibiting frequent and intense lightning were responsible for numerous reports of severe weather (e.g., severe hail and 16 tornadoes) including catastrophic damage to the town of Northwood, North Dakota, caused by SC2. Biomass burning smoke from wildfires in Idaho and Montana was present prior to convective initiation. A positive CG lightning stroke rate of nearly 30 strokes per minute was observed 10 min before the EF4 tornado struck Northwood. SC2 was also responsible for all the reports of tornadoes exceeding an EF2 rating. The strongest peak currents (>200 kA) were observed in SC1-SC4 with SC2 having a maximum value of 280 kA. SC2 dominated the statistics of the line of supercells accounting for 27% of all CG lightning strokes. Positive CG lightning accounted for over 40% of all CG lightning strokes in SC4-SC7 on average, and the maximum exceeded 90% in SC6 and SC7. Increasing positive CG lightning dominance was correlated with an increasing northward gradient of smoke aerosol loading in addition to severe weather being reported before the maximum in positive CG lighting stroke rate (SC5 and SC6). This suggests that a complex combination of synoptic forcing and aerosol perturbation likely led to the observed anomalous positive CG lightning behavior in the supercells.

The complexity of atrial fibrillation newly diagnosed after ischemic stroke and transient ischemic attack: advances and uncertainties

PubMed Central

Cerasuolo, Joshua O.; Cipriano, Lauren E.; Sposato, Luciano A.

2017-01-01

Purpose of review Atrial fibrillation is being increasingly diagnosed after ischemic stroke and transient ischemic attack (TIA). Patient characteristics, frequency and duration of paroxysms, and the risk of recurrent ischemic stroke associated with atrial fibrillation detected after stroke and TIA (AFDAS) may differ from atrial fibrillation already known before stroke occurrence. We aim to summarize major recent advances in the field, in the context of prior evidence, and to identify areas of uncertainty to be addressed in future research. Recent findings Half of all atrial fibrillations in ischemic stroke and TIA patients are AFDAS, and most of them are asymptomatic. Over 50% of AFDAS paroxysms last less than 30 s. The rapid initiation of cardiac monitoring and its duration are crucial for its timely and effective detection. AFDAS comprises a heterogeneous mix of atrial fibrillation, possibly including cardiogenic and neurogenic types, and a mix of both. Over 25 single markers and at least 10 scores have been proposed as predictors of AFDAS. However, there are considerable inconsistencies across studies. The role of AFDAS burden and its associated risk of stroke recurrence have not yet been investigated. Summary AFDAS may differ from atrial fibrillation known before stroke in several clinical dimensions, which are important for optimal patient care strategies. Many questions remain unanswered. Neurogenic and cardiogenic AFDAS need to be characterized, as it may be possible to avoid some neurogenic cases by initiating timely preventive treatments. AFDAS burden may differ in ischemic stroke and TIA patients, with distinctive diagnostic and treatment implications. The prognosis of AFDAS and its risk of recurrent stroke are still unknown; therefore, it is uncertain whether AFDAS patients should be treated with oral anticoagulants. PMID:27984303

Circulating Mesenchymal Stem Cells Microparticles in Patients with Cerebrovascular Disease

PubMed Central

Cho, Yeon Hee; Kang, Ho Young; Hyung, Na Kyum; Kim, Donghee; Lee, Ji Hyun; Nam, Ji Yoon; Bang, Oh Young

2012-01-01

Preclinical and clinical studies have shown that the application of CD105+ mesenchymal stem cells (MSCs) is feasible and may lead to recovery after stroke. In addition, circulating microparticles are reportedly functional in various disease conditions. We tested the levels of circulating CD105+ microparticles in patients with acute ischemic stroke. The expression of CD105 (a surface marker of MSCs) and CXCR4 (a CXC chemokine receptor for MSC homing) on circulating microparticles was evaluated by flow cytometry of samples from 111 patients and 50 healthy subjects. The percentage of apoptotic CD105 microparticles was determined based on annexin V (AV) expression. The relationship between serum levels of CD105+/AV− microparticles, stromal cells derived factor-1α (SDF-1α), and the extensiveness of cerebral infarcts was also evaluated. CD105+/AV− microparticles were higher in stroke patients than control subjects. Correlation analysis showed that the levels of CD105+/AV− microparticles increased as the baseline stroke severity increased. Multivariate testing showed that the initial severity of stroke was independently associated with circulating CD105+/AV− microparticles (OR, 1.103 for 1 point increase in the NIHSS score on admission; 95% CI, 1.032–1.178) after adjusting for other variables. The levels of CD105+/CXCR4+/AV− microparticles were also increased in patients with severe disability (r = 0.192, p = 0.046 for NIHSS score on admission), but were decreased with time after stroke onset (r = −0.204, p = 0.036). Risk factor profiles were not associated with the levels of circulating microparticles or SDF-1α. In conclusion, our data showed that stroke triggers the mobilization of MSC-derived microparticles, especially in patients with extensive ischemic stroke. PMID:22615882

[Mobile stroke unit for prehospital stroke treatment].

PubMed

Walter, S; Grunwald, I Q; Fassbender, K

2016-01-01

The management of acute stroke patients suffers from several major problems in the daily clinical routine. In order to achieve optimal treatment a complex diagnostic work-up and rapid initiation of therapy are necessary; however, most patients arrive at hospital too late for any type of acute stroke treatment, although all forms of treatment are highly time-dependent according to the generally accepted "time is brain" concept. Recently, two randomized clinical trials demonstrated the feasibility of prehospital stroke diagnostic work-up and treatment. This was accomplished by use of a specialized ambulance, equipped with computed tomography for multimodal imaging and a point-of-care laboratory system. In both trials the results demonstrated a clear superiority of the prehospital treatment group with a significant reduction of treatment times, significantly increased number of patients treated within the first 60 min after symptom onset and an optimized triage to the correct target hospital. Currently, mobile stroke units are in operation in various countries and should lead to an improvement in stroke treatment; nevertheless, intensive research is still needed to analyze the best framework settings for prehospital stroke management.

Early Recurrence and Cerebral Bleeding in Patients With Acute Ischemic Stroke and Atrial Fibrillation: Effect of Anticoagulation and Its Timing: The RAF Study.

PubMed

Paciaroni, Maurizio; Agnelli, Giancarlo; Falocci, Nicola; Caso, Valeria; Becattini, Cecilia; Marcheselli, Simona; Rueckert, Christina; Pezzini, Alessandro; Poli, Loris; Padovani, Alessandro; Csiba, Laszló; Szabó, Lilla; Sohn, Sung-Il; Tassinari, Tiziana; Abdul-Rahim, Azmil H; Michel, Patrik; Cordier, Maria; Vanacker, Peter; Remillard, Suzette; Alberti, Andrea; Venti, Michele; Scoditti, Umberto; Denti, Licia; Orlandi, Giovanni; Chiti, Alberto; Gialdini, Gino; Bovi, Paolo; Carletti, Monica; Rigatelli, Alberto; Putaala, Jukka; Tatlisumak, Turgut; Masotti, Luca; Lorenzini, Gianni; Tassi, Rossana; Guideri, Francesca; Martini, Giuseppe; Tsivgoulis, Georgios; Vadikolias, Kostantinos; Liantinioti, Chrissoula; Corea, Francesco; Del Sette, Massimo; Ageno, Walter; De Lodovici, Maria Luisa; Bono, Giorgio; Baldi, Antonio; D'Anna, Sebastiano; Sacco, Simona; Carolei, Antonio; Tiseo, Cindy; Acciarresi, Monica; D'Amore, Cataldo; Imberti, Davide; Zabzuni, Dorjan; Doronin, Boris; Volodina, Vera; Consoli, Domenico; Galati, Franco; Pieroni, Alessio; Toni, Danilo; Monaco, Serena; Baronello, Mario Maimone; Barlinn, Kristian; Pallesen, Lars-Peder; Kepplinger, Jessica; Bodechtel, Ulf; Gerber, Johannes; Deleu, Dirk; Melikyan, Gayane; Ibrahim, Faisal; Akhtar, Naveed; Mosconi, Maria Giulia; Bubba, Valentina; Silvestri, Ilenia; Lees, Kennedy R

2015-08-01

The best time for administering anticoagulation therapy in acute cardioembolic stroke remains unclear. This prospective cohort study of patients with acute stroke and atrial fibrillation, evaluated (1) the risk of recurrent ischemic event and severe bleeding; (2) the risk factors for recurrence and bleeding; and (3) the risks of recurrence and bleeding associated with anticoagulant therapy and its starting time after the acute stroke. The primary outcome of this multicenter study was the composite of stroke, transient ischemic attack, symptomatic systemic embolism, symptomatic cerebral bleeding and major extracranial bleeding within 90 days from acute stroke. Of the 1029 patients enrolled, 123 had 128 events (12.6%): 77 (7.6%) ischemic stroke or transient ischemic attack or systemic embolism, 37 (3.6%) symptomatic cerebral bleeding, and 14 (1.4%) major extracranial bleeding. At 90 days, 50% of the patients were either deceased or disabled (modified Rankin score ≥3), and 10.9% were deceased. High CHA2DS2-VASc score, high National Institutes of Health Stroke Scale, large ischemic lesion and type of anticoagulant were predictive factors for primary study outcome. At adjusted Cox regression analysis, initiating anticoagulants 4 to 14 days from stroke onset was associated with a significant reduction in primary study outcome, compared with initiating treatment before 4 or after 14 days: hazard ratio 0.53 (95% confidence interval 0.30-0.93). About 7% of the patients treated with oral anticoagulants alone had an outcome event compared with 16.8% and 12.3% of the patients treated with low molecular weight heparins alone or followed by oral anticoagulants, respectively (P=0.003). Acute stroke in atrial fibrillation patients is associated with high rates of ischemic recurrence and major bleeding at 90 days. This study has observed that high CHA2DS2-VASc score, high National Institutes of Health Stroke Scale, large ischemic lesions, and type of anticoagulant administered each independently led to a greater risk of recurrence and bleedings. Also, data showed that the best time for initiating anticoagulation treatment for secondary stroke prevention is 4 to 14 days from stroke onset. Moreover, patients treated with oral anticoagulants alone had better outcomes compared with patients treated with low molecular weight heparins alone or before oral anticoagulants. © 2015 American Heart Association, Inc.

Impact of MCA stenosis on the early outcome in acute ischemic stroke patients

PubMed Central

Jeng, Jiann-Shing; Hsieh, Fang-I; Yeh, Hsu-Ling; Chen, Wei-Hung; Chiu, Hou-Chang; Tang, Sung-Chun; Liu, Chung-Hsiang; Lin, Huey-Juan; Hsu, Shih-Pin; Lo, Yuk-Keung; Chan, Lung; Chen, Chih-Hung; Lin, Ruey-Tay; Chen, Yu-Wei; Lee, Jiunn-Tay; Yeh, Chung-Hsin; Sun, Ming-Hui; Lai, Ta-Chang; Sun, Yu; Sun, Mu-Chien; Chen, Po-Lin; Chiang, Tsuey-Ru; Lin, Shinn-Kuang; Yip, Bak-Sau; Chen, Chin-I; Bai, Chi-Huey; Chen, Sien-Tsong; Chiou, Hung-Yi; Lien, Li-Ming; Hsu, Chung Y.

2017-01-01

Background Asians have higher frequency of intracranial arterial stenosis. The present study aimed to compare the clinical features and outcomes of ischemic stroke patients with and without middle cerebral artery (MCA) stenosis, assessed by transcranial sonography (TCS), based on the Taiwan Stroke Registry (TSR). Methods Patients with acute ischemic stroke or transient ischemic attack registered in the TSR, and received both carotid duplex and TCS assessment were categorized into those with stenosis (≥50%) and without (<50%) in the extracranial internal carotid artery (ICA) and MCA, respectively. Logistic regression analysis, Kaplan-Meier method and Cox proportional hazard model were applied to assess relevant variables between groups. Results Of 6003 patients, 23.3% had MCA stenosis, 10.1% ICA stenosis, and 3.9% both MCA and ICA stenosis. Patients with MCA stenosis had greater initial NIHSS, higher likelihood of stroke-in-evolution, and more severe disability than those without (all p<0.001). Patients with MCA stenosis had higher prevalence of hypertension, diabetes and hypercholesterolemia. Patients with combined MCA and extracranial ICA stenosis had even higher NIHSS, worse functional outcome, higher risk of stroke recurrence or death (hazard ratio, 2.204; 95% confidence intervals, 1.440–3.374; p<0.001) at 3 months after stroke than those without MCA stenosis. Conclusions In conclusion, MCA stenosis was more prevalent than extracranial ICA stenosis in ischemic stroke patients in Taiwan. Patients with MCA stenosis, especially combined extracranial ICA stenosis, had more severe neurological deficit and worse outcome. PMID:28388675

Postmenopausal hormone therapy and risk of stroke: A pooled analysis of data from population-based cohort studies

PubMed Central

Carrasquilla, Germán D.; Frumento, Paolo; Berglund, Anita; Borgfeldt, Christer; Bottai, Matteo; Chiavenna, Chiara; Eliasson, Mats; Engström, Gunnar; Hallmans, Göran; Jansson, Jan-Håkan; Nilsson, Peter M.; Pedersen, Nancy L.

2017-01-01

Background Recent research indicates a favourable influence of postmenopausal hormone therapy (HT) if initiated early, but not late, on subclinical atherosclerosis. However, the clinical relevance of timing of HT initiation for hard end points such as stroke remains to be determined. Further, no previous research has considered the timing of initiation of HT in relation to haemorrhagic stroke risk. The importance of the route of administration, type, active ingredient, and duration of HT for stroke risk is also unclear. We aimed to assess the association between HT and risk of stroke, considering the timing of initiation, route of administration, type, active ingredient, and duration of HT. Methods and findings Data on HT use reported by the participants in 5 population-based Swedish cohort studies, with baseline investigations performed during the period 1987–2002, were combined in this observational study. In total, 88,914 postmenopausal women who reported data on HT use and had no previous cardiovascular disease diagnosis were included. Incident events of stroke (ischaemic, haemorrhagic, or unspecified) and haemorrhagic stroke were identified from national population registers. Laplace regression was employed to assess crude and multivariable-adjusted associations between HT and stroke risk by estimating percentile differences (PDs) with 95% confidence intervals (CIs). The fifth and first PDs were calculated for stroke and haemorrhagic stroke, respectively. Crude models were adjusted for age at baseline only. The final adjusted models included age at baseline, level of education, smoking status, body mass index, level of physical activity, and age at menopause onset. Additional variables evaluated for potential confounding were type of menopause, parity, use of oral contraceptives, alcohol consumption, hypertension, dyslipidaemia, diabetes, family history of cardiovascular disease, and cohort. During a median follow-up of 14.3 years, 6,371 first-time stroke events were recorded; of these, 1,080 were haemorrhagic. Following multivariable adjustment, early initiation (<5 years since menopause onset) of HT was associated with a longer stroke-free period than never use (fifth PD, 1.00 years; 95% CI 0.42 to 1.57), but there was no significant extension to the time period free of haemorrhagic stroke (first PD, 1.52 years; 95% CI −0.32 to 3.37). When considering timing as a continuous variable, the stroke-free and the haemorrhagic stroke-free periods were maximal if HT was initiated approximately 0–5 years from the onset of menopause. If single conjugated equine oestrogen HT was used, late initiation of HT was associated with a shorter stroke-free (fifth PD, −4.41 years; 95% CI −7.14 to −1.68) and haemorrhagic stroke-free (first PD, −9.51 years; 95% CI −12.77 to −6.24) period than never use. Combined HT when initiated late was significantly associated with a shorter haemorrhagic stroke-free period (first PD, −1.97 years; 95% CI −3.81 to −0.13), but not with a shorter stroke-free period (fifth PD, −1.21 years; 95% CI −3.11 to 0.68) than never use. Given the observational nature of this study, the possibility of uncontrolled confounding cannot be excluded. Further, immortal time bias, also related to the observational design, cannot be ruled out. Conclusions When initiated early in relation to menopause onset, HT was not associated with increased risk of incident stroke, regardless of the route of administration, type of HT, active ingredient, and duration. Generally, these findings held also for haemorrhagic stroke. Our results suggest that the initiation of HT 0–5 years after menopause onset, as compared to never use, is associated with a decreased risk of stroke and haemorrhagic stroke. Late initiation was associated with elevated risks of stroke and haemorrhagic stroke when conjugated equine oestrogen was used as single therapy. Late initiation of combined HT was associated with haemorrhagic stroke risk. PMID:29149179

Circulating brain derived neurotrophic factor (BDNF) and frequency of BDNF positive T cells in peripheral blood in human ischemic stroke: Effect on outcome.

PubMed

Chan, Adeline; Yan, Jun; Csurhes, Peter; Greer, Judith; McCombe, Pamela

2015-09-15

The aim of this study was to measure the levels of circulating BDNF and the frequency of BDNF-producing T cells after acute ischaemic stroke. Serum BDNF levels were measured by ELISA. Flow cytometry was used to enumerate peripheral blood leukocytes that were labelled with antibodies against markers of T cells, T regulatory cells (Tregs), and intracellular BDNF. There was a slight increase in serum BDNF levels after stroke. There was no overall difference between stroke patients and controls in the frequency of CD4(+) and CD8(+) BDNF(+) cells, although a subgroup of stroke patients showed high frequencies of these cells. However, there was an increase in the percentage of BDNF(+) Treg cells in the CD4(+) population in stroke patients compared to controls. Patients with high percentages of CD4(+) BDNF(+) Treg cells had a better outcome at 6months than those with lower levels. These groups did not differ in age, gender or initial stroke severity. Enhancement of BDNF production after stroke could be a useful means of improving neuroprotection and recovery after stroke. Copyright © 2015 Elsevier B.V. All rights reserved.

Paramedic Initiated Lisinopril For Acute Stroke Treatment (PIL-FAST): results from the pilot randomised controlled trial

PubMed Central

Shaw, Lisa; Price, Christopher; McLure, Sally; Howel, Denise; McColl, Elaine; Younger, Paul; Ford, Gary A

2014-01-01

Background High blood pressure (BP) during acute stroke is associated with poorer stroke outcome. Trials of treatments to lower BP have not resulted in improved outcome, but this may be because treatment commenced too late. Emergency medical service staff (paramedics) are uniquely placed to administer early treatment; however, experience of prehospital randomised controlled trials (RCTs) is very limited. Methods We conducted a pilot RCT to determine the feasibility of a definitive prehospital BP-lowering RCT in acute stroke. Paramedics were trained to identify, consent and deliver a first dose of lisinopril or placebo to adults with suspected stroke and hypertension while responding to the emergency call. Further treatment continued in hospital. Study eligibility, recruitment rate, completeness of receipt of study medication and clinical data (eg, BP) were collected to inform the design of a definitive RCT. Results In 14 months, 14 participants (median age=73 years, median National Institute of Health Stroke Scale=4) were recruited and received the prehospital dose of medication. Median time from stroke onset (as assessed by paramedic) to treatment was 70 min. Four participants completed 7 days of study treatment. Of ambulance transported suspected stroke patients, 1% were both study eligible and attended by a PIL-FAST paramedic. Conclusions It is possible to conduct a paramedic initiated double-blind RCT of a treatment for acute stroke. However, to perform a definitive RCT in a reasonable timescale, a large number of trained paramedics across several ambulance services would be needed to recruit the number of patients likely to be required. Clinical trial registration http://www.clinicaltrials.gov. Unique identifier: NCT01066572. PMID:24078198

Potential determinants of efficacy of mirror therapy in stroke patients--A pilot study.

PubMed

Brunetti, Maddalena; Morkisch, Nadine; Fritzsch, Claire; Mehnert, Jan; Steinbrink, Jens; Niedeggen, Michael; Dohle, Christian

2015-01-01

Mirror therapy (MT) was found to improve motor function after stroke. However, there is high variability between patients regarding motor recovery. The following pilot study was designed to identify potential factors determining this variability between patients with severe upper limb paresis, receiving MT. Eleven sub-acute stroke patients with severe upper limb paresis participated, receiving in-patient rehabilitation. After a set of pre-assessments (including measurement of brain activity at the primary motor cortex and precuneus during the mirror illusion, using near-infrared spectroscopy as described previously), four weeks of MT were applied, followed by a set of post-assessments. Discriminant group analysis for MT responders and non-responders was performed. Six out of eleven patients were defined as responders and five as non-responders on the basis of their functional motor improvement. The initial motor function and the activity shift in both precunei (mirror index) were found to discriminate significantly between responders and non-responders. In line with earlier results, initial motor function was confirmed as crucial determinant of motor recovery. Additionally, activity response to the mirror illusion in both precunei was found to be a candidate for determination of the efficacy of MT.

Effects of Transferring to the Rehabilitation Ward on Long-Term Mortality Rate of First-Time Stroke Survivors: A Population-Based Study.

PubMed

Chen, Chien-Min; Yang, Yao-Hsu; Chang, Chia-Hao; Chen, Pau-Chung

2017-12-01

To assess the long-term health outcomes of acute stroke survivors transferred to the rehabilitation ward. Long-term mortality rates of first-time stroke survivors during hospitalization were compared among the following sets of patients: patients transferred to the rehabilitation ward, patients receiving rehabilitation without being transferred to the rehabilitation ward, and patients receiving no rehabilitation. Retrospective cohort study. Patients (N = 11,419) with stroke from 2005 to 2008 were initially assessed for eligibility. After propensity score matching, 390 first-time stroke survivors were included. None. Cox proportional hazards regression model was used to assess differences in 5-year poststroke mortality rates. Based on adjusted hazard ratios (HRs), the patients receiving rehabilitation without being transferred to the rehabilitation ward (adjusted HR, 2.20; 95% confidence interval [CI], 1.36-3.57) and patients receiving no rehabilitation (adjusted HR, 4.00; 95% CI, 2.55-6.27) had significantly higher mortality risk than the patients transferred to the rehabilitation ward. Mortality rate of the stroke survivors was affected by age ≥65 years (compared with age <45y; adjusted HR, 3.62), being a man (adjusted HR, 1.49), having ischemic stroke (adjusted HR, 1.55), stroke severity (Stroke Severity Index [SSI] score≥20, compared with SSI score<10; adjusted HR, 2.68), and comorbidity (Charlson-Deyo Comorbidity Index [CCI] score≥3, compared with CCI score=0; adjusted HR, 4.23). First-time stroke survivors transferred to the rehabilitation ward had a 5-year mortality rate 2.2 times lower than those who received rehabilitation without transfer to the rehabilitation ward and 4 times lower than those who received no rehabilitation. Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.

Developments in mechanical thrombectomy devices for the treatment of acute ischemic stroke.

PubMed

Mordasini, Pasquale; Gralla, Jan

2016-01-01

Several recent prospective randomized controlled trials of endovascular stroke therapy using latest generation thrombectomy devices, so called stent-retrievers, have shown significantly improved clinical outcome compared to the standard treatment with intra-venous thrombolysis using r-tPA alone. Despite some differences in inclusion criteria between these studies, all required non-invasive vessel imaging to proof occlusion of a major brain supplying vessel. Furthermore, in most studies additional imaging techniques were used to exclude patients with already established large cerebral infarction or unfavorable collateral or penumbral status. Patients with small infarct volume, severe neurological deficits and in whom thrombectomy can be initiated within the first 6 hours after symptom onset seem to benefit the most. Therefore, mechanical thrombectomy using stent-retrievers in addition to intra-venous thrombolysis is recommended for the treatment of acute ischemic stroke with proven major vessel occlusion in the anterior circulation.

Family history of stroke and severity of neurologic deficit after stroke

PubMed Central

Case, L.D.; Worrall, B.B.; Brown, R.D.; Brott, T.G.; Frankel, M.; Silliman, S.; Rich, S.S.

2008-01-01

Background A family history of stroke is an independent risk factor for stroke. Objective To assess whether severity of neurologic deficit after stroke is associated with a family history of stroke. Methods The Ischemic Stroke Genetics Study, a five-center study of first-ever symptomatic ischemic stroke, assessed case subjects prospectively for a family history of stroke-affected first-degree relatives. Certified adjudicators used the NIH Stroke Scale (NIHSS) to determine the severity of neurologic deficit. Results A total of 505 case subjects were enrolled (median age, 65 years; 55% male), with 81% enrolled within 1 week of onset of symptoms. A sibling history of stroke was associated with more severe stroke. The odds of an NIHSS score of 5 or higher were 2.0 times greater for cases with a sibling history of stroke compared with cases with no sibling history (95% CI, 1.0 to 3.9). An association of family history of stroke in parents or children with stroke severity was not detected. Conclusions A sibling history of stroke increased the likelihood of a more severe stroke in the case subjects, independent of age, sex, and other potential confounding factors. Other family history characteristics were not associated with stroke severity. PMID:17060565

[Evidence-based rehabilitation of mobility after stroke].

PubMed

Dohle, C; Tholen, R; Wittenberg, H; Quintern, J; Saal, S; Stephan, K M

2016-10-01

Approximately two thirds of stroke patients initially suffer from at least impaired mobility. Various rehabilitation concepts have been proposed. Based on the current literature, which rehabilitation methods can be recommended for improvement of gait, gait velocity, gait distance and balance? A systematic literature search was carried out for randomized clinical studies and reviews with clinically relevant outcome variables. Formulation of recommendations, separated for target variables and time after stroke. Restoration and improvement of gait function relies on a high number of repetitions of gait movements, which for more severely affected patients is preferentially machine-based. For improvement of gait velocity for less severely affected patients intensive gait training does not necessarily rely on mechanical support. Gait distance can be improved by aerobic endurance exercises with a cardiovascular effect, which have to be performed in a functional context. Improvement of balance should be achieved by intensive functional gait training. Additional stimulation techniques are only effective when included in a functionally relevant training program. These guidelines not only provide recommendations for action but also provide pathophysiological insights into functional restoration of stance and gait after stroke.

Feasibility of certified quality management in a comprehensive stroke care network using telemedicine: STENO project.

PubMed

Handschu, René; Scibor, Mateusz; Wacker, Angela; Stark, David R; Köhrmann, Martin; Erbguth, Frank; Oschmann, Patrick; Schwab, Stefan; Marquardt, Lars

2014-12-01

Stroke care networks with and without telemedicine have been established in several countries over the last decade to provide specialized stroke expertise to patients in rural areas. Acute consultation is a first step in the management of stroke, but not the only one. Methods of standardization of care and treatment are much needed. So far, quality management systems have only been used for single stroke units. To the best of our knowledge, we are the first stroke network worldwide to aim for certification of a network-wide quality management system. The Stroke Network Using Telemedicine in Northern Bavaria (STENO), currently with 20 associated medical institutions, is one of the world's largest stroke networks, caring for over 5000 stroke patients each year. In 2010, we initiated the implementation of a network-wide 'total' quality management system according to ISO standard 9001:2008 in cooperation with the German Stroke Society and a third-party certification organization (LGA InterCert). Certification according to ISO 9001:2008 was awarded in March 2011 and maintained over a complete certification cycle of 3 years without major deviation from the norm in three external third-party audits. Thrombolysis rate significantly increased from 8·2% (2009) to 12·8% (2012). Certified quality management within a large stroke network using telemedicine is possible and might improve stroke care procedures and thrombolysis rates. Outcome studies comparing conventional stroke care and telestroke care are inevitable. © 2014 World Stroke Organization.

Determining Polarities Of Distant Lightning Strokes

NASA Technical Reports Server (NTRS)

Blakeslee, Richard J.; Brook, Marx

1990-01-01

Method for determining polarities of lightning strokes more than 400 km away. Two features of signal from each stroke correlated. New method based on fact each stroke observed thus far for which polarity determined unambiguously, initial polarity of tail same as polarity of initial deflection before initial-deflection signal altered by propagation effects. Receiving station equipped with electric-field-change antenna coupled to charge amplifier having time constant of order of 1 to 10 seconds. Output of amplifier fed to signal-processing circuitry, which determines initial polarity of tail.

Factors Associated With Gastrostomy Tube Removal in Patients With Dysphagia After Stroke.

PubMed

Wilmskoetter, Janina; Herbert, Teri Lynn; Bonilha, Heather S

2017-04-01

Gastrostomy feeding tubes are commonly placed in patients with dysphagia after stroke. The subsequent removal of the tube is a primary goal during rehabilitation. The purpose of our review was to identify predictors and factors associated with gastrostomy tube removal in patients with dysphagia after stroke. We conducted a literature review following the PRISMA statement and included the search databases PubMed, Scopus, Web of Science, and CINAHL. Articles were included in the final analysis per predefined inclusion and exclusion criteria. Our search retrieved a total of 853 results consisting of 416 articles (after eliminating duplicates). Six articles met our final eligibility criteria. The following factors were identified in at least 1 article as being significantly associated with gastrostomy tube removal: reduced age, decreased number of comorbidities, prolonged inpatient rehabilitation stay, absence of bilateral stroke, nonhemorrhagic stroke, reduced dysphagia severity, absence of aspiration, absence of premature bolus loss, and timely initiation of pharyngeal swallow. Aspiration was the only factor that was investigated by 2 studies-both using multiple regression and both showing stable results, with absence of aspiration increasing the chances for tube removal. In conclusion, little is known about factors associated with gastrostomy tube removal in patients with dysphagia after stroke. Most of the identified factors are associated with stroke or disease severity; however, the role of the individual factors remains unclear. The strongest predictor appears to be absence of aspiration on modified barium swallow studies emphasizing the importance of instrumental swallow studies in this patient population.

Overcoming Practical Challenges to Conducting Clinical Research in the Inpatient Stroke Rehabilitation Setting

PubMed Central

Campbell, Grace B.; Skidmore, Elizabeth R.; Whyte, Ellen M.; Matthews, Judith T.

2015-01-01

There is a shortage of published empirical studies conducted in acute inpatient stroke rehabilitation, though such studies are greatly needed in order to shed light on the most efficacious inpatient stroke rehabilitation interventions. The inherent challenges of inpatient research may dissuade researchers from undertaking this important work. This paper describes our institution’s experience devising practical solutions to research barriers in this setting. Our efforts facilitated five simultaneous inpatient stroke rehabilitation studies, and led to several benefits, including increased effectiveness of research participant identification and enrollment, novel collaborative projects, innovative clinical care initiatives, and enhanced emotional and practical support for patients and their families. We provide recommendations based on lessons learned during our experience, and discuss benefits of this collaboration for our research participants, clinical staff, and the research team. PMID:25775955

Spinal Cord Infarction in Clinical Neurology: A Review of Characteristics and Long-Term Prognosis in Comparison to Cerebral Infarction.

PubMed

Romi, Fredrik; Naess, Halvor

2016-01-01

Spinal cord stroke is rare accounting for 0.3-1% of all strokes and is classified into upper (cervical) and lower (thoracolumbar) strokes. Patients present with severe deficits but later often show good functional improvement. On admission, younger age, male gender, hypertension, diabetes mellitus and elevated blood glucose indicate more severe spinal cord strokes. Treatment of these risk factors is essential in the acute phase. Biphasic spinal cord strokes are seen in one-fifth of the patients. These present with acute or transient sensory spinal cord deficits often preceded by radiating pain between the shoulders, and should be considered and treated as imminent spinal cord strokes. Spinal cord infarction patients are younger and more often women compared to cerebral infarction patients. Traditional cerebrovascular risk factors are less relevant in spinal cord infarction. Spinal cord infarction patients are more likely to be discharged home and show better improvement after initial treatment compared to cerebral infarction patients. On long-term follow-up, spinal cord infarction patients have lower mortality and higher emotional well-being scores than cerebral infarction patients. Despite more chronic pain, the frequency of re-employment is higher among spinal cord infarction patients compared to cerebral infarction patients who are more often afflicted with cognitive function deficits. © 2016 S. Karger AG, Basel.

Randomized trial of transcranial direct current stimulation for poststroke dysphagia.

PubMed

Suntrup-Krueger, Sonja; Ringmaier, Corinna; Muhle, Paul; Wollbrink, Andreas; Kemmling, Andre; Hanning, Uta; Claus, Inga; Warnecke, Tobias; Teismann, Inga; Pantev, Christo; Dziewas, Rainer

2018-02-01

We evaluated whether transcranial direct current stimulation (tDCS) is able to enhance dysphagia rehabilitation following stroke. Besides relating clinical effects with neuroplastic changes in cortical swallowing processing, we aimed to identify factors influencing treatment success. In this double-blind, randomized study, 60 acute dysphagic stroke patients received contralesional anodal (1mA, 20 minutes) or sham tDCS on 4 consecutive days. Swallowing function was thoroughly assessed before and after the intervention using the validated Fiberoptic Endoscopic Dysphagia Severity Scale (FEDSS) and clinical assessment. In 10 patients, swallowing-related brain activation was recorded applying magnetoencephalography before and after the intervention. Voxel-based statistical lesion pattern analysis was also performed. Study groups did not differ according to demographic data, stroke characteristics, or baseline dysphagia severity. Patients treated with tDCS showed greater improvement in FEDSS than the sham group (1.3 vs 0.4 points, mean difference = 0.9, 95% confidence interval [CI] = 0.4-1.4, p < 0.0005). Functional recovery was accompanied by a significant increase of activation (p < 0.05) in the contralesional swallowing network after real but not sham tDCS. Regarding predictors of treatment success, for every hour earlier that treatment was initiated, there was greater improvement on the FEDSS (adjusted odds ratio = 0.99, 95% CI = 0.98-1.00, p < 0.05) in multivariate analysis. Stroke location in the right insula and operculum was indicative of worse response to tDCS (p < 0.05). Application of tDCS over the contralesional swallowing motor cortex supports swallowing network reorganization, thereby leading to faster rehabilitation of acute poststroke dysphagia. Early treatment initiation seems beneficial. tDCS may be less effective in right-hemispheric insulo-opercular stroke. Ann Neurol 2018;83:328-340. © 2018 American Neurological Association.

Do Women With Atrial Fibrillation Experience More Severe Strokes? Results From the Austrian Stroke Unit Registry.

PubMed

Lang, Clemens; Seyfang, Leonhard; Ferrari, Julia; Gattringer, Thomas; Greisenegger, Stefan; Willeit, Karin; Toell, Thomas; Krebs, Stefan; Brainin, Michael; Kiechl, Stefan; Willeit, Johann; Lang, Wilfried; Knoflach, Michael

2017-03-01

Ischemic strokes associated with atrial fibrillation (AF) are more severe than those of other cause. We aim to study potential sex effects in this context. In this cross-sectional study, 74 425 adults with acute ischemic stroke from the Austrian Stroke Unit Registry were included between March 2003 and January 2016. In 63 563 patients, data on the National Institutes of Health Stroke Scale on admission to the stroke unit, presence of AF, vascular risk factors, and comorbidities were complete. Analysis was done by a multivariate regression model. Stroke severity in general increased with age. AF-related strokes were more severe than strokes of other causes. Sex-related differences in stroke severity were only seen in stroke patients with AF. Median (Q 25 , 75 ) National Institutes of Health Stroke Scale score points were 9 (4,17) in women and 6 (3,13) in men ( P <0.001). The interaction between AF and sex on stroke severity was independent of age, previous functional status, vascular risk factors, and vascular comorbidities and remained significant in various subgroups. Women with AF do not only have an increased risk of stroke when compared with men but also experience more severe strokes. © 2017 American Heart Association, Inc.

Risk factors for severe clinical events in male and female patients with Fabry disease treated with agalsidase beta enzyme replacement therapy: Data from the Fabry Registry.

PubMed

Hopkin, Robert J; Cabrera, Gustavo; Charrow, Joel; Lemay, Roberta; Martins, Ana Maria; Mauer, Michael; Ortiz, Alberto; Patel, Manesh R; Sims, Katherine; Waldek, Stephen; Warnock, David G; Wilcox, William R

2016-09-01

Fabry disease, an X-linked lysosomal storage disorder, causes intracellular accumulation of glycosphingolipids leading to progressive renal, cardiovascular, and cerebrovascular disease, and premature death. This longitudinal Fabry Registry study analyzed data from patients with Fabry disease to determine the incidence and type of severe clinical events following initiation of enzyme replacement therapy (ERT) with agalsidase beta, as well as risk factors associated with occurrence of these events. Severe events assessed included chronic dialysis, renal transplantation, cardiac events, stroke, and death. The analyses included 969 male and 442 female Fabry patients. The mean age at first agalsidase beta infusion was 35 and 44, and median treatment follow-up 4.3years and 3.2years, respectively. Among males, cardiac events were the most common on-ERT events, followed by renal, stroke, and non-cardiac death. Among females, cardiac events were also most common followed by stroke and renal events. Patients with on-ERT events had significantly more advanced cardiac and renal disease at baseline as compared with patients without on-ERT events. Severe events were also associated with older age at ERT initiation (males and females), a history of pre-ERT events (females; approaching statistical significance in males), and a higher urinary protein/creatinine ratio (females). Approximately 65% of patients with pre-ERT events did not experience subsequent on-ERT events. Of patients without pre-ERT events, most (84% of males, 92% of females) remained event-free. Patients with on-ERT severe events had more advanced Fabry organ involvement at baseline than those without such events and patients who initiated ERT at a younger age had less residual risk of on-ERT events. The observed patterns of residual risk may aid clinicians in multidisciplinary monitoring of male and female patients with Fabry disease receiving ERT, and in determining the need for administration of adjunctive therapies. Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.

Neuroprotection as initial therapy in acute stroke. Third Report of an Ad Hoc Consensus Group Meeting. The European Ad Hoc Consensus Group.

PubMed

1998-01-01

Although a considerable body of scientific data is now available on neuroprotection in acute ischaemic stroke, this field is not yet established in clinical practice. At its third meeting, the European Ad Hoc Consensus Group considered the potential for neuroprotection in acute stroke and the practical problems attendant on the existence of a very limited therapeutic window before irreversible brain damage occurs, and came to the following conclusions. NEUROPROTECTANTS IN CLINICAL DEVELOPMENT: Convincing clinical evidence for an efficacious neuroprotective treatment in acute stroke is still required. Caution should be exercised in interpreting and extrapolating experimental results to stroke patients, who are a very heterogeneous group. The limitations of the time windows and the outcome measures chosen in trials of acute stroke therapy have an important influence on the results. The overall distribution of functional outcomes provides more statistical information than the proportion above a threshold outcome value. Neurological outcome should also be assessed. Neuroprotectants should not be tested clinically in phase II or phase III trials in a time window that exceeds those determined in experimental studies. The harmful effects of a drug in humans may override its neuroprotective potential determined in animals. Agents that act at several different levels in the ischaemic cascade may be more effective than those with a single mechanism of action. CURRENT IN-HOSPITAL MANAGEMENT OF ACUTE STROKE: The four major physiological variables that must be monitored and managed are blood pressure, arterial blood gas levels, body temperature, and glycaemia. The effects of controlling these physiological variables have not been studied in prospective trials, though they may all contribute to the outcome of acute ischaemic stroke and affect the duration of the therapeutic window. Optimal physiological parameters are inherently neuroprotective. Trials of new agents for the treatment of acute stroke should aim to maintain these physiological variables as close to normal as possible, and certainly within strictly defined limits. THE PLACE OF NEUROPROTECTANTS IN ACUTE STROKE MANAGEMENT: Stroke patients are a very heterogeneous group with respect to stroke mechanisms and severity, general condition, age and co-morbidities. At the present time, the only firm guideline than can be proposed for patient selection is the need for early admission to enable neuroprotectant and/or thrombolytic treatment to be started as soon as possible within the therapeutic window. The severity of potential side-effects will largely determine who should assess a patient with suspected stroke and initiate treatment. There is little information on which to base the duration of neuroprotectant therapy, and more experimental data are needed. Even if prehospital treatment proves to be feasible, it should not replace comprehensive stroke management in a specialist hospital unit. Clinical trials of neuroprotectants should only be performed in stroke units. The combined approach of restoring blood flow and providing neuroprotection may be the most productive in human stroke, but current clinical trial design will have to change in order to test combination therapy. Important side-effects are those that interfere with any possible benefit or increase mortality. PHARMACO-ECONOMIC ASPECTS OF NEUROPROTECTANTS: The early increase in hospital cost associated with neuroprotectant therapy may be balanced by the shorter length of hospital stay and lesser degree of disability of the surviving patients. The overall direct financial cost is highly dependent on the number of patients eligible for neuroprotectant therapy, which is itself dependent on the length of the therapeutic window and the severity of potential side-effects. A treatment that achieves a good functional outcome is the most cost-effective approach.

Ethnic Differences in Post-Stroke Quality of Life in the Brain Attack Surveillance in Corpus Christi (BASIC) Project

PubMed Central

Reeves, Sarah L; Brown, Devin L; Baek, Jonggyu; Wing, Jeffrey J; Morgenstern, Lewis B; Lisabeth, Lynda D

2015-01-01

Background and Purpose Mexican Americans (MAs) have an increased risk of stroke and experience worse post-stroke disability than non-Hispanic whites (NHWs), which may translate into worse post-stroke quality of life (QOL). We assessed ethnic differences in post-stroke QOL, as well as potential modification of associations by age, sex, and initial stroke severity. Methods Ischemic stroke survivors were identified through the biethnic, population-based Brain Attack Surveillance in Corpus Christi (BASIC) Project. Data were collected from medical records, baseline interviews, and 90-day post-stroke interviews. Post-stroke QOL was measured at approximately 90 days by the validated short-form stroke-specific QOL in 3 domains: overall, physical, and psychosocial (range 0–5; higher scores represent better QOL). Tobit regression was used to model associations between ethnicity and post-stroke QOL scores, adjusted for demographics, clinical characteristics, and pre-stroke cognition and function. Results Among 290 eligible stroke survivors (66% MA, 34% NHW, median age=69 years), median scores for overall, physical, and psychosocial post-stroke QOL were 3.3, 3.8 and 2.7, respectively. Overall post-stroke QOL was lower for MAs than NHWs (mean difference = −0.30, 95%CI:−0.59,−0.01) and in the physical domain (mean difference = −0.47, 95%CI:−0.81,−0.14) after multivariable adjustment. No ethnic difference was found in the psychosocial domain. Age modified the associations between ethnicity and post-stroke QOL such that differences were present in older but not younger ages. Conclusions Disparities exist in post-stroke QOL for MAs and appear to be driven by differences in older stroke patients. Targeted interventions to improve outcomes among MA stroke survivors are urgently needed. PMID:26286542

Stroke as the Initial Manifestation of Atrial Fibrillation: The Framingham Heart Study.

PubMed

Lubitz, Steven A; Yin, Xiaoyan; McManus, David D; Weng, Lu-Chen; Aparicio, Hugo J; Walkey, Allan J; Rafael Romero, Jose; Kase, Carlos S; Ellinor, Patrick T; Wolf, Philip A; Seshadri, Sudha; Benjamin, Emelia J

2017-02-01

To prevent strokes that may occur as the first manifestation of atrial fibrillation (AF), screening programs have been proposed to identify patients with undiagnosed AF who may be eligible for treatment with anticoagulation. However, the frequency with which patients with AF present with stroke as the initial manifestation of the arrhythmia is unknown. We estimated the frequency with which AF may present as a stroke in 1809 community-based Framingham Heart Study participants with first-detected AF and without previous strokes, by tabulating the frequencies of strokes occurring on the same day, within 30 days before, 90 days before, and 365 days before first-detected AF. Using previously reported AF incidence rates, we estimated the incidence of strokes that may represent the initial manifestation of AF. We observed 87 strokes that occurred ≤1 year before AF detection, corresponding to 1.7% on the same day, 3.4% within 30 days before, 3.7% within 90 days before, and 4.8% ≤1 year before AF detection. We estimated that strokes may present as the initial manifestation of AF at a rate of 2 to 5 per 10 000 person-years, in both men and women. We observed that stroke is an uncommon but measureable presenting feature of AF. Our data imply that emphasizing cost-effectiveness of population-wide AF-screening efforts will be important given the relative infrequency with which stroke represents the initial manifestation of AF. © 2017 American Heart Association, Inc.

Large Vessel Occlusion Scales Increase Delivery to Endovascular Centers Without Excessive Harm From Misclassifications.

PubMed

Zhao, Henry; Coote, Skye; Pesavento, Lauren; Churilov, Leonid; Dewey, Helen M; Davis, Stephen M; Campbell, Bruce C V

2017-03-01

Clinical large vessel occlusion (LVO) triage scales were developed to identify and bypass LVO to endovascular centers. However, there are concerns that scale misclassification of patients may cause excessive harm. We studied the settings where misclassifications were likely to occur and the consequences of these misclassifications in a representative stroke population. Prospective data were collected from consecutive ambulance-initiated stroke alerts at 2 stroke centers, with patients stratified into typical (LVO with predefined severe syndrome and non-LVO without) or atypical presentations (opposite situations). Five scales (Rapid Arterial Occlusion Evaluation [RACE], Los Angeles Motor Scale [LAMS], Field Assessment Stroke Triage for Emergency Destination [FAST-ED], Prehospital Acute Stroke Severity scale [PASS], and Cincinnati Prehospital Stroke Severity Scale [CPSSS]) were derived from the baseline National Institutes of Health Stroke Scale scored by doctors and analyzed for diagnostic performance compared with imaging. Of a total of 565 patients, atypical presentations occurred in 31 LVO (38% of LVO) and 50 non-LVO cases (10%). Most scales correctly identified >95% of typical presentations but <20% of atypical presentations. Misclassification attributable to atypical presentations would have resulted in 4 M1/internal carotid artery occlusions, with National Institutes of Health Stroke Scale score ≥6 (5% of LVO) being missed and 9 non-LVO infarcts (5%) bypassing the nearest thrombolysis center. Atypical presentations accounted for the bulk of scale misclassifications, but the majority of these misclassifications were not detrimental, and use of LVO scales would significantly increase timely delivery to endovascular centers, with only a small proportion of non-LVO infarcts bypassing the nearest thrombolysis center. Our findings, however, would require paramedics to score as accurately as doctors, and this translation is made difficult by weaknesses in current scales that need to be addressed before widespread adoption. © 2017 American Heart Association, Inc.

Predictors of functional level and quality of life at 6 months after a first-ever stroke: the KOSCO study.

PubMed

Chang, Won Hyuk; Sohn, Min Kyun; Lee, Jongmin; Kim, Deog Young; Lee, Sam-Gyu; Shin, Yong-Il; Oh, Gyung-Jae; Lee, Yang-Soo; Joo, Min Cheol; Han, Eun Young; Kang, Chung; Kim, Yun-Hee

2016-06-01

Predicting functional outcome and quality of life (QOL) is critical to the treatment of patients with stroke. The purpose of this study was to analyze the factors influencing functional status and QOL of stroke patients 6 months after a first-ever stroke. This study was an interim analysis of the Korean Stroke Cohort for Functioning and Rehabilitation Study, designed to include 10 years of follow-up for first-ever stroke patients. This study analyzed data from 2857 patients who completed face-to-face assessments with the functional independence measurement (FIM) and Euro Quality of Life-5D (EQ-5D) at 6 months after stroke onset. A multivariate regression analysis was used to analyze factors that potentially influenced FIM and EQ-5D results at 6 months after stroke. Of the patients in this study, 80.1 % suffered from ischemic stroke and 19.9 % experienced hemorrhagic stroke. The independent predictors of functional independency measured by FIM at 6 months after stroke were age, initial stroke severity, duration of hospitalization, and functional level at discharge in terms of motor, ambulation, and language. For QOL measured by EQ-5D at 6 months after stroke, age, duration of hospitalization, and motor function at discharge were significant predictors. In conclusion, proper treatment to achieve maximal functional gain at discharge may be an important factor in improving functional independency and QOL in chronic stage stroke survivors. These results provide useful information for establishing comprehensive and systematic care for stroke patients.

Aspirin for acute stroke of unknown etiology in resource-limited settings: a decision analysis.

PubMed

Berkowitz, Aaron L; Westover, M Brandon; Bianchi, Matt T; Chou, Sherry H-Y

2014-08-26

To analyze the potential impact of aspirin on outcome at hospital discharge after acute stroke in resource-limited settings without access to neuroimaging to distinguish ischemic stroke from intracerebral hemorrhage (ICH). A decision analysis was conducted to evaluate aspirin use in all patients with acute stroke of unknown type for the duration of initial hospitalization. Data were obtained from the International Stroke Trial and Chinese Acute Stroke Trial. Predicted in-hospital mortality and stroke recurrence risk were determined across the worldwide reported range of the proportion of strokes caused by ICH. Sensitivity analyses were performed on aspirin-associated relative risks in patients with ICH. At the highest reported proportion of strokes due to ICH from a large epidemiologic study (34% in sub-Saharan Africa), aspirin initiation after acute stroke of undetermined etiology is predicted to reduce in-hospital mortality (from 85/1,000 without treatment to 81/1,000 with treatment), in-hospital stroke recurrence (58/1,000 to 50/1,000), and combined risk of in-hospital mortality or stroke recurrence (127/1,000 to 114/1,000). Benefits of aspirin therapy remained in sensitivity analyses across a range of plausible parameter estimates for relative risks associated with aspirin initiation after ICH. Aspirin treatment for the period of initial hospitalization after acute stroke of undetermined etiology is predicted to decrease acute stroke-related mortality and in-hospital stroke recurrence even at the highest reported proportion of acute strokes due to ICH. In the absence of clinical trials to test this approach empirically, clinical decisions require patient-specific evaluation of risks and benefits of aspirin in this context. © 2014 American Academy of Neurology.

Inflammatory Disequilibrium in Stroke

PubMed Central

Petrovic-Djergovic, Danica; Goonewardena, Sascha N.; Pinsky, David J.

2016-01-01

Over the past several decades, there have been substantial advances in our knowledge of the pathophysiology of stroke. Understanding the benefits of timely reperfusion has led to the development of thrombolytic therapy as the cornerstone of current management of ischemic stroke, but there remains much to be learned about mechanisms of neuronal ischemic and reperfusion injury and associated inflammation. For ischemic stroke, novel therapeutic targets have continued to remain elusive. When considering modern molecular biologic techniques, advanced translational stroke models, and clinical studies, a consistent pattern emerges, implicating perturbation of the immune equilibrium by stroke in both central nervous system injury and repair responses. Stroke triggers activation of the neuroimmune axis, comprised of multiple cellular constituents of the immune system resident within the parenchyma of the brain, leptomeninges, and vascular beds, as well as through secretion of biological response modifiers and recruitment of immune effector cells. This neuroimmune activation can directly impact the initiation, propagation, and resolution phases of ischemic brain injury. In order to leverage a potential opportunity to modulate local and systemic immune responses to favorably affect the stroke disease curve, it is necessary to expand our mechanistic understanding of the neuroimmune axis in ischemic stroke. This review explores the frontiers of current knowledge of innate and adaptive immune responses in the brain and how these responses together shape the course of ischemic stroke. PMID:27340273

The case for and against initiating either hydroxyurea therapy, blood transfusion therapy or hematopoietic stem cell transplant in asymptomatic children with sickle cell disease.

PubMed

Kassim, Adetola A; DeBaun, Michael R

2014-02-01

The perception of an asymptomatic sickle cell disease (SCD) state is a misnomer. Children without overt symptoms, likely have subclinical disease beginning in infancy with progression into adulthood. Predictive models of SCD severity are unable to predict a subgroup of asymptomatic children likely to develop severe SCD. The introduction of penicillin prophylaxis, conjugated pneumococcal and Haemophilus influenzae type B vaccines have dramatically decreased the rate of life-threatening infections, while use of hydroxyurea in children has decreased pain and acute chest syndrome events. Use of transcranial Doppler coupled with regular blood transfusion therapy has decreased the rate of overt strokes and premature death associated with strokes. Currently, therapy for asymptomatic children includes hydroxyurea, regular blood transfusion or allogeneic hematopoietic stem cell transplant (allo-HSCT). The pros and cons of initiating hydroxyurea, regular blood transfusion or allo-HSCT in asymptomatic children with SCD. Emerging evidence from observational studies indicates that hydroxyurea prolongs survival in children and adults with sickle cell anemia. Regular blood transfusions reduce incidence of strokes, acute chest and pain episodes, but is associated with the burden of monthly visits and excessive iron stores. Although curative, the perceived risk:benefit ratio associated with allo-HSCT limits its use in asymptomatic children.

Potential determinants of efficacy of mirror therapy in stroke patients – A pilot study

PubMed Central

Brunetti, Maddalena; Morkisch, Nadine; Fritzsch, Claire; Mehnert, Jan; Steinbrink, Jens; Niedeggen, Michael; Dohle, Christian

2015-01-01

Abstract Background: Mirror therapy (MT) was found to improve motor function after stroke. However, there is high variability between patients regarding motor recovery. Objectives: The following pilot study was designed to identify potential factors determining this variability between patients with severe upper limb paresis, receiving MT. Methods: Eleven sub-acute stroke patients with severe upper limb paresis participated, receiving in-patient rehabilitation. After a set of pre-assessments (including measurement of brain activity at the primary motor cortex and precuneus during the mirror illusion, using near-infrared spectroscopy as described previously), four weeks of MT were applied, followed by a set of post-assessments. Discriminant group analysis for MT responders and non-responders was performed. Results: Six out of eleven patients were defined as responders and five as non-responders on the basis of their functional motor improvement. The initial motor function and the activity shift in both precunei (mirror index) were found to discriminate significantly between responders and non-responders. Conclusions: In line with earlier results, initial motor function was confirmed as crucial determinant of motor recovery. Additionally, activity response to the mirror illusion in both precunei was found to be a candidate for determination of the efficacy of MT. PMID:26409402

Explaining poorer stroke outcomes in women: women surviving 3 months have more severe strokes than men despite a lower 3-month case fatality.

PubMed

Olsen, Tom Skyhøj; Andersen, Zorana Jovanovic; Andersen, Klaus Kaae

2012-06-01

Women who survive stroke are more disabled and more often institutionalized than men. We explore this phenomenon by studying case fatality and stroke severity in stroke survivors separately for men and women. A Danish stroke registry (2000-2007) contains information about 26,818 patients with first-ever ischemic stroke, including stroke severity (Scandinavian Stroke Scale, 0 worst to 58 best), computed tomography scan, cardiovascular risk factors, and death 3 months after stroke. We modeled stroke severity by generalized additive linear model and 3-month case fatality with logistic model adjusting for age and cardiovascular risk factors. Male to female ratio was 51.5% to 48.5%. Mean age was 68.8 (SD 12.6) years in men; 73.7 (13.8) years in women. Stroke was more severe in women (mean [SD] Scandinavian Stroke Scale, 42.2 [16.0]) than in men (mean [SD] Scandinavian Stroke Scale, 45.6 [14.2]) also after adjustment for age and cardiovascular risk factors; significant in patients older than 75 years. In survivors at 3 months, stroke was more severe in women than men, given same age and cardiovascular risk factor profile; significant in patients older than 75 years. More women (11.9%) had died within 3 months than men (8.6%). However, adjusting for age, stroke severity, and risk factor profile, 3-month case fatality was lower in women than men; significant in patients older than 78 years. Although 3-month case fatality was lower in women than men, strokes were more severe among survivors at 3 months in women than in men. In addition, strokes were more severe in women. Our data help elucidate why women survive stroke better but have poorer functional outcomes that require more care than men. Copyright © 2012 Elsevier HS Journals, Inc. All rights reserved.

Stroke outcomes measures must be appropriately risk adjusted to ensure quality care of patients: a presidential advisory from the American Heart Association/American Stroke Association.

PubMed

Fonarow, Gregg C; Alberts, Mark J; Broderick, Joseph P; Jauch, Edward C; Kleindorfer, Dawn O; Saver, Jeffrey L; Solis, Penelope; Suter, Robert; Schwamm, Lee H

2014-05-01

Because stroke is among the leading causes of death, disability, hospitalizations, and healthcare expenditures in the United States, there is interest in reporting outcomes for patients hospitalized with acute ischemic stroke. The American Heart Association/American Stroke Association, as part of its commitment to promote high-quality, evidence-based care for cardiovascular and stroke patients, fully supports the development of properly risk-adjusted outcome measures for stroke. To accurately assess and report hospital-level outcomes, adequate risk adjustment for case mix is essential. During the development of the Centers for Medicare & Medicaid Services 30-day stroke mortality and 30-day stroke readmission measures, concerns were expressed that these measures were not adequately designed because they do not include a valid initial stroke severity measure, such as the National Institutes of Health Stroke Scale. These outcome measures, as currently constructed, may be prone to mischaracterizing the quality of stroke care being delivered by hospitals and may ultimately harm acute ischemic stroke patients. This article details (1) why the Centers for Medicare & Medicaid Services acute ischemic stroke outcome measures in their present form may not provide adequate risk adjustment, (2) why the measures as currently designed may lead to inaccurate representation of hospital performance and have the potential for serious unintended consequences, (3) what activities the American Heart Association/American Stroke Association has engaged in to highlight these concerns to the Centers for Medicare & Medicaid Services and other interested parties, and (4) alternative approaches and opportunities that should be considered for more accurately risk-adjusting 30-day outcomes measures in patients with ischemic stroke.

Epidemiology of Stroke in Costa Rica: A 7-Year Hospital-Based Acute Stroke Registry of 1319 Consecutive Patients.

PubMed

Torrealba-Acosta, Gabriel; Carazo-Céspedes, Kenneth; Chiou, Sy Han; O'Brien, Anthony Terrence; Fernández-Morales, Huberth

2018-05-01

Limited data on stroke exist for Costa Rica. Therefore, we created a stroke registry out of patients with stroke seen in the Acute Stroke Unit of the Hospital Calderon Guardia. We analyzed 1319 patients enrolled over a 7-year period, which incorporated demographic, clinical, laboratory, and neuroimaging data. The mean age of patients with stroke was 68.0 ± 15.5 years. Seven hundred twenty-five were men and the age range was 13-104 years. The most prevalent risk factors were hypertension (78.8%), dyslipidemia (36.3%), and diabetes (31.9%). Fifteen percent had atrial fibrillation and 24.7% had a previous stroke or transient ischemic attack. Prevalence of hypertension and atrial fibrillation increased with age; however, younger patients were more associated with thrombophilia. We documented 962 (72.9%) ischemic and 270 (20.5%) hemorrhagic strokes. Of the ischemic strokes, 174 (18.1%) were considered secondary to large-artery atherothrombosis, 175 (18.2%) were due to cardiac embolism, 19 (2.0%) were due to lacunar infarcts, and 25 (2.6%) were due to other determined causes. Five hundred sixty-nine (59.1%) remained undetermined. Atherothrombotic strokes were mostly associated with dyslipidemia, diabetes, metabolic syndrome, and obesity, whereas lacunar infarcts were associated with hypertension, smoking, sedentary lifestyle, and previous stroke or transient ischemic attack. Of our patients, 69.9% scored between 0 and 9 in the initial National Institutes of Health Stroke Scale (NIHSS). We found differences in sociodemographic features, risk factors, and stroke severity among stroke subtypes. Risk factor prevalence was similar to other registries involving Hispanic populations. Copyright © 2018 National Stroke Association. All rights reserved.

"Weekend effect" on stroke mortality revisited: Application of a claims-based stroke severity index in a population-based cohort study.

PubMed

Hsieh, Cheng-Yang; Lin, Huey-Juan; Chen, Chih-Hung; Li, Chung-Yi; Chiu, Meng-Jun; Sung, Sheng-Feng

2016-06-01

Previous studies have yielded inconsistent results on whether weekend admission is associated with increased mortality after stroke, partly because of differences in case mix. Claims-based studies generally lack sufficient information on disease severity and, thus, suffer from inadequate case-mix adjustment. In this study, we examined the effect of weekend admission on 30-day mortality in patients with ischemic stroke by using a claims-based stroke severity index.This was an observational study using a representative sample of the National Health Insurance claims data linked to the National Death Registry. We identified patients hospitalized for ischemic stroke, and examined the effect of weekend admission on 30-day mortality with vs without adjustment for stroke severity by using multilevel logistic regression analysis adjusting for patient-, physician-, and hospital-related factors. We analyzed 46,007 ischemic stroke admissions, in which weekend admissions accounted for 23.0%. Patients admitted on weekends had significantly higher 30-day mortality (4.9% vs 4.0%, P < 0.001) and stroke severity index (7.8 vs 7.4, P < 0.001) than those admitted on weekdays. In multivariate analysis without adjustment for stroke severity, weekend admission was associated with increased 30-day mortality (odds ratio (OR), 1.20; 95% confidence interval [CI], 1.08-1.34). This association became null after adjustment for stroke severity (OR, 1.07; 95% CI, 0.95-1.20).The "weekend effect" on stroke mortality might be attributed to higher stroke severity in weekend patients. While claims data are useful for examining stroke outcomes, adequate adjustment for stroke severity is warranted.

Effect of a single dose of propofol and lack of dextrose administration in a child with mitochondrial disease: a case report.

PubMed

Mtaweh, Haifa; Bayır, Hülya; Kochanek, Patrick M; Bell, Michael J

2014-08-01

Propofol infusion syndrome is a recognized complication of prolonged propofol use in the pediatric population, but little is reported on other metabolic effects of propofol, especially in children with mitochondrial disorders. We report on a child with metabolic encephalopathy, lactic acidosis, and stroke-like syndrome who received a single dose of propofol for procedural sedation. The patient's initial presentation was consistent with a mild exacerbation of her underlying disease. She received a single dose of propofol and non-dextrose-containing fluids during a magnetic resonance imaging (MRI) study to rule out stroke and progressed to develop severe acidosis, neurologic deterioration, and cardiorespiratory compromise. This is the first case report of severe metabolic disturbances after a single dose of propofol administered for procedural sedation in a patient with metabolic encephalopathy, lactic acidosis, and stroke-like syndrome and it questions the safety of propofol and absence of dextrose infusions during an acute illness in patients with mitochondrial disorders. © The Author(s) 2013.

Stroke Location Is an Independent Predictor of Cognitive Outcome.

PubMed

Munsch, Fanny; Sagnier, Sharmila; Asselineau, Julien; Bigourdan, Antoine; Guttmann, Charles R; Debruxelles, Sabrina; Poli, Mathilde; Renou, Pauline; Perez, Paul; Dousset, Vincent; Sibon, Igor; Tourdias, Thomas

2016-01-01

On top of functional outcome, accurate prediction of cognitive outcome for stroke patients is an unmet need with major implications for clinical management. We investigated whether stroke location may contribute independent prognostic value to multifactorial predictive models of functional and cognitive outcomes. Four hundred twenty-eight consecutive patients with ischemic stroke were prospectively assessed with magnetic resonance imaging at 24 to 72 hours and at 3 months for functional outcome using the modified Rankin Scale and cognitive outcome using the Montreal Cognitive Assessment (MoCA). Statistical maps of functional and cognitive eloquent regions were derived from the first 215 patients (development sample) using voxel-based lesion-symptom mapping. We used multivariate logistic regression models to study the influence of stroke location (number of eloquent voxels from voxel-based lesion-symptom mapping maps), age, initial National Institutes of Health Stroke Scale and stroke volume on modified Rankin Scale and MoCA. The second part of our cohort was used as an independent replication sample. In univariate analyses, stroke location, age, initial National Institutes of Health Stroke Scale, and stroke volume were all predictive of poor modified Rankin Scale and MoCA. In multivariable analyses, stroke location remained the strongest independent predictor of MoCA and significantly improved the prediction compared with using only age, initial National Institutes of Health Stroke Scale, and stroke volume (area under the curve increased from 0.697-0.771; difference=0.073; 95% confidence interval, 0.008-0.155). In contrast, stroke location did not persist as independent predictor of modified Rankin Scale that was mainly driven by initial National Institutes of Health Stroke Scale (area under the curve going from 0.840 to 0.835). Similar results were obtained in the replication sample. Stroke location is an independent predictor of cognitive outcome (MoCA) at 3 months post stroke. © 2015 American Heart Association, Inc.

Validity of the modified Charlson Comorbidity Index as predictor of short-term outcome in older stroke patients.

PubMed

Denti, Licia; Artoni, Andrea; Casella, Monica; Giambanco, Fabiola; Scoditti, Umberto; Ceda, Gian Paolo

2015-02-01

The modified Charlson Comorbidity Index (MCCI) has been proposed as a tool for adjusting the outcomes of stroke for comorbidity, but its validity in such a context has been evaluated in only a few studies and needs to be further explored, especially in elderly patients. We aimed to retrospectively assess the validity of the MCCI as a predictor of the short-term outcomes in a cohort of 297 patients with first-ever ischemic stroke, older than 60 years, and managed according to a clinical pathway. The poor outcome (PO) at 1 month, defined as a modified Rankin Scale score of 3-6, was the primary end point. Furthermore, a new comorbidity index has been developed, specific to our cohort, according to the same statistical approach used for the original CCI. The MCCI showed a positive association with PO (odds ratio [OR] 1.62; 95% confidence interval [CI] .98-2.68) and mortality (hazard ratio [HR] 1.85; 95% CI .94-3.61), not statistically significant and totally dependent on its association with the severity of neurologic impairment at onset. The new comorbidity index showed, as expected, a significant association with the PO and mortality with higher point estimates of OR (2.74; 95% CI 1.64-4.59) and HR (2.73; 95% CI 1.51-4.94), but this association was also dependent on stroke severity and premorbid disability. Our results do not support the validity of the MCCI as a predictor of the short-term outcomes in elderly stroke patients nor could we develop a more valid index from the available data. This suggests the need for development of disease- and age-specific indexes, possibly according to a prospective design. In any case, initial stroke severity, a strong predictor of outcome, is associated with the degree of comorbidity. Copyright © 2015 National Stroke Association. Published by Elsevier Inc. All rights reserved.

In-Patient Code Stroke: A Quality Improvement Strategy to Overcome Knowledge-to-Action Gaps in Response Time.

PubMed

Kassardjian, Charles D; Willems, Jacqueline D; Skrabka, Krystyna; Nisenbaum, Rosane; Barnaby, Judith; Kostyrko, Pawel; Selchen, Daniel; Saposnik, Gustavo

2017-08-01

Stroke is a relatively common and challenging condition in hospitalized patients. Previous studies have shown delays in recognition and assessment of inpatient strokes leading to poor outcomes. The goal of this quality improvement initiative was to evaluate an in-hospital code stroke algorithm and educational program aimed at reducing the response times for inpatient stroke. An inpatient code stroke algorithm was developed, and an educational intervention was implemented over 5 months. Data were recorded and compared between the 36-month period before and the 15-month period after the intervention was implemented. Outcome measures included time from last seen normal to initial assessment and from last seen normal to brain imaging. During the study period, there were 218 inpatient strokes (131 before the intervention and 87 after the intervention). Inpatient strokes were more common on cardiovascular wards (45% of cases) and occurred mainly during the perioperative period (60% of cases). After implementation of an inpatient code stroke intervention and educational initiative, there were consistent reductions in all timed outcome measures (median time to initial assessment fell from 600 [109-1460] to 160 [35-630] minutes and time to computed tomographic scan fell from 925 [213-1965] to 348.5 [128-1587] minutes). Our study reveals the efficacy of an inpatient code stroke algorithm and educational intervention directed at nurses and allied health personnel to optimize the prompt management of inpatient strokes. Prompt assessment may lead to faster stroke interventions, which are associated with better outcomes. © 2017 American Heart Association, Inc.

Sex Disparities in Stroke: Women Have More Severe Strokes but Better Survival Than Men.

PubMed

Dehlendorff, Christian; Andersen, Klaus Kaae; Olsen, Tom Skyhøj

2015-07-06

Uncertainty remains about whether stroke affects men and women similarly. We studied differences between men and women with regard to stroke severity and survival. We used the Danish Stroke Registry, with information on all hospital admissions for stroke in Denmark between 2003 and 2012 (N=79 617), and the Danish Register of Causes of Death. Information was available on age, sex, marital status, stroke severity, stroke subtype, socioeconomic status, and cardiovascular risk profile. We studied only deaths due to the index stroke, with the assumption that death reported on death certificates as due to stroke was related to the index stroke if death occurred within the first week or month after stroke. Multivariate Cox regression analysis and multiple imputation were applied. Stroke was the cause of death for 4373 and 5512 of the 79 617 patients within 1 week (5.5%) or 1 month (6.9%), respectively. After the age of 60 years, women had more severe strokes than men. Up to ages in the mid-60s, no difference in the risk of death from stroke was seen between the 2 sexes. For people aged >65 years, however, the risk gradually became greater in men than in women and significantly so (>15%) from the mid-70s (adjusted for age, marital status, stroke severity, stroke subtype, socioeconomic status, and cardiovascular risk factors). Results were essentially the same when analyzing deaths within 1 week, 1 month and ischemic and hemorrhagic stroke separately. Stroke affects women and men differently. Elderly women were affected more severely than elderly men but were more likely to survive. © 2015 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

Sex Disparities in Stroke: Women Have More Severe Strokes but Better Survival Than Men

PubMed Central

Dehlendorff, Christian; Andersen, Klaus Kaae; Olsen, Tom Skyhøj

2015-01-01

Background Uncertainty remains about whether stroke affects men and women similarly. We studied differences between men and women with regard to stroke severity and survival. Methods and Results We used the Danish Stroke Registry, with information on all hospital admissions for stroke in Denmark between 2003 and 2012 (N=79 617), and the Danish Register of Causes of Death. Information was available on age, sex, marital status, stroke severity, stroke subtype, socioeconomic status, and cardiovascular risk profile. We studied only deaths due to the index stroke, with the assumption that death reported on death certificates as due to stroke was related to the index stroke if death occurred within the first week or month after stroke. Multivariate Cox regression analysis and multiple imputation were applied. Stroke was the cause of death for 4373 and 5512 of the 79 617 patients within 1 week (5.5%) or 1 month (6.9%), respectively. After the age of 60 years, women had more severe strokes than men. Up to ages in the mid-60s, no difference in the risk of death from stroke was seen between the 2 sexes. For people aged >65 years, however, the risk gradually became greater in men than in women and significantly so (>15%) from the mid-70s (adjusted for age, marital status, stroke severity, stroke subtype, socioeconomic status, and cardiovascular risk factors). Results were essentially the same when analyzing deaths within 1 week, 1 month and ischemic and hemorrhagic stroke separately. Conclusions Stroke affects women and men differently. Elderly women were affected more severely than elderly men but were more likely to survive. PMID:26150479

Modelling mortality and discharge of hospitalized stroke patients using a phase-type recovery model.

PubMed

Jones, Bruce; McClean, Sally; Stanford, David

2018-05-01

We model the length of in-patient hospital stays due to stroke and the mode of discharge using a phase-type stroke recovery model. The model allows for three different types of stroke: haemorrhagic (the most severe, caused by ruptured blood vessels that cause brain bleeding), cerebral infarction (less severe, caused by blood clots) and transient ischemic attack or TIA (the least severe, a mini-stroke caused by a temporary blood clot). A four-phase recovery process is used, where the initial phase depends on the type of stroke, and transition from one phase to the next depends on the age of the patient. There are three differing modes of absorption for this phase-type model: from a typical recovery phase, a patient may die (mode 1), be transferred to a nursing home (mode 2) or be discharged to the individual's usual residence (mode 3). The first recovery phase is characterized by a very high rate of mortality and very low rates of discharge by the other two modes. The next two recovery phases have progressively lower mortality rates and higher mode 2 and 3 discharge rates. The fourth recovery phase is visited only by those who experience a very mild TIA, and they are discharged to home after a short stay. The novelty of our approach to phase representation is two-fold: first, it aligns the phases with labelled diagnosis states, representing stages of illness severity; second, the model allows us to obtain expressions for Key Performance Indicators that are of use to healthcare professionals. This allows us to use a backward estimation process where we leverage the fact that we know the phase of admission (the diagnosis), but not which phases are subsequently entered or when this happens; this strategy improves both computational efficiency and accuracy. The model has clear practical value as it yields length of stay distributions by age and type of stroke, which are useful in resource planning. Also, inclusion of the three modes of discharge permits analyses of outcomes.

Smart phone video game simulation of parent-child interaction: Learning skills for effective vegetable parenting

USDA-ARS?s Scientific Manuscript database

Higher levels of vegetable intake have been associated with decreased risks of heart disease, diabetes, stroke, several cancers, and possibly obesity, but vegetable intake is generally low. Preference is an important determinant of vegetable intake, and food preferences are initiated early in life, ...

Severity and outcomes according to stroke etiology in patients under 50 years of age with ischemic stroke.

PubMed

Prefasi, Daniel; Martínez-Sánchez, Patricia; Fuentes, Blanca; Díez-Tejedor, Exuperio

2016-08-01

To analyze the association of stroke etiological subtypes with severity and outcomes at 3 and 12 months in patients ≤50 years. Observational study of patients admitted to a stroke unit (2007-2013). demographic data, vascular risk factors, comorbidities, severity on admission (NIHSS), and good functional outcome (mRS ≤ 1) at 3 and 12 months. We used multivariate analyses to evaluate the influence of stroke etiology on severity and outcomes. We included 214 patients, 58.3 % men, mean age 41.4 years. General linear models showed all etiologies were more severe than lacunar strokes (P < 0.05). Atherothrombotic strokes showed greater severity than those of undetermined and uncommon etiology, whereas cardioembolic strokes were more severe than cryptogenic. Taking into account specific etiologies, atherothrombotic strokes (B = 5.860; 95 % CI 2.979-8.751), cervical artery dissection (CAD) [B = 7.485; 95 % confidence interval (CI) 4.734-10.237], and atrial fibrillation (AF) strokes (B = 5.773; 95 % CI 2.704-8.132) were more severe than other etiologies. Logistic regression models showed that strokes of uncommon etiology, especially those not related to CAD, had a lower probability of good outcome at 3 months [odds ratio (OR) = 0.197; CI 95 % 0.044-0.873], whereas atherothrombotic strokes were associated with this probability at 12 months (OR = 0.187; 95 % CI 0.037-0.951; P = 0.007). In patients ≤50 years of age, strokes of atherothrombotic, cardioembolic (particularly those due to AF), and uncommon etiology had a greater severity than the rest. Furthermore, strokes of uncommon etiology, especially those different from CAD, decreased the probability of a good outcome at 3 months, as did atherothrombotic strokes at 1 year.

Successful endovascular stroke therapy in a 103-year-old woman.

PubMed

Boo, SoHyun; Duru, Uzoma B; Smith, Matthew S; Rai, Ansaar T

2015-11-03

People older than 80 years of age constitute the most rapidly growing age group in the world. Several trials confirming superior efficacy of endovascular therapy did not have an upper age limit and showed favorable treatment effects, regardless of age. Current American Heart Association/American Stroke Association guidelines do not restrict treatment based on age as long as other eligibility criteria are met. A 103-year-old woman presented 2 h after stroke onset secondary to a left internal carotid artery terminus (ICA-T) occlusion. Admission National Institutes of Health Stoke Scale (NIHSS) score was 38, with no early ischemic changes on imaging, pre-stroke modified Rankin Scale score was 0, and she lived independently with minimal help. After initiation of intravenous thrombolysis, the patient underwent successful mechanical thrombectomy with Thombosis in Cerebral Infaction-3 recanalization. She showed remarkable recovery (NIHSS score of 1 at 48 h). Stroke onset to recanalization was 3 h 40 min. Our objective in documenting the oldest patient to successfully undergo stroke intervention is to corroborate that with the current evidence, appropriate patients undergoing rapid treatment may allow us to advance the limits of endovascular therapy. 2015 BMJ Publishing Group Ltd.

Why does negative CG lightning have subsequent return strokes?

NASA Astrophysics Data System (ADS)

Wilkes, R. A.; Kotovsky, D. A.; Uman, M. A.; Carvalho, F. L.; Jordan, D.

2017-12-01

It is not understood why cloud-to-ground (CG) lightning flashes lowering negative charge often produce discrete dart-leader/return-stroke sequences rather than having the first stroke drain the available cloud charge, as is almost always the case for CG lightning lowering positive charge. Triggered lightning data obtained at the International Center for Lightning Research and Testing (ICLRT) in north-central Florida have been analyzed to clarify the subsequent return-stroke process. In summers 2013 through 2016 at the ICLRT, 53% of the rocket launches did not initiate any part of a lightning flash, 13% of the rocket launches created an initial stage only (ISO) and failed to produce a following dart-leader/return-stroke sequences, and 34% of rocket launches produced an initial stage (IS) followed by return strokes. The IS of the triggered lightning consists of the upward positive leader and a following initial continuing current, both being responsible for transporting negative charge from the cloud to ground. Our ISO events may well have some commonality with the roughly 20 percent of natural CG flashes that fail to produce a dart-leader/return-stroke. We have analyzed the IS of 41 triggered lightning flashes with (19 cases) and without (22 cases) following return strokes and compared areas and heights of the flash using data collected by a Lightning Mapping Array (LMA). In our preliminary analysis, we can find no geometrical feature of the lightning channel during the IS that will predict the occurrence or lack of occurrence of following return strokes. We also have compared the triggered-lightning electrical current and charge transfer observed at the ground. We found that the average current, duration, and charge transfer during the IS for ISO events is each about half that of ISs analyzed which are followed by dart-leader/return-stroke sequences, contrary to the results presented from the GCOELD in China. Summarizing, there appear to be no differences in the channel geometry between initial stages that do or do not yield dart-leader/return-stroke sequences. In contrast, we find that particular electrical characteristics of the initial stage may indicate whether or not a dart-leader/return-stroke sequence may follow, potentially shedding light on the physical processes necessary for dart-leader initiation.

Body-weight-supported treadmill rehabilitation after stroke.

PubMed

Duncan, Pamela W; Sullivan, Katherine J; Behrman, Andrea L; Azen, Stanley P; Wu, Samuel S; Nadeau, Stephen E; Dobkin, Bruce H; Rose, Dorian K; Tilson, Julie K; Cen, Steven; Hayden, Sarah K

2011-05-26

Locomotor training, including the use of body-weight support in treadmill stepping, is a physical therapy intervention used to improve recovery of the ability to walk after stroke. The effectiveness and appropriate timing of this intervention have not been established. We stratified 408 participants who had had a stroke 2 months earlier according to the extent of walking impairment--moderate (able to walk 0.4 to <0.8 m per second) or severe (able to walk <0.4 m per second)--and randomly assigned them to one of three training groups. One group received training on a treadmill with the use of body-weight support 2 months after the stroke had occurred (early locomotor training), the second group received this training 6 months after the stroke had occurred (late locomotor training), and the third group participated in an exercise program at home managed by a physical therapist 2 months after the stroke (home-exercise program). Each intervention included 36 sessions of 90 minutes each for 12 to 16 weeks. The primary outcome was the proportion of participants in each group who had an improvement in functional walking ability 1 year after the stroke. At 1 year, 52.0% of all participants had increased functional walking ability. No significant differences in improvement were found between early locomotor training and home exercise (adjusted odds ratio for the primary outcome, 0.83; 95% confidence interval [CI], 0.50 to 1.39) or between late locomotor training and home exercise (adjusted odds ratio, 1.19; 95% CI, 0.72 to 1.99). All groups had similar improvements in walking speed, motor recovery, balance, functional status, and quality of life. Neither the delay in initiating the late locomotor training nor the severity of the initial impairment affected the outcome at 1 year. Ten related serious adverse events were reported (occurring in 2.2% of participants undergoing early locomotor training, 3.5% of those undergoing late locomotor training, and 1.6% of those engaging in home exercise). As compared with the home-exercise group, each of the groups receiving locomotor training had a higher frequency of dizziness or faintness during treatment (P=0.008). Among patients with severe walking impairment, multiple falls were more common in the group receiving early locomotor training than in the other two groups (P=0.02). Locomotor training, including the use of body-weight support in stepping on a treadmill, was not shown to be superior to progressive exercise at home managed by a physical therapist. (Funded by the National Institute of Neurological Disorders and Stroke and the National Center for Medical Rehabilitation Research; LEAPS ClinicalTrials.gov number, NCT00243919.).

Mitochondrial Impairment in Cerebrovascular Endothelial Cells is Involved in the Correlation between Body Temperature and Stroke Severity

PubMed Central

Hu, Heng; Doll, Danielle N.; Sun, Jiahong; Lewis, Sara E.; Wimsatt, Jeffrey H.; Kessler, Matthew J.; Simpkins, James W.; Ren, Xuefang

2016-01-01

Stroke is the second leading cause of death worldwide. The prognostic influence of body temperature on acute stroke in patients has been recently reported; however, hypothermia has confounded experimental results in animal stroke models. This work aimed to investigate how body temperature could prognose stroke severity as well as reveal a possible mitochondrial mechanism in the association of body temperature and stroke severity. Lipopolysaccharide (LPS) compromises mitochondrial oxidative phosphorylation in cerebrovascular endothelial cells (CVECs) and worsens murine experimental stroke. In this study, we report that LPS (0.1 mg/kg) exacerbates stroke infarction and neurological deficits, in the mean time LPS causes temporary hypothermia in the hyperacute stage during 6 hours post-stroke. Lower body temperature is associated with worse infarction and higher neurological deficit score in the LPS-stroke study. However, warming of the LPS-stroke mice compromises animal survival. Furthermore, a high dose of LPS (2 mg/kg) worsens neurological deficits, but causes persistent severe hypothermia that conceals the LPS exacerbation of stroke infarction. Mitochondrial respiratory chain complex I inhibitor, rotenone, replicates the data profile of the LPS-stroke study. Moreover, we have confirmed that rotenone compromises mitochondrial oxidative phosphorylation in CVECs. Lastly, the pooled data analyses of a large sample size (n=353) demonstrate that stroke mice have lower body temperature compared to sham mice within 6 hours post-surgery; the body temperature is significantly correlated with stroke outcomes; linear regression shows that lower body temperature is significantly associated with higher neurological scores and larger infarct volume. We conclude that post-stroke body temperature predicts stroke severity and mitochondrial impairment in CVECs plays a pivotal role in this hypothermic response. These novel findings suggest that body temperature is prognostic for stroke severity in experimental stroke animal models and may have translational significance for clinical stroke patients - targeting endothelial mitochondria may be a clinically useful approach for stroke therapy. PMID:26816660

Mathematical Formulation of the Remote Electric and Magnetic Emissions of the Lightning Dart Leader and Return Stroke

NASA Astrophysics Data System (ADS)

Thiemann, Edward M. B.

Lightning detection and geolocation networks have found widespread use by the utility, air traffic control and forestry industries as a means of locating strikes and predicting imminent recurrence. Accurate lightning geolocation requires detecting VLF radio emissions at multiple sites using a distributed sensor network with typical baselines exceeding 150 km, along with precision time of arrival estimation to triangulate the origin of a strike. The trend has been towards increasing network accuracy without increasing sensor density by incorporating precision GPS synchronized clocks and faster front-end signal processing. Because lightning radio waveforms evolve as they propagate over a finitely conducting earth, and that measurements for a given strike may have disparate propagation path lengths, accurate models are required to determine waveform fiducials for precise strike location. The transition between the leader phase and return stroke phase may offer such a fiducial and warrants quantitative modeling to improve strike location accuracy. The VLF spectrum of the ubiquitous downward negative lightning strike is able to be modeled by the transfer of several Coulombs of negative charge from cloud to ground in a two-step process. The lightning stepped leader ionizes a plasma channel downward from the cloud at a velocity of approximately 0.05c, leaving a column of charge in its path. Upon connection with a streamer, the subsequent return stroke initiates at or near ground level and travels upward at an average but variable velocity of 0.3c. The return stroke neutralizes any negative charge along its path. Subsequent dart leader and return strokes often travel smoothly down the heated channel left by a preceding stroke, lacking the halting motion of the preceding initial stepped leader and initial return stroke. Existing lightning models often neglect the leader current and rely on approximations when solving for the return stroke. In this thesis, I present an analytic solution to Maxwell's Equations for the lightning leader followed by a novel return stroke model. I model the leader as a downward propagating boxcar function of uniform charge density and constant velocity, and the subsequent return stroke is modeled as an upward propagating boxcar with a time dependent velocity. Charge conservation is applied to ensure self-consistency of the driving current and charge sources, and physical observations are used to support model development. The resulting transient electric and magnetic fields are presented at various distances and delay times and compared with measured waveforms and previously published models.

Impact of prestroke selective serotonin reuptake inhibitor treatment on stroke severity and mortality.

PubMed

Mortensen, Janne Kaergaard; Larsson, Heidi; Johnsen, Søren Paaske; Andersen, Grethe

2014-07-01

Selective serotonin reuptake inhibitors (SSRIs) have been associated with an increased risk of bleeding but also a possible neuroprotective effect in stroke. We aimed to examine the implications of prestroke SSRI use in hemorrhagic and ischemic stroke. We conducted a registry-based propensity score-matched follow-up study among first-ever patients with hemorrhage and ischemic stroke in Denmark (2003-2012). Multiple conditional logistic regression was used to compute adjusted odds ratios of severe stroke and death within 30 days. Among 1252 hemorrhagic strokes (626 prestroke SSRI users and 626 propensity score-matched nonusers), prestroke SSRI use was associated with an increased risk of the strokes being severe (adjusted propensity score-matched odds ratios, 1.41; confidence interval, 1.08-1.84) and an increased risk of death within 30 days (adjusted propensity score-matched odds ratios, 1.60; confidence interval, 1.17-2.18). Among 8956 patients with ischemic stroke (4478 prestroke SSRI users and 4478 propensity score-matched nonusers), prestroke SSRI use was not associated with the risk of severe stroke or death within 30 days. Prestroke SSRI use is associated with increased stroke severity and mortality in patients with hemorrhagic stroke. Although prestroke depression in itself may increase stroke severity and mortality, this was not found in SSRI users with ischemic stroke. © 2014 American Heart Association, Inc.

Delay time between onset of ischemic stroke and hospital arrival.

PubMed

Biller, J; Patrick, J T; Shepard, A; Adams, H P

1993-01-01

Some current experimental protocols for acute ischemic stroke require the initiation of treatment within hours of the onset of stroke symptoms. We prospectively evaluated 30 patients with acute ischemic stroke based on clinical and computed tomography findings. The time between the onset of stroke symptoms and arrival in the emergency room and subsequently on the stroke service was determined. Within 3, 6,12, and 24 h of the onset of stroke symptoms, 16 (53%), 19 (63%), 22 (73%), and 25 (83%) patients had arrived at the emergency room and 0 (0%), 4 (13%), 14 (47%), and 22 (73%) of them on the stroke service, respectively. From the onset of stroke symptoms, the mean arrival time to the emergency room was 24 h (range, 30 min to 144 h) and to the stroke service was 61 h (range, 4-150 h). The mean time between arrival in the emergency room and stroke service was 8.6 h (range, 0-47 h). Even though 53% and 63% of our patients arrived at the emergency room within 3 and 6 h of the onset of stroke symptoms, only 0% and 13% of them arrived on the stroke service within the same time period for the initiation of treatment, respectively. Thus, in order for more patients to qualify for current experimental protocols, they must arrive on the stroke service more quickly or treatment must be initiated in the emergency room. Copyright © 1993. Published by Elsevier Inc.

Prestroke CHA2DS2-VASc Score and Severity of Acute Stroke in Patients with Atrial Fibrillation: Findings from RAF Study.

PubMed

Acciarresi, Monica; Paciaroni, Maurizio; Agnelli, Giancarlo; Falocci, Nicola; Caso, Valeria; Becattini, Cecilia; Marcheselli, Simona; Rueckert, Christina; Pezzini, Alessandro; Morotti, Andrea; Costa, Paolo; Padovani, Alessandro; Csiba, Laszló; Szabó, Lilla; Sohn, Sung-Il; Tassinari, Tiziana; Abdul-Rahim, Azmil H; Michel, Patrik; Cordier, Maria; Vanacker, Peter; Remillard, Suzette; Alberti, Andrea; Venti, Michele; D'Amore, Cataldo; Scoditti, Umberto; Denti, Licia; Orlandi, Giovanni; Chiti, Alberto; Gialdini, Gino; Bovi, Paolo; Carletti, Monica; Rigatelli, Alberto; Putaala, Jukka; Tatlisumak, Turgut; Masotti, Luca; Lorenzini, Gianni; Tassi, Rossana; Guideri, Francesca; Martini, Giuseppe; Tsivgoulis, Georgios; Vadikolias, Kostantinos; Liantinioti, Chrissoula; Corea, Francesco; Del Sette, Massimo; Ageno, Walter; De Lodovici, Maria Luisa; Bono, Giorgio; Baldi, Antonio; D'Anna, Sebastiano; Sacco, Simona; Carolei, Antonio; Tiseo, Cindy; Imberti, Davide; Zabzuni, Dorjan; Doronin, Boris; Volodina, Vera; Consoli, Domenico; Galati, Franco; Pieroni, Alessio; Toni, Danilo; Monaco, Serena; Baronello, Mario Maimone; Barlinn, Kristian; Pallesen, Lars-Peder; Kepplinger, Jessica; Bodechtel, Ulf; Gerber, Johannes; Deleu, Dirk; Melikyan, Gayane; Ibrahim, Faisal; Akhtar, Naveed; Mosconi, Maria Giulia; Lees, Kennedy R

2017-06-01

The aim of this study was to investigate for a possible association between both prestroke CHA 2 DS 2 -VASc score and the severity of stroke at presentation, as well as disability and mortality at 90 days, in patients with acute stroke and atrial fibrillation (AF). This prospective study enrolled consecutive patients with acute ischemic stroke, AF, and assessment of prestroke CHA 2 DS 2 -VASc score. Severity of stroke was assessed on admission using the National Institutes of Health Stroke Scale (NIHSS) score (severe stroke: NIHSS ≥10). Disability and mortality at 90 days were assessed by the modified Rankin Scale (mRS <3 or ≥3). Multiple logistic regression was used to correlate prestroke CHA 2 DS 2 -VASc and severity of stroke, as well as disability and mortality at 90 days. Of the 1020 patients included in the analysis, 606 patients had an admission NIHSS score lower and 414 patients higher than 10. At 90 days, 510 patients had mRS ≥3. A linear correlation was found between the prestroke CHA 2 DS 2 -VASc score and severity of stroke (P = .001). On multivariate analysis, CHA 2 DS 2 -VASc score correlated with severity of stroke (P = .041) and adverse functional outcome (mRS ≥3) (P = .001). A logistic regression with the receiver operating characteristic graph procedure (C-statistics) evidenced an area under the curve of .60 (P = .0001) for severe stroke. Furthermore, a correlation was found between prestroke CHA 2 DS 2 -VASc score and lesion size. In patients with AF, in addition to the risk of stroke, a high CHA 2 DS 2 -VASc score was independently associated with both stroke severity at onset and disability and mortality at 90 days. Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.

78 FR 59041 - National Institute of Neurological Disorders and Stroke; Notice of Closed Meetings

Federal Register 2010, 2011, 2012, 2013, 2014

2013-09-25

... Disorders and Stroke Initial Review, Group Neurological Sciences and Disorders C. Date: October 17-18, 2013... Officer, Scientific Review Branch, Division of Extramural Research, NINDS, NIH, NSC, 6001 Executive Blvd...: National Institute of Neurological Disorders and Stroke Initial Review, Group Neurological Sciences and...

Quality of life after stroke: the North East Melbourne Stroke Incidence Study (NEMESIS).

PubMed

Sturm, Jonathan W; Donnan, Geoffrey A; Dewey, Helen M; Macdonell, Richard A L; Gilligan, Amanda K; Srikanth, Velandai; Thrift, Amanda G

2004-10-01

Health-related quality of life (HRQoL) data are scarce from unselected populations. The aims were to assess HRQoL at 2 years poststroke, to identify determinants of HRQoL in stroke survivors, and to identify predictors at stroke onset of subsequent HRQoL. All first-ever cases of stroke in a population of 306 631 over a 1-year period were assessed. Stroke severity, comorbidity, and demographic information were recorded. Two-year poststroke HRQoL was assessed using the Assessment of Quality of Life (AQoL) instrument (deceased patients score=0). Handicap, disability, physical impairment, depression, anxiety, living arrangements, and recurrent stroke at 2 years were documented. If necessary, proxy assessments were obtained, except for mood. Linear regression analyses were performed to identify factors independently associated with HRQoL. Of 266 incident cases alive at 2 years, 225 (85%) were assessed. The mean AQoL utility score for all survivors was 0.47 (95% CI, 0.42 to 0.52). Almost 25% of survivors had a score of < or =0.1. The independent determinants of HRQoL in survivors were handicap, physical impairment, anxiety and depression, disability, institutionalization, dementia, and age. The factors present at stroke onset that independently predicted HRQoL at 2 years poststroke were age, female sex, initial NIHSS score, neglect, and low socioeconomic status. A substantial proportion of stroke survivors have very poor HRQoL. Interventions targeting handicap and mood have the potential to improve HRQoL independently of physical impairment and disability.

Prospective quality initiative to maximize dysphagia screening reduces hospital-acquired pneumonia prevalence in patients with stroke.

PubMed

Titsworth, W Lee; Abram, Justine; Fullerton, Amy; Hester, Jeannette; Guin, Peggy; Waters, Michael F; Mocco, J

2013-11-01

Dysphagia can lead to pneumonia and subsequent death after acute stroke. However, no prospective study has demonstrated reduced pneumonia prevalence after implementation of a dysphagia screen. We performed a single-center prospective interrupted time series trial of a quality initiative to improve dysphagia screening. Subjects included all patients with ischemic or hemorrhagic stroke admitted to our institution over 42 months with a 31-month (n=1686) preintervention and an 11-month (n=648) postintervention period. The intervention consisted of a dysphagia protocol with a nurse-administered bedside dysphagia screen and a reflexive rapid clinical swallow evaluation by a speech pathologist. The dysphagia initiative increased the percentage of patients with stroke screened from 39.3% to 74.2% (P<0.001). Furthermore, this initiative coincided with a drop in hospital-acquired pneumonia from 6.5% to 2.8% among patients with stroke (P<0.001). Patients admitted postinitiative had 57% lower odds of pneumonia, after controlling for multiple confounds (odds ratio=0.43; confidence interval, 0.255-0.711; P=0.0011). The best predictors of pneumonia were stroke type (P<0.0001), oral intake status (P<0.0001), dysphagia screening status (P=0.0037), and hospitalization before the beginning of the quality improvement initiative (P=0.0449). A quality improvement initiative using a nurse-administered bedside screen with rapid bedside swallow evaluation by a speech pathologist improves screening compliance and correlates with decreased prevalence of pneumonia among patients with stroke.

Ischemic Stroke and Epilepsy in a Patient with Tourette´s Syndrome: Association with the Antiphospholipid Syndrome and Good Response to Levetiracetam

PubMed Central

Seijo-Martínez, M; Mosquera-Martínez, J.A; Romero-Yuste, S; Cruz-Martinez, J

2008-01-01

The role played by different humoral factors, including antiphospholipid antibodies, in the pathogenesis of Tourette syndrome (TS) is still presently unclear. We present a patient with chronic and severe TS who, at the age of 16 years, presented an ischemic stroke in the left posterior cerebral artery and/or postero-inferior temporal branch of the left medial cerebral artery. A complete study was negative with the exception of a positive lupus anticoagulant. The stroke was related with the primary antiphospholipid syndrome (APS). The stroke manifested visual abnormalities and thereafter by secondary generalized complex partial seizures. The epileptic syndrome was initially difficult to control but responded dramatically to levetiracetam. With this therapy, the manifestations of TS, especially the tics, improved. We conclude that some TS cases may present APS. In addition, levetiracetam may be useful in the management of TS. Further investigations should pursue both these facts. PMID:19018305

Characterization of fluid physics effects on cardiovascular response to microgravity (G-572)

NASA Technical Reports Server (NTRS)

Pantalos, George M.; Bennett, Thomas E.; Sharp, M. Keith; Woodruff, Stewart; Oleary, Sean; Gillars, Kevin; Lemon, Mark; Sojka, Jan

1995-01-01

The investigation of cardiovascular adaptation to space flight has seen substantial advancement in the last several years. In-flight echocardiographic measurements of astronaut cardiac function on the Space Shuttle have documented an initial increase, followed by a progressive reduction in both left ventricular volume index and stroke volume with a compensatory increase in heart rate to maintain cardiac output. To date, the reduced cardiac size and stroke volume have been presumed to be the consequence of the reduction in circulating fluid volume within a few days after orbital insertion. However, no specific mechanism for the reduced stroke volume has been identified. The following investigation proposes the use of a hydraulic model of the cardiovascular system to examine the possibility that the observed reduction in stroke volume may, in part, be related to fluid physics effects on heart function. The automated model is being prepared to fly as a Get Away Special (GAS) payload within the next year.

A leader-return-stroke consistent macroscopic model for calculations of return stroke current and its optical and electromagnetic emissions

NASA Astrophysics Data System (ADS)

Cai, Shuyao; Chen, Mingli; Du, Yaping; Qin, Zilong

2017-08-01

A downward lightning flash usually starts with a downward leader and an upward connecting leader followed by an upward return stroke. It is the preceding leader that governs the following return stroke property. Besides, the return stroke property evolves with height and time. These two aspects, however, are not well addressed in most existing return stroke models. In this paper, we present a leader-return stroke consistent model based on the time domain electric field integral equation, which is a growth and modification of Kumar's macroscopic model. The model is further extended to simulate the optical and electromagnetic emissions of a return stroke by introducing a set of equations relating the return stroke current and conductance to the optical and electromagnetic emissions. With a presumed leader initiation potential, the model can then simulate the temporal and spatial evolution of the current, charge transfer, channel size, and conductance of the return stroke, furthermore the optical and electromagnetic emissions. The model is tested with different leader initiation potentials ranging from -10 to -140 MV, resulting in different return stroke current peaks ranging from 2.6 to 209 kA with different return stroke speed peaks ranging from 0.2 to 0.8 speed of light and different optical power peaks ranging from 4.76 to 248 MW/m. The larger of the leader initiation potential, the larger of the return stroke current and speed. Both the return stroke current and speed attenuate exponentially as it propagates upward. All these results are qualitatively consistent with those reported in the literature.

Artery of Percheron: an unusual stroke presentation.

PubMed

Pitts-Tucker, Toby; Small, Jeremy

2018-03-28

An 86-year-old woman was admitted with multiple episodes of transient loss of consciousness. She was initially treated for seizures, and stroke was not considered likely. MRI on the same day of admission showed acute bilateral medial thalamic infarcts in keeping with the Artery of Percheron (AOP) territory infarcts. Investigation for polycythaemia and thrombocytosis showed JAK2 positive myeloproliferative neoplasm.A diagnosis of AOP infarction is often missed or delayed because it is rare and presents with variable neurological symptoms. Initial imaging in the form of CT is often negative, and some report that initial MRI findings may also be normal.An awareness of a wide range of differential diagnoses alongside a multi-modality imaging approach is required to reach a diagnosis.Although there are several other case reports of AOP infarction in the literature, this is the first to present with transient symptoms initially mistaken for seizure activity. © BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Twelve-Month Clinical and Quality-of-Life Outcomes in the Interventional Management of Stroke III Trial.

PubMed

Palesch, Yuko Y; Yeatts, Sharon D; Tomsick, Thomas A; Foster, Lydia D; Demchuk, Andrew M; Khatri, Pooja; Hill, Michael D; Jauch, Edward C; Jovin, Tudor G; Yan, Bernard; von Kummer, Rüdiger; Molina, Carlos A; Goyal, Mayank; Schonewille, Wouter J; Mazighi, Mikael; Engelter, Stefan T; Anderson, Craig; Spilker, Judith; Carrozzella, Janice; Ryckborst, Karla J; Janis, L Scott; Simpson, Annie; Simpson, Kit N; Broderick, Joseph P

2015-05-01

Randomized trials have indicated a benefit for endovascular therapy in appropriately selected stroke patients at 3 months, but data regarding outcomes at 12 months are currently lacking. We compared functional and quality-of-life outcomes at 12 months overall and by stroke severity in stroke patients treated with intravenous tissue-type plasminogen activator followed by endovascular treatment as compared with intravenous tissue-type plasminogen activator alone in the Interventional Management of Stroke III Trial. The key outcome measures were a modified Rankin Scale score ≤2 (functional independence) and the Euro-QoL EQ-5D, a health-related quality-of-life measure. 656 subjects with moderate-to-severe stroke (National Institutes of Health Stroke Scale ≥8) were enrolled at 58 centers in the United States (41 sites), Canada (7), Australia (4), and Europe (6). There was an interaction between treatment group and stroke severity in the repeated measures analysis of modified Rankin Scale ≤2 outcome (P=0.039). In the 204 participants with severe stroke (National Institutes of Health Stroke Scale ≥20), a greater proportion of the endovascular group had a modified Rankin Scale ≤2 (32.5%) at 12 months as compared with the intravenous tissue-type plasminogen activator group (18.6%, P=0.037); no difference was seen for the 452 participants with moderately severe strokes (55.6% versus 57.7%). In participants with severe stroke, the endovascular group had 35.2 (95% confidence interval: 2.1, 73.3) more quality-adjusted-days over 12 months as compared with intravenous tissue-type plasminogen activator alone. Endovascular therapy improves functional outcome and health-related quality-of-life at 12 months after severe ischemic stroke. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00359424. © 2015 American Heart Association, Inc.

Effects of task-specific and impairment-based training compared with usual care on functional walking ability after inpatient stroke rehabilitation: LEAPS Trial.

PubMed

Nadeau, Stephen E; Wu, Samuel S; Dobkin, Bruce H; Azen, Stanley P; Rose, Dorian K; Tilson, Julie K; Cen, Steven Y; Duncan, Pamela W

2013-05-01

After inpatient stroke rehabilitation, many people still cannot participate in community activities because of limited walking ability. To compare the effectiveness of 2 conceptually different, early physical therapy (PT) interventions to usual care (UC) in improving walking 6 months after stroke. The locomotor experience applied post-stroke (LEAPS) study was a single-blind, randomized controlled trial conducted in 408 adults with disabling hemiparetic stroke. Participants were stratified at baseline (2 months) by impairment in walking speed: severe (<0.4 m/s) or moderate (0.4 to <0.8 m/s). Between 2 and 6 months, they received either only UC (n = 143) or UC plus 36 therapist-provided sessions of either (1) walking training on a treadmill using body-weight support and practice overground at clinics (locomotor training program [LTP], n = 139) or (2) impairment-based strength and balance exercise at home (home exercise program [HEP], n = 126). LTP participants were 18% more likely to transition to a higher functional walking level: severe to >0.4 m/s and moderate to >0.8 m/s than UC participants (95% confidence interval [CI] = 7%-29%), and HEP participants were 17% more likely to transition (95% CI = 5%-29%). Mean gain in walking speed in LTP participants was 0.13 m/s greater (95% CI = 0.09-0.18) and in HEP participants, 0.10 m/s greater (95% CI = 0.05-0.14) than in UC participants. Progressive PT, using either walking training on a treadmill and overground, conducted in a clinic, or strength and balance exercises conducted at home, was superior to UC in improving walking, regardless of severity of initial impairment.

SALGOT - Stroke Arm Longitudinal study at the University of Gothenburg, prospective cohort study protocol

PubMed Central

2011-01-01

Background Recovery patterns of upper extremity motor function have been described in several longitudinal studies, but most of these studies have had selected samples, short follow up times or insufficient outcomes on motor function. The general understanding is that improvements in upper extremity occur mainly during the first month after the stroke incident and little if any, significant recovery can be gained after 3-6 months. The purpose of this study is to describe the recovery of upper extremity function longitudinally in a non-selected sample initially admitted to a stroke unit with first ever stroke, living in Gothenburg urban area. Methods/Design A sample of 120 participants with a first-ever stroke and impaired upper extremity function will be consecutively included from an acute stroke unit and followed longitudinally for one year. Assessments are performed at eight occasions: at day 3 and 10, week 3, 4 and 6, month 3, 6 and 12 after onset of stroke. The primary clinical outcome measures are Action Research Arm Test and Fugl-Meyer Assessment for Upper Extremity. As additional measures, two new computer based objective methods with kinematic analysis of arm movements are used. The ABILHAND questionnaire of manual ability, Stroke Impact Scale, grip strength, spasticity, pain, passive range of motion and cognitive function will be assessed as well. At one year follow up, two patient reported outcomes, Impact on Participation and Autonomy and EuroQol Quality of Life Scale, will be added to cover the status of participation and aspects of health related quality of life. Discussion This study comprises a non-selected population with first ever stroke and impaired arm function. Measurements are performed both using traditional clinical assessments as well as computer based measurement systems providing objective kinematic data. The ICF classification of functioning, disability and health is used as framework for the selection of assessment measures. The study design with several repeated measurements on motor function will give us more confident information about the recovery patterns after stroke. This knowledge is essential both for optimizing rehabilitation planning as well as providing important information to the patient about the recovery perspectives. Trial registration ClinicalTrials.gov: NCT01115348 PMID:21612620

Prediction of outcome in neurogenic oropharyngeal dysphagia within 72 hours of acute stroke.

PubMed

Ickenstein, Guntram W; Höhlig, Carolin; Prosiegel, Mario; Koch, Horst; Dziewas, Rainer; Bodechtel, Ulf; Müller, Rainer; Reichmann, Heinz; Riecker, Axel

2012-10-01

Stroke is the most frequent cause of neurogenic oropharyngeal dysphagia (NOD). In the acute phase of stroke, the frequency of NOD is greater than 50% and, half of this patient population return to good swallowing within 14 days while the other half develop chronic dysphagia. Because dysphagia leads to aspiration pneumonia, malnutrition, and in-hospital mortality, it is important to pay attention to swallowing problems. The question arises if a prediction of severe chronic dysphagia is possible within the first 72 hours of acute stroke. On admission to the stroke unit, all stroke patients were screened for swallowing problems by the nursing staff within 2 hours. Patients showing signs of aspiration were included in the study (n = 114) and were given a clinical swallowing examination (CSE) by the swallowing/speech therapist within 24 hours and a swallowing endoscopy within 72 hours by the physician. The primary outcome of the study was the functional communication measure (FCM) of swallowing (score 1-3, tube feeding dependency) on day 90. The grading system with the FCM swallowing and the penetration-aspiration scale (PAS) in the first 72 hours was tested in a multivariate analysis for its predictive value for tube feeding-dependency on day 90. For the FCM level 1 to 3 (P < .0022) and PAS level 5 to 8 (P < .00001), the area under the curve (AUC) was 72.8% and showed an odds ratio of 11.8 (P < .00001; 95% confidence interval 0.036-0.096), achieving for the patient a 12 times less chance of being orally fed on day 90 and therefore still being tube feeding-dependent. We conclude that signs of aspiration in the first 72 hours of acute stroke can predict severe swallowing problems on day 90. Consequently, patients should be tested on admission to a stroke unit and evaluated with established dysphagia scales to prevent aspiration pneumonia and malnutrition. A dysphagia program can lead to better communication within the stroke unit team to initiate the appropriate diagnostics and swallowing therapy as soon as possible. Copyright © 2012 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Higher total serum cholesterol levels are associated with less severe strokes and lower all-cause mortality: ten-year follow-up of ischemic strokes in the Copenhagen Stroke Study.

PubMed

Olsen, Tom Skyhøj; Christensen, Rune Haubo Bojesen; Kammersgaard, Lars Peter; Andersen, Klaus Kaae

2007-10-01

Evidence of a causal relation between serum cholesterol and stroke is inconsistent. We investigated the relation between total serum cholesterol and both stroke severity and poststroke mortality to test the hypothesis that hypercholesterolemia is primarily associated with minor stroke. In the study, 652 unselected patients with ischemic stroke arrived at the hospital within 24 hours of stroke onset. A measure of total serum cholesterol was obtained in 513 (79%) within the 24-hour time window. Stroke severity was measured with the Scandinavian Stroke Scale (0=worst, 58=best); a full cardiovascular risk profile was established for all. Death within 10 years after stroke onset was obtained from the Danish Registry of Persons. Mean+/-SD age of the 513 patients was 75+/-10 years, 54% were women, and the mean+/-SD Scandinavian Stroke Scale score was 39+/-17. Serum cholesterol was inversely and almost linearly related to stroke severity: an increase of 1 mmol/L in total serum cholesterol resulted in an increase in the Scandinavian Stroke Scale score of 1.32 (95% CI, 0.28 to 2.36, P=0.013), meaning that higher cholesterol levels are associated with less severe strokes. A survival analysis revealed an inverse linear relation between serum cholesterol and mortality, meaning that an increase of 1 mmol/L in cholesterol results in a hazard ratio of 0.89 (95% CI, 0.82 to 0.97, P=0.01). The results of our study support the hypothesis that a higher cholesterol level favors development of minor strokes. Because of selection, therefore, major strokes are more often seen in patients with lower cholesterol levels. Poststroke mortality, therefore, is inversely related to cholesterol.

The clinical safety of high-dose piracetam--its use in the treatment of acute stroke.

PubMed

De Reuck, J; Van Vleymen, B

1999-03-01

Recent post-marketing surveillance reports have confirmed the benign safety profile and lack of organ toxicity shown by piracetam during its 25 years of clinical usage. Tolerance has proved equally good with the more recent use of larger doses (up to 24 g/day) for the long-term control of cortical myoclonus and when given intravenously to patients with acute stroke. This paper provides a brief review of these findings and records the safety of piracetam as found in the Piracetam in Acute Stroke Study (PASS), a randomized multicenter placebo-controlled study in 927 patients with acute ischemic stroke. Patients receive one intravenous bolus injection of placebo or 12 g piracetam, piracetam 12 g daily for 4 weeks and maintenance treatment for 8 weeks. The major results have been reported (De Deyn et al., Stroke 28 [1997] 2347-2352). Safety was assessed taking into account adverse events including abnormal laboratory test results and mortality. Death within 12 weeks occurred more frequently in the piracetam group but the difference from placebo was not significant. Of many potential risk, prognostic and treatment-related factors examined by logistic regression, 6 contributed significantly to death of which the most important were initial severity of stroke and age. Neither treatment nor any treatment-related factor contributed significantly to death. Adverse events were similar in frequency, type and severity in piracetam and placebo groups. Events of cerebral, non-cerebral and uncertain origin likewise occurred with similar frequency. Few patients discontinued because of adverse events. There was no difference between treatments in the frequency of events associated with bleeding, including hemorrhagic transformation of infarction. An important finding was that, of 31 patients with primary hemorrhagic stroke enrolled, 3 piracetam-treated patients died compared with 6 on placebo. The results suggest that piracetam in high dosage may be given to patients with acute stroke without significant adverse effects.

Prehospital use of magnesium sulfate as neuroprotection in acute stroke.

PubMed

Saver, Jeffrey L; Starkman, Sidney; Eckstein, Marc; Stratton, Samuel J; Pratt, Franklin D; Hamilton, Scott; Conwit, Robin; Liebeskind, David S; Sung, Gene; Kramer, Ian; Moreau, Gary; Goldweber, Robert; Sanossian, Nerses

2015-02-05

Magnesium sulfate is neuroprotective in preclinical models of stroke and has shown signals of potential efficacy with an acceptable safety profile when delivered early after stroke onset in humans. Delayed initiation of neuroprotective agents has hindered earlier phase 3 trials of neuroprotective agents. We randomly assigned patients with suspected stroke to receive either intravenous magnesium sulfate or placebo, beginning within 2 hours after symptom onset. A loading dose was initiated by paramedics before the patient arrived at the hospital, and a 24-hour maintenance infusion was started on the patient's arrival at the hospital. The primary outcome was the degree of disability at 90 days, as measured by scores on the modified Rankin scale (range, 0 to 6, with higher scores indicating greater disability). Among the 1700 enrolled patients (857 in the magnesium group and 843 in the placebo group), the mean (±SD) age was 69±13 years, 42.6% were women, and the mean pretreatment score on the Los Angeles Motor Scale of stroke severity (range, 0 to 10, with higher scores indicating greater motor deficits) was 3.7±1.3. The final diagnosis of the qualifying event was cerebral ischemia in 73.3% of patients, intracranial hemorrhage in 22.8%, and a stroke-mimicking condition in 3.9%. The median interval between the time the patient was last known to be free of stroke symptoms and the start of the study-drug infusion was 45 minutes (interquartile range, 35 to 62), and 74.3% of patients received the study-drug infusion within the first hour after symptom onset. There was no significant shift in the distribution of 90-day disability outcomes on the global modified Rankin scale between patients in the magnesium group and those in the placebo group (P=0.28 by the Cochran-Mantel-Haenszel test); mean scores at 90 days did not differ between the magnesium group and the placebo group (2.7 in each group, P=1.00). No significant between-group differences were noted with respect to mortality (15.4% in the magnesium group and 15.5% in the placebo group, P=0.95) or all serious adverse events. Prehospital initiation of magnesium sulfate therapy was safe and allowed the start of therapy within 2 hours after the onset of stroke symptoms, but it did not improve disability outcomes at 90 days. (Funded by the National Institute of Neurological Disorders and Stroke; FAST-MAG ClinicalTrials.gov number, NCT00059332.).

Functional Stroke Mimics: Incidence and Characteristics at a Primary Stroke Center in the Middle East

PubMed Central

Wilkins, Stacy Schantz; Bourke, Paula; Salam, Abdul; Akhtar, Naveed; D'Souza, Atlantic; Kamran, Saadat; Bhutta, Zain; Shuaib, Ashfaq

2018-01-01

ABSTRACT Objective Approximately 30% of individuals who initially present with stroke are found to be stroke mimics (SM), with functional/psychological SM (FSM) accounting for up to 6.4% of all stroke presentations. Middle Eastern countries may have higher rates of somatization of emotional distress. The aim of this study was to evaluate the incidence and characteristics of FSM at a large general hospital in the Middle East. Methods All patients presenting with an initial diagnosis of stroke from June 2015 to September 2016 were eligible for this study. Clinical and sociodemographic data were obtained from the hospital's stroke database. All SM and strokes were diagnosed by Joint Commission International–certified stroke program neurologists. SM was defined as any discharge diagnosis (other than acute stroke) for symptoms that prompted initial admission for suspected stroke. FSM were compared with medical stroke mimics (MSM) and strokes (ischemic, hemorrhagic, and transient ischemic attacks). Results A total of 1961 patients were identified; 161 FSM (8.2%), 390 MSM (19.9%), and 1410 strokes (71.9%) (985 ischemic strokes, 196 transient ischemic attacks, 229 intracerebral hemorrhages). Admission with FSM was related to patients' nationality, with the highest frequency in Arabic (15.6%) and African (16.8%) patients. FSM patients were younger, more often female, and had fewer cardiovascular risk factors except for smoking compared with the strokes. FSM patients presented with more left-sided weakness and had more magnetic resonance imagings than the stroke and MSM groups. A total of 9.9% of FSM patients received thrombolysis versus only 0.5% of the MSM and 16.4% of ischemic strokes. Conclusions FSM frequencies varied by nationality, with Arab and African nationals being twice as prevalent. Stress, vulnerable status as expats, sociopolitical instability, and exposure to trauma are proposed as potential factors contributing to FSM. PMID:29394187

Anxiety disorders and risk of stroke: A systematic review and meta-analysis.

PubMed

Pérez-Piñar, M; Ayerbe, L; González, E; Mathur, R; Foguet-Boreu, Q; Ayis, S

2017-03-01

Anxiety disorders are the most common mental health problem worldwide. However, the evidence on the association between anxiety disorders and risk of stroke is limited. This systematic review and meta-analysis presents a critical appraisal and summary of the available evidence on the association between anxiety disorders and risk of stroke. Cohort studies reporting risk of stroke among patients with anxiety disorders were searched in PubMed, Embase, PsycINFO, Scopus, and the Web of Science, from database inception to June 2016. The quality of the studies was assessed using standard criteria. A meta-analysis was undertaken to obtain pooled estimates of the risk of stroke among patients with anxiety disorders. Eight studies, including 950,759 patients, from the 11,764 references initially identified, were included in this review. A significantly increased risk of stroke for patients with anxiety disorders was observed, with an overall hazard ratio: 1.24 (1.09-1.41), P=0.001. No significant heterogeneity between studies was detected and the funnel plot suggested that publication bias was unlikely. Limited evidence suggests that the risk of stroke is increased shortly after the diagnosis of anxiety and that risk of stroke may be higher for patients with severe anxiety. Anxiety disorders are a very prevalent modifiable condition associated with risk of stroke increased by 24%. This evidence could inform the development of interventions for the management of anxiety and the prevention of stroke. Further studies on the risk of stroke in patients with anxiety, and the explanatory factors for this association, are required. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

Substantial Progress Yet Significant Opportunity for Improvement in Stroke Care in China.

PubMed

Li, Zixiao; Wang, Chunjuan; Zhao, Xingquan; Liu, Liping; Wang, Chunxue; Li, Hao; Shen, Haipeng; Liang, Li; Bettger, Janet; Yang, Qing; Wang, David; Wang, Anxin; Pan, Yuesong; Jiang, Yong; Yang, Xiaomeng; Zhang, Changqing; Fonarow, Gregg C; Schwamm, Lee H; Hu, Bo; Peterson, Eric D; Xian, Ying; Wang, Yilong; Wang, Yongjun

2016-11-01

Stroke is a leading cause of death in China. Yet the adherence to guideline-recommended ischemic stroke performance metrics in the past decade has been previously shown to be suboptimal. Since then, several nationwide stroke quality management initiatives have been conducted in China. We sought to determine whether adherence had improved since then. Data were obtained from the 2 phases of China National Stroke Registries, which included 131 hospitals (12 173 patients with acute ischemic stroke) in China National Stroke Registries phase 1 from 2007 to 2008 versus 219 hospitals (19 604 patients) in China National Stroke Registries phase 2 from 2012 to 2013. Multiple regression models were developed to evaluate the difference in adherence to performance measure between the 2 study periods. The overall quality of care has improved over time, as reflected by the higher composite score of 0.76 in 2012 to 2013 versus 0.63 in 2007 to 2008. Nine of 13 individual performance metrics improved. However, there were no significant improvements in the rates of intravenous thrombolytic therapy and anticoagulation for atrial fibrillation. After multivariate analysis, there remained a significant 1.17-fold (95% confidence interval, 1.14-1.21) increase in the odds of delivering evidence-based performance metrics in the more recent time periods versus older data. The performance metrics with the most significantly increased odds included stroke education, dysphagia screening, smoking cessation, and antithrombotics at discharge. Adherence to stroke performance metrics has increased over time, but significant opportunities remain for further improvement. Continuous stroke quality improvement program should be developed as a national priority in China. © 2016 American Heart Association, Inc.

Alzheimer's disease and other neurological disorders.

PubMed

Henderson, V W

2007-10-01

Menopausal status and estrogen-containing hormone therapy may influence several neurological disorders, including Alzheimer's disease, epilepsy, migraine headache, multiple sclerosis, Parkinson's disease, sleep disorders, and stroke. For most of these illnesses, evidence on hormone therapy is insufficient to guide practice decisions. For stroke, clinical trial evidence indicates that hormone therapy increases risk of cerebral infarction. For women with Alzheimer's disease, estrogen treatment trials have tended to be small and of short duration. Most suggest that estrogen started after the onset of dementia symptoms does not meaningfully improve cognition or slow disease progression. Hormone therapy initiated after age 64 increased all-cause dementia in the Women's Health Initiative Memory Study. Many observational studies, however, report protective associations between hormone use and Alzheimer risk. Apparent risk reduction may represent a bias toward hormone therapy, since hormones are more often prescribed to healthier women. However, when compared to the Women's Health Initiative Memory Study, estrogen exposures in many observational studies reflect hormone initiation at a younger age, closer to the time of menopause. One intriguing hypothesis is that hormone therapy initiated or used during an early critical window may reduce later Alzheimer incidence. Public health implications of this hypothesis are important, but current data are inadequate to decide the issue.

Long-Term Costs of Ischemic Stroke and Major Bleeding Events among Medicare Patients with Nonvalvular Atrial Fibrillation

PubMed Central

Mercaldi, Catherine J.; Siu, Kimberly; Sander, Stephen D.; Walker, David R.; Wu, You; Li, Qian; Wu, Ning

2012-01-01

Purpose. Acute healthcare utilization of stroke and bleeding has been previously examined among patients with nonvalvular atrial fibrillation (NVAF). The long-term cost of such outcomes over several years is not well understood. Methods. Using 1999–2009 Medicare medical and enrollment data, we identified incident NVAF patients without history of stroke or bleeding. Patients were followed from the first occurrence of ischemic stroke, major bleeding, or intracranial hemorrhage (ICH) resulting in hospitalization. Those with events were matched with 1–5 NVAF patients without events. Total incremental costs of events were calculated as the difference between costs for patients with events and matched controls for up to 3 years. Results. Among the 25,465 patients who experienced events, 94.5% were successfully matched. In the first year after event, average incremental costs were $32,900 for ischemic stroke, $23,414 for major bleeding, and $47,640 for ICH. At 3 years after these events, costs remained elevated by $3,156–$5,400 per annum. Conclusion. While the costs of stroke and bleeding among patients with NVAF are most dramatic in the first year, utilization remained elevated at 3 years. Cost consequences extend beyond the initial year after these events and should be accounted for when assessing the cost-effectiveness of treatment regimens for stroke prevention. PMID:23082276

Herpes Simplex Virus Encephalitis: Atypical Presentation as a Right Middle Cerebral Artery Stroke.

PubMed

Shoaib, Maria; Kraus, Jacqueline J; Khan, Muhammad T

2018-01-15

Herpes simplex virus encephalitis (HSVE) is a medical emergency associated with high mortality and morbidity. Definitive diagnosis is established by history, clinical examination, neuroimaging studies, supportive electroencephalogram (EEG) findings, and cerebrospinal fluid (CSF) analysis. We report a case of HSVE presenting as a stroke mimic in a 76-year-old female with a history of atrial fibrillation on warfarin. She was admitted to our medical intensive care unit with intermittent fever, lethargy, and new onset left-sided hemiparesis. A computed tomography (CT) of the head showed a right middle cerebral artery (MCA) acute ischemic stroke with midline shift and a dense right MCA sign. Brain magnetic resonance imaging (MRI) showed evidence of acute stroke with consideration of herpes encephalitis. CSF analysis was positive for herpes simplex virus (HSV) type one. She recovered with high-dose intravenous acyclovir therapy. Our patient was a diagnostic dilemma, initially being diagnosed with an acute ischemic stroke and yet found to have HSVE, which mimicked an acute ischemic stroke. Delay in treatment may result in devastating clinical outcomes that may include severe cognitive, focal neurological deficits, persistent seizures, and even death. This case highlights the importance of a multidisciplinary approach and the need for increased awareness of an atypical presentation of HSVE among emergency physicians, neurologist, intensivists, and radiologists.

Twelve-month Clinical and Quality-of-Life Outcomes in the Interventional Management of Stroke III Trial

PubMed Central

Palesch, Yuko Y.; Yeatts, Sharon D.; Tomsick, Thomas A; Foster, Lydia D.; Demchuk, Andrew M.; Khatri, Pooja; Hill, Michael D.; Jauch, Edward C.; Jovin, Tudor G.; Yan, Bernard; von Kummer, Rüdiger; Molina, Carlos A.; Goyal, Mayank; Schonewille, Wouter J.; Mazighi, Mikael; Engelter, Stefan T.; Anderson, Craig; Spilker, Judith; Carrozzella, Janice; Ryckborst, Karla J.; Janis, L. Scott; Simpson, Annie; Simpson, Kit N.; Broderick, Joseph P.

2015-01-01

Background and Purpose Randomized trials have indicated a benefit for endovascular therapy in appropriately selected stroke patients at 3 months but data regarding outcomes at 12 months are currently lacking. Methods We compared functional and quality of life outcomes at 12 months overall and by stroke severity in stroke patients treated with intravenous (IV) tissue plasminogen activator (t-PA) followed by endovascular treatment as compared to IV t-PA alone in the Interventional Management of Stroke (IMS) III Trial. The key outcome measures were a modified Rankin Scale (mRS) score ≤ 2 (functional independence) and the Euro-QoL EQ-5D, a health-related quality-of-life measure (HRQoL). Results 656 subjects with moderate to severe stroke (National Institutes of Health Stroke Scale ≥ 8) were enrolled at 58 centers in the United States (41 sites), Canada (7), Australia (4), and Europe (6). There was an interaction between treatment group and stroke severity in the repeated measures analysis of mRS ≤ 2 outcome (p=0.039). In the 204 participants with severe stroke (NIHSS ≥ 20), a greater proportion of the endovascular group had a mRS ≤ 2 (32.5%) at 12 months as compared to the IV t-PA group (18.6%, p=0.037); no difference was seen for the 452 participants with moderately-severe strokes (55.6% vs. 57.7%). In participants with severe stroke, the endovascular group had 35.2 (95% CI: 2.1, 73.3) more quality-adjusted-days over 12 months as compared to IV t-PA alone. Conclusions Endovascular therapy improves functional outcome and HRQoL at 12 months after severe ischemic stroke. PMID:25858239

Antihypertensive treatment prolongs tissue plasminogen activator door-to-treatment time: secondary analysis of the INSTINCT trial.

PubMed

Skolarus, Lesli E; Scott, Phillip A; Burke, James F; Adelman, Eric E; Frederiksen, Shirley M; Kade, Allison M; Kalbfleisch, Jack D; Ford, Andria L; Meurer, William J

2012-12-01

Identifying modifiable tissue plasminogen activator treatment delays may improve stroke outcomes. We hypothesized that prethrombolytic antihypertensive treatment (AHT) may prolong door-to-treatment time (DTT). We performed an analysis of consecutive tissue plasminogen activator-treated patients at 24 randomly selected community hospitals in the Increasing Stroke Treatment through Interventional Behavior Change Tactics (INSTINCT) trial between 2007 and 2010. DTT among stroke patients who received prethrombolytic AHT were compared with those who did not receive prethrombolytic AHT. We then calculated a propensity score for the probability of receiving prethrombolytic AHT using logistic regression with demographics, stroke risk factors, home medications, stroke severity (National Institutes of Health Stroke Scale), onset-to-door time, admission glucose, pretreatment blood pressure, emergency medical service transport, and location at time of stroke as independent variables. A paired t test was performed to compare the DTT between the propensity-matched groups. Of 534 tissue plasminogen activator-treated stroke patients analyzed, 95 received prethrombolytic AHT. In the unmatched cohort, patients who received prethrombolytic AHT had a longer DTT (mean increase, 9 minutes; 95% confidence interval, 2-16 minutes) than patients who did not. After propensity matching, patients who received prethrombolytic AHT had a longer DTT (mean increase, 10.4 minutes; 95% confidence interval, 1.9-18.8) than patients who did not receive prethrombolytic AHT. Prethrombolytic AHT is associated with modest delays in DTT. This represents a potential target for quality-improvement initiatives. Further research evaluating optimum prethrombolytic hypertension management is warranted.

Contraction of Blood Clots Is Impaired in Acute Ischemic Stroke.

PubMed

Tutwiler, Valerie; Peshkova, Alina D; Andrianova, Izabella A; Khasanova, Dina R; Weisel, John W; Litvinov, Rustem I

2017-02-01

Obstructive thrombi or thrombotic emboli are the pathogenic basis of ischemic stroke. In vitro blood clots and in vivo thrombi can undergo platelet-driven contraction (retraction), resulting in volume shrinkage. Clot contraction can potentially reduce vessel occlusion and improve blood flow past emboli or thrombi. The aim of this work was to examine a potential pathogenic role of clot contraction in ischemic stroke. We used a novel automated method that enabled us to quantify time of initiation and extent and rate of clot contraction in vitro. The main finding is that clot contraction from the blood of stroke patients was reduced compared with healthy subjects. Reduced clot contraction correlated with a lower platelet count and their dysfunction, higher levels of fibrinogen and hematocrit, leukocytosis, and other changes in blood composition that may affect platelet function and properties of blood clots. Platelets from stroke patents were spontaneously activated and displayed reduced responsiveness to additional stimulation. Clinical correlations with respect to severity and stroke pathogenesis suggest that the impaired clot contraction has the potential to be a pathogenic factor in ischemic stroke. The changeable ability of clots and thrombi to shrink in volume may be a novel unappreciated mechanism that aggravates or alleviates the course and outcomes of ischemic stroke. The clinical importance of clot or thrombus transformations in vivo and the diagnostic and prognostic value of this blood test for clot contraction need further exploration. © 2016 American Heart Association, Inc.

Contraction of Blood Clots is Impaired in Acute Ischemic Stroke

PubMed Central

Tutwiler, Valerie; Peshkova, Alina D.; Andrianova, Izabella A.; Khasanova, Dina R.; Weisel, John W.; Litvinov, Rustem I.

2016-01-01

Objective Obstructive thrombi or thrombotic emboli are the pathogenic basis of ischemic stroke. In vitro blood clots and in vivo thrombi can undergo platelet-driven contraction (retraction), resulting in volume shrinkage. Clot contraction can potentially reduce vessel occlusion and improve blood flow past emboli or thrombi. The aim of this work was to examine a potential pathogenic role of clot contraction in ischemic stroke. Approach and Results We employed a novel automated method that enabled us to quantify time of initiation, extent and rate of clot contraction in vitro. The main finding is clot contraction from the blood of stroke patients was reduced compared to healthy subjects. Reduced clot contraction correlated with a lower platelet count and their dysfunction, higher levels of fibrinogen and hematocrit, leukocytosis and other changes in blood composition that may affect platelet function and properties of blood clots. Platelets from stroke patents were spontaneously activated and displayed reduced responsiveness to additional stimulation. Clinical correlations with respect to severity and stroke etiology suggest that the impaired clot contraction has the potential to be a pathogenic factor in ischemic stroke. Conclusions The changeable ability of clots and thrombi to shrink in volume may be a novel unappreciated mechanism that aggravates or alleviates the course and outcomes of ischemic stroke. The clinical importance of clot or thrombus transformations in vivo and the diagnostic and prognostic value of this blood test for clot contraction needs further exploration. PMID:27908894

Microparticle Shedding from Neural Progenitor Cells and Vascular Compartment Cells Is Increased in Ischemic Stroke.

PubMed

Chiva-Blanch, Gemma; Suades, Rosa; Crespo, Javier; Peña, Esther; Padró, Teresa; Jiménez-Xarrié, Elena; Martí-Fàbregas, Joan; Badimon, Lina

2016-01-01

Ischemic stroke has shown to induce platelet and endothelial microparticle shedding, but whether stroke induces microparticle shedding from additional blood and vascular compartment cells is unclear. Neural precursor cells have been shown to replace dying neurons at sites of brain injury; however, if neural precursor cell activation is associated to microparticle shedding, and whether this activation is maintained at long term and associates to stroke type and severity remains unknown. We analyzed neural precursor cells and blood and vascular compartment cells microparticle shedding after an acute ischemic stroke. Forty-four patients were included in the study within the first 48h after the onset of stroke. The cerebral lesion size was evaluated at 3-7 days of the stroke. Circulating microparticles from neural precursor cells and blood and vascular compartment cells (platelets, endothelial cells, erythrocytes, leukocytes, lymphocytes, monocytes and smooth muscle cells) were analyzed by flow cytometry at the onset of stroke and at 7 and 90 days. Forty-four age-matched high cardiovascular risk subjects without documented vascular disease were used as controls. Compared to high cardiovascular risk controls, patients showed higher number of neural precursor cell- and all blood and vascular compartment cell-derived microparticles at the onset of stroke, and after 7 and 90 days. At 90 days, neural precursor cell-derived microparticles decreased and smooth muscle cell-derived microparticles increased compared to levels at the onset of stroke, but only in those patients with the highest stroke-induced cerebral lesions. Stroke increases blood and vascular compartment cell and neural precursor cell microparticle shedding, an effect that is chronically maintained up to 90 days after the ischemic event. These results show that stroke induces a generalized blood and vascular cell activation and the initiation of neuronal cell repair process after stroke. Larger cerebral lesions associate with deeper vessel injury affecting vascular smooth muscle cells.

Microparticle Shedding from Neural Progenitor Cells and Vascular Compartment Cells Is Increased in Ischemic Stroke

PubMed Central

Chiva-Blanch, Gemma; Suades, Rosa; Crespo, Javier; Peña, Esther; Padró, Teresa; Jiménez-Xarrié, Elena; Martí-Fàbregas, Joan; Badimon, Lina

2016-01-01

Purpose Ischemic stroke has shown to induce platelet and endothelial microparticle shedding, but whether stroke induces microparticle shedding from additional blood and vascular compartment cells is unclear. Neural precursor cells have been shown to replace dying neurons at sites of brain injury; however, if neural precursor cell activation is associated to microparticle shedding, and whether this activation is maintained at long term and associates to stroke type and severity remains unknown. We analyzed neural precursor cells and blood and vascular compartment cells microparticle shedding after an acute ischemic stroke. Methods Forty-four patients were included in the study within the first 48h after the onset of stroke. The cerebral lesion size was evaluated at 3–7 days of the stroke. Circulating microparticles from neural precursor cells and blood and vascular compartment cells (platelets, endothelial cells, erythrocytes, leukocytes, lymphocytes, monocytes and smooth muscle cells) were analyzed by flow cytometry at the onset of stroke and at 7 and 90 days. Forty-four age-matched high cardiovascular risk subjects without documented vascular disease were used as controls. Results Compared to high cardiovascular risk controls, patients showed higher number of neural precursor cell- and all blood and vascular compartment cell-derived microparticles at the onset of stroke, and after 7 and 90 days. At 90 days, neural precursor cell-derived microparticles decreased and smooth muscle cell-derived microparticles increased compared to levels at the onset of stroke, but only in those patients with the highest stroke-induced cerebral lesions. Conclusions Stroke increases blood and vascular compartment cell and neural precursor cell microparticle shedding, an effect that is chronically maintained up to 90 days after the ischemic event. These results show that stroke induces a generalized blood and vascular cell activation and the initiation of neuronal cell repair process after stroke. Larger cerebral lesions associate with deeper vessel injury affecting vascular smooth muscle cells. PMID:26815842

Early initiation of new oral anticoagulants in acute stroke and TIA patients with nonvalvular atrial fibrillation.

PubMed

Shibazaki, Kensaku; Kimura, Kazumi; Aoki, Junya; Saji, Naoki; Sakai, Kenichiro

2013-08-15

The aim of this study was to investigate whether early initiation of new oral anticoagulants (NOAC) for acute stroke or transient ischemic attack (TIA) patients with nonvalvular atrial fibrillation (NVAF) are safe. Between March 2011 and September 2012, stroke or TIA patients with NVAF who started NOAC within 2 weeks were enrolled retrospectively. Symptomatic intracerebral hemorrhage (ICH), hemorrhagic transformation (HT) on T2*-weighted MRI, recurrence of stroke or TIA, systemic embolism and any bleeding complications after initiation of NOAC were evaluated. 41 patients (25 males; mean age 76.2 years) started NOAC; of which, 39 (95%) patients had stroke, and 2 (5%) had TIA. The median (interquartile range) interval from onset to treatment with NOAC was 2 (1-6) days. Symptomatic ICH was not observed. HT on initial T2* and new HT on follow-up T2* were 5 (12%) and 11 (31%), but it was asymptomatic. Of 5 patients who had HT on the initial T2*, enlargement of hemorrhage on follow-up T2* (hemorrhagic infarction (HI) Type 1→HI Type 2) was observed in 1 patient, but it was asymptomatic. None of the patients had recurrent stroke or TIA, systemic embolism, and any bleeding complications. The NOAC may be safe in acute stroke or TIA patients with NVAF. A large, prospective study is needed to confirm this. Copyright © 2013 Elsevier B.V. All rights reserved.

Blood pressure in the initial phase of acute ischaemic stroke: evolution and its role as an independent prognosis factor at discharge and after 3 months of follow-up.

PubMed

Armario, Pedro; Mártin-Baranera, Montserrat; Miguel Ceresuela, Luis; Hernández Del Rey, Raquel; Iribarnegaray, Eduardo; Pintado, Sara; Avila, Asunción; Bello, Juan; Luis Tovar, José; Alvarez-Sabin, José

2008-01-01

A prospective observational study was aimed at assessing the role of blood pressure (BP) during the first 24 h from stroke onset on the outcome of acute ischaemic stroke. Subjects admitted within the first 3 h from stroke onset were included. Stroke severity was evaluated with the Canadian Stroke Scale (CSS). Functional recovery was defined as a modified Rankin Scale score < or =2. One hundred subjects were included. In a logistic regression model, the independent predictors of poor functional recovery at discharge were: age (OR = 1.12; 95% CI 1.04-1.21; p = 0.0033), non-lacunar stroke subtype (OR = 4.31; 95% CI 1.07-17.31; p = 0.0395), diabetes mellitus (OR = 8.38; 95% CI 1.67-41.95; p = 0.0097), a CSS score at admission < or =8 (OR = 28.64; 95% CI 5.59-146.68; p<0.0001), an average systolic BP during the first 6 h > or =180 mmHg (OR = 13.34; 95% CI 1.34-133.10; p = 0.0272) and a lower diastolic BP average from 6 to 24 h (OR for 5 mmHg increase: 0.57; CI 95% 0.36-0.88; p = 0.0115). Similar results were observed after 3 months of follow-up. In ischaemic stroke patients, systolic BP over 180 mmHg in the first 6 h and a decrease of diastolic BP during the 6-24 h from stroke onset were independent predictors of a poor functional recovery.

The rate and extent of improvement with therapy from the different types of aphasia in the first year after stroke.

PubMed

Bakheit, A M O; Shaw, S; Carrington, S; Griffiths, S

2007-10-01

To examine the rate and extent of improvement from the different types of aphasia in the first year after stroke. A prospective longitudinal study. A specialist stroke unit. Seventy-five aphasic patients with first-ever stroke. The type of aphasia was classified according to the criteria of the Western Aphasia Battery. The Western Aphasia Battery aphasia quotient was used to measure the initial severity and the rate and extent of improvement from aphasia. Assessments were made at baseline and 4, 8, 12 and 24 weeks later. The median percentage increase in the Western Aphasia Battery aphasia quotient was statistically higher in patients with Broca's aphasia than in the other groups at all weeks. Patients with Wernicke's aphasia had a significantly greater median percentage increase in their aphasia quotient than those with conduction and anomic aphasia at weeks 12 and 24, but less than patients with global aphasia at week 24. Patients with Broca's aphasia appear to have the best prognosis for improvement of language function in the first year of stroke. The extent of improvement in patients with global aphasia is better than that of patients with Wernicke's aphasia.

Stroke in the very old: incidence, risk factors, clinical features, outcomes and access to resources--a 22-year population-based study.

PubMed

Béjot, Yannick; Rouaud, Olivier; Jacquin, Agnès; Osseby, Guy-Victor; Durier, Jérôme; Manckoundia, Patrick; Pfitzenmeyer, Pierre; Moreau, Thibault; Giroud, Maurice

2010-01-01

For several years, the burden of stroke in very old patients has been increasing in western countries. Nevertheless, we have little information about this new challenge in individuals >or=80. We ascertained all first-ever strokes in the population of Dijon, France (150,000 inhabitants), from 1985 to 2006. The incidence of stroke, risk factors, clinical presentation, resource mobilization and 1-month outcome were evaluated in individuals >or=80 and compared to the data obtained in younger patients. We collected 1,410 first-ever strokes in people >or=80 years (39%) versus 2,130 in those <80 years. The incidence was 997/100,000, and 68/100,000, respectively. Over the 22 years, the incidence of stroke in individuals >or=80 years rose significantly. A lower prevalence of diabetes, hypercholesterolemia and alcohol intake, as well as a higher prevalence of hypertension, atrial fibrillation, previous myocardial infarction and use of prestroke antiplatelet agents were noted in patients >or=80 years. The clinical presentation was severer and the 1-month outcome in terms of case fatality and handicap was worse, despite improvements observed over time. Finally, in patients >or=80 years, the use of CT scan, MRI, cervical Doppler, angiography and carotid surgery were significantly lower than for younger patients. Length of stay >30 days was more frequent, and discharge to prestroke residence was less common. However, all these improved between the first and the last study periods. Our findings have important implications not only for clinical management but also for initiating preventive strategies and health policy. (c) 2009 S. Karger AG, Basel.

Brain-computer interfaces for post-stroke motor rehabilitation: a meta-analysis.

PubMed

Cervera, María A; Soekadar, Surjo R; Ushiba, Junichi; Millán, José Del R; Liu, Meigen; Birbaumer, Niels; Garipelli, Gangadhar

2018-05-01

Brain-computer interfaces (BCIs) can provide sensory feedback of ongoing brain oscillations, enabling stroke survivors to modulate their sensorimotor rhythms purposefully. A number of recent clinical studies indicate that repeated use of such BCIs might trigger neurological recovery and hence improvement in motor function. Here, we provide a first meta-analysis evaluating the clinical effectiveness of BCI-based post-stroke motor rehabilitation. Trials were identified using MEDLINE, CENTRAL, PEDro and by inspection of references in several review articles. We selected randomized controlled trials that used BCIs for post-stroke motor rehabilitation and provided motor impairment scores before and after the intervention. A random-effects inverse variance method was used to calculate the summary effect size. We initially identified 524 articles and, after removing duplicates, we screened titles and abstracts of 473 articles. We found 26 articles corresponding to BCI clinical trials, of these, there were nine studies that involved a total of 235 post-stroke survivors that fulfilled the inclusion criterion (randomized controlled trials that examined motor performance as an outcome measure) for the meta-analysis. Motor improvements, mostly quantified by the upper limb Fugl-Meyer Assessment (FMA-UE), exceeded the minimal clinically important difference (MCID=5.25) in six BCI studies, while such improvement was reached only in three control groups. Overall, the BCI training was associated with a standardized mean difference of 0.79 (95% CI: 0.37 to 1.20) in FMA-UE compared to control conditions, which is in the range of medium to large summary effect size. In addition, several studies indicated BCI-induced functional and structural neuroplasticity at a subclinical level. This suggests that BCI technology could be an effective intervention for post-stroke upper limb rehabilitation. However, more studies with larger sample size are required to increase the reliability of these results.

Exertional heat stroke in navy and marine personnel: a hot topic.

PubMed

Goforth, Carl W; Kazman, Josh B

2015-02-01

Although exertional heat stroke is considered a preventable condition, this life-threatening emergency affects hundreds of military personnel annually. Because heat stroke is preventable, it is important that Navy critical care nurses rapidly recognize and treat heat stroke casualties. Combined intrinsic and extrinsic risk factors can quickly lead to heat stroke if not recognized by deployed critical care nurses and other first responders. In addition to initial critical care nursing interventions, such as establishing intravenous access, determining body core temperature, and assessing hemodynamic status, aggressive cooling measures should be initiated immediately. The most important determinant in heat stroke outcome is the amount of time that patients sustain hyperthermia. Heat stroke survival approaches 100% when evidence-based cooling guidelines are followed, but mortality from heat stroke is a significant risk when care is delayed. Navy critical care and other military nurses should be aware of targeted assessments and cooling interventions when heat stroke is suspected during military operations. ©2015 American Association of Critical-Care Nurses.

Early Rivaroxaban Use After Cardioembolic Stroke May Not Result in Hemorrhagic Transformation: A Prospective Magnetic Resonance Imaging Study.

PubMed

Gioia, Laura C; Kate, Mahesh; Sivakumar, Leka; Hussain, Dulara; Kalashyan, Hayrapet; Buck, Brian; Bussiere, Miguel; Jeerakathil, Thomas; Shuaib, Ashfaq; Emery, Derek; Butcher, Ken

2016-07-01

Early anticoagulation after cardioembolic stroke remains controversial because of the potential for hemorrhagic transformation (HT). We tested the safety and feasibility of initiating rivaroxaban ≤14 days after cardioembolic stroke/transient ischemic attack. A prospective, open-label study of patients with atrial fibrillation treated with rivaroxaban ≤14 days of transient ischemic attack or ischemic stroke (National Institute of Health Stroke Scale <9). All patients underwent magnetic resonance imaging <24 hours of rivaroxaban initiation and day 7. The primary end point was symptomatic HT at day 7. Sixty patients (mean±SD age 71±19 years, 82% stroke/18% transient ischemic attack) were enrolled. Median (interquartile range) time from onset to rivaroxaban was 3 (5) days. At treatment initiation, median National Institute of Health Stroke Scale was 2 (4), and median diffusion-weighted imaging volume was 7.9 (13.7) mL. At baseline, HT was present in 25 (42%) patients (hemorrhagic infarct [HI]1=19, HI2=6). On follow-up magnetic resonance imaging, no patients developed symptomatic HT. New asymptomatic HI1 developed in 3 patients, and asymptomatic progression from HI1 to HI2 occurred in 5 patients; otherwise, HT remained unchanged at day 7. These data support the safety of rivaroxaban initiation ≤14 days of mild-moderate cardioembolic stroke/transient ischemic attack. Magnetic resonance imaging evidence of petechial HT, which is common, does not appear to increase the risk of symptomatic HT. © 2016 American Heart Association, Inc.

Epilepsy Characteristics and Clinical Outcome in Patients With Mitochondrial Encephalomyopathy, Lactic Acidosis, and Stroke-Like Episodes (MELAS).

PubMed

Lee, Ha Neul; Eom, Soyong; Kim, Se Hoon; Kang, Hoon-Chul; Lee, Joon Soo; Kim, Heung Dong; Lee, Young-Mock

2016-11-01

Epileptic seizures in patients with mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) are heterogeneous with no pathognomonic features. We reviewed epilepsy characteristics and clinical outcome exclusively in a pediatric population. Twenty-two children and adolescents (13 males) with confirmed mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes due to mitochondrial DNA A3243G mutation and epilepsy were recruited. Clinical data including seizure semiology, treatment response, neuroimaging findings, and electroencephalography were analyzed. We also examined the effect of the age at seizure onset and initial symptoms on the clinical variables. Seizure semiology and electroencephalography abnormalities showed no syndrome-specific findings. Focal seizures occurred in 21 of 22 subjects (95.5%), whereas generalized seizures developed in seven of 22 subjects (31.8%). Twenty of 22 subjects (90.9%) achieved partial to complete reduction of clinical seizures for more than one year with a combination of more than two antiepileptic drugs. The subgroup with earlier seizure onset presented significantly earlier and showed significantly higher rates of drug-resistant epilepsy compared with the late onset group, although there were no significant differences in the initial symptoms. The subjects with severe epileptic conditions tended to have more severe clinical dysfunction and more severe organ involvement. Both focal and generalized seizures occurred in patients with MELAS. Epilepsy in this population is drug resistant, but a certain degree of clinical seizure reduction was achievable with antiepileptic drugs, with more favorable outcomes than historically expected. Close observation and active epilepsy treatment of individuals with MELAS episodes and earlier seizure onset might improve the prognosis. Copyright © 2016 Elsevier Inc. All rights reserved.

Non-motor tasks improve adaptive brain-computer interface performance in users with severe motor impairment

PubMed Central

Faller, Josef; Scherer, Reinhold; Friedrich, Elisabeth V. C.; Costa, Ursula; Opisso, Eloy; Medina, Josep; Müller-Putz, Gernot R.

2014-01-01

Individuals with severe motor impairment can use event-related desynchronization (ERD) based BCIs as assistive technology. Auto-calibrating and adaptive ERD-based BCIs that users control with motor imagery tasks (“SMR-AdBCI”) have proven effective for healthy users. We aim to find an improved configuration of such an adaptive ERD-based BCI for individuals with severe motor impairment as a result of spinal cord injury (SCI) or stroke. We hypothesized that an adaptive ERD-based BCI, that automatically selects a user specific class-combination from motor-related and non motor-related mental tasks during initial auto-calibration (“Auto-AdBCI”) could allow for higher control performance than a conventional SMR-AdBCI. To answer this question we performed offline analyses on two sessions (21 data sets total) of cue-guided, five-class electroencephalography (EEG) data recorded from individuals with SCI or stroke. On data from the twelve individuals in Session 1, we first identified three bipolar derivations for the SMR-AdBCI. In a similar way, we determined three bipolar derivations and four mental tasks for the Auto-AdBCI. We then simulated both, the SMR-AdBCI and the Auto-AdBCI configuration on the unseen data from the nine participants in Session 2 and compared the results. On the unseen data of Session 2 from individuals with SCI or stroke, we found that automatically selecting a user specific class-combination from motor-related and non motor-related mental tasks during initial auto-calibration (Auto-AdBCI) significantly (p < 0.01) improved classification performance compared to an adaptive ERD-based BCI that only used motor imagery tasks (SMR-AdBCI; average accuracy of 75.7 vs. 66.3%). PMID:25368546

Outcomes after tissue plasminogen activator administration under the drip and ship paradigm may differ according to the regional stroke care system.

PubMed

Cha, Jae-Kwan; Nah, Hyun-Wook; Kang, Myung-Jin; Kim, Dae-Hyun; Park, Hyun-Seok; Kim, Sang-Beom; Jeong, Eun Hwan; Huh, Jae-Taeck

2014-01-01

The drip and ship paradigm for stroke patients enhances the rate of using intravenous tissue plasminogen activator (IVT) in community hospitals. The safety and outcomes of patients treated with IVT for acute ischemic stroke (AIS) under the drip and ship paradigm were compared with patients directly treated at a comprehensive stroke center in the Busan metropolitan area of Korea. This was a retrospective study of patients with AIS treated with IVT between January 2009 and January 2012. Information on patients' baseline characteristics, neuroimaging, symptomatic intracerebral hemorrhage (sICH), and outcome 90 days after using IVT was obtained from our stroke registry. We surveyed stroke neurologists regarding their pattern of post-thrombolysis care. During the observation periods, we selected 317 patients using IVT. Among these, 239 patients received IVT at our stroke center, and 78 were treated at 21 community hospitals under the drip and ship paradigm. Initial neurologic deficits and the size of ischemic lesions on magnetic resonance imaging were much more severe in patients treated with IVT under the drip and ship paradigm compared with patients treated at our comprehensive stroke center. The prevalence of a poor outcome (modified Rankin Scale score 3-6) 90 days after IVT was much higher in patients treated with the drip and ship paradigm than in those treated at our comprehensive stroke center. Regarding the occurrence of sICH, there was no significant difference between the 2 groups. The clinical characteristics and outcomes after using IVT under the drip and ship paradigm may differ greatly among stroke care systems. Crown Copyright © 2014. Published by Elsevier Inc. All rights reserved.

Inter-rater reliability of data elements from a prototype of the Paul Coverdell National Acute Stroke Registry

PubMed Central

Reeves, Mathew J; Mullard, Andrew J; Wehner, Susan

2008-01-01

Background The Paul Coverdell National Acute Stroke Registry (PCNASR) is a U.S. based national registry designed to monitor and improve the quality of acute stroke care delivered by hospitals. The registry monitors care through specific performance measures, the accuracy of which depends in part on the reliability of the individual data elements used to construct them. This study describes the inter-rater reliability of data elements collected in Michigan's state-based prototype of the PCNASR. Methods Over a 6-month period, 15 hospitals participating in the Michigan PCNASR prototype submitted data on 2566 acute stroke admissions. Trained hospital staff prospectively identified acute stroke admissions, abstracted chart information, and submitted data to the registry. At each hospital 8 randomly selected cases were re-abstracted by an experienced research nurse. Inter-rater reliability was estimated by the kappa statistic for nominal variables, and intraclass correlation coefficient (ICC) for ordinal and continuous variables. Factors that can negatively impact the kappa statistic (i.e., trait prevalence and rater bias) were also evaluated. Results A total of 104 charts were available for re-abstraction. Excellent reliability (kappa or ICC > 0.75) was observed for many registry variables including age, gender, black race, hemorrhagic stroke, discharge medications, and modified Rankin Score. Agreement was at least moderate (i.e., 0.75 > kappa ≥; 0.40) for ischemic stroke, TIA, white race, non-ambulance arrival, hospital transfer and direct admit. However, several variables had poor reliability (kappa < 0.40) including stroke onset time, stroke team consultation, time of initial brain imaging, and discharge destination. There were marked systematic differences between hospital abstractors and the audit abstractor (i.e., rater bias) for many of the data elements recorded in the emergency department. Conclusion The excellent reliability of many of the data elements supports the use of the PCNASR to monitor and improve care. However, the poor reliability for several variables, particularly time-related events in the emergency department, indicates the need for concerted efforts to improve the quality of data collection. Specific recommendations include improvements to data definitions, abstractor training, and the development of ED-based real-time data collection systems. PMID:18547421

Implication of left ventricular diastolic dysfunction in cryptogenic ischemic stroke.

PubMed

Seo, Jae-Young; Lee, Kyung Bok; Lee, Jung-Gon; Kim, Ji-Sun; Roh, Hakjae; Ahn, Moo-Young; Park, Byoung Won; Hyon, Min Su

2014-09-01

Left ventricular diastolic dysfunction (LVDD) is a predictor for atrial fibrillation (AF). This study was aimed to investigate whether LVDD in cryptogenic ischemic stroke (CS) could be a clue to stroke mechanism. The clinical and echocardiographic findings of 1589 consecutive patients with acute ischemic stroke or transient ischemic attack between 2004 and 2013 were reviewed. LVDDs among stroke subtypes were graded by transthoracic echocardiography into 4 groups by severity: normal, abnormal relaxation (grade I), pseudonormal (grade II), and restrictive diastolic filling (grade III), whereas severe LVDD was defined as grade III. We classified the lesion pattern of CS into cardioembolism-mimic or non-cardioembolism-mimic and determined whether cardioembolism-mimic lesions were associated with severe LVDD. The fraction of severe LVDD in CS was not different from that of stroke with AF (27.3% versus 37.1%; P=0.173) but was significantly higher than that of stroke without AF (27.3% versus 13.4%; P=0.008). Cardioembolism-mimic CS had more severe LVDD than non-cardioembolism-mimic CS (41.4% versus 11.5%; P=0.013). LVDD of grade II (odds ratio, 4.37; 95% confidence interval, 2.99-6.41) and grade III (odds ratio, 5.60; 95% confidence interval, 3.42-9.17) were independently related to stroke with AF after adjusting covariates. The severe LVDD could be a predictor of stroke with AF, and its frequency was similar between CS and stroke with AF. Cardioembolism-mimic CS had significantly more severe LVDD than non-cardioembolism-mimic CS. LVDD could be helpful to discriminate the stroke mechanism in the patients with acute CS. © 2014 American Heart Association, Inc.

Correlation Between the Integrity of the Circle of Willis and the Severity of Initial Noncardiac Cerebral Infarction and Clinical Prognosis

PubMed Central

Zhou, Houshi; Sun, Jian; Ji, Xiaotan; Lin, Jing; Tang, Shujin; Zeng, Jinsheng; Fan, Yu-hua

2016-01-01

Abstract The quality of collateral circulation affects the severity and prognosis of stroke patients. The effect of the circle of Willis, which is the primary collateral circulation, on ischemic stroke has attracted significant attention. This study was designed to investigate the effect of different circles of Willis types on stroke severity and prognosis in patients with noncardiac stroke. A total of 376 patients with noncardiac ischemic stroke, who were treated by the specialty team of cerebrovascular diseases at the First Affiliated Hospital of Sun Yat-sen Hospital, were successively enrolled in this study. The detailed clinical characteristics of the patients were recorded upon admission, including risk factors of vascular disease and National Institutes of Health Stroke Scale (NIHSS) scores. The patients were divided into groups of different circles of Willis types based on magnetic resonance angiography (MRA) that was performed within 3 days of admission—type I: complete circle of Willis; type II: complete anterior half of the circle of Willis and incomplete posterior half of the circle of Willis; type III: incomplete anterior half of the circle of Willis and complete posterior half of the circle of Willis; and type IV: incomplete anterior and posterior halves of the circle of Willis. Patients were re-evaluated for NIHSS scores at discharge and after discharge. The modified Rankin score (mRS) was recorded for 90 days, and stroke recurrence and death after 90 days were also recorded until the end of the study. The 376 patients were divided into 4 groups based on the MRA—type I group: 92 patients (24.5%); type II group: 215 patients (57.2%); type III group: 12 patients (3.2%), and type IV group: 57 patients (15.2%). NIHSS scores at admission and discharge were significantly lower for the type I group compared with those for the type II and type IV groups (P < 0.05). NIHSS scores were higher in the groups with an incomplete circle of Willis compared with the group with a complete circle of Willis. A poor recovery rate was highest for the type IV group, whereas a good recovery rate was highest for the type I group. The logistic regression analysis showed that a complete circle of Willis was one of the predictors of suitable recovery (odds ratio [OR] = 0.708, 95% confidence interval [CI]: 0.554–0.906). Circle of Willis type was associated with stroke severity and patient prognosis, whereas an incomplete circle of Willis was associated with more severe conditions and a higher 90-day poor diagnosis rate. A complete circle of Willis was an independent predictor of good prognosis. PMID:26962785

A population-based study of hospital care costs during five years after TIA and stroke

PubMed Central

Luengo-Fernandez, Ramon; Gray, Alastair M.; Rothwell, Peter M.

2016-01-01

Background and Purpose Few studies have evaluated long-term costs after stroke onset, with almost no cost data for TIA. We studied hospital costs during the 5 years after TIA or stroke in a population-based study. Methods Patients from a UK population-based cohort study (Oxford Vascular Study) were recruited from 2002 to 2007. Analysis was based on follow-up until 2010. Hospital resource usage was obtained from patients’ hospital records and valued using 2008/09 unit costs. As not all patients had full 5-year follow-up, we used non-parametric censoring techniques. Results Among 485 TIA and 729 stroke patients ascertained and included, mean censor-adjusted 5-year hospital costs after index stroke were $25,741 (95% CI: 23,659-27,914), with costs varying considerably by severity: $21,134 after minor stroke, $33,119 after moderate stroke, and $28,552 after severe stroke. For the 239 surviving stroke patients who had reached final follow-up, mean costs were $24,383 (20,156-28,595), with over half of costs ($12,972) being incurred in the first year after the event. After index TIA, the mean censor-adjusted 5-year costs were $18,091 (15,947-20,258). A multivariate analysis showed that event severity, recurrent stroke and coronary events after the index event were independent predictors of 5-year costs. Differences by stroke subtype were mostly explained by stroke severity and subsequent events. Conclusions Long-term hospital costs after TIA and stroke are considerable, but are mainly incurred over the first year after the index event. Event severity and suffering subsequent stroke and coronary events after the index event accounted for much of the increase in costs. PMID:23160884

Recovery of Dysphagia in Lateral Medullary Stroke

PubMed Central

Gupta, Hitesh; Banerjee, Alakananda

2014-01-01

Lateral medullary stroke is typically associated with increased likelihood of occurrence of dysphagia and exhibits the most severe and persistent form. Worldwide little research exists on dysphagia in brainstem stroke. An estimated 15% of all patients admitted to stroke rehabilitation units experience a brainstem stroke out of which about 47% suffer from dysphagia. In India, a study showed that 22.3% of posterior circulation stroke patients develop dysphagia. Dearth of literature on dysphagia and its outcome in brainstem stroke particularly lateral medullary stroke motivated the author to present an actual case study of a patient who had dysphagia following a lateral medullary infarct. This paper documents the severity and management approach of dysphagia in brainstem stroke, with traditional dysphagia therapy and VitalStim therapy. Despite being diagnosed with a severe form of dysphagia followed by late treatment intervention, the patient had complete recovery of the swallowing function. PMID:25045555

Recovery of Dysphagia in lateral medullary stroke.

PubMed

Gupta, Hitesh; Banerjee, Alakananda

2014-01-01

Lateral medullary stroke is typically associated with increased likelihood of occurrence of dysphagia and exhibits the most severe and persistent form. Worldwide little research exists on dysphagia in brainstem stroke. An estimated 15% of all patients admitted to stroke rehabilitation units experience a brainstem stroke out of which about 47% suffer from dysphagia. In India, a study showed that 22.3% of posterior circulation stroke patients develop dysphagia. Dearth of literature on dysphagia and its outcome in brainstem stroke particularly lateral medullary stroke motivated the author to present an actual case study of a patient who had dysphagia following a lateral medullary infarct. This paper documents the severity and management approach of dysphagia in brainstem stroke, with traditional dysphagia therapy and VitalStim therapy. Despite being diagnosed with a severe form of dysphagia followed by late treatment intervention, the patient had complete recovery of the swallowing function.

A New System for Classification of Chinese Characters: Initial Three-Stroke Index System (Tou San-Bi Jyandzfa).

ERIC Educational Resources Information Center

Wu, C. K.; Wu, K. S.

Since the 17th century, Chinese lexicography has been dominated by a character classification system divided into 214 radical groups. The proposed initial three-stroke system would eliminate the need to select (or guess) the proper radical and count strokes. The aim of the system is to facilitate the use of dictionaries and provide the student…

Locomotor Training and Strength and Balance Exercises for Walking Recovery After Stroke: Response to Number of Training Sessions.

PubMed

Rose, Dorian K; Nadeau, Stephen E; Wu, Samuel S; Tilson, Julie K; Dobkin, Bruce H; Pei, Qinglin; Duncan, Pamela W

2017-11-01

Evidence-based guidelines are needed to inform rehabilitation practice, including the effect of number of exercise training sessions on recovery of walking ability after stroke. The objective of this study was to determine the response to increasing number of training sessions of 2 interventions-locomotor training and strength and balance exercises-on poststroke walking recovery. This is a secondary analysis of the Locomotor Experience Applied Post-Stroke (LEAPS) randomized controlled trial. Six rehabilitation sites in California and Florida and participants' homes were used. Participants were adults who dwelled in the community (N=347), had had a stroke, were able to walk at least 3 m (10 ft) with assistance, and had completed the required number of intervention sessions. Participants received 36 sessions (3 times per week for 12 weeks), 90 minutes in duration, of locomotor training (gait training on a treadmill with body-weight support and overground training) or strength and balance training. Talking speed, as measured by the 10-Meter Walk Test, and 6-minute walking distance were assessed before training and following 12, 24, and 36 intervention sessions. Participants at 2 and 6 months after stroke gained in gait speed and walking endurance after up to 36 sessions of treatment, but the rate of gain diminished steadily and, on average, was very low during the 25- to 36-session epoch, regardless of treatment type or severity of impairment. Results may not generalize to people who are unable to initiate a step at 2 months after stroke or people with severe cardiac disease. In general, people who dwelled in the community showed improvements in gait speed and walking distance with up to 36 sessions of locomotor training or strength and balance exercises at both 2 and 6 months after stroke. However, gains beyond 24 sessions tended to be very modest. The tracking of individual response trajectories is imperative in planning treatment. Published by Oxford University Press on behalf of American Physical Therapy Association 2017.

Motor Learning in Stroke: Trained Patients Are Not Equal to Untrained Patients With Less Impairment

PubMed

Hardwick, Robert M; Rajan, Vikram A; Bastian, Amy J; Krakauer, John W; Celnik, Pablo A

2017-02-01

Stroke rehabilitation assumes motor learning contributes to motor recovery, yet motor learning in stroke has received little systematic investigation. Here we aimed to illustrate that despite matching levels of performance on a task, a trained patient should not be considered equal to an untrained patient with less impairment. We examined motor learning in healthy control participants and groups of stroke survivors with mild-to-moderate or moderate-to-severe motor impairment. Participants performed a series of isometric contractions of the elbow flexors to navigate an on-screen cursor to different targets, and trained to perform this task over a 4-day period. The speed-accuracy trade-off function (SAF) was assessed for each group, controlling for differences in self-selected movement speeds between individuals. The initial SAF for each group was proportional to their impairment. All groups were able to improve their performance through skill acquisition. Interestingly, training led the moderate-to-severe group to match the untrained (baseline) performance of the mild-to-moderate group, while the trained mild-to-moderate group matched the untrained (baseline) performance of the controls. Critically, this did not make the two groups equivalent; they differed in their capacity to improve beyond this matched performance level. Specifically, the trained groups had reached a plateau, while the untrained groups had not. Despite matching levels of performance on a task, a trained patient is not equal to an untrained patient with less impairment. This has important implications for decisions both on the focus of rehabilitation efforts for chronic stroke, as well as for returning to work and other activities.

Influence of statin therapy at time of stroke onset on functional outcome among patients with atrial fibrillation.

PubMed

Ko, Darae; Thigpen, Jonathan L; Otis, James A; Forster, Kristen; Henault, Lori; Quinn, Emily; Tripodis, Yorghos; Berger, Peter B; Limdi, Nita; Hylek, Elaine M

2017-01-15

Statin pretreatment has been associated with reduced infarct volume in nonlacunar strokes. The effect of statins on functional outcomes of strokes related to atrial fibrillation (AF) is unknown. We aimed to define the influence of prestroke statin use on functional outcome in AF. We assembled a cohort of consecutive ischemic stroke patients from 2006 to 2010. All patients underwent CT or MRI and were adjudicated by site investigators. AF was confirmed by electrocardiogram in 100% of patients. Site neurologists blinded to the study hypothesis affirmed the type of stroke and assessed the severity of disability at the time of hospital discharge. The frequency of death at 30-days was calculated. Ischemic stroke (n=1030) resulted in a severe neurological deficit or death (modified Rankin scale ≥4) at 30days in 711 patients (69%). Using multivariable logistic regression models adjusting for factors associated with statin treatment and factors associated with functional outcome, prestroke statin use was associated with a 32% reduction in frequency of severe stroke (odds ratio [OR], 0.68; 95% confidence interval [CI], 0.50-0.92; P=0.011). Other independent factors associated with severe stroke included older age, female sex, non-White race, diabetes mellitus, prior ischemic stroke, prior venous thromboembolism, and dementia. Ischemic strokes in AF are associated with high mortality and morbidity. Statin use at time of stroke onset among patients with AF was associated in this study with less severe stroke and warrant validation. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Disparities in stroke type and vascular risk factors between 2 Hispanic populations in Miami and Mexico city.

PubMed

Romano, Jose G; Arauz, Antonio; Koch, Sebastian; Dong, Chuanhui; Marquez, Juan M; Artigas, Carol; Merlos, Marlon; Hernandez, Bernardo; Roa, Luis F; Rundek, Tatjana; Sacco, Ralph L

2013-08-01

The heterogeneous nature and determinants of stroke among different Hispanic groups was examined by comparing hospitalized Hispanic stroke patients in Miami, where the Hispanic population is largely of Caribbean origin, to a Mestizo population in Mexico City. Consecutive Hispanic patients who were admitted with stroke or transient ischemic attack (TIA) and included in the prospective stroke registries of 2 tertiary care teaching hospitals were studied. Demographic factors, stroke subtypes, vascular risk factors, stroke severity, and outcomes were compared. Vascular risk factor definitions were standardized. A total of 928 patients (520 Mexicans and 408 Miami Hispanics) were analyzed. Mexicans were younger, with a greater proportion of women. More cerebral venous thromboses (CVTs) were admitted in Mexico, while TIA and stroke mimics were more commonly admitted in Miami; cardioembolic strokes were more commonly ascertained in Miami, and more cryptogenic strokes in Mexico. Stroke severity was similar for intracerebral hemorrhages, but more severe ischemic strokes and CVTs were included in the Mexican registry. Outcome at 1 and 3 months was similar in both registries after adjusting for age and baseline stroke severity. After adjusting for age and sex, hypertension, dyslipidemia, and atrial fibrillation were more frequent, and diabetes mellitus was less frequent, among Miami Hispanics compared to Mexicans. We found significant differences in the frequency of hypertension, diabetes, dyslipidemia, and atrial fibrillation in Miami Hispanics and Mexican stroke patients, highlighting the heterogeneity of the Hispanic ethnic group. Future studies are needed to clarify the relative contribution of genetic and environmental disparities amongst Mexican and Caribbean Hispanic stroke patients. Copyright © 2013 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Left Atrial Enlargement and Stroke Recurrence: The Northern Manhattan Stroke Study

PubMed Central

Yaghi, Shadi; Moon, Yeseon P.; Mora-McLaughlin, Consuelo; Willey, Joshua Z.; Cheung, Ken; Tullio, Marco R. Di; Homma, Shunichi; Kamel, Hooman; Sacco, Ralph L.; Elkind, Mitchell S. V.

2015-01-01

Background and purpose While left atrial enlargement (LAE) increases incident stroke risk, the association with recurrent stroke is less clear. Our aim was to determine the association of LAE with recurrent stroke most likely related to embolism (cryptogenic and cardioembolic), and all ischemic stroke recurrences. Methods We followed 655 first ischemic stroke patients in the Northern Manhattan Stroke Study for up to 5 years. LA size from 2-D echocardiography was categorized as normal (52.7%), mild LAE (31.6%), and moderate-severe LAE (15.7%). We used Cox proportional hazard models to calculate the hazard ratios and 95% confidence intervals (HR, 95%CI) for the association of LA size and LAE with recurrent cryptogenic/cardioembolic and total recurrent ischemic stroke. Results LA size was available in 529 (81%) patients. Mean age at enrollment was 69±13 years; 45.8% were male, 54.0% Hispanic, and 18.5% had atrial fibrillation. Over a median of 4 years there were 65 recurrent ischemic strokes (29 were cardioembolic or cryptogenic). In multivariable models adjusted for confounders including atrial fibrillation and heart failure, moderate-severe LAE compared to normal LA size was associated with greater risk of recurrent cardioembolic/cryptogenic stroke (adjusted HR 2.83, 95% CI 1.03-7.81), but not total ischemic stroke (adjusted HR 1.06, 95% CI, 0.48-2.30). Mild LAE was not associated with recurrent stroke. Conclusion Moderate to severe LAE was an independent marker of recurrent cardioembolic or cryptogenic stroke in a multiethnic cohort of ischemic stroke patients. Further research is needed to determine whether anticoagulant use may reduce risk of recurrence in ischemic stroke patients with moderate to severe LAE. PMID:25908460

Hemorrhagic Stroke in an Adolescent Female with HIV-Associated Thrombotic Thrombocytopenic Purpura

PubMed Central

Rakhmanina, Natella; Wong, Edward CC; Davis, Jeremiah C; Ray, Patricio E

2014-01-01

HIV-1 infection can trigger acute episodes of Idiopathic Thrombocytoponic Purpura (ITP), and Thrombotic Thrombocytopenic Purpura (TTP), particularly in populations with advanced disease and poor adherence to antiretroviral therapy (ART). These diseases should be distinguished because they respond to different treatments. Previous studies done in adults with HIV-TTP have recommended the prompt initiation or re-initiation of ART in parallel with plasma exchange therapy to improve the clinical outcome of these patients. Here, we describe a case of HIV-TTP resulting in an acute hemorrhagic stroke in a 16 year old female with perinatally acquired HIV infection and non-adherence to ART, who presented with severe thrombocytopenia, microangiopathic hemolytic anemia, and a past medical history of HIV-ITP. Both differential diagnosis and treatments for HIV-ITP and HIV-TTP were considered simultaneously. A decrease in plasma ADAMTS13 activity (<5%) without detectable inhibitory antibodies confirmed the diagnosis of HIV-TTP. Re-initiation of ART and plasma exchange resulted in a marked decrease in the HIV-RNA viral load, recovery of the platelet count, and complete recovery was achieved with sustained virologic suppression. PMID:25429351

Prediction of new-onset atrial fibrillation after first-ever ischemic stroke: A comparison of CHADS2, CHA2DS2-VASc and HATCH scores and the added value of stroke severity.

PubMed

Hsieh, Cheng-Yang; Lee, Cheng-Han; Wu, Darren Philbert; Sung, Sheng-Feng

2018-05-01

Early detection of atrial fibrillation after stroke is important for secondary prevention in stroke patients without known atrial fibrillation (AF). We aimed to compare the performance of CHADS 2 , CHA 2 DS 2 -VASc and HATCH scores in predicting AF detected after stroke (AFDAS) and to test whether adding stroke severity to the risk scores improves predictive performance. Adult patients with first ischemic stroke event but without a prior history of AF were retrieved from a nationwide population-based database. We compared C-statistics of CHADS 2 , CHA 2 DS 2 -VASc and HATCH scores for predicting the occurrence of AFDAS during stroke admission (cohort I) and during follow-up after hospital discharge (cohort II). The added value of stroke severity to prediction models was evaluated using C-statistics, net reclassification improvement, and integrated discrimination improvement. Cohort I comprised 13,878 patients and cohort II comprised 12,567 patients. Among them, 806 (5.8%) and 657 (5.2%) were diagnosed with AF, respectively. The CHADS 2 score had the lowest C-statistics (0.558 in cohort I and 0.597 in cohort II), whereas the CHA 2 DS 2 -VASc score had comparable C-statistics (0.603 and 0.644) to the HATCH score (0.612 and 0.653) in predicting AFDAS. Adding stroke severity to each of the three risk scores significantly increased the model performance. In stroke patients without known AF, all three risk scores predicted AFDAS during admission and follow-up, but with suboptimal discrimination. Adding stroke severity improved their predictive abilities. These risk scores, when combined with stroke severity, may help prioritize patients for continuous cardiac monitoring in daily practice. Copyright © 2018 Elsevier B.V. All rights reserved.

Task-oriented aerobic exercise in chronic hemiparetic stroke: training protocols and treatment effects.

PubMed

Macko, R F; Ivey, F M; Forrester, L W

2005-01-01

Stroke is the leading cause of disability in older Americans. Each year 750,000 Americans suffer a stroke, two thirds of whom are left with neurological deficits that persistently impair function. Principal among them is hemiparetic gait that limits mobility and increases fall risk, promoting a sedentary lifestyle. These events propagate disability by physical deconditioning and "learned non-use," with further functional declines accelerated by the sarcopenia and fitness decrements of advancing age. Conventional rehabilitation care typically provides little or no structured therapeutic exercise beyond the subacute stroke recovery period, based on natural history studies showing little or no further functional motor recovery beyond 6 months after stroke. Emerging evidence suggests that new models of task-oriented exercise have the potential to improve motor function even years after stroke. This article presents treadmill as a task-oriented training paradigm to optimize locomotor relearning while eliciting cardiovascular conditioning in chronic stroke patients. Protocols for exercise testing and longitudinal aerobic training progression are presented that provide fundamental formulas that safely approach the complex task of customizing aerobic training to gait deficit severity in the high CVD risk stroke population. The beneficial effects of 6 months task-oriented treadmill exercise on cardiovascular-metabolic fitness, energy cost of hemiparetic gait, ADL mobility task performance, and leg strength are discussed with respect to the central and peripheral neuromuscular adaptations targeted by the training. Collectively, these findings constitute one initial experience in a much broader neuroscience and exercise rehabilitation development of task-oriented training paradigms that offer a multisystems approach to improving both neurological and cardiovascular health outcomes in the chronic stroke population.

Successful endovascular stroke therapy in a 103-year-old woman.

PubMed

Boo, SoHyun; Duru, Uzoma B; Smith, Matthew S; Rai, Ansaar T

2016-11-01

People older than 80 years of age constitute the most rapidly growing age group in the world. Several trials confirming superior efficacy of endovascular therapy did not have an upper age limit and showed favorable treatment effects, regardless of age. Current American Heart Association/American Stroke Association guidelines do not restrict treatment based on age as long as other eligibility criteria are met. A 103-year-old woman presented 2 h after stroke onset secondary to a left internal carotid artery terminus (ICA-T) occlusion. Admission National Institutes of Health Stoke Scale (NIHSS) score was 38, with no early ischemic changes on imaging, pre-stroke modified Rankin Scale score was 0, and she lived independently with minimal help. After initiation of intravenous thrombolysis, the patient underwent successful mechanical thrombectomy with Thombosis in Cerebral Infaction-3 recanalization. She showed remarkable recovery (NIHSS score of 1 at 48 h). Stroke onset to recanalization was 3 h 40 min. Our objective in documenting the oldest patient to successfully undergo stroke intervention is to corroborate that with the current evidence, appropriate patients undergoing rapid treatment may allow us to advance the limits of endovascular therapy. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Mobile Real-time Tracking of Acute Stroke Patients and Instant, Secure Inter-team Communication - the Join App.

PubMed

Munich, Stephan A; Tan, Lee A; Nogueira, Danilo M; Keigher, Kiffon M; Chen, Michael; Crowley, R Webster; Conners, James J; Lopes, Demetrius K

2017-09-01

The primary correlate to survival and preservation of neurologic function in patients suffering from an acute ischemic stroke is time from symptom onset to initiation of therapy and reperfusion. Communication and coordination among members of the stroke team are essential to maximizing efficiency and subsequently early reperfusion. In this work, we aim to describe our preliminary experience using the Join mobile application as a means to improve interdisciplinary team communication and efficiency. We describe our pilot experience with the initiation of the Join mobile application between July 2015 and July 2016. With this application, a mobile beacon is transported with the patient on the ambulance. Transportation milestone timestamps and geographic coordinates are transmitted to the treating facility and instantly communicated to all treatment team members. The transport team / patient can be tracked en route to the treating facility. During our pilot study, 62 patients were triaged and managed using the Join application. Automated time-stamping of critical events, geographic tracking of patient transport and summary documents were obtained for all patients. Treatment team members had an overall favorable impression of the Join application and recommended its continued use. The Join application is one of several components of a multi-institutional, interdisciplinary effort to improve the treatment of patients with acute ischemic stroke. The ability of the treatment team to track patient transport and communicate with the transporting team may improve reperfusion time and, therefore, improve neurologic outcomes.

The real estate factor: quantifying the impact of infarct location on stroke severity.

PubMed

Menezes, Nina M; Ay, Hakan; Wang Zhu, Ming; Lopez, Chloe J; Singhal, Aneesh B; Karonen, Jari O; Aronen, Hannu J; Liu, Yawu; Nuutinen, Juho; Koroshetz, Walter J; Sorensen, A Gregory

2007-01-01

The severity of the neurological deficit after ischemic stroke is moderately correlated with infarct volume. In the current study, we sought to quantify the impact of location on neurological deficit severity and to delineate this impact from that of volume. We developed atlases consisting of location-weighted values indicating the relative importance in terms of neurological deficit severity for every voxel of the brain. These atlases were applied to 80 first-ever ischemic stroke patients to produce estimates of clinical deficit severity. Each patient had an MRI and National Institutes of Health Stroke Scale (NIHSS) examination just before or soon after hospital discharge. The correlation between the location-based deficit predictions and measured neurological deficit (NIHSS) scores were compared with the correlation obtained using volume alone to predict the neurological deficit. Volume-based estimates of neurological deficit severity were only moderately correlated with measured NIHSS scores (r=0.62). The combination of volume and location resulted in a significantly better correlation with clinical deficit severity (r=0.79, P=0.032). The atlas methodology is a feasible way of integrating infarct size and location to predict stroke severity. It can estimate stroke severity better than volume alone.

Combined Electrical Stimulation and Exercise for Swallow Rehabilitation Post-Stroke: A Pilot Randomized Control Trial

ERIC Educational Resources Information Center

Sproson, Lise; Pownall, Sue; Enderby, Pam; Freeman, Jenny

2018-01-01

Background: Dysphagia is common after stroke, affecting up to 50% of patients initially. It can lead to post-stroke pneumonia, which causes 30% of stroke-related deaths, a longer hospital stay and poorer health outcomes. Dysphagia care post-stroke generally focuses on the management of symptoms, via modified oral intake textures and adapted…

Frequency of unrecognized Fabry disease among young European-American and African-American men with first ischemic stroke.

PubMed

Wozniak, Marcella A; Kittner, Steven J; Tuhrim, Stanley; Cole, John W; Stern, Barney; Dobbins, Mark; Grace, Marie E; Nazarenko, Irina; Dobrovolny, Robert; McDade, Eric; Desnick, Robert J

2010-01-01

The cause of initial ischemic stroke in up to 30% of young patients remains unclear. Fabry disease, due to deficient alpha-galactosidase A (alpha-Gal A) activity, is a vascular endothelial glycosphingolipid storage disease typically presenting in childhood. With advancing age, patients develop renal, cardiac, and cerebrovascular disease and die prematurely. A European study suggested an increased prevalence of unrecognized Fabry disease in patients with cryptogenic stroke. We hypothesized that alpha-Gal A deficiency is a rare cause of initial early-onset ischemic stroke in men. The Stroke Prevention in Young Men Study enrolled >550 men (15 to 49 years) with first ischemic stroke in the Baltimore-Washington area in 2004 to 2007. Frozen plasma samples were assayed for alpha-Gal A activity, and DNA from patients with consistently low plasma alpha-Gal A activities were sequenced. The study sample consisted of 558 men (42% African-American; median age 44 years). Stroke was cryptogenic in 154 men (40% African-American). In 10 patients with low plasma alpha-Gal A activities, DNA sequencing identified alterations in the alpha-Gal A gene in 2 patients. The polymorphism, D313Y, which results in low plasma enzyme activity, but near normal levels of cellular activity was seen in one European-American male. The Fabry disease-causing A143T mutation was seen in an African-American male with cryptogenic stroke (0.18% of all strokes: upper 95% CI=0.53%; 0.65% of cryptogenic strokes: upper 95% CI=1.92%). In this biracial population, unrecognized Fabry disease is a rare but treatable cause of initial ischemic stroke in young men.

Initial testing of a variable-stroke Stirling engine

NASA Technical Reports Server (NTRS)

Thieme, L. G.

1985-01-01

In support of the U.S. Department of Energy's Stirling Engine Highway Vehicle Systems Program, NASA Lewis Research Center is evaluating variable-stroke control for Stirling engines. The engine being tested is the Advenco Stirling engine; this engine was manufactured by Philips Research Laboratories of the Netherlands and uses a variable-angle swash-plate drive to achieve variable stroke operation. The engine is described, initial steady-state test data taken at Lewis are presented, a major drive system failure and subsequent modifications are described. Computer simulation results are presented to show potential part-load efficiency gains with variable-stroke control.

Anxiety, Depression, and Adverse Clinical Outcomes in Patients With Atrial Fibrillation Starting Warfarin: Cardiovascular Research Network WAVE Study.

PubMed

Baumgartner, Christine; Fan, Dongjie; Fang, Margaret C; Singer, Daniel E; Witt, Daniel M; Schmelzer, John R; Williams, Marc S; Gurwitz, Jerry H; Sung, Sue Hee; Go, Alan S

2018-04-14

Anxiety and depression are associated with worse outcomes in several cardiovascular conditions, but it is unclear whether they affect outcomes in atrial fibrillation (AF). In a large diverse population of adults with AF, we evaluated the association of diagnosed anxiety and/or depression with stroke and bleeding outcomes. The Cardiovascular Research Network WAVE (Community-Based Control and Persistence of Warfarin Therapy and Associated Rates and Predictors of Adverse Clinical Events in Atrial Fibrillation and Venous Thromboembolism) Study included adults with AF newly starting warfarin between 2004 and 2007 within 5 health delivery systems in the United States. Diagnosed anxiety and depression and other patient characteristics were identified from electronic health records. We identified stroke and bleeding outcomes from hospitalization databases using validated International Classification of Diseases, Ninth Revision ( ICD-9 ), codes. We used multivariable Cox regression to assess the relation between anxiety and/or depression with outcomes after adjustment for stroke and bleeding risk factors. In 25 570 adults with AF initiating warfarin, 490 had an ischemic stroke or intracranial hemorrhage (1.52 events per 100 person-years). In multivariable analyses, diagnosed anxiety was associated with a higher adjusted rate of combined ischemic stroke and intracranial hemorrhage (hazard ratio, 1.52; 95% confidence interval, 1.01-2.28). Results were not materially changed after additional adjustment for patient-level percentage of time in therapeutic anticoagulation range on warfarin (hazard ratio, 1.56; 95% confidence interval, 1.03-2.36). In contrast, neither isolated depression nor combined depression and anxiety were significantly associated with outcomes. Diagnosed anxiety was independently associated with increased risk of combined ischemic stroke and intracranial hemorrhage in adults with AF initiating warfarin that was not explained by differences in risk factors or achieved anticoagulation quality. © 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

Racial and gender differences in stroke severity, outcomes, and treatment in patients with acute ischemic stroke.

PubMed

Boehme, Amelia K; Siegler, James E; Mullen, Michael T; Albright, Karen C; Lyerly, Michael J; Monlezun, Dominique J; Jones, Erica M; Tanner, Rikki; Gonzales, Nicole R; Beasley, T Mark; Grotta, James C; Savitz, Sean I; Martin-Schild, Sheryl

2014-04-01

Previous research has indicated that women and blacks have worse outcomes after acute ischemic stroke (AIS). Little research has been done to investigate the combined influence of race and gender in the presentation, treatment, and outcome of patients with AIS. We sought to determine the association of race and gender on initial stroke severity, thrombolysis, and functional outcome after AIS. AIS patients who presented to 2 academic medical centers in the United States (2004-2011) were identified through prospective registries. In-hospital strokes were excluded. Stroke severity, measured by admission National Institutes of Health Stroke Scale (NIHSS) scores, treatment with tissue plasminogen activator (tPA), neurologic deterioration (defined by a ≥2-point increase in NIHSS score), and functional outcome at discharge, measured by the modified Rankin Scale, were investigated. These outcomes were compared across race/gender groups. A subanalysis was conducted to assess race/gender differences in exclusion criteria for tPA. Of the 4925 patients included in this study, 2346 (47.6%) were women and 2310 (46.9%) were black. White women had the highest median NIHSS score on admission (8), whereas white men had the lowest median NIHSS score on admission (6). There were no differences in outcomes between black men and white men. A smaller percentage of black women than white women were treated with tPA (27.6% versus 36.6%, P < .0001), partially because of a greater proportion of white women presenting within 3 hours (51% versus 45.5%, P = .0005). Black women had decreased odds of poor functional outcome relative to white women (odds ratio [OR] = .85, 95% confidence interval [CI] .72-1.00), but after adjustment for baseline differences in age, NIHSS, and tPA use, this association was no longer significant (OR = 1.2, 95% CI .92-1.46, P = .22). Black women with an NIHSS score less than 7 on admission were at lower odds of receiving tPA than the other race/gender groups, even after adjusting for arriving within 3 hours and admission glucose (OR = .66, 95% CI .44-.99, P = .0433). Race and gender were not significantly associated with short-term outcome, although black women were significantly less likely to be treated with tPA. Black women had more tPA exclusions than any other group. The primary reason for tPA exclusion in this study was not arriving within 3 hours of stroke symptom onset. Given the growth in incident strokes projected in minority groups in the next 4 decades, identifying factors that contribute to black women not arriving to the emergency department in time are of great importance. Copyright © 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Incidence, predictors and clinical characteristics of orolingual angio-oedema complicating thrombolysis with tissue plasminogen activator for ischaemic stroke.

PubMed

Hurford, Robert; Rezvani, Sean; Kreimei, Mohammad; Herbert, Annie; Vail, Andy; Parry-Jones, Adrian R; Douglass, Chris; Molloy, Jane; Alachkar, Hana; Tyrrell, Pippa J; Smith, Craig J

2015-05-01

Orolingual angio-oedema is a recognised complication of tissue plasminogen activator (tPA) for ischaemic stroke. We investigated its incidence, clinical characteristics and relationship with other factors in patients receiving tPA at a UK centre. 530 consecutive patients (median age 70 years) receiving tPA treatment for confirmed ischaemic stroke were included. Cases were defined as those developing angio-oedema within 24 h of initiation of tPA. Angio-oedema was retrospectively classified as mild, moderate or severe using predefined criteria. The primary analysis was the association between prior ACE inhibitor (ACE-I) treatment and angio-oedema. Orolingual angio-oedema was observed in 42 patients (7.9%; 95% CI 5.5% to 10.6%), ranging from 5 to 189 min after initiation of tPA (median 65 min). 12% of the angio-oedema cases were severe (1% of all patients treated with tPA), requiring urgent advanced airway management. 172 patients (33%) were taking ACE-I. In multifactorial analyses, only prior ACE-I treatment remained a significant independent predictor of angio-oedema (odds ratio (OR) 2.3; 95% CI 1.1 to 4.7). Angio-oedema occurs more frequently than previously reported and is associated with preceding ACE-I treatment. Angio-oedema may be delayed and progress to life-threatening airway compromise, which has implications for the assessment and delivery of thrombolysis. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Novel Regenerative Therapies Based on Regionally Induced Multipotent Stem Cells in Post-Stroke Brains: Their Origin, Characterization, and Perspective.

PubMed

Takagi, Toshinori; Yoshimura, Shinichi; Sakuma, Rika; Nakano-Doi, Akiko; Matsuyama, Tomohiro; Nakagomi, Takayuki

2017-12-01

Brain injuries such as ischemic stroke cause severe neural loss. Until recently, it was believed that post-ischemic areas mainly contain necrotic tissue and inflammatory cells. However, using a mouse model of cerebral infarction, we demonstrated that stem cells develop within ischemic areas. Ischemia-induced stem cells can function as neural progenitors; thus, we initially named them injury/ischemia-induced neural stem/progenitor cells (iNSPCs). However, because they differentiate into more than neural lineages, we now refer to them as ischemia-induced multipotent stem cells (iSCs). Very recently, we showed that putative iNSPCs/iSCs are present within post-stroke areas in human brains. Because iNSPCs/iSCs isolated from mouse and human ischemic tissues can differentiate into neuronal lineages in vitro, it is possible that a clearer understanding of iNSPC/iSC profiles and the molecules that regulate iNSPC/iSC fate (e.g., proliferation, differentiation, and survival) would make it possible to perform neural regeneration/repair in patients following stroke. In this article, we introduce the origin and traits of iNSPCs/iSCs based on our reports and recent viewpoints. We also discuss their possible contribution to neurogenesis through endogenous and exogenous iNSPC/iSC therapies following ischemic stroke.

Knowledge Regarding Basic Facts of Stroke Among Final Year MBBS Students and House Officers: A Cross-Sectional Survey of 708 Respondents from Pakistan.

PubMed

Khubaib, Mohammad U; Rathore, Farooq A; Waqas, Ahmed; Jan, Mohsin M; Sohail, Sana

2016-03-23

Stroke is the leading cause of neurological disability in the world. In Pakistan, house officers (HOs) are usually the first contact for a stroke patient in the emergency department. Sometimes they need to make quick decisions regarding diagnosis and management without specialist supervision. Thousands of current final year MBBS (Bachelor of Medicine, Bachelor of Surgery) students will be performing the duties of HOs soon. This study documents the knowledge and confidence levels of final year students and HOs in Pakistan regarding basic facts related to initial diagnosis and management of stroke. A questionnaire was developed using two standard textbooks of medicine and current stroke guidelines of the American Heart Association. The pre-tested self-administered questionnaire was distributed among 800 final year MBBS students and HOs in 14 medical colleges and hospitals in four different cities. The response rate was 88.5%. Data analysis was done using SPSS V.21. The CMH Lahore Medical College Ethics Review Committee approved this project. Respondents included medical students (n=496) and HOs (N= 212); most were female (n = 452, 63.9%). Of these, 31.4% had managed or assisted in the management of a patient with a stroke and had a higher confidence level in its diagnosis (p< 0.001) and management (p <0.001). Having a family member with stroke was associated with higher confidence in the diagnosis of stroke (p < 0.05) but not with confidence in its management (p = 0.41). Most correctly defined stroke (60.6%), identified the CT scan as the initial diagnostic modality (88.1%), knew the dosage of aspirin (64.9%), knew the time limit for thrombolysis (67.4%), and were familiar with the risk of deep vein thrombosis in immobilized stroke patients (85.4%). Less than half (44.5%) chose tissue plasminogen activator (t-PA) as the preferred initial intervention for acute ischemic stroke. This multicenter survey shows that the knowledge and confidence of medical students and HOs in Pakistan regarding initial diagnosis and management of stroke are inadequate in most domains. There is a need to improve the medical training for stroke in emergency departments for optimal outcomes. Public education campaigns about stroke should be conducted to increase the general awareness of the population about the prevention, signs, symptoms, and emergency steps to be taken when encountering a case of stroke.

Temporal profile of body temperature in acute ischemic stroke: relation to stroke severity and outcome.

PubMed

Karaszewski, Bartosz; Thomas, Ralph G R; Dennis, Martin S; Wardlaw, Joanna M

2012-10-18

Pyrexia after stroke (temperature ≥37.5°C) is associated with poor prognosis, but information on timing of body temperature changes and relationship to stroke severity and subtypes varies. We recruited patients with acute ischemic stroke, measured stroke severity, stroke subtype and recorded four-hourly tympanic (body) temperature readings from admission to 120 hours after stroke. We sought causes of pyrexia and measured functional outcome at 90 days. We systematically summarised all relevant previous studies. Amongst 44 patients (21 males, mean age 72 years SD 11) with median National Institute of Health Stroke Score (NIHSS) 7 (range 0-28), 14 had total anterior circulation strokes (TACS). On admission all patients, both TACS and non-TACS, were normothermic (median 36.3°C vs 36.5°C, p=0.382 respectively) at median 4 hours (interquartile range, IQR, 2-8) after stroke; admission temperature and NIHSS were not associated (r(2)=0.0, p=0.353). Peak temperature, occurring at 35.5 (IQR 19.0 to 53.8) hours after stroke, was higher in TACS (37.7°C) than non-TACS (37.1°C, p<0.001) and was associated with admission NIHSS (r(2)=0.20, p=0.002). Poor outcome (modified Rankin Scale ≥3) at 90 days was associated with higher admission (36.6°C vs. 36.2°C p=0.031) and peak (37.4°C vs. 37.0°C, p=0.016) temperatures. Sixteen (36%) patients became pyrexial, in seven (44%) of whom we found no cause other than the stroke. Normothermia is usual within the first 4 hours of stroke. Peak temperature occurs at 1.5 to 2 days after stroke, and is related to stroke severity/subtype and more closely associated with poor outcome than admission temperature. Temperature-outcome associations after stroke are complex, but normothermia on admission should not preclude randomisation of patients into trials of therapeutic hypothermia.

Swallowing difficulties for cerebellar stroke may recover beyond three years.

PubMed

Périé, S; Wajeman, S; Vivant, R; St Guily, J L

1999-01-01

Swallowing disorders after stroke or skull base surgery can be life threatening. Although late recovery can occur, it remains poorly documented. We report a case of a 54-year-old woman with dysphagia resulting from a cerebellar stroke with hemorrhage that was evacuated through craniotomy. Swallowing difficulties were assessed by a videoendoscopic swallowing study. She presented with disruption of swallow initiation and impairment of the pharyngeal stage, resulting in hypopharyngeal stasis and penetration with aspiration. Supportive swallowing therapy was conducted with careful reeducation to assist initiation of the pharyngeal stage as well as development of compensatory postural technique. Initial improvement was very slow but became rapidly progressive from the 31st month after the stroke. By the 34th month, oral feeding was possible without aspiration. This case demonstrates that improvement in swallowing function can be expected even 3 years after stroke or skull base surgery. Determination of predictive factors for late functional recovery is of great importance and should be the focus of further investigation.

Progress in reducing the burden of stroke.

PubMed

Chalmers, J; Chapman, N

2001-12-01

1. The burden of stroke worldwide is growing rapidly, driven by an ageing population and by the rapid rate of urbanization and industrialization in the developing world. There are approximately 5 million fatal and 15 million non-fatal strokes each year and over 50 million survivors of stroke alive, worldwide, today. 2. The most important determinant of stroke risk is blood pressure, with a strong, continuous relationship between the level of the systolic and diastolic pressures and the risk of initial and recurrent stroke, in both Western and Asian populations. 3. Randomized clinical trials have clearly demonstrated that blood pressure lowering reduces the risk of initial stroke by 35-40% in hypertensive patients; but, until recently, there was no conclusive evidence that blood pressure lowering was effective in the secondary prevention of stroke. 4. The Perindopril Protection Against Recurrent Stroke Study (PROGRESS) has provided definitive evidence that blood pressure lowering in patients with previous stroke or transient ischaemic attack (TIA) reduces the incidence of secondary stroke by 28%, of major vascular events by 26% and of major coronary events by 26%. These reductions were all magnified by approximately 50% in a subgroup of patients in whom the angiotensin-converting enzyme inhibitor perindopril was routinely combined with the diuretic indapamide. 5. Successful global implementation of a treatment with perindopril and indapamide in patients with a history of stroke or TIA would markedly reduce the burden of stroke and could avert between 0.5 and one million strokes each year, worldwide.

Cost of post-stroke outpatient care in Malaysia.

PubMed

Akhavan Hejazi, Seyed Majid; Mazlan, Mazlina; Abdullah, Saini Jeffery Freddy; Engkasan, Julia Patrick

2015-02-01

This study aimed to investigate the direct cost of outpatient care for patients with stroke, as well as the relationship between the aforementioned cost and the sociodemographic and stroke characteristics of the patients. This was a cross-sectional study involving patients with first-ever stroke who were attending outpatient stroke rehabilitation, and their family members. Participants were interviewed using a structured questionnaire designed to obtain information regarding the cost of outpatient care. Stroke severity was measured using the National Institute of Health Stroke Scale. This study comprised 49 patients (28 men, 21 women) with a mean age of 60.2 (range 35-80) years. The mean total cost incurred was USD 547.10 (range USD 53.50-4,591.60), of which 36.6% was spent on attendant care, 25.5% on medical aids, 15.1% on travel expenses, 14.1% on medical fees and 8.5% on out-of-pocket expenses. Stroke severity, age > 70 years and haemorrhagic stroke were associated with increased cost. The mean cost of attending outpatient therapy per patient was USD 17.50 per session (range USD 6.60-30.60), with travelling expenses (41.8%) forming the bulk of the cost, followed by medical fees (38.1%) and out-of-pocket expenses (10.9%). Multiple regression analysis showed that stroke severity was the main determinant of post-stroke outpatient care cost (p < 0.001). Post-stroke outpatient care costs are significantly influenced by stroke severity. The cost of attendant care was the main cost incurred during the first three months after hospital discharge, while travelling expenses was the main cost incurred when attending outpatient stroke rehabilitation therapy.

Effect of Visual Art School-Based Stroke Intervention for Middle School Students.

PubMed

Johnson, Ashleigh B; Montgomery, Chelsea M; Dillard, Wesley A; Morrill, Kenneth; Hoesli, Coral; Gillette, Wesley M; Johnson, Brandon K; Nathaniel, Thomas I

2017-08-01

Community stroke awareness initiatives have traditionally been used to expand knowledge of stroke signs and risk factors to high-risk adult populations. Here, we use a novel unfettered, visual art-based approach for an elementary school initiative to raise stroke awareness. Seventh graders in a middle school art class received stroke awareness training during the course of the 2015 to 2016 school year through their teacher in the visual arts class. In turn, they used this training to develop their own artistic interpretations of key stroke awareness concepts via project-based learning and then present their projects to raise awareness about stroke. We evaluated our predata and postdata to determine whether the visual art school-based stroke intervention was effective in both educating students about stroke and enabling them to effectively disseminate this information to parents and other adults in their community. The pretest evaluation indicates a fair or good knowledge about stroke, and no student indicated an "outstanding" or "excellent" knowledge. The posttest evaluation indicated a higher degree of stroke awareness because students were rated as having an "outstanding," "excellent," or "very good" performance especially in the ability to translate knowledge of stroke awareness lessons learned in their art class into a well-articulated stroke-related project and presentation. Pearson χ test reveals significant difference (P < .001) between the pretest and posttest evaluations. Our results indicate that our school-based stroke intervention was effective in both educating students about stroke and enabling them to effectively disseminate this information to parents and other adults in their community. The use of a visual art teacher to lead the educational component in the intervention indicates that expertise in neurology or stroke is not necessary to facilitate understanding of stroke and highlights the importance of creativeness in stroke education for children.

Endovascular stent thrombectomy: the new standard of care for large vessel ischaemic stroke.

PubMed

Campbell, Bruce C V; Donnan, Geoffrey A; Lees, Kennedy R; Hacke, Werner; Khatri, Pooja; Hill, Michael D; Goyal, Mayank; Mitchell, Peter J; Saver, Jeffrey L; Diener, Hans-Christoph; Davis, Stephen M

2015-08-01

Results of initial randomised trials of endovascular treatment for ischaemic stroke, published in 2013, were neutral but limited by the selection criteria used, early-generation devices with modest efficacy, non-consecutive enrollment, and treatment delays. In the past year, six positive trials of endovascular thrombectomy for ischaemic stroke have provided level 1 evidence for improved patient outcome compared with standard care. In most patients, thrombectomy was performed in addition to thrombolysis with intravenous alteplase, but benefits were also reported in patients ineligible for alteplase treatment. Despite differences in the details of eligibility requirements, all these trials required proof of major vessel occlusion on non-invasive imaging and most used some imaging technique to exclude patients with a large area of irreversibly injured brain tissue. The results indicate that modern thrombectomy devices achieve faster and more complete reperfusion than do older devices, leading to improved clinical outcomes compared with intravenous alteplase alone. The number needed to treat to achieve one additional patient with independent functional outcome was in the range of 3·2-7·1 and, in most patients, was in addition to the substantial efficacy of intravenous alteplase. No major safety concerns were noted, with low rates of procedural complications and no increase in symptomatic intracerebral haemorrhage. WHERE NEXT?: Thrombectomy benefits patients across a range of ages and levels of clinical severity. A planned meta-analysis of individual patient data might clarify effects in under-represented subgroups, such as those with mild initial stroke severity or elderly patients. Imaging-based selection, used in some of the recent trials to exclude patients with large areas of irreversible brain injury, probably contributed to the proportion of patients with favourable outcomes. The challenge is how best to implement imaging in clinical practice to maximise benefit for the entire population and to avoid exclusion of patients with smaller yet clinically important potential to benefit. Although favourable imaging identifies patients who might benefit despite long delays from symptom onset to treatment, the proportion of patients with favourable imaging decreases with time. Health systems therefore need to be reorganised to deliver treatment as quickly as possible to maximise benefits. On the basis of available trial data, intravenous alteplase remains the initial treatment for all eligible patients within 4·5 h of stroke symptom onset. Those patients with major vessel occlusion should, in parallel, proceed to endovascular thrombectomy immediately rather than waiting for an assessment of response to alteplase, because minimising time to reperfusion is the ultimate aim of treatment. Copyright © 2015 Elsevier Ltd. All rights reserved.

78 FR 13359 - National Institute of Neurological Disorders and Stroke; Notice of Closed Meetings

Federal Register 2010, 2011, 2012, 2013, 2014

2013-02-27

... Neurological Disorders and Stroke; Notice of Closed Meetings Pursuant to section 10(d) of the Federal Advisory... Neurological Disorders and Stroke Initial Review Group Neurological Sciences and Disorders K. Date: March 7... review and funding cycle. Name of Committee: National Institute of Neurological Disorders and Stroke...

Acute Stroke Care at Rural Hospitals in Idaho: Challenges in Expediting Stroke Care

ERIC Educational Resources Information Center

Gebhardt, James G.; Norris, Thomas E.

2006-01-01

Context: Thrombolytics are currently the most effective treatment for stroke. However, the National Institute for Neurological Disorders and Stroke criteria for initiation of thrombolytic therapy, most notably the 3-hour time limit from symptom onset, have proven challenging for many rural hospitals to achieve. Purpose: To provide a snapshot of…

77 FR 33470 - National Institute of Neurological Disorders and Stroke Notice of Closed Meetings

Federal Register 2010, 2011, 2012, 2013, 2014

2012-06-06

... Neurological Disorders and Stroke Notice of Closed Meetings Pursuant to section 10(d) of the Federal Advisory... Disorders and Stroke Initial Review Group; Neurological Sciences and Disorders K. Date: June 25-26, 2012..., [email protected] . Name of Committee: National Institute of Neurological Disorders and Stroke Special...

77 FR 2740 - National Institute of Neurological Disorders and Stroke Notice of Closed Meeting

Federal Register 2010, 2011, 2012, 2013, 2014

2012-01-19

... Neurological Disorders and Stroke Notice of Closed Meeting Pursuant to section 10(d) of the Federal Advisory... Disorders and Stroke Initial Review Group; Neurological Sciences and Disorders B. Date: February 23, 2012... Disorders and Stroke, NIH, NSC, 6001 Executive Blvd., Room 3202, MSC 9529, Bethesda, MD 20892-9529, (301...

Kids Identifying and Defeating Stroke (KIDS): design of a school-based intervention to improve stroke awareness.

PubMed

Gonzales, Nicole R; Brown, Devin L; Maddox, Katherine E; Conley, Kathleen M; Espinosa, Nina; Pary, Jennifer K; Karim, Asha P; Moyé, Lemuel A; Grotta, James C; Morgenstern, Lewis B

2007-01-01

We describe the design and baseline data of an educational intervention targeting predominantly Mexican American middle school students and their parents in an effort to improve stroke awareness. Increasing awareness in this group may increase the number of patients eligible for acute stroke treatment by encouraging emergency medical services (EMS) activation. This is a prospective, randomized study in which six middle schools were randomly assigned to receive a stroke education program or the standard health class. Primary outcome measures are the percentage of students and parents who recognize stroke symptoms and express the intent to activate EMS upon recognition of these findings. A total of 547 students (271 control, 276 intervention) and 484 parents (231 control, 253 intervention) have been enrolled. Pretests were administered. The intervention has been successfully carried out in the parent and student cohorts over a three-year period. Posttests and persistence test results are pending. Implementing a school-based stroke education initiative is feasible. Followup testing will demonstrate whether this educational initiative translates into a measurable and persistent improvement in stroke knowledge and behavioral intent to activate EMS upon recognition of stroke symptoms.

Two decades of nation-wide community-based stroke support - The Singapore National Stroke Association.

PubMed

Venketasubramanian, Narayanaswamy; Yin, Ann; Lee, Lay B; De Silva, Deidre A

2017-04-01

The Singapore National Stroke Association, registered in 1996, offers support and information to stroke survivors and caregivers, and aims to raise public stroke awareness. In the last 20 years, we have developed programs to equip stroke survivors and caregivers with knowledge, life skills, comfort, and opportunities for socialization and reintegration. We have on-going public education and advocacy initiatives. Obtaining funding, member recruitment, volunteer retention, and leadership renewal are on-going challenges. Singapore National Stroke Association will continue to strive for the betterment of stroke survivors, their caregivers, and the public.

Periodic Limb Movements and White Matter Hyperintensities in First-Ever Minor Stroke or High-Risk Transient Ischemic Attack.

PubMed

Boulos, Mark I; Murray, Brian J; Muir, Ryan T; Gao, Fuqiang; Szilagyi, Gregory M; Huroy, Menal; Kiss, Alexander; Walters, Arthur S; Black, Sandra E; Lim, Andrew S; Swartz, Richard H

2017-03-01

Emerging evidence suggests that periodic limb movements (PLMs) may contribute to the development of cerebrovascular disease. White matter hyperintensities (WMHs), a widely accepted biomarker for cerebral small vessel disease, are associated with incident stroke and death. We evaluated the association between increased PLM indices and WMH burden in patients presenting with stroke or transient ischemic attack (TIA), while controlling for vascular risk factors and stroke severity. Thirty patients presenting within 2 weeks of a first-ever minor stroke or high-risk TIA were prospectively recruited. PLM severity was measured with polysomnography. WMH burden was quantified using the Age Related White Matter Changes (ARWMC) scale based on neuroimaging. Partial Spearman's rank-order correlations and multiple linear regression models tested the association between WMH burden and PLM severity. Greater WMH burden was correlated with elevated PLM index and stroke volume. Partial Spearman's rank-order correlations demonstrated that the relationship between WMH burden and PLM index persisted despite controlling for vascular risk factors. Multivariate linear regression models revealed that PLM index was a significant predictor of an elevated ARWMC score while controlling for age, stroke volume, stroke severity, hypertension, and apnea-hypopnea index. The quantity of PLMs was associated with WMH burden in patients with first-ever minor stroke or TIA. PLMs may be a risk factor for or marker of WMH burden, even after considering vascular risk factors and stroke severity. These results invite further investigation of PLMs as a potentially useful target to reduce WMH and stroke burden. © Sleep Research Society (SRS) 2016. All rights reserved. For permissions, please email: journals.permissions@oup.com

Cultural adaptation and validation of Stroke Impact Scale 3.0 version in Uganda: A small-scale study

PubMed Central

Kamwesiga, Julius T; von Koch, Lena; Kottorp, Anders; Guidetti, Susanne

2016-01-01

Background: Knowledge is scarce about the impact of stroke in Uganda, and culturally adapted, psychometrically tested patient-reported outcome measures are lacking. The Stroke Impact Scale 3.0 is recommended, but it has not been culturally adapted and validated in Uganda. Objective: To culturally adapt and determine the psychometric properties of the Stroke Impact Scale 3.0 in the Ugandan context on a small scale. Method: The Stroke Impact Scale 3.0 was culturally adapted to form Stroke Impact Scale 3.0 Uganda (in English) by involving 25 participants in three different expert committees. Subsequently, Stroke Impact Scale 3.0 Uganda from English to Luganda language was done in accordance with guidelines. The first language in Uganda is English and Luganda is the main spoken language in Kampala city and its surroundings. Translation of Stroke Impact Scale 3.0 Uganda (both in English and Luganda) was then tested psychometrically by applying a Rasch model on data collected from 95 participants with stroke. Results: Overall, 10 of 59 (17%) items in the eight domains of the Stroke Impact Scale 3.0 were culturally adapted. The majority were 6 of 10 items in the domain Activities of Daily Living, 2 of 9 items in the domain Mobility, and 2 of 5 items in the domain Hand function. Only in two domains, all items demonstrated acceptable goodness of fit to the Rasch model. There were also more than 5% person misfits in the domains Participation and Emotion, while the Communication, Mobility, and Hand function domains had the lowest proportions of person misfits. The reliability coefficient was equal or larger than 0.90 in all domains except the Emotion domain, which was below the set criterion of 0.80 (0.75). Conclusion: The cultural adaptation and translation of Stroke Impact Scale 3.0 Uganda provides initial evidence of validity of the Stroke Impact Scale 3.0 when used in this context. The results provide support for several aspects of validity and precision but also point out issues for further adaptation and improvement of the Stroke Impact Scale. PMID:27746913

Cultural adaptation and validation of Stroke Impact Scale 3.0 version in Uganda: A small-scale study.

PubMed

Kamwesiga, Julius T; von Koch, Lena; Kottorp, Anders; Guidetti, Susanne

2016-01-01

Knowledge is scarce about the impact of stroke in Uganda, and culturally adapted, psychometrically tested patient-reported outcome measures are lacking. The Stroke Impact Scale 3.0 is recommended, but it has not been culturally adapted and validated in Uganda. To culturally adapt and determine the psychometric properties of the Stroke Impact Scale 3.0 in the Ugandan context on a small scale. The Stroke Impact Scale 3.0 was culturally adapted to form Stroke Impact Scale 3.0 Uganda ( in English ) by involving 25 participants in three different expert committees. Subsequently, Stroke Impact Scale 3.0 Uganda from English to Luganda language was done in accordance with guidelines. The first language in Uganda is English and Luganda is the main spoken language in Kampala city and its surroundings. Translation of Stroke Impact Scale 3.0 Uganda ( both in English and Luganda ) was then tested psychometrically by applying a Rasch model on data collected from 95 participants with stroke. Overall, 10 of 59 (17%) items in the eight domains of the Stroke Impact Scale 3.0 were culturally adapted. The majority were 6 of 10 items in the domain Activities of Daily Living, 2 of 9 items in the domain Mobility, and 2 of 5 items in the domain Hand function. Only in two domains, all items demonstrated acceptable goodness of fit to the Rasch model. There were also more than 5% person misfits in the domains Participation and Emotion, while the Communication, Mobility, and Hand function domains had the lowest proportions of person misfits. The reliability coefficient was equal or larger than 0.90 in all domains except the Emotion domain, which was below the set criterion of 0.80 (0.75). The cultural adaptation and translation of Stroke Impact Scale 3.0 Uganda provides initial evidence of validity of the Stroke Impact Scale 3.0 when used in this context. The results provide support for several aspects of validity and precision but also point out issues for further adaptation and improvement of the Stroke Impact Scale.

Diagnostic Error in Stroke-Reasons and Proposed Solutions.

PubMed

Bakradze, Ekaterina; Liberman, Ava L

2018-02-13

We discuss the frequency of stroke misdiagnosis and identify subgroups of stroke at high risk for specific diagnostic errors. In addition, we review common reasons for misdiagnosis and propose solutions to decrease error. According to a recent report by the National Academy of Medicine, most people in the USA are likely to experience a diagnostic error during their lifetimes. Nearly half of such errors result in serious disability and death. Stroke misdiagnosis is a major health care concern, with initial misdiagnosis estimated to occur in 9% of all stroke patients in the emergency setting. Under- or missed diagnosis (false negative) of stroke can result in adverse patient outcomes due to the preclusion of acute treatments and failure to initiate secondary prevention strategies. On the other hand, the overdiagnosis of stroke can result in inappropriate treatment, delayed identification of actual underlying disease, and increased health care costs. Young patients, women, minorities, and patients presenting with non-specific, transient, or posterior circulation stroke symptoms are at increased risk of misdiagnosis. Strategies to decrease diagnostic error in stroke have largely focused on early stroke detection via bedside examination strategies and a clinical decision rules. Targeted interventions to improve the diagnostic accuracy of stroke diagnosis among high-risk groups as well as symptom-specific clinical decision supports are needed. There are a number of open questions in the study of stroke misdiagnosis. To improve patient outcomes, existing strategies to improve stroke diagnostic accuracy should be more broadly adopted and novel interventions devised and tested to reduce diagnostic errors.

Remote supervision of IV-tPA for acute ischemic stroke by telemedicine or telephone before transfer to a regional stroke center is feasible and safe.

PubMed

Pervez, Muhammad A; Silva, Gisele; Masrur, Shihab; Betensky, Rebecca A; Furie, Karen L; Hidalgo, Renzo; Lima, Fabricio; Rosenthal, Eric S; Rost, Natalia; Viswanathan, Anand; Schwamm, Lee H

2010-01-01

Because of a shortage of stroke specialists, many outlying or "spoke" hospitals initiate intravenous (IV) thrombolysis using telemedicine or telephone consultation before transferring patients to a regional stroke center (RSC) hub. We analyzed complications and outcomes of patients treated with IV tissue plasminogen activator (tPA) using the "drip and ship" approach compared to those treated directly at the RSC. A retrospective review of our Get With the Guidelines Stroke (GWTG-Stroke) database from 01/2003 to 03/2008 identified 296 patients who received IV tPA within 3 hours of symptom onset without catheter-based reperfusion. GWTG-Stroke definitions for symptomatic intracranial (sICH), systemic hemorrhage, discharge functional status, and destination were applied. Follow-up modified Rankin Score was recorded when available. Of 296 patients, 181 (61.1%) had tPA infusion started at an outside spoke hospital (OSH) and 115 (38.9%) at the RSC hub. OSH patients were younger with fewer severe strokes than RSC patients. Patients treated based on telestroke were more frequently octogenarians than patients treated based on a telephone consult. Mortality, sICH, and functional outcomes were not different between OSH versus RSC and telephone versus telestroke patients. Among survivors, mean length of stay was shorter for OSH patients but discharge status was similar and 75% of patients walked independently at discharge. Outcomes in OSH "drip and ship" patients treated in a hub-and-spoke network were comparable to those treated directly at an RSC. These data suggest that "drip and ship" is a safe and effective method to shorten time to treatment with IV tPA.

Early functional MRI activation predicts motor outcome after ischemic stroke: a longitudinal, multimodal study.

PubMed

Du, Juan; Yang, Fang; Zhang, Zhiqiang; Hu, Jingze; Xu, Qiang; Hu, Jianping; Zeng, Fanyong; Lu, Guangming; Liu, Xinfeng

2018-05-15

An accurate prediction of long term outcome after stroke is urgently required to provide early individualized neurorehabilitation. This study aimed to examine the added value of early neuroimaging measures and identify the best approaches for predicting motor outcome after stroke. This prospective study involved 34 first-ever ischemic stroke patients (time since stroke: 1-14 days) with upper limb impairment. All patients underwent baseline multimodal assessments that included clinical (age, motor impairment), neurophysiological (motor-evoked potentials, MEP) and neuroimaging (diffusion tensor imaging and motor task-based fMRI) measures, and also underwent reassessment 3 months after stroke. Bivariate analysis and multivariate linear regression models were used to predict the motor scores (Fugl-Meyer assessment, FMA) at 3 months post-stroke. With bivariate analysis, better motor outcome significantly correlated with (1) less initial motor impairment and disability, (2) less corticospinal tract injury, (3) the initial presence of MEPs, (4) stronger baseline motor fMRI activations. In multivariate analysis, incorporating neuroimaging data improved the predictive accuracy relative to only clinical and neurophysiological assessments. Baseline fMRI activation in SMA was an independent predictor of motor outcome after stroke. A multimodal model incorporating fMRI and clinical measures best predicted the motor outcome following stroke. fMRI measures obtained early after stroke provided independent prediction of long-term motor outcome.

The Effects of Delirium Prevention Guidelines on Elderly Stroke Patients.

PubMed

Song, Jihye; Lee, Minkyung; Jung, Dukyoo

2017-07-01

This study aimed to evaluate the effectiveness of the delirium prevention interventions recommended by the Delirium Prevention Guidelines for Elderly Stroke Patients (DPGESP). The DPGESP comprises nine dimensions with 28 interventions, including risk factor assessment, orientation disorder prevention, sleeping pattern maintenance, sensory interventions, constipation, dehydration, hypoxia and infection prevention, pain management, and appropriate nutrition maintenance. This quasi-experimental study used a nonequivalent control group and a pretest-posttest design. The experimental and control groups each included 54 patients, and the participants were elderly patients who were admitted to the stroke unit. The study outcomes were the delirium incidence and severity, stroke impact, and length of hospitalization. Posttest values for delirium incidence, severity, stroke impact, and length of hospitalization were significantly improved in the experimental group. Implementation of the DPGESP had beneficial effects on the delirium incidence and severity, stroke impact, and length of hospitalization among elderly patients admitted to a stroke unit.

Cohesive and coherent connected speech deficits in mild stroke.

PubMed

Barker, Megan S; Young, Breanne; Robinson, Gail A

2017-05-01

Spoken language production theories and lesion studies highlight several important prelinguistic conceptual preparation processes involved in the production of cohesive and coherent connected speech. Cohesion and coherence broadly connect sentences with preceding ideas and the overall topic. Broader cognitive mechanisms may mediate these processes. This study aims to investigate (1) whether stroke patients without aphasia exhibit impairments in cohesion and coherence in connected speech, and (2) the role of attention and executive functions in the production of connected speech. Eighteen stroke patients (8 right hemisphere stroke [RHS]; 6 left [LHS]) and 21 healthy controls completed two self-generated narrative tasks to elicit connected speech. A multi-level analysis of within and between-sentence processing ability was conducted. Cohesion and coherence impairments were found in the stroke group, particularly RHS patients, relative to controls. In the whole stroke group, better performance on the Hayling Test of executive function, which taps verbal initiation/suppression, was related to fewer propositional repetitions and global coherence errors. Better performance on attention tasks was related to fewer propositional repetitions, and decreased global coherence errors. In the RHS group, aspects of cohesive and coherent speech were associated with better performance on attention tasks. Better Hayling Test scores were related to more cohesive and coherent speech in RHS patients, and more coherent speech in LHS patients. Thus, we documented connected speech deficits in a heterogeneous stroke group without prominent aphasia. Our results suggest that broader cognitive processes may play a role in producing connected speech at the early conceptual preparation stage. Copyright © 2017 Elsevier Inc. All rights reserved.

The Mataró Stroke Registry: a 10-year registry in a community hospital.

PubMed

Palomeras Soler, E; Fossas Felip, P; Casado Ruiz, V; Cano Orgaz, A; Sanz Cartagena, P; Muriana Batiste, D

2015-06-01

A prospective stroke registry leads to improved knowledge of the disease. We present data on the Mataró Hospital Registry. In February-2002 a prospective stroke registry was initiated in our hospital. It includes sociodemographic data, previous diseases, clinical, topographic, etiological and prognostic data. We have analyzed the results of the first 10 years. A total of 2,165 patients have been included, 54.1% male, mean age 73 years. The most frequent vascular risk factor was hypertension (65.4%). Median NIHSS on admission: 3 (interquartile range, 1-8). Stroke subtype: 79.7% ischemic strokes, 10.9% hemorrhagic, and 9.4% TIA. Among ischemic strokes, the etiology was cardioembolic in 26.5%, large-vessel disease in 23.7%, and small-vessel in 22.9%. The most frequent topography of hemorrhages was lobar (47.4%), and 54.8% were attributed to hypertension. The median hospital stay was 8 days. At discharge, 60.7% of patients were able to return directly to their own home, and 52.7% were independent for their daily life activities. After 3 months these percentages were 76.9% and 62.9%, respectively. Hospital mortality was 6.5%, and after 3 months 10.9%. Our patient's profile is similar to those of other series, although the severity of strokes was slightly lower. Length of hospital stay, short-term and medium term disability, and mortality rates are good, if we compare them with other series. Copyright © 2013 Sociedad Española de Neurología. Published by Elsevier España, S.L.U. All rights reserved.

Clopidogrel with aspirin in acute minor stroke or transient ischemic attack.

PubMed

Wang, Yongjun; Wang, Yilong; Zhao, Xingquan; Liu, Liping; Wang, David; Wang, Chunxue; Wang, Chen; Li, Hao; Meng, Xia; Cui, Liying; Jia, Jianping; Dong, Qiang; Xu, Anding; Zeng, Jinsheng; Li, Yansheng; Wang, Zhimin; Xia, Haiqin; Johnston, S Claiborne

2013-07-04

Stroke is common during the first few weeks after a transient ischemic attack (TIA) or minor ischemic stroke. Combination therapy with clopidogrel and aspirin may provide greater protection against subsequent stroke than aspirin alone. In a randomized, double-blind, placebo-controlled trial conducted at 114 centers in China, we randomly assigned 5170 patients within 24 hours after the onset of minor ischemic stroke or high-risk TIA to combination therapy with clopidogrel and aspirin (clopidogrel at an initial dose of 300 mg, followed by 75 mg per day for 90 days, plus aspirin at a dose of 75 mg per day for the first 21 days) or to placebo plus aspirin (75 mg per day for 90 days). All participants received open-label aspirin at a clinician-determined dose of 75 to 300 mg on day 1. The primary outcome was stroke (ischemic or hemorrhagic) during 90 days of follow-up in an intention-to-treat analysis. Treatment differences were assessed with the use of a Cox proportional-hazards model, with study center as a random effect. Stroke occurred in 8.2% of patients in the clopidogrel-aspirin group, as compared with 11.7% of those in the aspirin group (hazard ratio, 0.68; 95% confidence interval, 0.57 to 0.81; P<0.001). Moderate or severe hemorrhage occurred in seven patients (0.3%) in the clopidogrel-aspirin group and in eight (0.3%) in the aspirin group (P=0.73); the rate of hemorrhagic stroke was 0.3% in each group. Among patients with TIA or minor stroke who can be treated within 24 hours after the onset of symptoms, the combination of clopidogrel and aspirin is superior to aspirin alone for reducing the risk of stroke in the first 90 days and does not increase the risk of hemorrhage. (Funded by the Ministry of Science and Technology of the People's Republic of China; CHANCE ClinicalTrials.gov number, NCT00979589.).

Delay in seeking medical help following Transient Ischemic Attack (TIA) or "mini-stroke": a qualitative study.

PubMed

Mc Sharry, Jennifer; Baxter, Alison; Wallace, Louise M; Kenton, Anthony; Turner, Andrew; French, David P

2014-01-01

Prompt treatment following Transient Ischemic Attack (TIA) can reduce the risk of subsequent stroke and disability. However, many patients delay in making contact with medical services. This study aimed to explore TIA patients' accounts of delay between symptom onset and contacting medical services including how decisions to contact services were made and the factors discussed in relation to delay. Twenty interviews were conducted with TIA patients in England. Using a previous systematic review as an initial framework, interview data were organised into categories of symptom recognition, presence of others and type of care sought. A thematic analysis was then conducted to explore descriptions of care-seeking relevant to each category. Delay in contacting medical services varied from less than an hour to eight days. Awareness of typical stroke symptoms could lead to urgent action when more severe TIA symptoms were present but could lead to delay when experienced symptoms were less severe. The role of friends and family varied widely from deciding on and enacting care-seeking decisions to simply providing transport to the GP practice. When family or friends played a greater role, and both made and enacted care-seeking decisions, delays were often shorter, even when patients themselves failed to identify symptoms. Healthcare professionals also impacted on patients' care-seeking with greater delays in seeking further care for the same episode described when patients perceived a lack of urgency during initial healthcare interactions. This study provides new information on patients' decisions to contact medical services following TIA and identifies overlapping factors that can lead to delay in receiving appropriate treatment. While recognition of symptoms may contribute to delay in contacting medical services, additional factors, including full responsibility being taken by others and initial healthcare interactions, can over-ride or undermine the importance of patients' own identification of TIA.

Mechanical arm trainer for the treatment of the severely affected arm after a stroke: a single-blinded randomized trial in two centers.

PubMed

Hesse, S; Werner, C; Pohl, M; Mehrholz, J; Puzich, U; Krebs, H I

2008-10-01

To test whether training with a new mechanical arm trainer leads to better outcomes than electrical stimulation of the paretic wrist extensors in subacute stroke patients with severe upper limb paresis. Electrical stimulation is a standard and reimbursable form of therapy in Germany. Randomized controlled trial of 54 inpatients enrolled 4-8 wks from stroke onset, mean upper-extremity subsection of Fugl-Meyer assessment (0-66) at admission less than 18. In addition to standard care, all patients practiced 20-30 mins arm trainer or electrical stimulation every workday for 6 wks, totaling 30 sessions. Primary outcome was the Fugl-Meyer assessment, secondary outcomes were the Box and Block test, the Medical Research Council and the modified Ashworth scale, blindly assessed at enrollment, after 6 wks, and at 3-mo follow-up. Both groups were homogeneous at study onset. Shoulder pain occurred in two arm trainer patients. The primary Fugl-Meyer assessment outcome improved for both groups over time (P < 0.001), but this improvement did not differ between groups. The initial (terminal) mean Fugl-Meyer assessment scores were 8.8 +/- 4.8 (19.2 +/- 14.5) for the arm trainer and 8.6 +/- 3.5 (13.6 +/- 7.9) for the electrical stimulation group. No patient could transport a block initially, but at completion significantly more arm trainer patients were able to transport at least three blocks (five vs. zero, P = 0.023). No significant differences were observed between the groups on the secondary Box and Block outcome at follow-up (eight vs. four patients). All Box and Block responders had an initial Fugl-Meyer assessment > or =10. Arm trainer training did not lead to a superior primary outcome over electrical stimulation training. However, "good performers" on the secondary outcome seemed to benefit more from the arm trainer training.

Protection characteristics of a Faraday cage compromised by lightning burnthrough.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Warne, Larry Kevin; Bystrom, Edward; Jorgenson, Roy Eberhardt

2012-01-01

A lightning flash consists of multiple, high-amplitude but short duration return strokes. Between the return strokes is a lower amplitude, continuing current which flows for longer duration. If the walls of a Faraday cage are made of thin enough metal, the continuing current can melt a hole through the metal in a process called burnthrough. A subsequent return stroke can couple energy through this newly-formed hole. This LDRD is a study of the protection provided by a Faraday cage when it has been compromised by burnthrough. We initially repeated some previous experiments and expanded on them in terms of scopemore » and diagnostics to form a knowledge baseline of the coupling phenomena. We then used a combination of experiment, analysis and numerical modeling to study four coupling mechanisms: indirect electric field coupling, indirect magnetic field coupling, conduction through plasma and breakdown through the hole. We discovered voltages higher than those encountered in the previous set of experiments (on the order of several hundreds of volts).« less

77 FR 27783 - National Institute of Neurological Disorders and Stroke Notice of Closed Meetings

Federal Register 2010, 2011, 2012, 2013, 2014

2012-05-11

... Neurological Disorders and Stroke Notice of Closed Meetings Pursuant to section 10(d) of the Federal Advisory... Disorders and Stroke Special Emphasis Panel, Center Core Grants. Date: June 28, 2012. Time: 8:00 a.m. to 6... Institute of Neurological Disorders and Stroke Initial Review Group, Neurological Sciences and Disorders B...

77 FR 6570 - National Institute of Neurological Disorders and Stroke; Notice of Closed Meetings

Federal Register 2010, 2011, 2012, 2013, 2014

2012-02-08

... Neurological Disorders and Stroke; Notice of Closed Meetings Pursuant to section 10(d) of the Federal Advisory... Disorders and Stroke Initial Review Group; Neurological Sciences and Disorders C. Date: March 1-2, 2012... Disorders and Stroke, NIH, NSC, 6001 Executive Blvd., Room 3202, MSC 9529, Bethesda, MD 20892-9529, (301...

Severe ipsilateral carotid stenosis and middle cerebral artery disease in lacunar ischaemic stroke: innocent bystanders?

PubMed

Mead, G E; Lewis, S C; Wardlaw, J M; Dennis, M S; Warlow, C P

2002-03-01

Lacunar infarcts are thought to be mostly due to intracranial small vessel disease. Therefore, when a stroke patient with a relevant lacunar infarct does have severe ipsilateral internal carotid artery (ICA) or middle cerebral artery (MCA) disease, it is unclear whether the arterial disease is causative or coincidental. If causative, we would expect ICA/MCA disease to be more severe on the symptomatic side than on the asymptomatic side. Therefore, our aim was to compare the severity of ipsilateral with contralateral ICA and MCA disease in patients with lacunar ischaemic stroke. We studied 259 inpatients and outpatients with a recent lacunar ischaemic stroke and no other prior stroke. We used carotid Duplex ultrasound and transcranial Doppler (TCD) ultrasound to identify ICA and MCA disease, and compared our results with previously published data. In our study, there was no difference between the severity of ipsilateral and contralateral ICA stenosis within individuals (median difference 0%, Wilcoxon paired data p=0.24, comparing severity of ipsilateral and contralateral stenosis). The overall prevalence of severe ipsilateral stenosis was 5%, and the prevalence of severe contralateral stenosis was 4% (OR 1.6, 95% CI 0.6, 4.8). There was no difference in the prevalence of ipsilateral and contralateral MCA disease. A systematic review of the other available studies strengthened this conclusion. Carotid stenosis in patients with a lacunar ischaemic stroke may be coincidental. Further studies are required to elucidate the causes of lacunar stroke, and to evaluate the role of carotid endarterectomy.

Effects of continuous haemofiltration on serum enzyme concentrations, endotoxemia, homeostasis and survival in dogs with severe heat stroke.

PubMed

Chen, Guang-ming; Xu, Hui-na; Gao, Li-fang; Lu, Jin-fu; Wang, Wen-rui; Chen, Jian

2012-05-01

To examine the effectiveness of continuous haemofiltration as a treatment for severe heat stroke in dogs. Dogs were randomly allocated to a control or continuous haemofiltration group (both n=8). Heat stroke was induced by placing anaesthetised dogs in a high temperature cabin simulator. Upon confirmation of heat stroke (rectal temperature>42 °C, mean arterial pressure (MAP) decrease>25 mmHg), dogs were removed from the chamber and continuous haemofiltration was initiated and continued for 3h for dogs in the continuous haemofiltration group. Dogs in the control group were observed at room temperature. Rectal temperature, haemodynamics, pH, blood gases and electrolyte concentrations rapidly returned to baseline in the continuous haemofiltration group, but not the control group. After 3h, rectal temperature was 36.68±0.51 °C in the continuous haemofiltration group and 39.83±1.10 °C in the control group (P<0.05). Continuous haemofiltration prevented endotoxin and all serum enzyme concentrations from increasing and caused malondialdehyde concentrations to decrease. After 3h, endotoxin concentrations were 0.14±0.02 EU ml(-1) in the continuous haemofiltration group and 0.23±0.05 EU ml(-1) in the control group (P=0.003), while malondialdehyde concentrations were 4.86±0.61 mmol l(-1) in the continuous haemofiltration group and 8.63±0.66 mmol l(-1) in the control group (P<0.001). Five dogs died in the control group within 3h, whereas no dogs died in the continuous haemofiltration group. Continuous haemofiltration rapidly reduced body temperature, normalised haemodynamics and electrolytes, improved serum enzyme concentrations and increased survival in dogs with heat stroke. Continuous haemofiltration may be an effective treatment for heat stroke. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.

Long-term survival and regeneration of neuronal and vasculature cells inside the core region after ischemic stroke in adult mice.

PubMed

Jiang, Michael Qize; Zhao, Ying-Ying; Cao, Wenyuan; Wei, Zheng Zachory; Gu, Xiaohuan; Wei, Ling; Yu, Shan Ping

2017-07-01

Focal cerebral ischemia results in an ischemic core surrounded by the peri-infarct region (penumbra). Most research attention has been focused on penumbra while the pattern of cell fates inside the ischemic core is poorly defined. In the present investigation, we tested the hypothesis that, inside the ischemic core, some neuronal and vascular cells could survive the initial ischemic insult while regenerative niches might exist many days after stroke in the adult brain. Adult mice were subjected to focal cerebral ischemia induced by permanent occlusion of distal branches of the middle cerebral artery (MCA) plus transient ligations of bilateral common carotid artery (CCA). The ischemic insult uniformly reduced the local cerebral blood flow (LCBF) by 90%. Massive cell death occurred due to multiple mechanisms and a significant infarction was cultivated in the ischemic cortex 24 h later. Nevertheless, normal or even higher levels of brain-derived neurotrophic factor (BDNF) and vascular endothelial growth factor (VEGF) persistently remained in the core tissue, some NeuN-positive and Glut-1/College IV-positive cells with intact ultrastructural features resided in the core 7-14 days post stroke. BrdU-positive but TUNEL-negative neuronal and endothelial cells were detected in the core where extensive extracellular matrix infrastructure developed. Meanwhile, GFAP-positive astrocytes accumulated in the penumbra and Iba-1-positive microglial/macrophages invaded the core several days after stroke. The long term survival of neuronal and vascular cells inside the ischemic core was also seen after a severe ischemic stroke induced by permanent embolic occlusion of the MCA. We demonstrate that a therapeutic intervention of pharmacological hypothermia could save neurons/endothelial cells inside the core. These data suggest that the ischemic core is an actively regulated brain region with residual and newly formed viable neuronal and vascular cells acutely and chronically after at least some types of ischemic strokes. © 2016 International Society of Neuropathology.

Comparison of Medicare Claims vs. Physician Adjudication for Identifying Stroke Outcomes in the Women’s Health Initiative

PubMed Central

Lakshminarayan, Kamakshi; Larson, Joseph C.; Virnig, Beth; Fuller, Candace; Allen, Norrina Bai; Limacher, Marian; Winkelmayer, Wolfgang C.; Safford, Monika M.; Burwen, Dale R.

2014-01-01

Background and Purpose Many studies use medical record review for ascertaining outcomes. One large, longitudinal study, the Women’s Health Initiative (WHI) ascertains strokes using participant self-report and subsequent physician review of medical records. This is resource-intensive. Herein, we assess whether Medicare data can reliably assess stroke events in the WHI. Methods Subjects were WHI participants with fee-for-service Medicare. Four stroke definitions were created for Medicare data using discharge diagnoses in hospitalization claims. Definition 1: stroke codes in any position; Definition 2: primary position stroke codes; Definitions 3 & 4: hemorrhagic and ischemic stroke codes respectively. WHI data were randomly split into training (50%) and test sets. A concordance matrix was used to examine agreement between WHI and Medicare stroke diagnosis. A WHI stroke and a Medicare stroke were considered a match if they occurred within +/− 7 days of each other. Refined analyses excluded Medicare events where medical records were unavailable for comparison. Results Training data (n=24,428): There were 577 WHI strokes and 557 Medicare strokes using definition 1. Of these, 478 were a match. Algorithm performance: Specificity 99.7%; Negative Predictive Value 99.7%; Sensitivity 82.8%; Positive Predictive Value 85.8%; kappa 0.84. Performance was similar for test data. While specificity and negative predictive value exceeded 99%, sensitivity ranged from 75 to 88% and positive predictive value ranged from 80 to 90% across stroke definitions. Conclusion Medicare data appear useful for population-based stroke research; however the performance characteristics depend on the definition selected. PMID:24525955

Sex Differences in Stroke Severity, Symptoms, and Deficits After First-Ever Ischemic Stroke

PubMed Central

Barrett, Kevin M.; Brott, Thomas G.; Brown, Robert D.; Frankel, Michael R.; Worrall, Bradford B.; Silliman, Scott L.; Case, L. Douglas; Rich, Stephen S.; Meschia, James F.

2007-01-01

Objective The purpose of the study was to assess whether there were sex differences in stroke severity, infarct characteristics, symptoms, or the symptoms-deficit relationship at the time of acute stroke presentation. Methods In a prospective study of 505 patients with first-ever ischemic stroke (the Ischemic Stroke Genetics Study), stroke subtype was centrally adjudicated and infarcts were characterized by imaging. Deficits were assessed by National Institutes of Health Stroke Scale and stroke symptoms were assessed using a structured interview. Kappa statistics were generated to assess agreement between the National Institutes of Health Stroke Scale and the structured interview, and a χ2 test was used to assess agreement between the National Institutes of Health Stroke Scale and the structured interview by sex. Results Two hundred seventy-six patients (55%) were men and 229 (45%) were women. Ages ranged from 19 to 94 years (median, 65 years). The mean (±SD) National Institutes of Health Stroke Scale score of 3.8 (±4.5) for men and 4.3 (±5.2) for women was similar (P=.15). No sex difference was observed for the symptoms of numbness, visual deficits, or language. Weakness occurred in a greater proportion of women (69%) than men (59%) (P=.03). Stroke subtype did not differ significantly between sexes (P=.79). Infarct size and location were similar for each sex. The association between symptoms and neurologic deficits did not differ by sex. Conclusions We found no sex difference in stroke severity, stroke subtype, or infarct size and location in patients with incident ischemic stroke. A greater proportion of women presented with weakness; however, similar proportions of men and women presented with other traditional stroke symptoms. PMID:17689390

The effects of neuromuscular electrical stimulation for dysphagia in opercular syndrome: a case study

PubMed Central

Speyer, Renée; Roodenburg, Nel; Manni, Johannes J.

2008-01-01

A 76-year-old man with opercular syndrome characterized by complete bilateral loss of voluntary control of facial, lingual, pharyngeal and masticatory muscles is presented with focus on the severe dysphagia. Three years earlier the patient had experienced two strokes resulting in opercular syndrome with severe dysphagia. Despite initial logopedic dysphagia treatment, swallowing did not improve. A new treatment for dysphagia, consisting of neuromuscular electrical stimulation was applied on the patient. He returned to oral feeding. Clinical and treatment observations are reported. PMID:18180938

Anti-hypertensive treatment prolongs tPA door-to-treatment time: Secondary analysis of the INSTINCT trial.

PubMed Central

Skolarus, Lesli E.; Scott, Phillip A.; Burke, James F.; Adelman, Eric E.; Frederiksen, Shirley M.; Kade, Allison M.; Kalbfleisch, Jack D.; Ford, Andria L.; Meurer, William J.

2012-01-01

Background/Purpose Identifying modifiable tPA treatment delays may improve stroke outcomes. We hypothesized that pre-thrombolytic anti-hypertensive treatment (AHT) may prolong door-to-treatment time (DTT). Methods Analysis of consecutive tPA-treated patients at 24 randomly selected community hospitals in the INSTINCT trial between 2007-2010. DTTs among stroke patients who received pre-thrombolytic AHT were compared to those that did not receive pre-thrombolytic AHT. We then calculated a propensity score for the probability of receiving pre-thrombolytic AHT using logistic regression with demographics, stroke risk factors, home medications, stroke severity (NIHSS), onset-to-door time, admission glucose, pretreatment blood pressure, EMS transport and location at time of stroke as independent variables. A paired t-test was performed to compare the DTTs between the propensity matched groups. Results Of 534 tPA treated stroke patients analyzed, 95 received pre-thrombolytic AHT. In the unmatched cohort, patients who received pre-thrombolytic AHT had a longer DTT (mean increase 9 minutes; 95% confidence interval (CI) 2-16 minutes) than patients who did not. After propensity matching, patients who received pre-thrombolytic AHT had a longer DTT (mean increase 10.4 minutes, 95% CI 1.9 - 18.8) than patients who did not receive pre-thrombolytic AHT. Conclusion Pre-thrombolytic AHT is associated with modest delays in DTT. This represents a potential target for quality improvement initiatives. Further research evaluating optimum pre-thrombolytic hypertension management is warranted. PMID:23033348

Dancing to death: A case of heat stroke.

PubMed

Nadesan, K; Kumari, Chandra; Afiq, Mohd

2017-08-01

Heat stroke is a medical emergency which may lead to mortality unless diagnosed early and treated effectively. Heat stroke may manifest rapidly, hence making it difficult to differentiate it from other clinical causes in a collapsed victim. 1 We are presenting a case report of twelve patients who were admitted to our emergency department from a music festival held on 13-15th of March 2014. They developed complications arising from a combination of severe adverse weather condition, prolonged outdoor physical exertion due to long hours of dancing and drug-use, resulting in heat stroke. Three of them died while the remaining patients survived. Their condition was initially misdiagnosed as a classical illicit drug overdose. This was based on the history of drug ingestion by some of the patients who attended the music festival on that day. The information in this case report aims, to create awareness amongst members of the medical team on duty in outdoor events, pre hospital responders and ED physicians when treating and managing similar cases in the future. In addition it is intended to warn the organizers of such events to take adequate precautions to avoid such tragedies in the future. Copyright © 2017. Published by Elsevier Ltd.

Developing a stroke severity index based on administrative data was feasible using data mining techniques.

PubMed

Sung, Sheng-Feng; Hsieh, Cheng-Yang; Kao Yang, Yea-Huei; Lin, Huey-Juan; Chen, Chih-Hung; Chen, Yu-Wei; Hu, Ya-Han

2015-11-01

Case-mix adjustment is difficult for stroke outcome studies using administrative data. However, relevant prescription, laboratory, procedure, and service claims might be surrogates for stroke severity. This study proposes a method for developing a stroke severity index (SSI) by using administrative data. We identified 3,577 patients with acute ischemic stroke from a hospital-based registry and analyzed claims data with plenty of features. Stroke severity was measured using the National Institutes of Health Stroke Scale (NIHSS). We used two data mining methods and conventional multiple linear regression (MLR) to develop prediction models, comparing the model performance according to the Pearson correlation coefficient between the SSI and the NIHSS. We validated these models in four independent cohorts by using hospital-based registry data linked to a nationwide administrative database. We identified seven predictive features and developed three models. The k-nearest neighbor model (correlation coefficient, 0.743; 95% confidence interval: 0.737, 0.749) performed slightly better than the MLR model (0.742; 0.736, 0.747), followed by the regression tree model (0.737; 0.731, 0.742). In the validation cohorts, the correlation coefficients were between 0.677 and 0.725 for all three models. The claims-based SSI enables adjusting for disease severity in stroke studies using administrative data. Copyright © 2015 Elsevier Inc. All rights reserved.

Racial and Gender Differences in Stroke Severity, Outcomes and Treatment in Patients with Acute Ischemic Stroke

PubMed Central

Boehme, Amelia K; Siegler, James E; Mullen, Michael T.; Albright, Karen C; Lyerly, Michael J.; Monlezun, Dominique J; Jones, Erica M.; Gonzales, Nicole R.; Beasley, T. Mark; Grotta, James C.; Savitz, Sean I.; Martin-Schild, Sheryl

2014-01-01

Background Previous research has indicated that women and Blacks have worse outcomes following acute ischemic stroke (AIS). Little research has been done to investigate the combined influence of race and gender in the presentation, treatment and outcome of patients with AIS. We sought to determine the association of race and gender on initial stroke severity, thrombolysis and functional outcome after AIS. Methods AIS patients who presented to two academic medical centers in the United States (2004-2011) were identified through prospective registries. In-hospital strokes were excluded. Stroke severity, measured by admission National Institutes of Health Stroke Scale (NIHSS) scores, treatment with tissue plasminogen activator (tPA), neurologic deterioration (defined by a ≥2 point increase in NIHSS), and functional outcome at discharge, measured by the modified Rankin Scale (mRS), were investigated. These outcomes were compared across race/gender groups. A sub-analysis was conducted to assess race/gender differences in exclusion criteria for tPA. Results Of the 4925 patients included in this study, 2346 (47.6%) were women and 2310 (46.9%) were black. White women had the highest median NIHSS on admission (8) with White men had the lowest median NIHSS on admission (6). There were no differences in outcomes between Black men and White men. A smaller percentage of Black women than White women were treated with tPA (27.6% vs. 36.6%, p<0.0001), partially due to a greater proportion of White women presenting within 3 hours (51% vs. 45.5%, p =0.0005). Black women had decreased odds of poor functional outcome relative to White women (OR=0.85, 95%CI 0.72-1.00), but after adjustment for baseline differences in age, NIHSS and tPA use this association was no longer significant (OR=1.2, 95%CI 0.92-1.46, p=0.22). Black women with a NIHSS on admission of less than 7 were at lower odds of receiving tPA than the other race gender groups, even after adjusting for arriving within 3 hours and admission glucose (OR 0.66, 95%CI 0.44-0.99, p=0.0433). Conclusion Race and gender were not significantly associated with short-term outcome, although Black women were significantly less likely to be treated with tPA. Black women had more tPA exclusions than any other group. The primary reason for tPA exclusion in this study was not arriving within 3 hours of stroke symptom onset. Given the growth in incident strokes projected in minority groups in the next 4 decades, identifying factors that contribute to Black women not arriving to the ED in time is of great importance. PMID:24468069

Temporal profile of body temperature in acute ischemic stroke: relation to stroke severity and outcome

PubMed Central

2012-01-01

Background Pyrexia after stroke (temperature ≥37.5°C) is associated with poor prognosis, but information on timing of body temperature changes and relationship to stroke severity and subtypes varies. Methods We recruited patients with acute ischemic stroke, measured stroke severity, stroke subtype and recorded four-hourly tympanic (body) temperature readings from admission to 120 hours after stroke. We sought causes of pyrexia and measured functional outcome at 90 days. We systematically summarised all relevant previous studies. Results Amongst 44 patients (21 males, mean age 72 years SD 11) with median National Institute of Health Stroke Score (NIHSS) 7 (range 0–28), 14 had total anterior circulation strokes (TACS). On admission all patients, both TACS and non-TACS, were normothermic (median 36.3°C vs 36.5°C, p=0.382 respectively) at median 4 hours (interquartile range, IQR, 2–8) after stroke; admission temperature and NIHSS were not associated (r2=0.0, p=0.353). Peak temperature, occurring at 35.5 (IQR 19.0 to 53.8) hours after stroke, was higher in TACS (37.7°C) than non-TACS (37.1°C, p<0.001) and was associated with admission NIHSS (r2=0.20, p=0.002). Poor outcome (modified Rankin Scale ≥3) at 90 days was associated with higher admission (36.6°C vs. 36.2°C p=0.031) and peak (37.4°C vs. 37.0°C, p=0.016) temperatures. Sixteen (36%) patients became pyrexial, in seven (44%) of whom we found no cause other than the stroke. Conclusions Normothermia is usual within the first 4 hours of stroke. Peak temperature occurs at 1.5 to 2 days after stroke, and is related to stroke severity/subtype and more closely associated with poor outcome than admission temperature. Temperature-outcome associations after stroke are complex, but normothermia on admission should not preclude randomisation of patients into trials of therapeutic hypothermia. PMID:23075282

Air Pollution and Subtypes, Severity and Vulnerability to Ischemic Stroke—A Population Based Case-Crossover Study

PubMed Central

Maheswaran, Ravi; Pearson, Tim; Beevers, Sean D.; Campbell, Michael J.; Wolfe, Charles D.

2016-01-01

Background and Purpose Few studies have examined the association between air pollutants and ischemic stroke subtypes. We examined acute effects of outdoor air pollutants (PM10, NO2, O3, CO, SO2) on subtypes and severity of incident ischemic stroke and investigated if pre-existing risk factors increased susceptibility. Methods We used a time stratified case-crossover study and stroke cases from the South London Stroke Register set up to capture all incident cases of first ever stroke occurring amongst residents in a geographically defined area. The Oxford clinical and TOAST etiological classifications were used to classify subtypes. A pragmatic clinical classification system was used to assess severity. Air pollution concentrations from the nearest background air pollution monitoring stations to patients’ residential postcode centroids were used. Lags from 0 to 6 days were investigated. Results There were 2590 incident cases of ischemic stroke (1995–2006). While there were associations at various lag times with several pollutants, overall, there was no consistent pattern between exposure and risk of ischemic stroke subtypes or severity. The possible exception was the association between NO2 exposure and small vessel disease stroke—adjusted odds ratio of 1.51 (1.12–2.02) associated with an inter-quartile range increase in the lag 0–6 day average for NO2. There were no clear associations in relation to pre-existing risk factors. Conclusions Overall, we found little consistent evidence of association between air pollutants and ischemic stroke subtypes and severity. There was however a suggestion that increasing NO2 exposure might be associated with higher risk of stroke caused by cerebrovascular small vessel disease. PMID:27362783

Design and Validation of a Prehospital Scale to Predict Stroke Severity: The Cincinnati Prehospital Stroke Severity Scale

PubMed Central

Katz, Brian S.; McMullan, Jason T.; Sucharew, Heidi; Adeoye, Opeolu; Broderick, Joseph P.

2015-01-01

Background and Purpose We derived and validated the Cincinnati Prehospital Stroke Severity Scale (CPSSS) to identify patients with severe strokes and large vessel occlusion (LVO). Methods CPSSS was developed with regression tree analysis, objectivity, anticipated ease in administration by EMS personnel, and the presence of cortical signs. We derived and validated the tool using the two NINDS t-PA Stroke Study trials and IMS III Trial cohorts, respectively, to predict severe stroke [NIH stroke scale (NIHSS) ≥15] and LVO. Standard test characteristics were determined and receiver operator curves were generated and summarized by the area under the curve (AUC). Results CPSSS score ranges from 0-4; composed and scored by individual NIHSS items: 2 points for presence of conjugate gaze (NIHSS ≥1); 1 point for presence of arm weakness (NIHSS ≥2); and 1 point for presence abnormal level of consciousness (LOC) commands and questions (NIHSS LOC ≥1 each). In the derivation set, CPSSS had an AUC of 0.89; score ≥2 was 89% sensitive and 73% specific in identifying NIHSS ≥15. Validation results were similar with an AUC of 0.83; score ≥2 was 92% sensitive, 51% specific, a positive likelihood ratio (PLR) of 3.3 and a negative likelihood ratio (NLR) of 0.15 in predicting severe stroke. For 222/303 IMS III subjects with LVO, CPSSS had an AUC of 0.67; a score ≥2 was 83% sensitive, 40% specific, PLR of 1.4, and NLR of 0.4 in predicting LVO. Conclusions CPSSS can identify stroke patients with NIHSS ≥15 and LVO. Prospective prehospital validation is warranted. PMID:25899242

Quality of life after TIA and stroke: ten-year results of the Oxford Vascular Study.

PubMed

Luengo-Fernandez, Ramon; Gray, Alastair M; Bull, Linda; Welch, Sarah; Cuthbertson, Fiona; Rothwell, Peter M

2013-10-29

To evaluate the 5-year impact of stroke and TIA on utility and quality-adjusted survival. TIA and stroke patients from a UK population-based study (Oxford Vascular Study) were recruited from 2002 to 2007, and followed up until 2012. Quality of life was assessed over 5 years using the EQ-5D (EuroQol-5 Dimensions), with responses converted into utilities ranging from -0.59 (worse than death) to 1 (perfect health), using UK population valuations. Utilities for stroke and TIA patients were compared with those in matched controls obtained from the 2006 Health Survey for England. Five-year quality-adjusted life years were estimated by combining utility and survival information. Four hundred forty TIA and 748 stroke patients were ascertained and included. Utility remained constant at approximately 0.78 over the 5 years after TIA. Utility improved from 0.64 one month after stroke to 0.70 at 6 months (p = 0.006), remaining at approximately 0.70 thereafter. Matched controls had considerably higher utility levels than stroke/TIA patients (0.85, p < 0.001). Event severity and recurrent stroke were significant predictors of decreased long-term utility. Five-year quality-adjusted life expectancy was 3.32 (95% confidence interval: 3.22-3.48) quality-adjusted life years after TIA and 2.21 (2.15-2.37) after stroke, varying considerably by severity (minor: 2.94; moderate: 1.65; and severe: 0.70). Quality-adjusted survival is low over the 5 years after stroke and TIA, with severity and recurrent stroke being major predictors. There remains considerable scope for improvements in acute treatment and secondary prevention to improve the quality of life after TIA and stroke.

Predictors of intracerebral hemorrhage severity and its outcome in Japanese stroke patients.

PubMed

Hosomi, Naohisa; Naya, Takayuki; Ohkita, Hiroyuki; Mukai, Mao; Nakamura, Takehiro; Ueno, Masaki; Dobashi, Hiroaki; Murao, Koji; Masugata, Hisashi; Miki, Takanori; Kohno, Masakazu; Kobayashi, Shotai; Koziol, James A

2009-01-01

The aim of this investigation was to determine the factors influencing acute intracerebral hemorrhage severity on admission and clinical outcomes at discharge. Sixty acute stroke hospitals throughout Japan participated in the Japan Standard Stroke Registry Study (JSSRS), documenting the in-hospital course of 16,630 consecutive patients with acute stroke from January 2001 to March 2004. We identified 2,840 adult patients from the JSSRS who had intracerebral hemorrhage. Intracerebral hemorrhage severity on admission was strongly related to age, previous stroke history, and hemorrhage size in a monotone fashion [chi(2)(9) = 374.5, p < 0.0001]. Drinking history was also predictive of intracerebral hemorrhage severity on admission, but the association was not monotone. Interestingly, intracerebral hemorrhage severity on admission was increased in nondrinking and heavy drinking compared to mild drinking (p < 0.05). Unsuccessful outcome (modified Rankin scale score = 3-6) was related to age, previous stroke history, hemorrhage size, and intracerebral hemorrhage severity on admission [chi(2)(9) = 830.4, p < 0.0001]. Mortality was related to hemorrhage size, intraventricular hemorrhage, intracerebral hemorrhage severity on admission, and surgical operation [chi(2)(7) = 540.4, p < 0.0001]. We could find four varied factors associated with intracerebral hemorrhage severity and its outcomes. Interestingly, intracerebral hemorrhage severity tended to be greater in nondrinking and heavy drinking than mild drinking. Additionally, surgical operation decreased intracerebral hemorrhage mortality. Copyright 2008 S. Karger AG, Basel.

Wake-Up Stroke versus Stroke with Known Onset Time: Clinical and Multimodality CT Imaging Characteristics.

PubMed

Dankbaar, Jan W; Bienfait, Henri P; van den Berg, Coen; Bennink, Edwin; Horsch, Alexander D; van Seeters, Tom; van der Schaaf, Irene C; Kappelle, L Jaap; Velthuis, Birgitta K

2018-05-17

Current guidelines for the treatment of acute ischemic stroke are mainly based on the time between symptom onset and initiation of treatment. This time is unknown in patients with wake-up stroke (WUS). We investigated clinical and multimodality CT imaging characteristics on admission in patients with WUS and in patients with a stroke with a known onset time. All patients were selected from a large prospective cohort study (Dutch acute stroke study). WUS patients last seen well > 4.5 and ≤4.5 h were separately compared to patients with a known onset time ≤4.5 h. In addition, WUS patients with a proximal occlusion of the anterior circulation last seen well > 6 and ≤6 h were separately compared to patients with a known onset time ≤6 h and a proximal occlusion. National Institute of Health Stroke Score, age, gender, history of atrial fibrillation, non-contrast CT (NCCT) Alberta Stroke Program Early CT Score (ASPECTS), CT-perfusion abnormalities, proximal occlusions, and collateral filling on CT angiography were compared between groups using the Mann-Whitney U test and Fisher's exact test. WUS occurred in 149/1,393 (10.7%) patients. Admission clinical and imaging characteristics of WUS patients last seen well > 4.5 h (n = 81) were not different from WUS patients last seen well ≤4.5 h (n = 68). Although WUS patients last seen well > 4.5 h had a significantly lower NCCT ASPECTS than patients with a known time of stroke symptom onset of ≤4.5 h (n = 1,026), 85.2% had an NCCT ASPECTS > 7 and 75% had a combination of favorable ASPECTS > 7 and good collateral filling. There were no statistically significant differences between the admission clinical and imaging characteristics of WUS patients with proximal occlusions last seen well > 6 h (n = 23), last seen well ≤6 h (n = 40), and patients with a known time to stroke symptom onset ≤6 h (n = 399). Of all WUS patients with proximal occlusions last seen well > 6 h, only 4.3% had severe ischemia (ASPECTS < 5), 13 (56.5%) had ASPECTS > 7 and good collateral filling. There are only minor differences between clinical and imaging characteristics of WUS patients and patients who arrive in the hospital within the time criteria for intravenous or endovascular treatment. Therefore, CT imaging may help to identify WUS patients who would benefit from treatment and rule out those patients with severe ischemia and poor collaterals. © 2018 S. Karger AG, Basel.

Effects of aspirin on risk and severity of early recurrent stroke after transient ischaemic attack and ischaemic stroke: time-course analysis of randomised trials.

PubMed

Rothwell, Peter M; Algra, Ale; Chen, Zhengming; Diener, Hans-Christoph; Norrving, Bo; Mehta, Ziyah

2016-07-23

Aspirin is recommended for secondary prevention after transient ischaemic attack (TIA) or ischaemic stroke on the basis of trials showing a 13% reduction in long-term risk of recurrent stroke. However, the risk of major stroke is very high for only the first few days after TIA and minor ischaemic stroke, and observational studies show substantially greater benefits of early medical treatment in the acute phase than do longer-term trials. We hypothesised that the short-term benefits of early aspirin have been underestimated. Pooling the individual patient data from all randomised trials of aspirin versus control in secondary prevention after TIA or ischaemic stroke, we studied the effects of aspirin on the risk and severity of recurrent stroke, stratified by the following time periods: less than 6 weeks, 6-12 weeks, and more than 12 weeks after randomisation. We compared the severity of early recurrent strokes between treatment groups with shift analysis of modified Rankin Scale (mRS) score. To understand possible mechanisms of action, we also studied the time course of the interaction between effects of aspirin and dipyridamole in secondary prevention of stroke. In a further analysis we pooled data from trials of aspirin versus control in which patients were randomised less than 48 h after major acute stroke, stratified by severity of baseline neurological deficit, to establish the very early time course of the effect of aspirin on risk of recurrent ischaemic stroke and how this differs by severity at baseline. We pooled data for 15,778 participants from 12 trials of aspirin versus control in secondary prevention. Aspirin reduced the 6 week risk of recurrent ischaemic stroke by about 60% (84 of 8452 participants in the aspirin group had an ischaemic stroke vs 175 of 7326; hazard ratio [HR] 0·42, 95% CI 0·32-0·55, p<0·0001) and disabling or fatal ischaemic stroke by about 70% (36 of 8452 vs 110 of 7326; 0·29, 0·20-0·42, p<0·0001), with greatest benefit noted in patients presenting with TIA or minor stroke (at 0-2 weeks, two of 6691 participants in the aspirin group with TIA or minor stroke had a disabling or fatal ischaemic stroke vs 23 of 5726 in the control group, HR 0·07, 95% CI 0·02-0·31, p=0·0004; at 0-6 weeks, 14 vs 60 participants, 0·19, 0·11-0·34, p<0·0001). The effect of aspirin on early recurrent ischaemic stroke was due partly to a substantial reduction in severity (mRS shift analysis odds ratio [OR] 0·42, 0·26-0·70, p=0·0007). These effects were independent of dose, patient characteristics, or aetiology of TIA or stroke. Some further reduction in risk of ischaemic stroke accrued for aspirin only versus control from 6-12 weeks, but there was no benefit after 12 weeks (stroke risk OR 0·97, 0·84-1·12, p=0·67; severity mRS shift OR 1·00, 0·77-1·29, p=0·97). By contrast, dipyridamole plus aspirin versus aspirin alone had no effect on risk or severity of recurrent ischaemic stroke within 12 weeks (OR 0·90, 95% CI 0·65-1·25, p=0·53; mRS shift OR 0·90, 0·37-1·72, p=0·99), but dipyridamole did reduce risk thereafter (0·76, 0·63-0·92, p=0·005), particularly of disabling or fatal ischaemic stroke (0·64, 0·49-0·84, p=0·0010). We pooled data for 40,531 participants from three trials of aspirin versus control in major acute stroke. The reduction in risk of recurrent ischaemic stroke at 14 days was most evident in patients with less severe baseline deficits, and was substantial by the second day after starting treatment (2-3 day HR 0·37, 95% CI 0·25-0·57, p<0·0001). Our findings confirm that medical treatment substantially reduces the risk of early recurrent stroke after TIA and minor stroke and identify aspirin as the key intervention. The considerable early benefit from aspirin warrants public education about self-administration after possible TIA. The previously unrecognised effect of aspirin on severity of early recurrent stroke, the diminishing benefit with longer-term use, and the contrasting time course of effects of dipyridamole have implications for understanding mechanisms of action. Wellcome Trust, the National Institute of Health Research (NIHR) Biomedical Research Centre, Oxford. Copyright © 2016 Rothwell et al. Open Access article distributed under the terms of CC BY. Published by Elsevier Ltd.. All rights reserved.

Long-term functional outcomes of patients with very mild stroke: does a NIHSS score of 0 mean no disability? An interim analysis of the KOSCO study.

PubMed

Chang, Won Hyuk; Sohn, Min Kyun; Lee, Jongmin; Kim, Deog Young; Lee, Sam-Gyu; Shin, Yong-Il; Oh, Gyung-Jae; Lee, Yang-Soo; Joo, Min Cheol; Han, Eun Young; Kim, Min Su; Jang, Shin Yi; Kim, Jeong Hyun; Kim, Yun-Hee

2017-05-01

To explore the long-term functional outcomes of stroke patients with very mild severity at 6 months after stroke. This study presents the interim results of the Korean Stroke Cohort for Functioning and Rehabilitation. On day 7, stroke evaluation was performed using the functional assessment battery including the National Institute of Health Stroke Scale (NIHSS). At 6 months after stroke, functional outcomes using the face-to-face functional assessment battery including Functional Independence Measure (FIM) were analyzed in the patients who had a score of 0 on the NIHSS at 7 days after stroke onset. In the very mild stroke group, 455 patients were followed up at 6 months. Out of these patients, 11.0% had impairments in cognitive function, 14.1% had motor impairment, and 2.1% had impairments in their mobility measured by the functional assessment battery. At 6 months after onset, 3.3% of stroke survivors without recurrence showed dependency according to the FIM. Many acute stroke patients with mild stroke severity as assessed by the NIHSS had impairments in various functional domains, and could have been easily overlooked for intensive rehabilitation therapy. Candidates for comprehensive rehabilitation therapy might be better identified by the functional assessment battery. Implications for rehabilitation Many acute stroke patients with mild stroke severity assessed by NIHSS could be easily overlooked for intensive rehabilitation therapy. Candidates for comprehensive rehabilitation therapy should be evaluated using a functional assessment battery rather than the NIHSS.

Pharyngolaryngeal Sensory Deficits in Patients with Middle Cerebral Artery Infarction: Lateralization and Relation to Overall Dysphagia Severity

PubMed Central

Marian, Thomas; Schröder, Jens Burchard; Muhle, Paul; Claus, Inga; Riecker, Axel; Warnecke, Tobias; Suntrup-Krueger, Sonja; Dziewas, Rainer

2017-01-01

Background Dysphagia is a frequent and dangerous complication of acute stroke. Apart from a well-timed oropharyngeal muscular contraction pattern, sensory feedback is of utmost importance for safe and efficient swallowing. In the present study, we therefore analyzed the relation between pharyngolaryngeal sensory deficits and post-stroke dysphagia (PSD) severity in a cohort of acute stroke patients with middle cerebral artery (MCA) infarction. Methods Eighty-four first-ever MCA stroke patients (41 left, 43 right) were included in this trial. In all patients, fiberoptic endoscopic evaluation of swallowing (FEES) was performed according to a standardized protocol within 96 h after stroke onset. PSD was classified according to the 6-point fiberoptic endoscopic dysphagia severity scale. Pharyngolaryngeal sensation was semi-quantitatively evaluated by a FEES-based touch technique. Results PSD severity was closely related to the pharyngolaryngeal sensory deficit. With regards to lateralization of the sensory deficit, there was a slight but significant preponderance of sensory loss contralateral to the side of stroke. Apart from that, right hemispheric stroke patients were found to present with a more severe PSD. Conclusions This study provides evidence that an intact sensory feedback is of utmost importance to perform nonimpaired swallowing and highlights the key role of disturbed pharyngeal and laryngeal afferents in the pathophysiology of PSD. PMID:28972945

Open Heart Surgery Does Not Increase the Incidence of Ipsilateral Ischemic Stroke in Patients with Asymptomatic Severe Carotid Stenosis.

PubMed

Castaldo, John E; Yacoub, Hussam A; Li, Yuebing; Kincaid, Hope; Jenny, Donna

2017-10-01

We evaluated the incidence of perioperative stroke following the institution's 2007 practice change of discontinuing combined carotid endarterectomy and open heart surgery (OHS) for patients with severe carotid stenosis. In this retrospective cohort study, we compared 113 patients undergoing coronary artery bypass grafting, aortic valve replacement, or both from 2007 to 2011 with data collected from 2001 to 2006 from a similar group of patients. Our aim was to assess whether the practice change led to a greater incidence of stroke. A total of 7350 consecutive patients undergoing OHS during the specified time period were screened. Of these, 3030 had OHS between 2007 and 2011 but none were combined with carotid artery surgery (new cohort). The remaining 4320 had OHS before 2007 and 44 had combined procedures (old cohort). Of patients undergoing OHS during the 10-year period of observation, 230 had severe (>80%) carotid stenosis. In the old cohort (before 2007), carotid stenosis was associated with perioperative stroke in 2.5% of cases. None of the 113 patients having cardiac procedures after 2007 received combined carotid artery surgery; only 1 of these patients harboring severe carotid stenosis had an ischemic stroke (.9%) during the perioperative period. The difference in stroke incidence between the 2 cohorts was statistically significant (P = .002). The incidence of stroke in patients with severe carotid artery stenosis undergoing OHS was lower after combined surgery was discontinued. Combined carotid and OHS itself seems to be an important risk factor for stroke. Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.

[Mechanical thrombectomy in acute ischemic stroke. What is the position after the latest study results?].

PubMed

Hacke, W; Diener, H-C

2015-06-01

Mechanical devices for the recanalization of vessel occlusions in severe acute ischemic stroke have been developed for more than a decade. Several devices have been approved for clinical use on the basis of uncontrolled case series. Many neurologists have asked for randomized clinical trials comparing the new devices with standard treatment, e.g. thrombolytic therapy within a 4.5 h time window. The first 3 investigator initiated randomized trials published in 2013 failed to show superiority of mechanical thrombectomy over standard treatment. In the aftermath of these negative results several new trials with changes in design (e.g. shorter time window and only proximal vessel occlusions) and the use of modern devices with proven higher recanalization rates, so called stent retrievers, have been launched. In October 2014 the first of these new trials was presented and showed a clear superiority of thrombectomy. Based on this result interim analyses of five other studies were performed and most were prematurely terminated because of overwhelming efficacy. Only one trial testing another type of recanalization device failed to reach a statistically significant result. Currently five studies have already been published and two more studies have been presented at scientific conferences. This article provides an overview of the study protocols and the results of the individual studies, their common features and the characteristics of patients who benefit from this treatment. Finally, the consequences that these results may have for the treatment of patients with severe stroke caused by proximal vessel occlusion are discussed.

Reasons and evolution of non-thrombolysis in acute ischaemic stroke

PubMed Central

Reiff, T; Michel, P

2017-01-01

Introduction Despite increasing evidence of its efficacy in advanced age or in mild or severe strokes, intravenous thrombolysis remains underused for acute ischaemic stroke (AIS). Our aim was to obtain an updated view of reasons for non-thrombolysis and to identify its changing patterns over time. Methods This is a retrospective study of prospectively collected data from the Acute Stroke Registry and Analysis of Lausanne (ASTRAL) from the years 2003–2011. Patients admitted with acute stroke in the past 24 hours who had not had thrombolysis were identified; reasons for non-thrombolysis documented in the prospectively entered data were tabulated and analysed for the group as a whole. Data were analysed for the years 2003–2006 and 2007 forward because of changes in contraindications. A subgroup of patients who arrived within the treatment window ≤180 min was separately analysed for reasons for non-thrombolysis. Predictors of non-thrombolysis were investigated via multivariate regression analyses. Results In the 2019 non-thrombolysed patients the most frequent reasons for non-thrombolysis were admission delays (66.3%), stroke severity (mostly mild) (47.9%) and advanced age (14.1%); 55.9% had more than one exclusion criterion. Among patients arriving ≤180 min after onset, the main reasons were stroke severity and advanced age. After 2006, significantly fewer patients were excluded because of age (OR 2.65, p<0.001) or (mostly mild) stroke severity (OR 10.56, p=0.029). Retrospectively, 18.7% of all non-thrombolysed patients could have been treated because they only had relative contraindications. Conclusion Onset-to-admission delays remain the main exclusion criterion for thrombolysis. Among early arrivals, relative contraindications such as minor stroke severity and advanced age were frequent. Thrombolysis rate increased with the reduction of thrombolysis restrictions (eg, age and stroke severity). PMID:27797870

Secondary prevention lifestyle interventions initiated within 90 days after TIA or 'minor' stroke: a systematic review and meta-analysis of rehabilitation programmes.

PubMed

Heron, Neil; Kee, Frank; Cardwell, Christopher; Tully, Mark A; Donnelly, Michael; Cupples, Margaret E

2017-01-01

Strokes are often preceded by a transient ischaemic attack (TIA) or 'minor' stroke. The immediate period after a TIA/minor stroke is a crucial time to initiate secondary prevention. However, the optimal approach to prevention, including non-pharmacological measures, after TIA is not clear. To systematically review evidence about the effectiveness of delivering secondary prevention, with lifestyle interventions, in comprehensive rehabilitation programmes, initiated within 90 days of a TIA/minor stroke. Also, to categorise the specific behaviour change techniques used. The review identified randomised controlled trials by searching the Cochrane Library, Ovid MEDLINE, Ovid EMBASE, Web of Science, EBSCO CINAHL and Ovid PsycINFO. Two review authors independently screened titles and abstracts for eligibility (programmes initiated within 90 days of event; outcomes reported for TIA/minor stroke) and extracted relevant data from appraised studies; a meta-analysis was used to synthesise the results. A total of 31 potentially eligible papers were identified and four studies, comprising 774 patients post-TIA or minor stroke, met the inclusion criteria; two had poor methodological quality. Individual studies reported increased aerobic capacity but meta-analysis found no significant change in resting and peak systolic blood pressure, resting heart rate, aerobic capacity, falls, or mortality. The main behaviour change techniques were goal setting and instructions about how to perform given behaviours. There is limited evidence of the effectiveness of early post-TIA rehabilitation programmes with preventive lifestyle interventions. Further robust randomised controlled trials of comprehensive rehabilitation programmes that promote secondary prevention and lifestyle modification immediately after a TIA are needed. © British Journal of General Practice 2017.

Acute neurovascular events in cancer patients receiving anti-vascular endothelial growth factor agents: Clinical experience in Paris University Hospitals.

PubMed

Tlemsani, Camille; Mir, Olivier; Psimaras, Dimitri; Vano, Yann-Alexandre; Ducreux, Michel; Escudier, Bernard; Rousseau, Benoit; Loirat, Delphine; Ceccaldi, Bernard; André, Thierry; Goldwasser, François; Ricard, Damien

2016-10-01

Despite the increasing and broadening use of agents targeting the vascular endothelial growth factor (VEGF) pathway, little is known on their acute neurovascular toxicities. This retrospective, multi-centre study examined the characteristics of patients with solid tumours who experienced an ischaemic or haemorrhagic stroke, a transient ischaemic accident (TIA) or a posterior reversible encephalopathy syndrome (PRES) while under anti-VEGF and until 8 weeks after termination of treatment and evaluated their management in our institutions from 2004 to 2014. Patients with newly diagnosed or progressive cerebral metastases at the time of the acute neurovascular event were excluded. Thirty-four patients (55.9% men) were identified, and experienced either ischaemic stroke (n = 18), PRES (n = 9), TIA (n = 6) or haemorrhagic stroke (n = 1). At initiation of anti-VEGF agents, 64.7% of patients had previous cardiovascular risk factors, and 52.9% had hypertension. Eight patients (23.5%) had received cerebral radiotherapy, five of which concomitantly to anti-VEGF treatment. Six (17%) patients died in the 8 weeks following the acute neurovascular event, and only 55.9% recovered their initial neurological status. Overall, 1-year and 2-year survival rates after the acute neurovascular event were 67.9% and 50%, respectively. When anti-VEGF agents were reintroduced (n = 6), severe vascular toxicity recurred in two patients. Neurovascular events under VEGF treatments are potentially severe, and the management of comorbid conditions has to be improved. A prospective collection of data and standardised management of such events is therefore being structured in our institutions. Copyright © 2016 Elsevier Ltd. All rights reserved.

Lightning energetics: Estimates of energy dissipation in channels, channel radii, and channel-heating risetimes

DOE Office of Scientific and Technical Information (OSTI.GOV)

Borovsky, J.E.

1998-05-01

In this report, several lightning-channel parameters are calculated with the aid of an electrodynamic model of lightning. The electrodynamic model describes dart leaders and return strokes as electromagnetic waves that are guided along conducting lightning channels. According to the model, electrostatic energy is delivered to the channel by a leader, where it is stored around the outside of the channel; subsequently, the return stroke dissipates this locally stored energy. In this report this lightning-energy-flow scenario is developed further. Then the energy dissipated per unit length in lightning channels is calculated, where this quantity is now related to the linear chargemore » density on the channel, not to the cloud-to-ground electrostatic potential difference. Energy conservation is then used to calculate the radii of lightning channels: their initial radii at the onset of return strokes and their final radii after the channels have pressure expanded. Finally, the risetimes for channel heating during return strokes are calculated by defining an energy-storage radius around the channel and by estimating the radial velocity of energy flow toward the channel during a return stroke. In three appendices, values for the linear charge densities on lightning channels are calculated, estimates of the total length of branch channels are obtained, and values for the cloud-to-ground electrostatic potential difference are estimated. {copyright} 1998 American Geophysical Union« less

Interferon-β Modulates Inflammatory Response in Cerebral Ischemia.

PubMed

Kuo, Ping-Chang; Scofield, Barbara A; Yu, I-Chen; Chang, Fen-Lei; Ganea, Doina; Yen, Jui-Hung

2016-01-08

Stroke is a leading cause of death in the world. In >80% of strokes, the initial acute phase of ischemic injury is due to the occlusion of a blood vessel resulting in severe focal hypoperfusion, excitotoxicity, and oxidative damage. Interferon-β (IFNβ), a cytokine with immunomodulatory properties, was approved by the US Food and Drug Administration for the treatment of relapsing-remitting multiple sclerosis for more than a decade. Its anti-inflammatory properties and well-characterized safety profile suggest that IFNβ has therapeutic potential for the treatment of ischemic stroke. We investigated the therapeutic effect of IFNβ in the mouse model of transient middle cerebral artery occlusion/reperfusion. We found that IFNβ not only reduced infarct size in ischemic brains but also lessened neurological deficits in ischemic stroke animals. Further, multiple molecular mechanisms by which IFNβ modulates ischemic brain inflammation were identified. IFNβ reduced central nervous system infiltration of monocytes/macrophages, neutrophils, CD4(+) T cells, and γδ T cells; inhibited the production of inflammatory mediators; suppressed the expression of adhesion molecules on brain endothelial cells; and repressed microglia activation in the ischemic brain. Our results demonstrate that IFNβ exerts a protective effect against ischemic stroke through its anti-inflammatory properties and suggest that IFNβ is a potential therapeutic agent, targeting the reperfusion damage subsequent to the treatment with tissue plasminogen activator. © 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

Effectiveness and safety of apixaban versus warfarin in non-valvular atrial fibrillation patients in "real-world" clinical practice. A propensity-matched analysis of 76,940 patients.

PubMed

Li, Xiaoyan Shawn; Deitelzweig, Steve; Keshishian, Allison; Hamilton, Melissa; Horblyuk, Ruslan; Gupta, Kiran; Luo, Xuemei; Mardekian, Jack; Friend, Keith; Nadkarni, Anagha; Pan, Xianying; Lip, Gregory Y H

2017-06-02

The ARISTOTLE trial showed a risk reduction of stroke/systemic embolism (SE) and major bleeding in non-valvular atrial fibrillation (NVAF) patients treated with apixaban compared to warfarin. This retrospective study used four large US claims databases (MarketScan, PharMetrics, Optum, and Humana) of NVAF patients newly initiating apixaban or warfarin from January 1, 2013 to September 30, 2015. After 1:1 warfarin-apixaban propensity score matching (PSM) within each database, the resulting patient records were pooled. Kaplan-Meier curves and Cox proportional hazards models were used to estimate the cumulative incidence and hazard ratios (HRs) of stroke/SE and major bleeding (identified using the first listed diagnosis of inpatient claims) within one year of therapy initiation. The study included a total of 76,940 (38,470 warfarin and 38,470 apixaban) patients. Among the 38,470 matched pairs, 14,563 were from MarketScan, 7,683 were from PharMetrics, 7,894 were from Optum, and 8,330 were from Humana. Baseline characteristics were balanced between the two cohorts with a mean (standard deviation [SD]) age of 71 (12) years and a mean (SD) CHA 2 DS 2 -VASc score of 3.2 (1.7). Apixaban initiators had a significantly lower risk of stroke/SE (HR: 0.67, 95 % CI: 0.59-0.76) and major bleeding (HR: 0.60, 95 % CI: 0.54-0.65) than warfarin initiators. Different types of stroke/SE and major bleeding - including ischaemic stroke, haemorrhagic stroke, SE, intracranial haemorrhage, gastrointestinal bleeding, and other major bleeding - were all significantly lower for apixaban compared to warfarin treatment. Subgroup analyses (apixaban dosage, age strata, CHA 2 DS 2 -VASc or HAS-BLED score strata, or dataset source) all show consistently lower risks of stroke/SE and major bleeding associated with apixaban as compared to warfarin treatment. This is the largest "real-world" study on apixaban effectiveness and safety to date, showing that apixaban initiation was associated with significant risk reductions in stroke/SE and major bleeding compared to warfarin initiation after PSM. These benefits were consistent across various high-risk subgroups and both the standard- and low-dose apixaban dose regimens.

Recurrence of stroke caused by nocturnal hypoxia-induced blood pressure surge in a young adult male with severe obstructive sleep apnea syndrome.

PubMed

Yoshida, Tetsuro; Kuwabara, Mitsuo; Hoshide, Satoshi; Kario, Kazuomi

2016-03-01

Obstructive sleep apnea syndrome (OSAS) causes resistant hypertension and a hypopnea-related nocturnal blood pressure (BP) surge. This could lead to an increase of not only the nocturnal BP level but also nocturnal BP variability, both of which increase an individual's cardiovascular risk. We recently developed a trigger sleep BP monitoring method that initiates BP measurement when an individual's oxygen desaturation falls below a variable threshold, and we demonstrated that it can detect a BP surge during apnea episodes. We here report the case of a 36-year-old man with severe OSAS who experienced the recurrence of stroke due to nocturnal hypoxia and a nocturnal BP surge measured by this trigger sleep BP monitoring device. A nocturnal BP surge during sleep in OSAS patients could be a strong trigger of cardiovascular events. Copyright © 2016 American Society of Hypertension. Published by Elsevier Inc. All rights reserved.

A Summary of the NASA Lightning Nitrogen Oxides Model (LNOM) and Recent Results

NASA Technical Reports Server (NTRS)

Koshak, William; Peterson, Harld

2011-01-01

The NASA Marshall Space Flight Center introduced the Lightning Nitrogen Oxides Model (LNOM) a couple of years ago to combine routine state-of-the-art measurements of lightning with empirical laboratory results of lightning NOx production. The routine measurements included VHF lightning source data [such as from the North Alabama Lightning Mapping Array (LMA)], and ground flash location, peak current, and stroke multiplicity data from the National Lightning Detection Network(TradeMark) (NLDN). Following these initial runs of LNOM, the model was updated to include several non-return stroke lightning NOx production mechanisms, and provided the impact of lightning NOx on an August 2006 run of CMAQ. In this study, we review the evolution of the LNOM in greater detail and discuss the model?s latest upgrades and applications. Whereas previous applications were limited to five summer months of data for North Alabama thunderstorms, the most recent LNOM analyses cover several years. The latest statistics of ground and cloud flash NOx production are provided.

The optical and radiation field signatures produced by lightning return strokes

NASA Technical Reports Server (NTRS)

Guo, C.; Krider, E. P.

1982-01-01

Typical examples of the signals that are produced by first and subsequent return strokes in cloud-to-ground lightning on a microsecond time scale are presented. Statistics on the structure of the waveforms and the radiance of the channels are given. The relationship between the light signals and the associated electric field signatures is discussed. It is shown that the initial light signal from a return stroke tends to be linear for about 15 microsec and then rises more slowly to a peak that is delayed by approximately 60 microsec from the electric field peak. It is thought that the transition between the fast linear portion and the slower rise may be due to the return stroke entering the cloud base. A small percentage of the records suggest that two different branches of the same stepped leader can initiate separate return strokes. The light pulses from cloud discharges tend to be smaller and to vary more slowly than those from return strokes.

Observations of lightning processes using VHF radio interferometry

NASA Technical Reports Server (NTRS)

Rhodes, C. T.; Shao, X. M.; Krehbiel, P. R.; Thomas, R.

1991-01-01

A single station, multiple baseline radio interferometer was used to locate the direction of VHF radiation from lightning discharges with microsec time resolution. Radiation source directions and electric field waveforms were analyzed for various types of breakdown events. These include initial breakdown and K type events of in-cloud activity, and the leaders of initial and subsequent strokes to ground and activity during and following return strokes. Radiation during the initial breakdown of a flash and in the early stages of initial leaders to ground is found to be similar. In both instances, the activity consists of localized bursts of radiation that are intense and slow moving. Motion within a given burst is unresolved by the interferometer. Radiation from in-cloud K type events is essentially the same as that from dart leaders; in both cases it is produced at the leading edge of a fast moving streamer that propagates along a well defined, often extensive path. K type events are sometimes terminated by fast field changes that are similar to the return stroke initiated by dart leaders; such K type events are the in-cloud analog of the dart leader return stroke process.

Discharge destination's effect on bounce-back risk in Black, White, and Hispanic acute ischemic stroke patients.

PubMed

Kind, Amy J H; Smith, Maureen A; Liou, Jinn-Ing; Pandhi, Nancy; Frytak, Jennifer R; Finch, Michael D

2010-02-01

To determine whether racial and ethnic effects on bounce-back risk (ie, movement to settings of higher care intensity within 30 d of hospital discharge) in acute stroke patients vary depending on initial posthospital discharge destination. Retrospective analysis of administrative data. Four hundred twenty-two hospitals, southern/eastern United States. All Medicare beneficiaries 65 years or more with hospitalization for acute ischemic stroke within one of the 422 target hospitals during the years 1999 or 2000 (N=63,679). Not applicable. Adjusted predicted probabilities for discharge to and for bouncing back from each initial discharge site (ie, home, home with home health care, skilled nursing facility [SNF], or rehabilitation center) by race (ie, black, white, and Hispanic). Models included sociodemographics, comorbidities, stroke severity, and length of stay. Blacks and Hispanics were significantly more likely to be discharged to home health care (blacks=21% [95% confidence interval (CI), 19.9-22.8], Hispanic=19% [17.1-21.7] vs whites=16% [15.5-16.8]) and less likely to be discharged to SNFs (blacks=26% [95% CI, 23.6-29.3], Hispanics=28% [25.4-31.6] vs whites=33% [31.8-35.1]) than whites. However, blacks and Hispanics were significantly more likely to bounce back when discharged to SNFs than whites (blacks=26% [95% CI, 24.2-28.6], Hispanics=28% [24-32.6] vs whites=21% [20.3-21.9]). Hispanics had a lower risk of bouncing back when discharged home than either blacks or whites (Hispanics=14% [95% CI, 11.3-17] vs blacks=20% [18.4-22.2], whites=18% [16.8-18.3]). Patients discharged to home health care or rehabilitation centers demonstrated no significant differences in bounce-back risk. Racial/ethnic bounce-back risk differs depending on initial discharge destination. Additional research is needed to fully understand this variation in effect. Copyright 2010 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.

External validation of a six simple variable model of stroke outcome and verification in hyper-acute stroke.

PubMed

Reid, J M; Gubitz, G J; Dai, D; Reidy, Y; Christian, C; Counsell, C; Dennis, M; Phillips, S J

2007-12-01

We aimed to validate a previously described six simple variable (SSV) model that was developed from acute and sub-acute stroke patients in our population that included hyper-acute stroke patients. A Stroke Outcome Study enrolled patients from 2001 to 2002. Functional status was assessed at 6 months using the modified Rankin Scale (mRS). SSV model performance was tested in our cohort. 538 acute ischaemic (87%) and haemorrhagic stroke patients were enrolled, 51% of whom presented to hospital within 6 h of symptom recognition. At 6 months post-stroke, 42% of patients had a good outcome (mRS < or = 2). Stroke patients presenting within 6 h of symptom recognition were significantly older with higher stroke severity. In our Stroke Outcome Study dataset, the SSV model had an area under the curve of 0.792 for 6 month outcomes and performed well for hyper-acute or post-acute stroke, age < or > or = 75 years, haemorrhagic or ischaemic stroke, men or women, moderate and severe stroke, but poorly for mild stroke. This study confirms the external validity of the SSV model in our hospital stroke population. This model can therefore be utilised for stratification in acute and hyper-acute stroke trials.

Observation of incomplete drainage of a branched negative stepped leader system during the initial return stroke, and its implications

NASA Astrophysics Data System (ADS)

Petersen, D.; Beasley, W. H.

2012-12-01

We present high-speed video, taken at 75,000 frames per second, of an anomalous lightning flash that involved two distinct return strokes from different branches of the same branched negative stepped leader system. During the initial return stroke the leader system was incompletely drained, resulting in the continued development of a large side branch. The upper portions of this side branch exhibited a pulse of luminosity during the initial return stroke, but the luminosity did not extend down the branch. The lower portion of the branch continued to develop downward as a negative stepped leader, but at a much slower velocity. Continued stepping activity was observed in this branch as it continued downward at a significantly reduced velocity, finally attaching to the earth 1.8 milliseconds after the main return stroke. The ensuing return stroke was characterized by a slower vertical velocity and weaker luminous pulse. Based on this observation, we coin the term "orphaned branch" to describe a branch of a leader system that is not drained during a return stroke. While our case involves a branch that eventually connected to the ground and produced a return stroke, we also consider the possibility that such branches may also simply cease to progress and effectively deposit large amounts of space charge near their extremities. Such space charge would have a strong influence on subsequent breakdown activity in their vicinity, such as shielding subsequent descending negative stepped leaders or triggering upward positive leaders from earth's surface.

Effect of Right Insular Involvement on Death and Functional Outcome After Acute Ischemic Stroke in the IST-3 Trial (Third International Stroke Trial).

PubMed

Sposato, Luciano A; Cohen, Geoffrey; Wardlaw, Joanna M; Sandercock, Peter; Lindley, Richard I; Hachinski, Vladimir

2016-12-01

In patients with acute ischemic stroke, whether involvement of the insular cortex influences outcome is controversial. Much of the apparent adverse outcome may relate to such strokes usually being severe. We examined the influence of right and left insular involvement on stroke outcomes among patients from the IST-3 study (Third International Stroke Trial) who had visible ischemic stroke on neuroimaging. We used multiple logistic regression to compare outcomes of left versus right insular and noninsular strokes across strata of stroke severity, on death, proportion dead or dependent, and level of disability (ordinalized Oxford Handicap Score) at 6 months, with adjustment for the effects of age, lesion size, and presence of atrial fibrillation. Of 3035 patients recruited, 2099 had visible ischemic strokes limited to a single hemisphere on computed tomography/magnetic resonance scans. Of these, 566 and 714 had infarction of right and left insula. Six months after randomization, right insular involvement was associated with increased odds of death when compared with noninsular strokes on the left side (adjusted odds ratio, 1.83; 95% confidence interval, 1.33-2.52), whereas the adjusted odds ratio comparing mortality after insular versus noninsular strokes on the left side was not significant. Among mild/moderate strokes, outcomes for right insular involvement were worse than for left insular, but among more severe strokes, the difference in outcomes was less substantial. We found an association between right insular involvement and higher odds of death and worse functional outcome. The difference between right- and left-sided insular lesions on outcomes seemed to be most evident for mild/moderate strokes. URL: http://www.isrctn.com. Unique identifier: ISRCTN25765518. © 2016 American Heart Association, Inc.

Predictors of functional outcome vary by the hemisphere of involvement in major ischemic stroke treated with intra-arterial therapy: a retrospective cohort study.

PubMed

Yoo, Albert J; Romero, Javier; Hakimelahi, Reza; Nogueira, Raul G; Rabinov, James D; Pryor, Johnny C; González, R Gilberto; Hirsch, Joshua A; Schaefer, Pamela W

2010-04-23

Conflicting data exists regarding the effect of hemispheric lateralization on acute ischemic stroke outcome. Some of this variability may be related to heterogeneous study populations, particularly with respect to the level of arterial occlusion. Furthermore, little is known about the relationship between stroke lateralization and predictors of outcome. The purpose of this study was to characterize the impact of stroke lateralization on both functional outcome and its predictors in a well-defined population of anterior circulation proximal artery occlusions treated with IAT. Thirty-five consecutive left- and 35 consecutive right-sided stroke patients with intracranial ICA and/or MCA occlusions who underwent IAT were retrospectively analyzed. Ischemic change on pre-treatment imaging was quantified. Reperfusion success was graded using the Mori scale. Good outcome at three months was defined as an mRS

Lesion location associated with balance recovery and gait velocity change after rehabilitation in stroke patients.

PubMed

Moon, Hyun Im; Lee, Hyo Jeong; Yoon, Seo Yeon

2017-06-01

Impaired gait function after stroke contributes strongly to overall patient disability. However, the response to rehabilitation varies between individuals. The aims of this study were to identify predictors of gait velocity change and to elucidate lesion location associated with change of balance and gait function. We reviewed 102 stroke patients. The patients were divided into two groups according to gait ability post-rehabilitation, and we analyzed differences in their characteristics, such as demographic information, lesion factors, and initial balance function. Multivariate regression analyses were performed to examine the predictors of rehabilitation response. Lesion location and volume were measured on brain magnetic resonance images. We generated statistical maps of the lesions related to functional gains in gait and balance using voxel-based lesion symptom mapping (VLSM). The group of patients who regained independent ambulation function showed a smaller lesion size, a shorter duration from stroke onset, and higher initial balance function. In the regression model, gait velocity changes were predicted with the initial Berg balance scale (BBS) and duration post-onset. Absolute BBS changes were also correlated with the duration post-onset and initial BBS, and relative BBS changes were predicted by the baseline BBS. Using VLSM, lesion locations associated with gait velocity changes and balance adjusting for other factors were the insula, internal capsule, and adjacent white matter. Initial balance function as well as the interval between stroke onset and the initiation of therapy might influence balance recovery and gait velocity changes. Damage to the insula and internal capsule also affected gait velocity change after rehabilitation.

Does outcome of neuropsychological treatment in patients with unilateral spatial neglect after stroke affect functional outcome?

PubMed

Matano, A; Iosa, M; Guariglia, C; Pizzamiglio, L; Paolucci, S

2015-12-01

Unilateral spatial neglect (USN) after stroke is associated to severe disability and to a poor rehabilitation outcome. However it is still unclear if a reduction of USN after a specific neurophsycological treatment could also favor the functional recovery. The first aim of this study was to determine if low responders to neuropsychological treatment of unilateral spatial neglect may have a worse functional prognosis for activities of daily living. The second aim was to investigate which variables can predict a low response to neuropsychological treatment. Observational study. Neurorehabilitation hospital in Italy. Two hundred inpatients with the diagnosis of ischemic stroke were screened in this observational study. Inclusion criteria were: patients in subacute phase of first ischemic stroke in right hemisphere. Exclusion criteria were: presence of previous and/or other disabling pathologies, medical conditions contraindicating physical therapy. Data of 73 patients who performed neurorehabilitation and visual scanning training for reducing USN were analysed, while the remaining others were excluded for at least one of the following reasons: hemorrhagic lesions, presence of other chronic disabling pathologies, contraindications for therapy. USN was evaluated using: Letter Cancellation Test, Barrage Test, Sentence Reading Test and Wundt-Jastrow Area Illusion Test. Barthel Index (BI), Beck Depression Inventory, and Canadian Neurological Scale were also administered. According to the aim of the study, forward binary logistic regressions were performed to evaluate the effects of different factors on functional recovery. Three factors were identified as predictors of low effectiveness in terms of BI-score: older age (odds ratio OR=9.882, P=0.002), severity of disease at admission (OR=12.594, P=0.002) and being low responders to neuropsychological treatment (OR=3.847, P=0.027). Further, the initial barrage score (OR=3.313, P=0.027) and the initial BI-score (OR=3.252, P=0.039) effectively predict the response to neuropsychological treatment. The outcome of the whole rehabilitation resulted affected by the outcome of neuropsychological treatment in patients with USN, being a low score at Barrage test at the beginning of therapy a negative predictor of USN recovery. Patients with USN after stroke can benefit of a specific training for reducing USN also in terms of functional outcome. Further, the simple use of Barrage test could provide important prognostic information about recovery.

Impact of treatment with pioglitazone on stroke outcomes: a real world database analysis.

PubMed

Morgan, Christopher Ll; Inzucchi, Silvio E; Puelles, Jorge; Jenkins-Jones, Sara; Currie, Craig J

2018-05-07

Randomised controlled trials have reported an association between pioglitazone and reduced incidence of stroke in type 2 diabetic (T2DM) and insulin-resistant populations. We investigated this association within a real-world database. T2DM patients initiating pioglitazone between 2000-2012 were extracted from the Clinical Practice Research Datalink (CPRD); a UK routine. Two non-exposed control cohorts were matched on age, gender, HbA1c, diabetes duration, stroke history, co-morbidities and prior T2DM regimen. Control cohort-1 comprised patients initiating a new T2DM therapy as their respective case initiated pioglitazone. Control cohort-2 remained on the same T2DM regimen as their respective case prior to the case initiating pioglitazone. The primary outcome was incident stroke; other outcomes included mortality, hospital length of stay and stroke recurrence. 4,234 pioglitazone patients matched to controls in cohort-1 and 3,604 in cohort-2. For the primary outcome there were significantly reduced hazard ratios (HRs) for cases:controls. Cohort 1, the HR was 0.627 (95% CI, 0.404-0.972) during the therapy period and 0.640 (0.485-0.843) over the entire observation period; respective HRs were 0.516 (0.336-0.794) and 0.773 (0.611-0.978) for cohort 2. There was no significant difference in 30-day mortality rate or rate of recurrent stroke. For hospitalised stroke events there was a significant difference in length of stay for patients discharged to usual residence (median 3.0 days versus 7.0 days; p=0.008) for control cohort-2 whilst on-treatment. In support of evidence from two large randomized trials, these observational data show that pioglitazone has a potent effect in reducing stroke events in patients with type 2 diabetes. This article is protected by copyright. All rights reserved.

Thrombolytic therapy

MedlinePlus

... thinning medicines such as Coumadin Trauma Uncontrolled (severe) high blood pressure STROKES Most strokes are caused when blood clots move to a blood vessel in the brain and block blood flow to that area. For such strokes (ischemic strokes), ...

77 FR 24971 - National Institute of Neurological Disorders and Stroke; Notice of Closed Meetings

Federal Register 2010, 2011, 2012, 2013, 2014

2012-04-26

... Disorders and Stroke Initial Review Group; Neurological Sciences and Disorders C. Date: June 18-19, 2012..., Scientific Review Branch, Division of Extramural Research, NINDS, NIH, NSC, 6001 Executive Blvd., Suite 3204...: Neurological Sciences Training Initial Review Group; NST-2 Subcommittee. Date: June 25-26, 2012. Time: 8 a.m...

77 FR 59939 - National Institute of Neurological Disorders and Stroke; Notice of Closed Meetings

Federal Register 2010, 2011, 2012, 2013, 2014

2012-10-01

... Disorders and Stroke Initial Review Group; Neurological Sciences and Disorders B. Date: October 25-26, 2012... Officer, Scientific Review Branch, Division of Extramural Research, NINDS/NIH/DHHS, NSC, 6001 Executive...: Neurological Sciences Training Initial Review Group; NST-2 Subcommittee. Date: November 5-6, 2012. Time: 8:00 a...

Obstructive Sleep Apnea: An Unusual Cause of Hemorrhagic Stroke.

PubMed

Pawar, Nilesh H; O'Riordan, Jennifer A; Malik, Preeti; Vasanwala, Farhad F

2017-09-27

Stroke is one of the most common causes of mortality and morbidity worldwide. Hemorrhagic stroke comprises 10-20% of strokes. Here, we present a case report of hemorrhagic stroke that may have been secondary to untreated Obstructive Sleep Apnea (OSA) in a young man with no other cardiovascular risk factors or features of metabolic syndrome. A 32-year-old man was admitted for hemorrhagic stroke. An initial thorough workup for the etiology of stroke was inconclusive. Eventually, a polysomnography was done, which demonstrated OSA suggesting that untreated OSA may have contributed to his stroke. OSA may cause hemorrhagic stroke by nocturnal blood pressure surge. So, all physicians should consider doing polysomnography for unexplained hemorrhagic stroke or in patients at risk. Diagnosing and treating OSA would be critical in preventing hemorrhagic stroke and its recurrences.

Differential characteristics, stroke recurrence, and predictors of covert atrial fibrillation of embolic strokes of undetermined source.

PubMed

Hawkes, Maximiliano A; Farez, Mauricio F; Pertierra, Lucia; Gomez-Schneider, Maia M; Pastor-Rueda, José M; Ameriso, Sebastián F

2018-02-01

Background and purpose Identifying embolic strokes of undetermined source (ESUS) patients likely to harbor atrial fibrillation may have diagnostic and therapeutic implications. Our aim was to examine differences between ESUS and cardioembolic strokes, to evaluate stroke recurrence rate among ESUS and to identify baseline characteristics of ESUS patients who were later diagnosed with atrial fibrillation. Materials and methods We assessed all ischemic stroke patients admitted between June 2012 and November 2013. ESUS were compared to cardioembolic strokes at discharge. After at least 12-month follow-up, ESUS patients diagnosed with atrial fibrillation were compared to those who remained as ESUS. Results There were 236 ischemic strokes, 32.6% were ESUS. Compared to cardioembolic strokes, ESUS were younger (p < 0.0001), had milder strokes (p < 0.05), less prevalence of hypertension (p < 0.05), peripheral vascular disease (p < 0.05), and previous ischemic stroke (p < 0.05). After follow-up, 15% of ESUS patients had stroke recurrences and 12% evidenced paroxysmal atrial fibrillation. ESUS patients diagnosed with atrial fibrillation in the follow-up were older (p < 0.0001), had higher erythrocyte sedimentation rate (p < 0.05), and were more likely to have ≥2 infarcts in the same arterial territory in the initial magnetic resonance imaging (p < 0.05). Conclusions Older age, small-scattered infarcts on initial magnetic resonance imaging and high erythrocyte sedimentation rate levels appear to identify ESUS patients more likely to be diagnosed of atrial fibrillation during follow-up.

Effect of Rehabilitation Intensity on Mortality Risk After Stroke.

PubMed

Hsieh, Cheng-Yang; Huang, Hsiu-Chen; Wu, Darren Philbert; Li, Chung-Yi; Chiu, Meng-Jun; Sung, Sheng-Feng

2018-06-01

To determine the relation between rehabilitation intensity and poststroke mortality. Retrospective cohort study. Nationwide claims data. From Taiwan's National Health Insurance claims databases, patients (N=6737; mean age, 66.9y; 40.3% women) hospitalized between 2001 and 2013 for a first-ever stroke who had mild to moderate stroke and survived the first 90 days of stroke were enrolled. The intensity of rehabilitation therapy within 90 days after stroke was categorized into low, medium, or high based on the tertile distribution of the number of rehabilitation sessions. Long-term all-cause mortality. The Cox proportional hazard models with Bonferroni correction were used to assess the association between rehabilitation intensity and mortality, adjusting for age, comorbidities, stroke severity, and other covariates. Patients in the high-intensity group were younger but had a higher burden of comorbidities and greater stroke severity. During follow-up, the high-intensity group was associated with a significantly lower adjusted risk (hazard ratio [HR], .73; 95% confidence interval [CI], .63-.84) of mortality than the low-intensity group, whereas the medium-intensity group carried a similar risk of mortality (HR, 0.94; 95% CI, 0.84-1.06) compared with the low-intensity group. This association was not modified by stroke severity. Among patients with mild to moderate stroke severity, high-intensity rehabilitation therapy within the first 90 days was associated with a lower mortality risk than low-intensity therapy. Efforts to promote high-intensity rehabilitation therapy for this group of patients with stroke should be encouraged. Copyright © 2017 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.

PLUMBER Study (Prevalence of Large Vessel Occlusion Strokes in Mecklenburg County Emergency Response).

PubMed

Dozois, Adeline; Hampton, Lorrie; Kingston, Carlene W; Lambert, Gwen; Porcelli, Thomas J; Sorenson, Denise; Templin, Megan; VonCannon, Shellie; Asimos, Andrew W

2017-12-01

The recently proposed American Heart Association/American Stroke Association EMS triage algorithm endorses routing patients with suspected large vessel occlusion (LVO) acute ischemic strokes directly to endovascular centers based on a stroke severity score. The predictive value of this algorithm for identifying LVO is dependent on the overall prevalence of LVO acute ischemic stroke in the EMS population screened for stroke, which has not been reported. We performed a cross-sectional study of patients transported by our county's EMS agency who were dispatched as a possible stroke or had a primary impression of stroke by paramedics. We determined the prevalence of LVO by reviewing medical record imaging reports based on a priori specified criteria. We enrolled 2402 patients, of whom 777 (32.3%) had an acute stroke-related diagnosis. Among 485 patients with acute ischemic stroke, 24.1% (n=117) had an LVO, which represented only 4.87% (95% confidence interval, 4.05%-5.81%) of the total EMS population screened for stroke. Overall, the prevalence of LVO acute ischemic stroke in our EMS population screened for stroke was low. This is an important consideration for any EMS stroke severity-based triage protocol and should be considered in predicting the rates of overtriage to endovascular stroke centers. © 2017 American Heart Association, Inc.

Ethnic Differences in Poststroke Quality of Life in the Brain Attack Surveillance in Corpus Christi (BASIC) Project.

PubMed

Reeves, Sarah L; Brown, Devin L; Baek, Jonggyu; Wing, Jeffrey J; Morgenstern, Lewis B; Lisabeth, Lynda D

2015-10-01

Mexican Americans (MAs) have an increased risk of stroke and experience worse poststroke disability than non-Hispanic whites, which may translate into worse poststroke quality of life (QOL). We assessed ethnic differences in poststroke QOL, as well as potential modification of associations by age, sex, and initial stroke severity. Ischemic stroke survivors were identified through the biethnic, population-based Brain Attack Surveillance in Corpus Christi (BASIC) Project. Data were collected from medical records, baseline interviews, and 90-day poststroke interviews. Poststroke QOL was measured at ≈90 days by the validated short-form stroke-specific QOL in 3 domains: overall, physical, and psychosocial (range, 0-5; higher scores represent better QOL). Tobit regression was used to model associations between ethnicity and poststroke QOL scores, adjusted for demographics, clinical characteristics, and prestroke cognition and function. Among 290 eligible stroke survivors (66% MA, 34% non-Hispanic whites, median age=69 years), median scores for overall, physical, and psychosocial poststroke QOL were 3.3, 3.8, and 2.7, respectively. Poststroke QOL was lower for MAs than non-Hispanic whites both overall (mean difference, -0.30; 95% confidence interval, -0.59, -0.01) and in the physical domain (mean difference, -0.47; 95% confidence interval, -0.81, -0.14) after multivariable adjustment. No ethnic difference was found in the psychosocial domain. Age modified the associations between ethnicity and poststroke QOL such that differences were present in older but not in younger ages. Disparities exist in poststroke QOL for MAs and seem to be driven by differences in older stroke patients. Targeted interventions to improve outcomes among MA stroke survivors are urgently needed. © 2015 American Heart Association, Inc.

Variations and Determinants of Hospital Costs for Acute Stroke in China

PubMed Central

Wei, Jade W.; Heeley, Emma L.; Jan, Stephen; Huang, Yining; Huang, Qifang; Wang, Ji-Guang; Cheng, Yan; Xu, En; Yang, Qidong; Anderson, Craig S.

2010-01-01

Background The burden of stroke is high and increasing in China. We modelled variations in, and predictors of, the costs of hospital care for patients with acute stroke in China. Methods and Findings Baseline characteristics and hospital costs for 5,255 patients were collected using the prospective register-based ChinaQUEST study, conducted in 48 Level 3 and 14 Level 2 hospitals in China during 2006–2007. Ordinary least squares estimation was used to determine factors associated with hospital costs. Overall mean cost of hospitalisation was 11,216 Chinese Yuan Renminbi (CNY) (≈US$1,602) per patient, which equates to more than half the average annual wage in China. Variations in cost were largely attributable to stroke severity and length of hospital stay (LOS). Model forecasts showed that reducing LOS from the mean of 20 days for Level 3 and 18 days for Level 2 hospitals to a duration of 1 week, which is common among Western countries, afforded cost reductions of 49% and 19%, respectively. Other lesser determinants varied by hospital level: in Level 3 hospitals, health insurance and the occurrence of in-hospital complications were each associated with 10% and 18% increases in cost, respectively, whilst treatment in a teaching hospital was associated with approximately 39% decrease in cost on average. For Level 2 hospitals, stroke due to intracerebral haemorrhage was associated with a 19% greater cost than for ischaemic stroke. Conclusions Changes to hospital policies to standardise resource use and reduce the variation in LOS could attenuate costs and improve efficiencies for acute stroke management in China. The success of these strategies will be enhanced by broader policy initiatives currently underway to reform hospital reimbursement systems. PMID:20927384

A comparison of acute hemorrhagic stroke outcomes in 2 populations: the Crete-Boston study.

PubMed

Zaganas, Ioannis; Halpin, Amy P; Oleinik, Alexandra; Alegakis, Athanasios; Kotzamani, Dimitra; Zafiris, Spiros; Chlapoutaki, Chryssanthi; Tsimoulis, Dimitris; Giannakoudakis, Emmanouil; Chochlidakis, Nikolaos; Ntailiani, Aikaterini; Valatsou, Christina; Papadaki, Efrosini; Vakis, Antonios; Furie, Karen L; Greenberg, Steven M; Plaitakis, Andreas

2011-12-01

Although corticosteroid use in acute hemorrhagic stroke is not widely adopted, management with intravenous dexamethasone has been standard of care at the University Hospital of Heraklion, Crete with observed outcomes superior to those reported in the literature. To explore this further, we conducted a retrospective, multivariable-adjusted 2-center study. We studied 391 acute hemorrhagic stroke cases admitted to the University Hospital of Heraklion, Crete between January 1997 and July 2010 and compared them with 510 acute hemorrhagic stroke cases admitted to Massachusetts General Hospital, Boston, from January 2003 to September 2009. Of the Cretan cases, 340 received a tapering scheme of intravenous dexamethasone, starting with 16 to 32 mg/day, whereas the Boston patients were managed without steroids. The 2 cohorts had comparable demographics and stroke severity on admission, although anticoagulation was more frequent in Boston. The in-hospital mortality was significantly lower on Crete (23.8%, n=340) than in Boston (38.0%, n=510; P<0.001) as was the 30-day mortality (Crete: 25.4%, n=307; Boston: 39.4%, n=510; P<0.001). Exclusion of patients on anticoagulants showed even greater differences (30-day mortality: Crete 20.8%; n=259; Boston 37.0%; n=359; P<0.001). The improved survival on Crete was observed 3 days after initiation of intravenous dexamethasone and was pronounced for deep-seated hemorrhages. After adjusting for acute hemorrhagic stroke volume/location, Glasgow Coma Scale, hypertension, diabetes mellitus, smoking, coronary artery disease and statin, antiplatelet, and anticoagulant use, intravenous dexamethasone treatment was associated with better functional outcomes and significantly lower risk of death at 30 days (OR, 0.357; 95% CI, 0.174-0.732). This study suggests that intravenous dexamethasone improves outcome in acute hemorrhagic stroke and supports a randomized clinical trial using this approach.

Safety and efficacy of Cerebrolysin in early post-stroke recovery: a meta-analysis of nine randomized clinical trials.

PubMed

Bornstein, Natan M; Guekht, Alla; Vester, Johannes; Heiss, Wolf-Dieter; Gusev, Eugene; Hömberg, Volker; Rahlfs, Volker W; Bajenaru, Ovidiu; Popescu, Bogdan O; Muresanu, Dafin

2018-04-01

This meta-analysis combines the results of nine ischemic stroke trials, assessing efficacy of Cerebrolysin on global neurological improvement during early post-stroke period. Cerebrolysin is a parenterally administered neuropeptide preparation approved for treatment of stroke. All included studies had a prospective, randomized, double-blind, placebo-controlled design. The patients were treated with 30-50 ml Cerebrolysin once daily for 10-21 days, with treatment initiation within 72 h after onset of ischemic stroke. For five studies, original analysis data were available for meta-analysis (individual patient data analysis); for four studies, aggregate data were used. The combination by meta-analytic procedures was pre-planned and the methods of synthesis were pre-defined under blinded conditions. Search deadline for the present meta-analysis was December 31, 2016. The nonparametric Mann-Whitney (MW) effect size for National Institutes of Health Stroke Scale (NIHSS) on day 30 (or 21), combining the results of nine randomized, controlled trials by means of the robust Wei-Lachin pooling procedure (maximin-efficient robust test), indicated superiority of Cerebrolysin as compared with placebo (MW 0.60, P < 0.0001, N = 1879). The combined number needed to treat for clinically relevant changes in early NIHSS was 7.7 (95% CI 5.2 to 15.0). The additional full-scale ordinal analysis of modified Rankin Scale at day 90 in moderate to severe patients resulted in MW 0.61 with statistical significance in favor of Cerebrolysin (95% CI 0.52 to 0.69, P = 0.0118, N = 314). Safety aspects were comparable to placebo. Our meta-analysis confirms previous evidence that Cerebrolysin has a beneficial effect on early global neurological deficits in patients with acute ischemic stroke.

Anabolic steroids abuse-induced cardiomyopathy and ischaemic stroke in a young male patient.

PubMed

Shamloul, Reham Mohammed; Aborayah, Ahmed Fathy; Hashad, Assem; Abd-Allah, Foad

2014-02-26

We report a case of a 37-year-old man presented with acute stroke and hepatorenal impairment which were associated with anabolic-androgenic steroids (AAS) abuse over 2 years. Despite the absence of apparent symptoms and signs of congestive heart failure at presentation, an AAS-induced dilated cardiomyopathy with multiple thrombi in the left ventricle was attributed to be the underlying cause of his condition. Awareness of the complications of AAS led to the prompt treatment of the initially unrecognised dilated cardiomyopathy, and improved the liver and kidney functions. However, the patient was exposed to a second severe ischaemic event, which led to his death. This unique and complex presentation of AAS complications opens for better recognition and treatment of their potentially fatal effects.

Management of acute ischemic stroke. What is the role of tPA and antithrombotic agents?

PubMed

Meschia, J F

2000-05-15

Every patient with acute stroke who presents to a medical center that has appropriate resources should undergo evaluation for intravenous tPA therapy. Such therapy should not be given unless the patient meets strict eligibility criteria based on clinical, radiographic, and laboratory data. Intra-arterial thrombolysis may be a promising alternative to intravenous tPA therapy, but it should still be regarded as experimental. Daily aspirin therapy should be initiated immediately in most patients who do not receive intravenous tPA therapy and after 24 hours in most patients who receive this treatment. Measures should be taken to prevent medical complications, such as aspiration pneumonia, deep vein thrombosis, contractures, and pressure sores. Early initiation of rehabilitation can maximize stroke recovery. Whenever feasible, institutions should have stroke teams or units to streamline care and provide expertise for patients with acute stroke.

Lightning Reporting at 45th Weather Squadron: Recent Improvements

NASA Technical Reports Server (NTRS)

Finn, Frank C.; Roeder, William P.; Buchanan, Michael D.; McNamara, Todd M.; McAllenan, Michael; Winters, Katherine A.; Fitzpatrick, Michael E.; Huddleston, Lisa L.

2010-01-01

The 45th Weather Squadron (45 WS) provides daily lightning reports to space launch customers at CCAFS/KSC. These reports are provided to assess the need to inspect the electronics of satellite payloads, space launch vehicles, and ground support equipment for induced current damage from nearby lightning strokes. The 45 WS has made several improvements to the lightning reports during 2008-2009. The 4DLSS, implemented in April 2008, provides all lightning strokes as opposed to just one stroke per flash as done by the previous system. The 45 WS discovered that the peak current was being truncated to the nearest kilo amp in the database used to generate the daily lightning reports, which led to an up to 4% underestimate in the peak current for average lightning. This error was corrected and led to elimination of this underestimate. The 45 WS and their mission partners developed lightning location error ellipses for 99% and 95% location accuracies tailored to each individual stroke and began providing them in the spring of 2009. The new procedure provides the distance from the point of interest to the best location of the stroke (the center of the error ellipse) and the distance to the closest edge of the ellipse. This information is now included in the lightning reports, along with the peak current of the stroke. The initial method of calculating the error ellipses could only be used during normal duty hours, i.e. not during nights, weekends, or holidays. This method was improved later to provide lightning reports in near real-time, 24/7. The calculation of the distance to the closest point on the ellipse was also significantly improved later. Other improvements were also implemented. A new method to calculate the probability of any nearby lightning stroke. being within any radius of any point of interest was developed and is being implemented. This may supersede the use of location error ellipses. The 45 WS is pursuing adding data from nine NLDN sensors into 4DLSS in real-time. This will overcome the problem of 4DLSS missing some of the strong local strokes. This will also improve the location accuracy, reduce the size and eccentricity of the location error ellipses, and reduce the probability of nearby strokes being inside the areas of interest when few of the 4DLSS sensors are used in the stroke solution. This will not reduce 4DLSS performance when most of the 4DLSS sensors are used in the stroke solution. Finally, several possible future improvements were discussed, especially for improving the peak current estimate and the error estimate for peak current, and upgrading the 4DLSS. Some possible approaches for both of these goals were discussed.

Mediterranean Diet in patients with acute ischemic stroke: Relationships between Mediterranean Diet score, diagnostic subtype, and stroke severity index.

PubMed

Tuttolomondo, Antonino; Casuccio, Alessandra; Buttà, Carmelo; Pecoraro, Rosaria; Di Raimondo, Domenico; Della Corte, Vittoriano; Arnao, Valentina; Clemente, Giuseppe; Maida, Carlo; Simonetta, Irene; Miceli, Giuseppe; Lucifora, Benedetto; Cirrincione, Anna; Di Bona, Danilo; Corpora, Francesca; Maugeri, Rosario; Iacopino, Domenico Gerardo; Pinto, Antonio

2015-11-01

Adherence to a Mediterranean Diet appears to reduce the risk of cardiovascular disease, cancer, Alzheimer's disease, and Parkinson's disease, as well as the risk of death due to cardiovascular disease. No study has addressed the association between diagnostic subtype of stroke and its severity and adherence to a Mediterranean Diet in subjects with acute ischemic stroke. To evaluate the association between Mediterranean Diet adherence, TOAST subtype, and stroke severity by means of a retrospective study. The type of acute ischemic stroke was classified according to the TOAST criteria. All patients admitted to our ward with acute ischemic stroke completed a 137-item validated food-frequency questionnaire adapted to the Sicilian population. A scale indicating the degree of adherence to the traditional Mediterranean Diet was used (Me-Di score: range 0-9). 198 subjects with acute ischemic stroke and 100 control subjects without stroke. Stroke subjects had a lower mean Mediterranean Diet score compared to 100 controls without stroke. We observed a significant positive correlation between Me-Di score and SSS score, whereas we observed a negative relationship between Me-Di score and NIHSS and Rankin scores. Subjects with atherosclerotic (LAAS) stroke subtype had a lower mean Me-Di score compared to subjects with other subtypes. Multinomial logistic regression analysis in a simple model showed a negative relationship between MeDi score and LAAS subtype vs. lacunar subtype (and LAAS vs. cardio-embolic subtype). Patients with lower adherence to a Mediterranean Diet are more likely to have an atherosclerotic (LAAS) stroke, a worse clinical presentation of ischemic stroke at admission and a higher Rankin score at discharge. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Stroke Burden in Rwanda: A Multicenter Study of Stroke Management and Outcome.

PubMed

Nkusi, Agabe Emmy; Muneza, Severien; Nshuti, Steven; Hakizimana, David; Munyemana, Paulin; Nkeshimana, Menelas; Rudakemwa, Emmanuel; Amendezo, Etienne

2017-10-01

Cerebrovascular accidents or stroke constitute the second leading cause of mortality worldwide. Low- and middle-income countries bear most of the stroke burden worldwide. The main objective of this study is to determine the burden of stroke in Rwanda. This was a prospective observational study in 2 parts: 6 months baseline data collection and outcome assessment sessions at 1 year. A total of 96 patients were enrolled in our series. Stroke constituted 2100 per 100,000 population. Of all patients, 55.2% were male and most (60%) were 55 years and older. Of all patients and/or caretakers, 22% were not aware of their previous health status and 53.5% of hypertensive patients were not on treatment by the time of the event. Median presentation delay was 72 hours for patients with ischemic stroke and 24 hours for patients with hemorrhagic stroke. Most patients had hemorrhagic stroke (65% vs. 35%), and more patients with hemorrhagic stroke presented with loss of consciousness (80% vs. 51%). Many patients (62% ischemic group and 44% hemorrhagic group) presented with severe stroke scores, and this was associated with worst outcome (P = 0.004). At 1 year follow-up, 24.7% had no or mild disability, 14.3% were significantly disabled, and 61% had died. Our results show that stroke is a significant public health concern in Rwanda. Risk factor awareness and control are still low and case fatality of stroke is significantly high. The significant delay in presentation to care and presentation with severe stroke are major contributors for the high mortality and severe disability rates. Copyright © 2017 Elsevier Inc. All rights reserved.

Stroke Location and Brain Function in an Embolic Rabbit Stroke Model

PubMed Central

Brown, Aliza T.; Skinner, Robert D.; Flores, Rene; Hennings, Leah; Borrelli, Michael J.; Lowery, John; Culp, William C.

2010-01-01

Purpose Current rabbit stroke models often depend on symptoms as endpoints for embolization and produce wide variation in location, size, and severity of strokes. To further refine our angiographic embolic stroke model we correlated localized infarctions to neurological deficits. Our goal is a rabbit model for long term studies of therapies after stroke. Materials and Methods New Zealand White rabbits (4–5 kg) (n=71) had selective internal carotid artery (ICA) angiography and a single clot was injected. At 24 hours neurological assessment scores (NAS) were measured on a 0=normal to 10=dead scale. Brains were removed and stained to identify stroke areas. All animals with single strokes, N=31, were analyzed by specific brain structure involvement and NAS values were correlated. Results Stroke incidence differed by location with cortex, subcortical, and basal ganglia regions highest. Distributions of middle cerebral artery (MCA) at 52% and anterior cerebral artery (ACA) at 29% were most commonly involved with largest stroke volumes in the ACA distribution. Brain stem and cerebellum strokes had disproportionately severe neurological deficits, scoring 2.25±1.0 vs. cortex (0.5±0.2), subcortical (1.3±0.4) and basal ganglia (0.5±0.3) all in the frontal or parietal regions on NAS (P≤0.02). Conclusions MCA and ACA distributions included 81% of strokes. These sites were relatively silent (potentially allowing longer term survival studies) while others in the posterior circulation produced disproportionately severe symptoms. Symptoms were not reliable indicators of stroke occurrence and other endpoints such as imaging may be required. These are important steps towards refinement of the rabbit stroke model. PMID:20417119

Reproductive age modulates the impact of focal ischemia on the forebrain as well as the effects of estrogen treatment in female rats

PubMed Central

Selvamani, Amutha; Sohrabji, Farida

2009-01-01

While human observational studies and animal studies report a neuroprotective role for estrogen therapy in stroke, the multicenter placebo-controlled Women's Health Initiative (WHI) study concluded that hormone therapy increased the risk for stroke in postmenopausal women. The present study therefore tested the hypothesis that estrogen replacement would increase the severity of a stroke-like injury in females when this replacement occurs after a prolonged hypoestrogenic period, such as the menopause or reproductive senescence, but not when given to females that were normally cycling immediately prior to the hormone replacement. Two groups of female rats were used: multiparous females with normal but lengthened estrus cycles (mature adults), and older multiparous females currently in a persistent acyclic state (reproductive senescent). Animals were either used intact, or were bilaterally ovariectomized and immediately replaced with a 17β-estradiol pellet or control pellet. Animals were subject to a forelimb placing test (a test for sensorimotor deficit) and thereafter to middle cerebral artery occlusion (MCAo) by stereotaxic injection of the vasoconstrictive peptide endothelin-1, adjacent to the MCA. One week after stroke, behavioral tests were performed again. Cortical and striatal infarct volume, measured from brain slices, was significantly greater in intact reproductive senescent females as compared to intact mature adults. Furthermore, estrogen treatment to ovariectomized mature adult females significantly reduced the cortical infarct volume. Paradoxically, estrogen treatment to ovariectomized reproductive senescent females significantly increased cortical and striatal infarct volumes as compared to control pellet replaced senescent females. Significant post-stroke behavioral deficit was observed in all groups on the side contralateral to the lesion, while senescent females also exhibited deficits on the ipsilateral side, in the cross-midline forelimb placement test. Using an animal model that approximates the natural ovarian aging process, these findings strongly support the hypothesis that the effectiveness of estrogen therapy in protecting brain health may depend critically on the time of initiation with respect to a female's reproductive status. PMID:18829137

Analysis of Time-Dependent Brain Network on Active and MI Tasks for Chronic Stroke Patients

PubMed Central

Chang, Won Hyuk; Kim, Yun-Hee; Lee, Seong-Whan; Kwon, Gyu Hyun

2015-01-01

Several researchers have analyzed brain activities by investigating brain networks. However, there is a lack of the research on the temporal characteristics of the brain network during a stroke by EEG and the comparative studies between motor execution and imagery, which became known to have similar motor functions and pathways. In this study, we proposed the possibility of temporal characteristics on the brain networks of a stroke. We analyzed the temporal properties of the brain networks for nine chronic stroke patients by the active and motor imagery tasks by EEG. High beta band has a specific role in the brain network during motor tasks. In the high beta band, for the active task, there were significant characteristics of centrality and small-worldness on bilateral primary motor cortices at the initial motor execution. The degree centrality significantly increased on the contralateral primary motor cortex, and local efficiency increased on the ipsilateral primary motor cortex. These results indicate that the ipsilateral primary motor cortex constructed a powerful subnetwork by influencing the linked channels as compensatory effect, although the contralateral primary motor cortex organized an inefficient network by using the connected channels due to lesions. For the MI task, degree centrality and local efficiency significantly decreased on the somatosensory area at the initial motor imagery. Then, there were significant correlations between the properties of brain networks and motor function on the contralateral primary motor cortex and somatosensory area for each motor execution/imagery task. Our results represented that the active and MI tasks have different mechanisms of motor acts. Based on these results, we indicated the possibility of customized rehabilitation according to different motor tasks. We expect these results to help in the construction of the customized rehabilitation system depending on motor tasks by understanding temporal functional characteristics on brain network for a stroke. PMID:26656269

Urinary Tract Infections in Hospitalized Ischemic Stroke Patients: Source and Impact on Outcome

PubMed Central

Bogason, Einar; Morrison, Kathy; Zalatimo, Omar; Ermak, David M; Lehman, Erik; Markley, Eric

2017-01-01

Background: Urinary tract infections (UTIs) in ischemic stroke patients are a common occurrence and the frequent focus of quality improvement initiatives. However, many UTIs are community-acquired and the impact of such infections on patient outcomes remains controversial. Methods: We conducted a retrospective analysis of our Stroke Center Database and electronic medical records to determine the incidence of both community-acquired UTI (CA-UTI) and hospital-acquired UTI (HA-UTI) in hospitalized ischemic stroke patients. We assessed risk factors for UTI, as well as clinical outcome, the length of stay (LOS), and hospital charges. Results: In our study sample of 395 patients, UTIs were found in 11.7% and the majority of these (65%) were found on admission. Patients admitted from another hospital were more likely to be diagnosed with a UTI of any type compared to those arriving from home (odds ratio (OR) 2.42 95%, confidence interval (CI) 1.18, 4.95) and were considerably more likely to have an HA-UTI than a CA-UTI (OR 12.06 95% CI 2.14, 95.32). Those with a Foley catheter were also more likely to have a UTI (OR 2.65 95% CI 1.41, 4.98). In the multivariable analysis, we did not find a statistically significant relationship between any UTI or a specific UTI subtype and discharge modified Rankin Score (mRS), LOS, or hospital charges. Admission stroke severity remained associated with higher odds of discharge in poor condition (adjusted odds ratio (aOR) 6.23 95% CI2.33, 16.62), an extended LOS (6.84 vs 5.07, p = 0.006), and higher hospital charges ($18,305 vs $12,162, p = 0.001).  Conclusions: Urinary tract infections remain a common occurrence in stroke patients. However, the majority of UTIs are present on admission and may have little impact on discharge clinical condition, LOS, or hospital charges. These results may have implications for quality improvement (QI) initiatives that focus on the prevention and treatment of hospital-acquired UTIs. PMID:28331776

The Montreal Cognitive Assessment is superior to National Institute of Neurological Disease and Stroke-Canadian Stroke Network 5-minute protocol in predicting vascular cognitive impairment at 1 year.

PubMed

Dong, YanHong; Xu, Jing; Chan, Bernard Poon-Lap; Seet, Raymond Chee Seong; Venketasubramanian, Narayanaswamy; Teoh, Hock Luen; Sharma, Vijay Kumar; Chen, Christopher Li-Hsian

2016-04-12

The predictive ability of National Institute of Neurological Disease and Stroke-Canadian Stroke Network (NINDS-CSN) 5-minute protocol and Montreal Cognitive Assessment (MoCA) administered sub-acutely and at the convalescent phase after stroke for significant vascular cognitive impairment (VCI) at 1 year is unknown. We compared prognostic values of these tests. Patients with ischemic stroke and transient ischemic attack (TIA) received MoCA sub-acutely (within 2 weeks) and 3-6 months after stroke followed by a formal neuropsychological evaluation at 1 year. The total score of NINDS-CSN 5-minutes protocol was derived from MoCA. Moderate-severe VCI was defined as neuropsychological impairment in ≥ 3 domains. Area under the receiver operating characteristic curve (AUC) analyses were conducted to establish the optimal cutoff points and discriminatory properties of the MoCA and NINDS-CSN 5-minute protocol in detecting moderate-severe VCI. Four hundre patients were recruited at baseline. Of these, 291 received a formal neuropsychological assessment 1 year after stroke. 19% patients had moderate-severe VCI. The MoCA was superior to the NINDS-CSN 5-minute protocol [sub-acute AUCs: 0.89 vs 0.80, p < 0.01; 3-6 months AUCs: 0.90 vs 0.83, p < 0.01] in predicting for moderate-severe VCI at 1 year. At respective cutoff points, MoCA had significantly higher sensitivity than the NINDS-CSN 5-minute protocol at baseline (p = 0.01) and 3-6 months (p = 0.04). MoCA administered sub-acutely and 3-6 months after stroke is superior to the NINDS-CSN 5-minute protocol in predicting moderate-severe VCI at 1 year.

75 FR 4577 - National Institute of Neurological Disorders and Stroke; Notice of Closed Meeting

Federal Register 2010, 2011, 2012, 2013, 2014

2010-01-28

... DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health National Institute of Neurological Disorders and Stroke; Notice of Closed Meeting Pursuant to section 10(d) of the Federal Advisory... Disorders and Stroke, Initial Review Group Neurological Sciences and Disorders C. Dates: February 18-19...

A prognostic role for Low tri-iodothyronine syndrome in acute stroke patients: A systematic review and meta-analysis.

PubMed

Lamba, Nayan; Liu, Chunming; Zaidi, Hasan; Broekman, M L D; Simjian, Thomas; Shi, Chen; Doucette, Joanne; Ren, Steven; Smith, Timothy R; Mekary, Rania A; Bunevicius, Adomas

2018-06-01

Low triiodothyronine (T3) syndrome could be a powerful prognostic factor for acute stroke; yet, a prognostic role for low T3 has not been given enough importance in stroke management. This meta-analysis aimed to evaluate whether low T3 among acute stroke patients could be used as a prognostic biomarker for stroke severity, functional outcome, and mortality. Studies that investigated low T3 prognostic roles in acute stroke patients were sought from PubMed/Medline, Embase, and Cochrane databases through 11/23/2016. Pooled estimates of baseline stroke severity, mortality, and functional outcomes were assessed from fixed-effect (FE) and random-effects (RE) models. Eighteen studies met the inclusion criteria. Six studies (1,203 patients) provided data for low-T3 and normal-T3 patients and were meta-analyzed. Using the FE model, pooled results revealed low-T3 patients exhibited a significantly higher stroke severity, as assessed by the National Institutes of Health Stroke Scale (NIHSS) score at admission (mean difference = 3.18; 95%CI = 2.74, 3.63; I 2  = 61.9%), had 57% higher risk of developing poor functional outcome (RR = 1.57; 95%CI = 1.33,1.8), and had 83% higher odds of mortality (Peto-OR = 1.83; 95%CI = 1.21, 1.99) compared to normal-T3 patients. In a univariate meta-regression analysis, the low-T3 and stroke severity association was reduced in studies with higher smokers% (slope = -0.11; P = 0.02), higher hypertension% (slope = -0.11; P = 0.047), older age (slope = -0.54; P = 0.02), or longer follow-up (slope = -0/17, P < 0.01). RE models yielded similar results. No significant publication bias was observed for either outcome using Begg's and Egger's tests. Low-T3 syndrome in acute stroke patients is an effective prognostic factor for predicting greater baseline stroke severity, poorer functional outcome, and higher overall mortality risk. Copyright © 2018 Elsevier B.V. All rights reserved.

Are we armed with the right data? Pooled individual data review of biomarkers in people with severe upper limb impairment after stroke.

PubMed

Hayward, Kathryn S; Schmidt, Julia; Lohse, Keith R; Peters, Sue; Bernhardt, Julie; Lannin, Natasha A; Boyd, Lara A

2017-01-01

To build an understanding of the neurobiology underpinning arm recovery in people with severe arm impairment due to stroke, we conducted a pooled individual data systematic review to: 1) characterize brain biomarkers; 2) determine relationship(s) between biomarkers and motor outcome; and 3) establish relationship(s) between biomarkers and motor recovery. Three electronic databases were searched up to October 2, 2015. Eligible studies included adults with severe arm impairment after stroke. Descriptive statistics were calculated to characterize brain biomarkers, and pooling of individual patient data was performed using mixed-effects linear regression to examine relationships between brain biomarkers and motor outcome and recovery. Thirty-eight articles including individual data from 372 people with severe arm impairment were analysed. The majority of individuals were in the chronic (> 6 months) phase post stroke (51%) and had a subcortical stroke (49%). The presence of a motor evoked potential (indexed by transcranial magnetic stimulation) was the only biomarker related to better motor outcome ( p  = 0.02). There was no relationship between motor outcome and stroke volume (cm 3 ), location (cortical, subcortical, mixed) or side (left vs. right), and corticospinal tract asymmetry index (extracted from diffusion weighted imaging). Only one study had longitudinal data, thus no data pooling was possible to address change over time (preventing our third objective). Based on the available evidence, motor evoked potentials at rest were the only biomarker that predicted motor outcome in individuals with severe arm impairment following stroke. Given that few biomarkers emerged, this review highlights the need to move beyond currently known biomarkers and identify new indices with sufficient variability and sensitivity to guide recovery models in individuals with severe motor impairments following stroke. CRD42015026107.

Shoulder pain in people with a stroke: a population-based study.

PubMed

Ratnasabapathy, Yogini; Broad, Joanna; Baskett, Jonathan; Pledger, Megan; Marshall, Jane; Bonita, Ruth

2003-05-01

To measure the occurrence of shoulder pain after stroke. To identify the factors that predict risk of shoulder pain after stroke. Auckland Stroke Study, population-based case-cohort study. All cases of stroke, including those managed outside hospital, over a 12-month period ending February 1992 were considered in Auckland. Self-reported shoulder pain at one week, one month and six months after the onset of stroke for each person. A total of 1,761 stroke events were identified. Self-reported shoulder pain among survivors increased from 256/1474 (17%) at one week, to 261/1,336 (20%) at one month and 284/1,201 (23%) at six months. Shoulder pain was positively associated with motor deficit, side of deficit and severity of deficit. In those surviving to six months after stroke, the risk of shoulder pain was higher in those with severe upper limb motor deficit (odds ratio (OR) 4.94; 95% confidence interval (CI) 3.06-7.98) and in diabetics (OR 1.57, 95% CI 1.15-2.14). Risk of shoulder pain increased with time and was lower for those in institutional care. Shoulder pain after stroke is common, especially in patients with severe sensorimotor deficits, diabetics and those living at home. Appropriate management may reduce the rate of occurrence.

Correlated observations of three triggered lightning flashes

NASA Technical Reports Server (NTRS)

Idone, V. P.; Orville, R. E.; Hubert, P.; Barret, L.; Eybert-Berard, A.

1984-01-01

Three triggered lightning flashes, initiated during the Thunderstorm Research International Program (1981) at Langmuir Laboratory, New Mexico, are examined on the basis of three-dimensional return stroke propagation speeds and peak currents. Nonlinear relationships result between return stroke propagation speed and stroke peak current for 56 strokes, and between return stroke propagation speed and dart leader propagation speed for 32 strokes. Calculated linear correlation coefficients include dart leader propagation speed and ensuing return stroke peak current (32 strokes; r = 0.84); and stroke peak current and interstroke interval (69 strokes; r = 0.57). Earlier natural lightning data do not concur with the weak positive correlation between dart leader propagation speed and interstroke interval. Therefore, application of triggered lightning results to natural lightning phenomena must be made with certain caveats. Mean values are included for the three-dimensional return stroke propagation speed and for the three-dimensional dart leader propagation speed.

Air pollution and stroke - an overview of the evidence base.

PubMed

Maheswaran, Ravi

2016-08-01

Air pollution is being increasingly recognized as a significant risk factor for stroke. There are numerous sources of air pollution including industry, road transport and domestic use of biomass and solid fuels. Early reports of the association between air pollution and stroke come from studies investigating health effects of severe pollution episodes. Several daily time series and case-crossover studies have reported associations with stroke. There is also evidence linking chronic air pollution exposure with stroke and with reduced survival after stroke. A conceptual framework linking air pollution exposure and stroke is proposed. It links acute and chronic exposure to air pollution with pathways to acute and chronic effects on stroke risk. Current evidence regarding potential mechanisms mainly relate to particulate air pollution. Whilst further evidence would be useful, there is already sufficient evidence to support consideration of reduction in air pollution as a preventative measure to reduce the stroke burden globally. Copyright © 2016 Elsevier Ltd. All rights reserved.

Time trends in patient characteristics treated on acute stroke-units: results from the Austrian Stroke Unit Registry 2003-2011.

PubMed

Teuschl, Yvonne; Brainin, Michael; Matz, Karl; Dachenhausen, Alexandra; Ferrari, Julia; Seyfang, Leonhard; Lang, Wilfried

2013-04-01

Demographic changes, increased awareness of vascular risk factors, better diagnostic, progress in medical care, and increasing primary stroke prevention influence the profile of patients admitted to stroke-units. Changes in patient population and stroke type have important consequences on outcome and management at stroke-units. Data from the national database of the Austrian Stroke Unit Registry were analyzed for time-trends in demography, risk factors, cause, and stroke severity. Data of 48 038 ischemic and 5088 hemorrhagic strokes were analyzed. Between 2003 and 2011, median age increased significantly for ischemic strokes from 68 to 71 years in men and from 76 to 78 years in women, respectively. Ischemic stroke patients showed significantly increased rates of hypertension, hypercholesterolemia, and atrial fibrillation. In hemorrhagic strokes an increase for hypercholesterolemia and cardiac diseases other than atrial fibrillation and myocardial infarction were only found in men. A small but significant decrease in stroke severity was found for ischemic strokes from 4 to 3 points on the National Institutes of Health Stroke Scale in men and from 5 to 4 in women, and for hemorrhagic strokes from 9 to 6 points in men and from 9 to 7 in women. Cardioembolic strokes increased slightly, whereas macroangiopathy decreased. Significant time trends were seen for characteristics of ischemic and hemorrhagic stroke patients admitted to acute stroke-units in Austria. These include trends for older age and toward milder strokes with more cardioembolic causes. This signals a need for increased resources for managing multimorbidity and enabling early mobilization.

Meeting the nutritional needs of patients with severe dysphagia following a stroke: an interdisciplinary approach.

PubMed

Rodrigue, Nathalie; Côté, Robert; Kirsch, Connie; Germain, Chantal; Couturier, Céline; Fraser, Roxanne

2002-03-01

Dysphagia is a common problem with individuals who have experienced a stroke. The interdisciplinary stroke team noted delays in clinical decision-making, or in implementing plans for patients with severe dysphagia requiring an alternative method to oral feeding, such as enteral feeding via Dobhoff (naso-jejunum) or PEG (percutaneous endoscopic gastrostomy) tubes, occurred because protocols had not been established. This resulted in undernourishment, which in turn contributed to clinical problems, such as infections and confusion, which delayed rehabilitation and contributed to excess disability. The goal of the project was to improve quality of care and quality of life for stroke patients experiencing swallowing problems by creating a dysphagia management decision-making process. The project began with a retrospective chart review of 91 cases over a period of six months to describe the population characteristics, dysphagia frequency, stroke and dysphagia severity, and delays encountered with decision-making regarding dysphagia management. A literature search was conducted, and experts in the field were consulted to provide current knowledge prior to beginning the project. Using descriptive statistics, dysphagia was present in 44% of the stroke population and 69% had mild to moderate stroke severity deficit. Delays were found in the decision to insert a PEG (mean 10 days) and the time between decision and PEG insertion (mean 12 days). Critical periods were examined in order to speed up the process of decision-making and intervention. This resulted in the creation of a decision-making algorithm based on stroke and dysphagia severity that will be tested during winter 2002.

Endovascular Therapy after Intravenous t-PA versus t-PA Alone for Stroke

PubMed Central

Broderick, Joseph P.; Palesch, Yuko Y.; Demchuk, Andrew M.; Yeatts, Sharon D.; Khatri, Pooja; Hill, Michael D.; Jauch, Edward C.; Jovin, Tudor G.; Yan, Bernard; Silver, Frank L.; von Kummer, Rüdiger; Molina, Carlos A.; Demaerschalk, Bart M.; Budzik, Ronald; Clark, Wayne M.; Zaidat, Osama O.; Malisch, Tim W.; Goyal, Mayank; Schonewille, Wouter J.; Mazighi, Mikael; Engelter, Stefan T.; Anderson, Craig; Spilker, Judith; Carrozzella, Janice; Ryckborst, Karla J.; Janis, L. Scott; Martin, Renée H.; Foster, Lydia D.; Tomsick, Thomas A.

2013-01-01

BACKGROUND Endovascular therapy is increasingly used after the administration of intravenous tissue plasminogen activator (t-PA) for patients with moderate-to-severe acute ischemic stroke, but whether a combined approach is more effective than intravenous t-PA alone is uncertain. METHODS We randomly assigned eligible patients who had received intravenous t-PA within 3 hours after symptom onset to receive additional endovascular therapy or intravenous t-PA alone, in a 2:1 ratio. The primary outcome measure was a modified Rankin scale score of 2 or less (indicating functional independence) at 90 days (scores range from 0 to 6, with higher scores indicating greater disability). RESULTS The study was stopped early because of futility after 656 participants had undergone randomization (434 patients to endovascular therapy and 222 to intravenous t-PA alone). The proportion of participants with a modified Rankin score of 2 or less at 90 days did not differ significantly according to treatment (40.8% with endovascular therapy and 38.7% with intravenous t-PA; absolute adjusted difference, 1.5 percentage points; 95% confidence interval [CI], −6.1 to 9.1, with adjustment for the National Institutes of Health Stroke Scale [NIHSS] score [8–19, indicating moderately severe stroke, or ≥20, indicating severe stroke]), nor were there significant differences for the predefined subgroups of patients with an NIHSS score of 20 or higher (6.8 percentage points; 95% CI, −4.4 to 18.1) and those with a score of 19 or lower (−1.0 percentage point; 95% CI, −10.8 to 8.8). Findings in the endovascular-therapy and intravenous t-PA groups were similar for mortality at 90 days (19.1% and 21.6%, respectively; P = 0.52) and the proportion of patients with symptomatic intracerebral hemorrhage within 30 hours after initiation of t-PA (6.2% and 5.9%, respectively; P = 0.83). CONCLUSIONS The trial showed similar safety outcomes and no significant difference in functional independence with endovascular therapy after intravenous t-PA, as compared with intravenous t-PA alone. (Funded by the National Institutes of Health and others; ClinicalTrials.gov number, NCT00359424.) PMID:23390923

Aggressive surgical interventions for severe stroke: Impact on quality of life, caregiver burden and family outcomes.

PubMed

Green, Theresa; Demchuk, Andrew; Newcommon, Nancy

2015-01-01

Decompressive hemicraniectomy, clot evacuation, and aneurysmal interventions are considered aggressive surgical therapeutic options for treatment of massive cerebral artery infarction (MCA), intracerebral hemorrhage (ICH), and severe subarachnoid hemorrhage (SAH) respectively. Although these procedures are saving lives, little is actually known about the impact on outcomes other than short-term survival and functional status. The purpose of this study was to gain a better understanding of personal and social consequences of surviving these aggressive surgical interventions in order to aid acute care clinicians in helping family members make difficult decisions about undertaking such interventions. An exploratory mixed method study using a convergent parallel design was conducted to examine functional recovery (NIHSS, mRS & BI), cognitive status (Montreal Cognitive Assessment Scale, MoCA), quality of life (Euroqol 5-D), and caregiver outcomes (Bakas Caregiver Outcome Scale, BCOS) in a cohort of patients and families who had undergone aggressive surgical intervention for severe stroke between the years 2000-2007 Data were analyzed using descriptive statistics, univariate and multivariate analysis of variance, and multivariate logistic regression. Content analysis was used to analyze the qualitative interviews conducted with stroke survivors and family members. Twenty-seven patients and 13 spouses participated in this study. Based on patient MOCA scores, overall cognitive status was 25.18 (range 23.4-26.9); current functional outcomes scores: NIHSS 2.22, mRS 1.74, and BI 88.5. EQ-5D scores revealed no significant differences between patients and caregivers (p = 0.585) and caregiver outcomes revealed no significant diferences between male/female caregivers or patient diagnostic group (MCA, SAH, ICH; p = 0.103). Overall, patients and families were satisfied with quality of life and decisions made at the time of the initial stroke. There was consensus among study participants that formal community-based support (e.g., handibus, caregiving relief, rehabilitation assessments) should be continued for extended periods (e.g, years)post-stroke. Ongoing contact with health care professionals is valuable to help them navigate in the community as needs change over time.

Sex differences in sleep-disordered breathing after stroke: results from the BASIC project.

PubMed

McDermott, Mollie; Brown, Devin L; Li, Chengwei; Garcia, Nelda M; Case, Erin; Chervin, Ronald D; Morgenstern, Lewis B; Lisabeth, Lynda D

2018-03-01

Sleep-disordered breathing (SDB), an independent risk factor for stroke, is associated with worse post-stroke outcomes. Differences in the relationship between SDB and stroke may exist for women versus men. In this population-based study, we compared the prevalence of both pre- and post-stroke SDB by sex. We also explored whether menopausal status is related to post-stroke SDB. We performed a cross-sectional study of subjects enrolled in the Brain Attack Surveillance in Corpus Christi (BASIC) project. Each subject (n = 1815) underwent a baseline interview including the Berlin Questionnaire to assess pre-stroke SDB risk and, if relevant, questions regarding menopausal status. Subjects were offered overnight SDB screening with a validated portable respiratory device (n = 832 with complete data). Log Poisson and linear regression models were used to assess the differences in SDB between men and women with adjustment for demographics, stroke risk factors, stroke severity, and other potential confounders. Women were less likely than men to be at high risk for pre-stroke SDB (56.6% versus 61.9%) (prevalence ratio [PR] 0.87 for women; 95% confidence interval [CI], 0.81-0.95). A lower proportion of women than men (50.8% versus 70.2%) had post-stroke SDB by respiratory monitoring (PR 0.71; 95% CI, 0.63-0.80). SDB severity was higher for men than for women (mean difference in respiratory event index [REI] 6.5; 95% CI, 4.3-8.7). No significant association existed between post-stroke SDB and either menopausal status or age at menopause. After acute ischemic stroke, SDB was more prevalent and more severe in men than in women. Copyright © 2017 Elsevier B.V. All rights reserved.

Carotid Artery Stent Placement and Carotid Endarterectomy: A Challenge for Urgent Treatment after Stroke-Early and 12-Month Outcomes in a Comprehensive Stroke Center.

PubMed

Rocco, Alessandro; Sallustio, Fabrizio; Toschi, Nicola; Rizzato, Barbara; Legramante, Jacopo; Ippoliti, Arnaldo; Marchetti, Andrea Ascoli; Pampana, Enrico; Gandini, Roberto; Diomedi, Marina

2018-06-20

To compare feasibility, 12-month outcome, and periprocedural and postprocedural risks between carotid artery stent (CAS) placement and carotid endarterectomy (CEA) performed within 1 week after transient ischemic attack (TIA) or mild to severe stroke onset in a single comprehensive stroke center. Retrospective analysis of prospective data collected from 1,148 patients with ischemic stroke admitted to a single stroke unit between January 2013 and July 2015 was conducted. Among 130 consecutive patients with symptomatic carotid stenosis, 110 (10 with TIA, 100 with stroke) with a National Institutes of Health Stroke Scale (NIHSS) score < 20 and a prestroke modified Rankin Scale (mRS) score < 2 were eligible for CAS placement or CEA and treated according to the preference of the patient or a surrogate. Periprocedural (< 48 h) and postprocedural complications, functional outcome, stroke, and death rate up to 12 months were analyzed. Sixty-two patients were treated with CAS placement and 48 were treated with CEA. Several patients presented with moderate or major stroke (45.8% CEA, 64.5% CAS). NIHSS scores indicated slightly greater severity at onset in patients treated with a CAS vs CEA (6.6 ± 5.7 vs 4.2 ± 3.4; P = .08). Complication rates were similar between groups. mRS scores showed a significant improvement over time and a significant interaction with age in both groups. Similar incidences of death or stroke were shown on survival analysis. A subanalysis in patients with NIHSS scores ≥ 4 showed no differences in complication rate and outcome. CAS placement and CEA seem to offer early safe and feasible secondary stroke prevention treatments in experienced centers, even after major atherosclerotic stroke. Copyright © 2018 SIR. Published by Elsevier Inc. All rights reserved.

Missed Ischemic Stroke Diagnosis in the Emergency Department by Emergency Medicine and Neurology Services.

PubMed

Arch, Allison E; Weisman, David C; Coca, Steven; Nystrom, Karin V; Wira, Charles R; Schindler, Joseph L

2016-03-01

The failure to recognize an ischemic stroke in the emergency department is a missed opportunity for acute interventions and for prompt treatment with secondary prevention therapy. Our study examined the diagnosis of acute ischemic stroke in the emergency department of an academic teaching hospital and a large community hospital. A retrospective chart review was performed from February 2013 to February 2014. A total of 465 patients with ischemic stroke were included in the analysis; 280 patients from the academic hospital and 185 patients from the community hospital. One hundred three strokes were initially misdiagnosed that is 22% of the included strokes at the combined centers. Fifty-five of these were missed at the academic hospital (22%) [corrected] and 48 were at the community hospital (26%, P=0.11). Thirty-three percent of missed cases presented within a 3-hour time window for recombinant tissue-type plasminogen activator eligibility. An additional 11% presented between 3 and 6 hours of symptom onset for endovascular consideration. Symptoms independently associated with greater odds of a missed stroke diagnosis were nausea/vomiting (odds ratio, 4.02; 95% confidence interval, 1.60-10.1), dizziness (odds ratio, 1.99; 95% confidence interval, 1.03-3.84), and a positive stroke history (odds ratio, 2.40; 95% confidence interval, 1.30-4.42). Thirty-seven percent of posterior strokes were initially misdiagnosed compared with 16% of anterior strokes (P<0.001). Atypical symptoms associated with posterior circulation strokes lead to misdiagnoses. This was true at both an academic center and a large community hospital. Future studies need to focus on the evaluation of identification systems and tools in the emergency department to improve the accuracy of stroke diagnosis. © 2016 American Heart Association, Inc.

Variations in apolipoprotein D and sigma non-opioid intracellular receptor 1 genes with relation to risk, severity and outcome of ischemic stroke.

PubMed

Lövkvist, Håkan; Jönsson, Ann-Cathrin; Luthman, Holger; Jood, Katarina; Jern, Christina; Wieloch, Tadeusz; Lindgren, Arne

2014-09-28

In experimental studies, the apolipoprotein D (APOD) and the sigma receptor type 1 (SIGMAR1) have been related to processes of brain damage, repair and plasticity. We examined blood samples from 3081 ischemic stroke (IS) patients and 1595 control subjects regarding 10 single nucleotide polymorphisms (SNPs) in the APOD (chromosomal location 3q29) and SIGMAR1 (chromosomal location 9p13) genes to find possible associations with IS risk, IS severity (NIHSS-score) and recovery after IS (modified Rankin Scale, mRS, at 90 days). Simple/multiple logistic regression and Spearman's rho were utilized for the analyses. Among the SNPs analyzed, rs7659 within the APOD gene showed a possible association with stroke risk (OR = 1.12; 95% CI: 1.01-1.25; P = 0.029) and stroke severity (NIHSS ≥ 16) (OR = 0.70; 95% CI: 0.54-0.92; P = 0.009) when controlling for age, sex and vascular risk factors for stroke. No SNP showed an association with stroke recovery (mRS). We conclude that the SNP rs7659 within the APOD gene might be related to risk and severity of ischemic stroke in patients.

The frequency and severity of extinction after stroke affecting different vascular territories.

PubMed

Chechlacz, Magdalena; Rotshtein, Pia; Demeyere, Nele; Bickerton, Wai-Ling; Humphreys, Glyn W

2014-02-01

We examined the frequency and severity of visual versus tactile extinction based on data from a large group of sub-acute patients (n=454) with strokes affecting different vascular territories. After right hemisphere damage visual and tactile extinction were equally common. However, after left hemisphere damage tactile extinction was more common than visual. The frequency of extinction was significantly higher in patients with right compared to left hemisphere damage in both visual and tactile modalities but this held only for strokes affecting the MCA and PCA territories and not for strokes affecting other vascular territories. Furthermore, the severity of extinction did not differ as a function of either the stimulus modality (visual versus tactile), the affected hemisphere (left versus right) or the stroke territory (MCA, PCA or other vascular territories). We conclude that the frequency but not severity of extinction in both modalities relates to the side of damage (i.e. left versus right hemisphere) and the vascular territories affected by the stroke, and that left hemisphere dominance for motor control may link to the greater incidence of tactile than visual extinction after left hemisphere stroke. We discuss the implications of our findings for understanding hemispheric lateralization within visuospatial attention networks. Copyright © 2014 Elsevier Ltd. All rights reserved.

Limb Remote Ischemic Conditioning: Mechanisms, Anesthetics, and the Potential for Expanding Therapeutic Options

PubMed Central

Chen, Gangling; Thakkar, Mrugesh; Robinson, Christopher; Doré, Sylvain

2018-01-01

Novel and innovative approaches are essential in developing new treatments and improving clinical outcomes in patients with ischemic stroke. Remote ischemic conditioning (RIC) is a series of mechanical interruptions in blood flow of a distal organ, following end organ reperfusion, shown to significantly reduce infarct size through inhibition of oxidation and inflammation. Ischemia/reperfusion (I/R) is what ultimately leads to the irreversible brain damage and clinical picture seen in stroke patients. There have been several reports and reviews about the potential of RIC in acute ischemic stroke; however, the focus here is a comprehensive look at the differences in the three types of RIC (remote pre-, per-, and postconditioning). There are some limited uses of preconditioning in acute ischemic stroke due to the unpredictability of the ischemic event; however, it does provide the identification of biomarkers for clinical studies. Remote limb per- and postconditioning offer a more promising treatment during patient care as they can be harnessed during or after the initial ischemic insult. Though further research is needed, it is imperative to discuss the importance of preclinical data in understanding the methods and mechanisms involved in RIC. This understanding will facilitate translation to a clinically feasible paradigm for use in the hospital setting. PMID:29467715

Comparison of Two Post-Stroke Rehabilitation Programs: A Follow-Up Study among Primary versus Specialized Health Care

PubMed Central

Vega-Ramírez, Francisco Antonio; Rocamora-Pérez, Patricia; Aguilar-Parra, José Manuel; Padilla-Góngora, David

2016-01-01

Objective To compare home-based rehabilitation (RITH) and standard outpatient rehabilitation in a hospital setting, in terms of improving the functional recovery and quality of life of stroke patients. Study Design and Setting This was a prospective cohort study in Andalusia (Spain). Participants One hundred and forty-five patients completed the outcome data. Measures Daily activities were measured by the Barthel index, Canadian Neurological Scale (to assess mental state), Tinetti scale (balance and gait), and Short Form Health Survey-36 (SF-36 to compare the quality of life). Results No statistically significant differences were found between the two groups regarding the clinical characteristics of patients in the initial measurement, except for age and mental state (younger and with greater neurological impairment in the hospital group). After physical therapy, both groups showed statistically significant improvements from baseline in each of the measures. These improvements were better in RITH patients than in the hospital patients on all functionality scales with a smaller number of sessions. Conclusions Home rehabilitation is at least as effective as the outpatient rehabilitation programs in a hospital setting, in terms of recovery of functionality in post-stroke patients. Overall quality of life is severely impaired in both groups, as stroke is a very disabling disease that radically affects patients’ lives. PMID:27835673

Losartan/Hydrochlorothiazide: a review of its use in the treatment of hypertension and for stroke risk reduction in patients with hypertension and left ventricular hypertrophy.

PubMed

Keating, Gillian M

2009-06-18

Losartan/hydrochlorothiazide (HCTZ) [Hyzaar(R)] is a fixed-dose combination of the angiotensin II receptor antagonist (angiotensin receptor blocker [ARB]) losartan and the thiazide diuretic HCTZ. It is indicated for the treatment of hypertension (including as initial therapy in severe hypertension) and for stroke risk reduction in patients with hypertension and left ventricular hypertrophy (LVH). Losartan/HCTZ is an effective combination therapy, lowering blood pressure (BP) to a greater extent than losartan or HCTZ alone in patients with hypertension. Other ARB/HCTZ fixed-dose combinations generally lowered BP to a greater extent than losartan/HCTZ in patients with hypertension, although whether this translates into improvements in cardiovascular outcomes is not known. In the LIFE study, losartan-based therapy was associated with a lower incidence of cardiovascular morbidity and mortality than atenolol-based therapy, mainly as a result of a reduced risk of stroke; the incidence of new-onset diabetes mellitus was also lower with losartan-based therapy. Losartan/HCTZ is a well tolerated combination therapy. Thus, losartan/HCTZ remains an important option in the treatment of hypertension, as well as being indicated to reduce stroke risk in patients with hypertension and LVH.

Secondary Stroke Prevention: Improving Diagnosis and Management with Newer Technologies.

PubMed

Imam, Yahia Z; D'Souza, Atlantic; Malik, Rayaz A; Shuaib, Ashfaq

2016-12-01

Treatment of hypertension, diabetes, high cholesterol, smoking cessation, and healthy lifestyle have all contributed to the decline in the incidence of vascular disease over the last several decades. Patients who suffer an acute stroke are at a high risk for recurrence. Introduction of newer technologies and their wider use allows for better identification of patients in whom the risk of recurrence following an acute stroke may be very high. Traditionally, the major focus for diagnosis and management has focused on patient history, examination, imaging for carotid stenosis/occlusion, and detection of AF and paroxysmal AF (PAF) with 24-48 h cardiac monitoring. This review focuses on the usefulness of three newer investigative tools that are becoming widely available and lead to better prevention. Continuous ambulatory blood pressure measurements for 24 h or longer and 3D Doppler measures of the carotid arteries provide key useful information on the state of vascular health and enhance our ability to monitor the response to preventive therapies. Furthermore, the detection of PAF can be significantly improved with prolonged cardiac monitoring for 3 weeks or longer, enabling the initiation of appropriate prevention therapy. This review will focus on the potential impact and importance of these emerging technologies on the prevention of recurrent stroke in high-risk patients.

76 FR 20691 - National Institute of Neurological Disorders and Stroke; Notice of Closed Meetings

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76 FR 25702 - National Institute of Neurological Disorders and Stroke; Notice of Closed Meeting

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... DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health National Institute of Neurological Disorders and Stroke; Notice of Closed Meeting Pursuant to section 10(d) of the Federal Advisory... Disorders and Stroke Initial Review Group, Neurological Sciences and Disorders A. Date: June 22-23, 2011...

A piano training program to improve manual dexterity and upper extremity function in chronic stroke survivors.

PubMed

Villeneuve, Myriam; Penhune, Virginia; Lamontagne, Anouk

2014-01-01

Music-supported therapy was shown to induce improvements in motor skills in stroke survivors. Whether all stroke individuals respond similarly to the intervention and whether gains can be maintained over time remain unknown. We estimated the immediate and retention effects of a piano training program on upper extremity function in persons with chronic stroke. Thirteen stroke participants engaged in a 3-week piano training comprising supervised sessions (9 × 60 min) and home practice. Fine and gross manual dexterity, movement coordination, and functional use of the upper extremity were assessed at baseline, pre-intervention, post-intervention, and at a 3-week follow-up. Significant improvements were observed for all outcomes at post-intervention and follow-up compared to pre-intervention scores. Larger magnitudes of change in manual dexterity and functional use of the upper extremity were associated with higher initial levels of motor recovery. Piano training can result in sustainable improvements in upper extremity function in chronic stroke survivors. Individuals with a higher initial level of motor recovery at baseline appear to benefit the most from this intervention.

Quantitative characterization of the progression of focal brain ischemia in a rat photochemical stroke model using in-vivo MRI

NASA Astrophysics Data System (ADS)

Van der Linden, Anne-Marie; Verhoye, Marleen; De Ryck, M.

2000-04-01

Stroke models, if used in drug evaluation studies, should have a predictable and reproducible course and outcome. While most drug trials focus on the lesion outcome, our study shows the importance of studying lesion growth instead of lesion outcome. In the study reported here, the time course of a photochemically induced neocortical infarct is studied in rats, using diffusion-weighted magnetic resonance imaging, while the rats were submitted to a rigorous control of physiological parameters, ensuring constant body temperature, blood gases (pO2 and pCO2), arterial pressure, heart rate and plasma glucose levels. Under such a stable physiological condition, rats were imaged as soon as possible after lesion up to 6 hours, which is the most important period to determine the slope of further lesion growth and final outcome. The data show that the initial size of the lesion is important for the further outcome of the stroke, both in lesion size and severity of the ischemic damage, as reflected by changes in the Apparent Diffusion Coefficient.

Training Rapid Stepping Responses in an Individual With Stroke

PubMed Central

Inness, Elizabeth L.; Komar, Janice; Biasin, Louis; Brunton, Karen; Lakhani, Bimal; McIlroy, William E.

2011-01-01

Background and Purpose Compensatory stepping reactions are important responses to prevent a fall following a postural perturbation. People with hemiparesis following a stroke show delayed initiation and execution of stepping reactions and often are found to be unable to initiate these steps with the more-affected limb. This case report describes a targeted training program involving repeated postural perturbations to improve control of compensatory stepping in an individual with stroke. Case Description Compensatory stepping reactions of a 68-year-old man were examined 52 days after left hemorrhagic stroke. He required assistance to prevent a fall in all trials administered during his initial examination because he showed weight-bearing asymmetry (with more weight borne on the more-affected right side), was unable to initiate stepping with the right leg (despite blocking of the left leg in some trials), and demonstrated delayed response times. The patient completed 6 perturbation training sessions (30–60 minutes per session) that aimed to improve preperturbation weight-bearing symmetry, to encourage stepping with the right limb, and to reduce step initiation and completion times. Outcomes Improved efficacy of compensatory stepping reactions with training and reduced reliance on assistance to prevent falling were observed. Improvements were noted in preperturbation asymmetry and step timing. Blocking the left foot was effective in encouraging stepping with the more-affected right foot. Discussion This case report demonstrates potential short-term adaptations in compensatory stepping reactions following perturbation training in an individual with stroke. Future work should investigate the links between improved compensatory step characteristics and fall risk in this vulnerable population. PMID:21511992

Increased Th17/Treg Ratio in Poststroke Fatigue

PubMed Central

Liu, Xinjing; Kenkare, Komal; Li, Shanshan; Desai, Varsha; Wong, John; Luo, Xun; Wood, Lisa J.; Xu, Yuming; Wang, Qing Mei

2015-01-01

Fatigue is a major debilitating symptom after stroke. The biological mechanisms underlying poststroke fatigue (PFS) are unknown. We hypothesized that PSF is associated with an alteration in the balance between Th17 and Treg cells. To test this hypothesis we assessed fatigue in 30 stroke survivors using the Fatigue Scale for Motor and Cognitive Functions (FSMC). Peripheral blood was collected for assessment of Th17 and Treg cell populations and measurement of interleukin-10 (IL-10). Participants were dichotomized into severe fatigue (n = 14) and low-moderate fatigue (n = 16) groups by K-mean cluster analysis of FSMC scores. There were no group differences in age, gender, stroke type, stroke severity, or time since stroke. Stroke survivors in the severe fatigue group reported greater anxiety (p = 0.004) and depression (p = 0.001) than in the low-moderate fatigue group. The ratio of Th17 to Treg cells was significantly increased in the severe fatigue group relative to the mild-moderate fatigue group (p = 0.035). Serum levels of IL-10 negatively correlated withTh17/Treg ratio (r = −0.408,  p = 0.025). Our preliminary findings suggest that an imbalance in the Th17/Treg ratio is associated with the severity of PSF. PMID:26166952

Evaluation of exercise capacity after severe stroke using robotics-assisted treadmill exercise: a proof-of-concept study.

PubMed

Stoller, O; de Bruin, E D; Schindelholz, M; Schuster, C; de Bie, R A; Hunt, K J

2013-01-01

Robotics-assisted treadmill exercise (RATE) with focus on motor recovery has become popular in early post-stroke rehabilitation but low endurance for exercise is highly prevalent in these individuals. This study aimed to develop an exercise testing method using robotics-assisted treadmill exercise to evaluate aerobic capacity after severe stroke. Constant load testing (CLT) based on body weight support (BWS) control, and incremental exercise testing (IET) based on guidance force (GF) control were implemented during RATE. Analyses focussed on step change, step response kinetics, and peak performance parameters of oxygen uptake. Three subjects with severe motor impairment 16-23 days post-stroke were included. CLT yielded reasonable step change values in oxygen uptake, whereas response kinetics of oxygen uptake showed low goodness of fit. Peak performance parameters were not obtained during IET. Exercise testing in post-stroke individuals with severe motor impairments using a BWS control strategy for CLT is deemed feasible and safe. Our approach yielded reasonable results regarding cardiovascular performance parameters. IET based on GF control does not provoke peak cardiovascular performance due to uncoordinated walking patterns. GF control needs further development to optimally demand active participation during RATE. The findings warrant further research regarding the evaluation of exercise capacity after severe stroke.

Inter-rater reliability of kinesthetic measurements with the KINARM robotic exoskeleton.

PubMed

Semrau, Jennifer A; Herter, Troy M; Scott, Stephen H; Dukelow, Sean P

2017-05-22

Kinesthesia (sense of limb movement) has been extremely difficult to measure objectively, especially in individuals who have survived a stroke. The development of valid and reliable measurements for proprioception is important to developing a better understanding of proprioceptive impairments after stroke and their impact on the ability to perform daily activities. We recently developed a robotic task to evaluate kinesthetic deficits after stroke and found that the majority (~60%) of stroke survivors exhibit significant deficits in kinesthesia within the first 10 days post-stroke. Here we aim to determine the inter-rater reliability of this robotic kinesthetic matching task. Twenty-five neurologically intact control subjects and 15 individuals with first-time stroke were evaluated on a robotic kinesthetic matching task (KIN). Subjects sat in a robotic exoskeleton with their arms supported against gravity. In the KIN task, the robot moved the subjects' stroke-affected arm at a preset speed, direction and distance. As soon as subjects felt the robot begin to move their affected arm, they matched the robot movement with the unaffected arm. Subjects were tested in two sessions on the KIN task: initial session and then a second session (within an average of 18.2 ± 13.8 h of the initial session for stroke subjects), which were supervised by different technicians. The task was performed both with and without the use of vision in both sessions. We evaluated intra-class correlations of spatial and temporal parameters derived from the KIN task to determine the reliability of the robotic task. We evaluated 8 spatial and temporal parameters that quantify kinesthetic behavior. We found that the parameters exhibited moderate to high intra-class correlations between the initial and retest conditions (Range, r-value = [0.53-0.97]). The robotic KIN task exhibited good inter-rater reliability. This validates the KIN task as a reliable, objective method for quantifying kinesthesia after stroke.

Athletics, minor trauma, and pediatric arterial ischemic stroke.

PubMed

Sepelyak, Kathryn; Gailloud, Philippe; Jordan, Lori C

2010-05-01

Pediatric arterial ischemic stroke may occur as the result of trivial head or neck trauma sustained during a sports activity. We describe three cases of sports-related stroke in previously healthy school-age children and discuss acute and long-term stroke care. Possible mechanisms of sports-related stroke are addressed, as is evaluation for cause of stroke in children. In one of the reported cases, the child was found to have a vertebral artery dissection as the cause of his stroke, but no definitive cause of stroke was identified in the other two cases despite extensive evaluation. The advisability and timing of returning to athletic activities after stroke is also discussed. Many children with sports-related stroke are initially seen by a sports trainer, a pediatrician, or an ER physician. Thus, it is particularly important that these professionals are aware of the possibility of ischemic stroke occurring after even mild athletic injury. Childhood stroke may result from injuries sustained during athletic activities and should be considered when a child has acute focal neurologic signs.

Risk Factors and Stroke Characteristic in Patients with Postoperative Strokes.

PubMed

Dong, Yi; Cao, Wenjie; Cheng, Xin; Fang, Kun; Zhang, Xiaolong; Gu, Yuxiang; Leng, Bing; Dong, Qiang

2017-07-01

Intravenous thrombolysis and intra-arterial thrombectomy are now the standard therapies for patients with acute ischemic stroke. In-house strokes have often been overlooked even at stroke centers and there is no consensus on how they should be managed. Perioperative stroke happens rather frequently but treatment protocol is lacking, In China, the issue of in-house strokes has not been explored. The aim of this study is to explore the current management of in-house stroke and identify the common risk factors associated with perioperative strokes. Altogether, 51,841 patients were admitted to a tertiary hospital in Shanghai and the records of those who had a neurological consult for stroke were reviewed. Their demographics, clinical characteristics, in-hospital complications and operations, and management plans were prospectively studied. Routine laboratory test results and risk factors of these patients were analyzed by multiple logistic regression model. From January 1, 2015, to December 31, 2015, over 1800 patients had neurological consultations. Among these patients, 37 had an in-house stroke and 20 had more severe stroke during the postoperative period. Compared to in-house stroke patients without a procedure or operation, leukocytosis and elevated fasting glucose levels were more common in perioperative strokes. In multiple logistic regression model, perioperative strokes were more likely related to large vessel occlusion. Patients with perioperative strokes had different risk factors and severity from other in-house strokes. For these patients, obtaining a neurological consultation prior to surgery may be appropriate in order to evaluate the risk of perioperative stroke. Copyright © 2017. Published by Elsevier Inc.

Suboptimal lipid management before and after ischaemic stroke and TIA-the North Dublin Population Stroke Study.

PubMed

Ní Chróinín, Danielle; Ní Chróinín, Chantelle; Akijian, Layan; Callaly, Elizabeth L; Hannon, Niamh; Kelly, Lisa; Marnane, Michael; Merwick, Áine; Sheehan, Órla; Horgan, Gillian; Duggan, Joseph; Kyne, Lorraine; Dolan, Eamon; Murphy, Seán; Williams, David; Kelly, Peter J

2018-01-24

Few population-based studies have assessed lipid adherence to international guidelines for primary and secondary prevention in stroke/transient ischaemic attack (TIA) patients. This study aims to evaluate adherence to lipid-lowering therapy (LLT) guidelines amongst patients with ischaemic stroke/TIA. Using hot and cold pursuit methods from multiple hospital/community sources, all stroke and TIA cases in North Dublin City were prospectively ascertained over a 1-year period. Adherence to National Cholesterol Education Programme (NCEP) III guidelines, before and after index ischaemic stroke/TIA, was assessed. Amongst 616 patients (428 ischaemic stroke, 188 TIA), total cholesterol was measured following the qualifying event in 76.5% (471/616) and low-density lipoprotein (LDL) in 60.1% (370/616). At initial stroke/TIA presentation, 54.1% (200/370) met NCEP III LDL goals. Compliance was associated with prior stroke (odds ratio [OR] 2.19, p = 0.02), diabetes (OR 1.91, p = 0.04), hypertension (OR 1.57, p = 0.03), atrial fibrillation (OR 1.78, p = 0.01), pre-event LLT (OR 2.85, p < 0.001) and higher individual LDL goal (p = 0.001). At stroke/TIA onset, 32.7% (195/596) was on LLT. Nonetheless, LDL exceeded individual NCEP goal in 29.2% (56/192); 21.6% (53/245) warranting LLT was not on treatment prior to stroke/TIA onset. After index stroke/TIA, 75.9% (422/556) was on LLT; 15.3% (30/196) meeting NCEP III criteria was not prescribed a statin as recommended. By 2 years, actuarial survival was 72.8% and 11.9% (59/497) experienced stroke recurrence. No association was observed between initial post-event target adherence and 2-year outcomes. In this population-based study, LLT recommended by international guidelines was under-used, before and after index stroke/TIA. Strategies to improve adherence are needed.

Neural correlates of motor recovery after stroke: a longitudinal fMRI study

PubMed Central

Ward, N. S.; Brown, M. M.; Thompson, A. J.; Frackowiak, R. S. J.

2013-01-01

Summary Recovery of motor function after stroke may occur over weeks or months and is often attributed to cerebral reorganization. We have investigated the longitudinal relationship between recovery after stroke and task-related brain activation during a motor task as measured using functional MRI (fMRI). Eight first-ever stroke patients presenting with hemiparesis resulting from cerebral infarction sparing the primary motor cortex, and four control subjects were recruited. Subjects were scanned on a number of occasions whilst performing an isometric dynamic visually paced hand grip task. Recovery in the patient group was assessed using a battery of outcome measures at each time point. Task-related brain activations decreased over sessions as a function of recovery in a number of primary and non-primary motor regions in all patients, but no session effects were seen in the controls. Furthermore, consistent decreases across sessions correlating with recovery were seen across the whole patient group independent of rate of recovery or initial severity, in primary motor cortex, premotor and prefrontal cortex, supplementary motor areas, cingulate sulcus, temporal lobe, striate cortex, cerebellum, thalamus and basal ganglia. Although recovery-related increases were seen in different brain regions in four patients, there were no consistent effects across the group. These results further our understanding of the recovery process by demonstrating for the first time a clear temporal relationship between recovery and task-related activation of the motor system after stroke. PMID:12937084

Endovascular Therapy Is Effective and Safe for Patients With Severe Ischemic Stroke: Pooled Analysis of Interventional Management of Stroke III and Multicenter Randomized Clinical Trial of Endovascular Therapy for Acute Ischemic Stroke in the Netherlands Data.

PubMed

Broderick, Joseph P; Berkhemer, Olvert A; Palesch, Yuko Y; Dippel, Diederik W J; Foster, Lydia D; Roos, Yvo B W E M; van der Lugt, Aad; Tomsick, Thomas A; Majoie, Charles B L M; van Zwam, Wim H; Demchuk, Andrew M; van Oostenbrugge, Robert J; Khatri, Pooja; Lingsma, Hester F; Hill, Michael D; Roozenbeek, Bob; Jauch, Edward C; Jovin, Tudor G; Yan, Bernard; von Kummer, Rüdiger; Molina, Carlos A; Goyal, Mayank; Schonewille, Wouter J; Mazighi, Mikael; Engelter, Stefan T; Anderson, Craig S; Spilker, Judith; Carrozzella, Janice; Ryckborst, Karla J; Janis, L Scott; Simpson, Kit N

2015-12-01

We assessed the effect of endovascular treatment in acute ischemic stroke patients with severe neurological deficit (National Institutes of Health Stroke Scale score, ≥20) after a prespecified analysis plan. The pooled analysis of the Interventional Management of Stroke III (IMS III) and Multicenter Randomized Clinical Trial of Endovascular Therapy for Acute Ischemic Stroke in the Netherlands (MR CLEAN) trials included participants with an National Institutes of Health Stroke Scale score of ≥20 before intravenous tissue-type plasminogen activator (tPA) treatment (IMS III) or randomization (MR CLEAN) who were treated with intravenous tPA ≤3 hours of stroke onset. Our hypothesis was that participants with severe stroke randomized to endovascular therapy after intravenous tPA would have improved 90-day outcome (distribution of modified Rankin Scale scores), when compared with those who received intravenous tPA alone. Among 342 participants in the pooled analysis (194 from IMS III and 148 from MR CLEAN), an ordinal logistic regression model showed that the endovascular group had superior 90-day outcome compared with the intravenous tPA group (adjusted odds ratio, 1.78; 95% confidence interval, 1.20-2.66). In the logistic regression model of the dichotomous outcome (modified Rankin Scale score, 0-2, or functional independence), the endovascular group had superior outcomes (adjusted odds ratio, 1.97; 95% confidence interval, 1.09-3.56). Functional independence (modified Rankin Scale score, ≤2) at 90 days was 25% in the endovascular group when compared with 14% in the intravenous tPA group. Endovascular therapy after intravenous tPA within 3 hours of symptom onset improves functional outcome at 90 days after severe ischemic stroke. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00359424 (IMS III) and ISRCTN10888758 (MR CLEAN). © 2015 American Heart Association, Inc.

Neighborhood income and stroke care and outcomes

PubMed Central

Fang, Jiming; Chan, Crystal; Alter, David A.; Bronskill, Susan E.; Hill, Michael D.; Manuel, Douglas G.; Tu, Jack V.; Anderson, Geoffrey M.

2012-01-01

Objective: To evaluate factors that may contribute to the increased stroke case fatality rates observed in individuals from low-income areas. Methods: We conducted a cohort study on a population-based sample of all patients with stroke or TIA seen at 153 acute care hospitals in the province of Ontario, Canada, between April 1, 2002, and March 31, 2003, and April 1, 2004, and March 31, 2005. Socioeconomic status measured as income quintiles was imputed from median neighborhood income. In the study sample of 7,816 patients we determined 1-year mortality by grouped income quintile and used multivariable analyses to assess whether differences in survival were explained by cardiovascular risk factors, stroke severity, stroke management, or other prognostic factors. Results: There was no significant gradient across income groups for stroke severity or stroke management. However, 1-year mortality rates were higher in those from the lowest income group compared to those from the highest income group, even after adjustment for age, sex, stroke type and severity, comorbid conditions, hospital and physician characteristics, and processes of care (adjusted hazard ratio for low- vs high-income groups, 1.18; 95 confidence interval 1.03 to 1.29). Conclusions: In Ontario, 1-year survival rates after an index stroke are higher for those from the richest compared to the least wealthy areas, and this is only partly explained by age, sex, comorbid conditions, and other baseline risk factors. PMID:22895592

Transient ischemic attack and minor stroke are the most common manifestations of acute cerebrovascular disease: a prospective, population-based study--the Aarhus TIA study.

PubMed

von Weitzel-Mudersbach, Paul; Andersen, Grethe; Hundborg, Heidi H; Johnsen, Søren P

2013-01-01

Severity of acute vascular illness may have changed in the last decades due to improvements in primary and secondary prevention. Population-based data on the severity of acute ischemic cerebrovascular disease are sparse. We aimed to examine incidence, characteristics and severity of acute ischemic cerebrovascular disease in a well-defined population. All patients admitted with transient ischemic attack (TIA) or acute ischemic stroke from March 1, 2007, to February 29, 2008, with residence in the Aarhus area, were included. Incidence rates and characteristics of TIA and ischemic stroke were compared. TIA accounted for 30%, TIA and minor stroke combined for 65% of all acute ischemic cerebrovascular events. Age-adjusted incidence rates of TIA and ischemic stroke were 72.2/100,000 and 129.5/100,000 person-years, respectively. TIA patients were younger than stroke patients (66.3 vs. 72.7 years; p < 0.001). Atrial fibrillation, previous myocardial infarction and previous stroke were significantly more frequent in stroke patients; no differences in other baseline characteristics were found. Minor events are the most common in ischemic cerebrovascular disease, and may constitute a larger proportion than previously reported. TIA and stroke patients share many characteristics; however, TIA patients are younger and have fewer manifestations of atherosclerotic diseases, indicating a high potential for secondary prevention. Copyright © 2012 S. Karger AG, Basel.

Employment status, social function decline and caregiver burden among stroke survivors. A South Indian study.

PubMed

Sreedharan, Sapna Erat; Unnikrishnan, J P; Amal, M G; Shibi, B S; Sarma, Sankara; Sylaja, P N

2013-09-15

Stroke leaves at least 60% of the survivors with moderate to severe disability limiting their employment status and social functioning leading to high levels of caregiver burden. We sought to study the employment status and level of change of social functioning of stroke survivors and their principal caregiver and correlate it with severity of stroke, functional disability, and anxiety and depression scores. One hundred and fifty stroke survivors and principal caregivers (3 months-2 years post-stroke) were recruited for the study. The employment status pre- and post-stroke was assessed. The social function of the patient and caregiver was analyzed using a 6 item social function scale developed for the study, encompassing culturally relevant questions. A 20 point scale adapted from Burden assessment schedule was used to assess the caregiver burden. Mean age of the study group was 54.37±12.072 (range 22-75 years), with 116 males and 34 females. Spouse was the principal caregiver for 142/150 patients (94.6%). In the stroke survivors, compared to the pre-stroke employment status of 62.7%, only 20.7% were employed post-stroke with half having change of job. But the employment status of caregiver was not reduced post-stroke (34.7% vs 33.3%). Employment loss in stroke survivors had a statistically significant association with severity of functional disability, male gender and presence of limb weakness (p values 0.037, 0.0001 and 0.043 respectively). There was an overall decline in social functions among the 6 parameters assessed in both the stroke survivors and caregivers. Of the caregiver burden, financial burden was more among female and older caregivers. The functional status and motor weakness of the stroke survivors did not tend to worsen the overall caregiver burden. Loss of occupation among stroke survivors is high. The decline in social function among stroke survivors and caregivers was significant. Even though functional disability contributed to employment loss and social function decline among stroke survivors, it did not have a significant impact on caregiver burden. © 2013 Elsevier B.V. All rights reserved

Post-stroke infection: a role for IL-1ra?

PubMed

Tanzi, Pat; Cain, Kevin; Kalil, Angela; Zierath, Dannielle; Savos, Anna; Gee, J Michael; Shibata, Dean; Hadwin, Jessica; Carter, Kelly; Becker, Kyra

2011-04-01

Infection is common following stroke and is independently associated with worse outcome. Clinical studies suggest that infections occur more frequently in those individuals with stroke-induced immunologic dysfunction. This study sought to explore the contribution of immunomodulatory cytokines and hormones to lymphocyte function and infection risk. Patients (N = 112) were enrolled as soon as possible after the onset of ischemic stroke. Blood was drawn to assess plasma cortisol, IL-10, IL-1ra, lymphocyte numbers, and lymphocyte function at 72 h after stroke onset; infections were censored through 21 days after stroke onset. Infection occurred in 25% of patients. Stroke severity was the most important predictor of infection risk. Increased plasma cortisol, IL-10, and IL-1ra, as well as decreased lymphocyte numbers, at 72 h after stroke onset were associated with risk of subsequent infection. After controlling for stroke severity, only IL-1ra was independently associated with infection risk, and the degree of risk was consistent throughout the post-stroke period. Infection, but not IL-1ra itself, was associated with worse outcome at 3 months. In this study cohort, increased plasma IL-1ra was independently associated with the risk of post-stroke infection. Further studies are needed to validate this finding, which could have important implications for stroke therapy.

Holter-electrocardiogram-monitoring in patients with acute ischaemic stroke (Find-AFRANDOMISED): an open-label randomised controlled trial.

PubMed

Wachter, Rolf; Gröschel, Klaus; Gelbrich, Götz; Hamann, Gerhard F; Kermer, Pawel; Liman, Jan; Seegers, Joachim; Wasser, Katrin; Schulte, Anna; Jürries, Falko; Messerschmid, Anna; Behnke, Nico; Gröschel, Sonja; Uphaus, Timo; Grings, Anne; Ibis, Tugba; Klimpe, Sven; Wagner-Heck, Michaela; Arnold, Magdalena; Protsenko, Evgeny; Heuschmann, Peter U; Conen, David; Weber-Krüger, Mark

2017-04-01

Atrial fibrillation is a major risk factor for recurrent ischaemic stroke, but often remains undiagnosed in patients who have had an acute ischaemic stroke. Enhanced and prolonged Holter-electrocardiogram-monitoring might increase detection of atrial fibrillation. We therefore investigated whether enhanced and prolonged rhythm monitoring was better for detection of atrial fibrillation than standard care procedures in patients with acute ischaemic stroke. Find-AF randomised is an open-label randomised study done at four centres in Germany. We recruited patients with acute ischaemic stroke (symptoms for 7 days or less) aged 60 years or older presenting with sinus rhythm and without history of atrial fibrillation. Patients were included irrespective of the suspected cause of stroke, unless they had a severe ipsilateral carotid or intracranial artery stenosis, which were the exclusion criteria. We used a computer-generated allocation sequence to randomly assign patients in a 1:1 ratio with permuted block sizes of 2, 4, 6, and 8, stratified by centre, to enhanced and prolonged monitoring (ie, 10-day Holter-electrocardiogram [ECG]-monitoring at baseline, and at 3 months and 6 months of follow-up) or standard care procedures (ie, at least 24 h of rhythm monitoring). Participants and study physicians were not masked to group assignment, but the expert committees that adjudicated endpoints were. The primary endpoint was the occurrence of atrial fibrillation or atrial flutter (30 sec or longer) within 6 months after randomisation and before stroke recurrence. Because Holter ECG is a widely used procedure and not known to harm patients, we chose not to assess safety in detail. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01855035. Between May 8, 2013, and Aug 31, 2014, we recruited 398 patients. 200 patients were randomly assigned to the enhanced and prolonged monitoring group and 198 to the standard care group. After 6 months, we detected atrial fibrillation in 14% of 200 patients in the enhanced and prolonged monitoring group (27 patients) versus 5% in the control group (nine of 198 patients, absolute difference 9·0%; 95% CI 3·4-14·5, p=0·002; number needed to screen 11). Enhanced and prolonged monitoring initiated early in patients with acute ischaemic stroke aged 60 years or older was better than standard care for the detection of atrial fibrillation. These findings support the consideration of all patients aged 60 years or older with stroke for prolonged monitoring if the detection of atrial fibrillation would result in a change in medical management (eg, initiation of anticoagulation). Boehringer Ingelheim. Copyright © 2017 Elsevier Ltd. All rights reserved.

Direct stimulation of angiotensin II type 2 receptor initiated after stroke ameliorates ischemic brain damage.

PubMed

Min, Li-Juan; Mogi, Masaki; Tsukuda, Kana; Jing, Fei; Ohshima, Kousei; Nakaoka, Hirotomo; Kan-No, Harumi; Wang, Xiao-Li; Chisaka, Toshiyuki; Bai, Hui-Yu; Iwanami, Jun; Horiuchi, Masatsugu

2014-08-01

Stroke is a leading cause of death and disability; however, meta-analysis of randomized controlled trials of blood pressure-lowering drugs in acute stroke has shown no definite evidence of a beneficial effect on functional outcome. Accumulating evidence suggests that angiotensin II type 1 receptor blockade with angiotensin II type 2 (AT2) receptor stimulation could contribute to protection against ischemic brain damage. We examined the possibility that direct AT2 receptor stimulation by compound 21 (C21) initiated even after stroke can prevent ischemic brain damage. Stroke was induced by middle cerebral artery (MCA) occlusion, and the area of cerebral infarction was measured by magnetic resonant imaging. C21 (10 µg/kg/day) treatment was initiated immediately after MCA occlusion by intraperitoneal injection followed by treatment with C21 once daily. We observed that ischemic area was enlarged in a time dependent fashion and decreased on day 5 after MCA occlusion. Treatment with C21 initiated after MCA occlusion significantly reduced the ischemic area, with improvement of neurological deficit in a time-dependent manner without affecting blood pressure. The decrease of cerebral blood flow after MCA occlusion was also ameliorated by C21 treatment. Moreover, treatment with C21 significantly attenuated superoxide anion production and expression of proinflammatory cytokines, monocyte chemoattractant protein 1, and tumor necrosis factor α. Interestingly, C21 administration significantly decreased blood-brain barrier permeability and cerebral edema on the ischemic side. These results provide new evidence that direct AT2 receptor stimulation with C21 is a novel therapeutic approach to prevent ischemic brain damage after acute stroke. © American Journal of Hypertension, Ltd 2014. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Trends in chronic diseases among the oldest-old in China

NASA Astrophysics Data System (ADS)

Teh, Jane K. L.; Tey, Nai Peng

2015-12-01

This study examined the prevalence of several chronic diseases among the oldest-old in China. Data came from the Chinese Longitudinal Healthy Longevity Survey (CLHLS) of 4 waves collected in 2002, 2005, 2008 and 2011, filtered to include individuals aged 80 and above. Bivariate and logistic regression methods were used in analyses. There were significant differences in the prevalence of hypertension, diabetes, chronic heart diseases, stroke/cardiovascular diseases, cancer and dementia, which generally saw an increase across the 4 waves. By contrast, prevalence of Parkinson was not significantly different over the 4 waves. Logistic regression results revealed that since 2002, hypertension had been significantly higher in subsequent waves in 2005, 2008 and 2011. Stroke had also shown significant increase in the 2008 and 2011 waves. Other chronic diseases such as diabetes, heart disease, cancer, Parkinson and dementia were only found to be significantly higher in the recent 2011 wave compared to the initial wave in 2002. Arthritis, which initially increased in earlier waves, had dropped significantly in the recent 2011 wave. However, respiratory conditions had been significantly lower since the initial wave in 2002. Generally, findings confirmed the increasing trend of chronic morbidity in recent years among the oldest-old in China. Long life expectancy coupled with chronic morbidity in very late age will duly have societal and economic implications.

Understanding the Role of Autoimmune Disorders on the Initial Presentation of Cardiovascular Disease

ClinicalTrials.gov

2015-04-20

Myocardial Infarction; Ischemic Stroke; Stroke; Subarachnoid Haemorrhage; Venous Thrombosis; Transient Ischemic Attack; Stable Angina Pectoris; Unstable Angina; Heart Failure; Peripheral Arterial Disease; Abdominal Aortic Aneurysm

The initial glycemic variability is associated with early neurological deterioration in diabetic patients with acute ischemic stroke.

PubMed

Hui, Jiaojie; Zhang, Jianping; Mao, Xuqiang; Li, Zaiwang; Li, Xinxin; Wang, Fengyun; Wang, Tao; Yuan, Qingfang; Wang, Sunwei; Pu, Mengjia; Xi, Guangjun

2018-06-05

The association between glycemic variability and early neurological deterioration (END) in acute ischemic stroke remains unclear. This study attempted to explore whether initial glycemic variability increases END in diabetic patients with acute ischemic stroke. We enrolled type 2 diabetic patients undergoing acute ischemic stroke from November 2015 to November 2016. A total of 336 patients within 72 h from stroke onset were included. The serum glucose levels were checked four times per day during the initial 3 hospital days. The standard deviation of blood glucose (SDBG) values and the mean amplitude of glycemic excursions (MAGE) were calculated for glycemic variability. END was defined as an increase in the National Institutes of Health Stroke Scale (NIHSS) ≥ 2 points between hospital days 0 and 5. The frequencies of END and HbA1c were significantly different in subjects grouped according to tertiles of MAGE (9.09, 12.07 and 50.00%, p < 0.001 for END; 7.36 ± 1.91, 7.83 ± 1.93 and 8.56 ± 1.79, p < 0.001 for HbA1c). Compared to patients without END, patients with END had significantly higher HbA1c levels (8.30 ± 1.92 vs 7.80 ± 1.93, p = 0.043), increased SDBG (3.42 ± 1.14 vs 2.60 ± 0.96, p < 0.001), and increased MAGE (6.46 ± 2.09 vs 4.59 ± 1.91, p < 0.001). In a multivariable logistic regression, stroke etiology (OR 0.675; 95% CI 0.485-0.940, p = 0.020), baseline NIHSS (OR 1.086; 95% CI 1.004-1.175, p = 0.040), and MAGE (OR 1.479; 95% CI 1.162-1.882, p = 0.001) were significantly associated with END. Initial glycemic variability is associated with END in diabetic patients with acute ischemic stroke.

Impact of atrial fibrillation on stroke-related healthcare costs.

PubMed

Sussman, Matthew; Menzin, Joseph; Lin, Iris; Kwong, Winghan J; Munsell, Michael; Friedman, Mark; Selim, Magdy

2013-11-25

Limited data exist on the economic implications of stroke among patients with atrial fibrillation (AF). This study assesses the impact of AF on healthcare costs associated with ischemic stroke (IS), hemorrhagic stroke (HS), or transient ischemic attack (TIA). A retrospective analysis of MarketScan claims data (2005-2011) for AF patients ≥18 years old with ≥1 inpatient claim for stroke, or ≥1 ED or inpatient claim for TIA as identified by ICD-9-CM codes who had ≥12 months continuous enrollment prior to initial stroke. Initial event- and stroke-related costs 12 months post-index were compared among patients with AF and without AF. Adjusted costs were estimated, controlling for demographics, comorbidities, anticoagulant use, and baseline resource use. Data from 23,807 AF patients and 136,649 patients without AF were analyzed. Unadjusted mean cost of the index event was $20,933 for IS, $59,054 for HS, $8616 for TIA hospitalization, and $3395 for TIA ED visit. After controlling for potential confounders, adjusted mean incremental costs (index plus 12-month post-index) for AF patients were higher than those for non-AF patients by: $4726, $7824, and $1890 for index IS, HS, TIA (identified by hospitalization), respectively, and $1700 for TIA (identified by ED) (all P<0.01). In multivariate regression analysis, AF was associated with a 20% (IS), 13% (HS), and 18% (TIA) increase in total stroke-related costs. Stroke-related care for IS, HS, and TIA is costly, especially among individuals with AF. Reducing the risk of AF-related stroke is important from both clinical and economic standpoints.

Strategies for improving outcomes in the acute management of ischemic stroke in rural emergency departments: a quality improvement initiative in the Stroke Belt.

PubMed

Jauch, Edward C; Huang, David Y; Gardner, Allison J; Blum, Julie L

2018-01-01

The timely evaluation and initiation of treatment for acute ischemic stroke (AIS) is critical to optimal patient outcomes. However, clinical practice often falls short of guideline-established goals. Hospitals in rural regions of the USA, and notably those in the Stroke Belt, are particularly challenged to meet timing goals since the vast majority of primary stroke centers (PSCs) are concentrated in urban academic institutions. Between May 2015 and May 2017, emergency department (ED) teams from 5 non-PSC hospitals in the Stroke Belt participated in a quality improvement (QI) initiative. The intervention included a baseline practice assessment survey, repeat audit-and-feedback cycles with patient data on AIS treatment timing, personalized Continuing Medical Education/Continuing Education-certified grand rounds sessions at each participating site with expert study faculty, targeted reinforcement of best practices, and follow-up to evaluate the benefits and limitations of the intervention. At the start of the initiative, clinical staff from participating EDs overestimated the proportion of patients with AIS who received alteplase within the guideline-recommended 60-minute door-to-needle window at their facility. At the end of the 6-month intervention period, significantly more patients were treated with alteplase within 60 minutes of ED arrival compared to baseline across the entire sample (1.9% of patients at baseline vs. 5.2% at 6 months; P < 0.01). Similarly, there was a trend toward a decrease in the percentage of patients whose alteplase treatment was initiated more than 60 minutes after their arrival at the ED (67.3% at baseline vs. 22.2% at 6 months). Structured QI interventions that engage ED care teams to reflect on processes related to AIS diagnosis and treatment and deploy repeat audit-and-feedback cycles with real-time patient data have the potential to support an increase in the number of patients who receive alteplase within the guideline-recommended timeframe of 60 minutes from hospital arrival.

Return Stroke Current Reflections in Rocket-Triggered Lightning

NASA Astrophysics Data System (ADS)

Caicedo, J.; Uman, M. A.; Jordan, D.; Biagi, C. J.; Hare, B.

2015-12-01

In the six years from 2009 to 2014, there have been eight triggered flashes at the ICLRT, from a total of 125, in which a total of ten return stroke channel-base currents exhibited a dip 3.0 to 16.6 μs after the initial current peak. Close range electric field measurements show a related dip following the initial electric field peak, and electric field derivative measurements show an associated bipolar pulse, confirming that this phenomenon is not an instrumentation effect in the current measurement. For six of the eight flashes, high-speed video frames show what appears to be suspended sections of unexploded triggering wire at heights of about 150 to 300 m that are illuminated when the upward current wave reaches them. The suspended wire can act as an impedance discontinuity, perhaps as it explodes, and cause a downward reflection of some portion of the upward-propagating current wave. This reflected wave travels down the channel and causes the dip in the measured channel-base current when it reaches ground and reflects upward. The modified transmission line model with exponential decay (MTLE) is used to model the close electric field and electric field derivatives of the postulated initial and reflected current waves, starting with the measured channel base current, and the results are compared favorably with measurements made at distances ranging from 92 to 444 m. From the measured time between current impulse initiation and the time the current reflection reaches the channel base and the current dip initiates, along with the reflection height from the video records, we find the average return stroke current speed for each of the ten strokes to be from 0.28 to 1.9×108 ms-1, with an error of ±0.01×108 ms-1 due to a ±0.1 μs uncertainty in the measurement. This represents the first direct measurement of return stroke current speed, all previous return stroke speed measurements being derived from the luminosity of the process.

Emerging Roles of microRNAs in Ischemic Stroke: As Possible Therapeutic Agents

PubMed Central

Khoshnam, Seyed Esmaeil; Winlow, William; Farbood, Yaghoob; Moghaddam, Hadi Fathi; Farzaneh, Maryam

2017-01-01

Stroke is one of the leading causes of death and physical disability worldwide. The consequences of stroke injuries are profound and persistent, causing in considerable burden to both the individual patient and society. Current treatments for ischemic stroke injuries have proved inadequate, partly owing to an incomplete understanding of the cellular and molecular changes that occur following ischemic stroke. MicroRNAs (miRNA) are endogenously expressed RNA molecules that function to inhibit mRNA translation and have key roles in the pathophysiological processes contributing to ischemic stroke injuries. Potential therapeutic areas to compensate these pathogenic processes include promoting angiogenesis, neurogenesis and neuroprotection. Several miRNAs, and their target genes, are recognized to be involved in these recoveries and repair mechanisms. The capacity of miRNAs to simultaneously regulate several target genes underlies their unique importance in ischemic stroke therapeutics. In this Review, we focus on the role of miRNAs as potential diagnostic and prognostic biomarkers, as well as promising therapeutic agents in cerebral ischemic stroke. PMID:28480877

Inflammation and hemostasis biomarkers for predicting stroke in postmenopausal women: The Women’s Health Initiative Observational Study

PubMed Central

Kaplan, Robert C; McGinn, Aileen P; Baird, Alison E; Hendrix, Susan L; Kooperberg, Charles; Lynch, John; Rosenbaum, Daniel M; Johnson, Karen C; Strickler, Howard D; Wassertheil-Smoller, Sylvia

2009-01-01

Background Inflammatory and hemostasis-related biomarkers may identify women at risk of stroke. Methods Hormones and Biomarkers Predicting Stroke is a study of ischemic stroke among postmenopausal women participating in the Women’s Health Initiative Observational Study (n = 972 case-control pairs). A Biomarker Risk Score was derived from levels of seven inflammatory and hemostasis-related biomarkers that appeared individually to predict risk of ischemic stroke: C-reactive protein, interleukin-6, tissue plasminogen activator, D-dimer, white blood cell count, neopterin, and homocysteine. The c index was used to evaluate discrimination. Results Of all the individual biomarkers examined, C-reactive protein emerged as the only independent single predictor of ischemic stroke (adjusted odds ratio comparing Q4 versus Q1 = 1.64, 95% confidence interval: 1.15–2.32, p = 0.01) after adjustment for other biomarkers and standard stroke risk factors. The Biomarker Risk Score identified a gradient of increasing stroke risk with a greater number of elevated inflammatory/hemostasis biomarkers, and improved the c index significantly compared with standard stroke risk factors (p = 0.02). Among the subset of individuals who met current criteria for “high risk” levels of C-reactive protein (> 3.0 mg/L), the Biomarker Risk Score defined an approximately two-fold gradient of risk. We found no evidence for a relationship between stroke and levels of E-selectin, fibrinogen, tumor necrosis factor-alpha, vascular cell adhesion molecule-1, prothrombin fragment 1+2, Factor VIIC, or plasminogen activator inhibitor-1 antigen (p >0.15). Discussion The findings support the further exploration of multiple-biomarker panels to develop approaches for stratifying an individual’s risk of stroke. PMID:18984425

Differences in the nature of stroke in a multiethnic urban South African population: the Johannesburg hospital stroke register.

PubMed

Connor, Myles D; Modi, Girish; Warlow, Charles P

2009-02-01

The burden of stroke is increasing in Sub-Saharan Africa (SSA) as the population undergoes epidemiological and demographic transition. Little is known about the nature (risk factors, stroke type and subtype, and causes) of stroke in SSA and whether it differs from stroke in high-income populations. We aimed to compare the nature of stroke between black and white populations in South Africa. We used overlapping sources to ascertain consecutive first-ever-in-a-lifetime stroke patients admitted to Johannesburg Hospital over 23 months. We assessed each patient's demographic details, risk factors, CT confirmed pathological stroke type, ischemic stroke subtype and stroke severity, and compared the nature of stroke between black and white stroke patients. 524 patients with presumed stroke were referred. Of these, 432 were first-ever strokes; 308 patients were black and 76 white. Black patients were significantly younger (mean age 51) than white patients (61). Stroke severity was similar (median NIH stroke score 10; 95% CI 8 to 11). More black than white patients had cerebral hemorrhage (27% versus 15%), lacunar stroke (28% versus 22%) and total anterior circulation infarcts (28% versus 22%). Large vessel atherosclerosis (none detected) and ischemic heart disease were very uncommon (1%) as a cause of stroke in black patients. Hypertension (70% versus 68%) and diabetes (14 versus 15%) were as common in black and white stroke patients, but mean cholesterol levels were lower (4.6 mmol/L; 95% CI 4.3 to 4.9 versus 5.3 mmol/L; 4.8 to 5.7) and cigarette smoking less frequent in black patients (23 versus 54%). Although this was a hospital-based study, the difference in the nature of stroke between black and white stroke patients likely reflects the profile of stroke risk factors. There is an opportunity to prevent an otherwise inevitable increase in atherosclerotic stroke (and IHD) by targeting dietary and smoking habits in the black South African population.

76 FR 6485 - National Institute of Neurological Disorders and Stroke; Notice of Closed Meeting

Federal Register 2010, 2011, 2012, 2013, 2014

2011-02-04

... DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health National Institute of Neurological Disorders and Stroke; Notice of Closed Meeting Pursuant to section 10(d) of the Federal Advisory... Disorders and Stroke Initial Review Group; NST-2 Subcommittee. Date: March 7-8, 2011. Time: 8 a.m. to 5 p.m...

[Severity assessment strategies based on administrative data using stroke as an example].

PubMed

Schubert, Ingrid; Hammer, Antje; Köster, Ingrid

2017-10-01

Information on disease severity is relevant for many studies with claims data in health service research, but only limited information is available in routine data. Stroke serves as an example to analyse whether the combination of different information in claims data can provide insight into the severity of a disease. As a first step, a literature search was conducted. Strategies to assess the severity of a disease by means of routine data were examined with regard to approval and applicability to German sickness fund data. In order to apply and extend the identified procedures, the statutory health insurance sample AOK Hessen/KV Hessen (VSH) served as data source. It is an 18.75 % random sample of persons insured by the AOK Hessen, with 2013 being the most recent year. Stroke patients were identified by the ICD-10 GM code I63 and I64. Patients with said diagnoses being coded as a hospital discharge diagnosis in 2012 were included due to an acute event in 2012 (n=944). The follow-up time was one year. Ten studies covering seven different methods to assess stroke severity were identified. Codes for coma (4.2 % of stroke patients in the SHI sample) as well as coma and/or the application of a PEG tube (9.8 % of the stroke patients) were applied as a proxy for disease severity of acute cases. Taking age, sex and comorbidity into consideration, patients in a coma show a significantly increased risk of mortality compared to those without coma. Three operationalisations were chosen as possible proxies for disease severity of stroke in the further course of disease: i) sequelae (hemiplegia, neurological neglect), ii) duration of the index inpatient stay, and iii) nursing care/ care level 3 for the first time after stroke. The latter proxy has the highest explanatory value for SHI costs. The studies identified use many variables mainly based on hospital information in order to describe disease severity. With the exception of coma, these proxies were neither validated nor did the authors provide more detailed grounds for their use. An identified score for stroke severity could not be applied to SHI data. To develop a comparable score requires a linkage of clinical and administrative data. Since routine data include information from all sectors of care, it should be explored whether these data (for example, the patients' care needs) are suitable to assess disease severity. For validation, separate databases and, optimally, primary patient data are necessary. Copyright © 2017. Published by Elsevier GmbH.

Slow Versus Fast Robot-Assisted Locomotor Training After Severe Stroke: A Randomized Controlled Trial.

PubMed

Rodrigues, Thais Amanda; Goroso, Daniel Gustavo; Westgate, Philip M; Carrico, Cheryl; Batistella, Linamara R; Sawaki, Lumy

2017-10-01

Robot-assisted locomotor training on a bodyweight-supported treadmill is a rehabilitation intervention that compels repetitive practice of gait movements. Standard treadmill speed may elicit rhythmic movements generated primarily by spinal circuits. Slower-than-standard treadmill speed may elicit discrete movements, which are more complex than rhythmic movements and involve cortical areas. Compare effects of fast (i.e., rhythmic) versus slow (i.e., discrete) robot-assisted locomotor training on a bodyweight-supported treadmill in subjects with chronic, severe gait deficit after stroke. Subjects (N = 18) were randomized to receive 30 sessions (5 d/wk) of either fast or slow robot-assisted locomotor training on a bodyweight-supported treadmill in an inpatient setting. Functional ambulation category, time up and go, 6-min walk test, 10-m walk test, Berg Balance Scale, and Fugl-Meyer Assessment were administered at baseline and postintervention. The slow group had statistically significant improvement on functional ambulation category (first quartile-third quartile, P = 0.004), 6-min walk test (95% confidence interval [CI] = 1.8 to 49.0, P = 0.040), Berg Balance Scale (95% CI = 7.4 to 14.8, P < 0.0001), time up and go (95% CI = -79.1 to 5.0, P < 0.0030), and Fugl-Meyer Assessment (95% CI = 24.1 to 45.1, P < 0.0001). The fast group had statistically significant improvement on Berg Balance Scale (95% CI = 1.5 to 10.5, P = 0.02). In initial stages of robot-assisted locomotor training on a bodyweight-supported treadmill after severe stroke, slow training targeting discrete movement may yield greater benefit than fast training.

Is hemiplegic cerebral palsy equivalent to amblyopia of the corticospinal system?

PubMed

Eyre, Janet A; Smith, Martin; Dabydeen, Lyvia; Clowry, Gavin J; Petacchi, Eliza; Battini, Roberta; Guzzetta, Andrea; Cioni, Giovanni

2007-11-01

Subjects with severe hemiplegic cerebral palsy have increased ipsilateral corticospinal projections from their noninfarcted cortex. We investigated whether their severe impairment might, in part, be caused by activity-dependent, competitive displacement of surviving contralateral corticospinal projections from the affected cortex by more active ipsilateral corticospinal projections from the nonaffected cortex, thereby compounding the impairment. Transcranial magnetic stimulation (TMS) characterized corticospinal tract development from each hemisphere over the first 2 years in 32 healthy children, 14 children with unilateral stroke, and 25 with bilateral lesions. Magnetic resonance imaging and anatomic studies compared corticospinal tract growth in 13 patients with perinatal stroke with 46 healthy subjects. Infants with unilateral lesions initially had responses after TMS of the affected cortex, which became progressively more abnormal, and seven were eventually lost. There was associated hypertrophy of the ipsilateral corticospinal axons projecting from the noninfarcted cortex. Magnetic resonance imaging and anatomic studies demonstrated hypertrophy of the corticospinal tract from the noninfarcted hemisphere. TMS findings soon after the stroke did not predict impairment; subsequent loss of responses and hypertrophy of ipsilateral corticospinal axons from the noninfarcted cortex predicted severe impairment at 2 years. Infants with bilateral lesions maintained responses to TMS from both hemispheres with a normal pattern of development. Rather than representing "reparative plasticity," increased ipsilateral projections from the noninfarcted cortex compound disability by competitively displacing surviving contralateral corticospinal projections from the infarcted cortex. This may provide a pathophysiological explanation for why signs of hemiplegic cerebral palsy appear late and progress over the first 2 years of life.

EMG based FES for post-stroke rehabilitation

NASA Astrophysics Data System (ADS)

Piyus, Ceethal K.; Anjaly Cherian, V.; Nageswaran, Sharmila

2017-11-01

Annually, 15 million in world population experiences stroke. Nearly 9 million stroke survivors every year experience mild to severe disability. The loss of upper extremity function in stroke survivors still remains a major rehabilitation challenge. The proposed EMG Abstract—Annually, 15 million in world population experiences stroke. Nearly 9 million stroke survivors every year experience mild to severe disability. The loss of upper extremity function in stroke survivors still remains a major rehabilitation challenge. The proposed EMG based FES system can be used for effective upper limb motor re-education in post stroke upper limb rehabilitation. The governing feature of the designed system is its synchronous activation, in which the FES stimulation is dependent on the amplitude of the EMG signal acquired from the unaffected upper limb muscle of the hemiplegic patient. This proportionate operation eliminates the undesirable damage to the patient’s skin by generating stimulus in proportion to voluntary EMG signals. This feature overcomes the disadvantages of currently available manual motor re-education systems. This model can be used in home-based post stroke rehabilitation, to effectively improve the upper limb functions.

Triggered lightning spectroscopy: Part 1. A qualitative analysis

NASA Astrophysics Data System (ADS)

Walker, T. Daniel; Christian, Hugh J.

2017-08-01

The first high-speed spectra of triggered lightning have been obtained. During the summers of 2012 and 2013, spectra were recorded at the International Center for Lightning Research and Testing, Camp Blanding, FL. The spectra were recorded with a high-speed camera with a grism mounted in front of it. The triggered lightning channels observed were generally at low altitude in a region that included the copper wire. Spectral emissions were recorded at each phase: the initial stage, dart leader, return stroke, and continuing current. These spectra are separated into two major regions: soft ultraviolet to visible (3800-6200 Å) and visible to near infrared (6200-8700 Å). The emissions during the initial stage reflect those of a copper wire burn in air. The majority of the emissions are neutral copper. After the initial stage comes the first return stroke which contains no detected molecular emissions; however, it does contain neutral, singly, and doubly ionized nitrogen and oxygen, neutral argon, and neutral hydrogen. Occasionally, before a return stroke, the dart leader coming down the channel will be stepped. During these occasions the leader spectra resemble that of the return stroke but are dimmer and shorter lived. After the initial portion of the return stroke, there are often changes in the luminosity of the spectrum which corresponds with fluctuations in the continuing current. During these "reillumination phases" no singly or doubly ionized lines have been observed to reemerge over the detection threshold, only neutral emission features.

Evaluation of Respiratory Muscle Strength in the Acute Phase of Stroke: The Role of Aging and Anthropometric Variables.

PubMed

Luvizutto, Gustavo José; Dos Santos, Maria Regina Lopes; Sartor, Lorena Cristina Alvarez; da Silva Rodrigues, Josiela Cristina; da Costa, Rafael Dalle Molle; Braga, Gabriel Pereira; de Oliveira Antunes, Letícia Cláudia; Souza, Juli Thomaz; de Carvalho Nunes, Hélio Rubens; Bazan, Silméia Garcia Zanati; Bazan, Rodrigo

2017-10-01

During hospitalization, stroke patients are bedridden due to neurologic impairment, leading to loss of muscle mass, weakness, and functional limitation. There have been few studies examining respiratory muscle strength (RMS) in the acute phase of stroke. This study aimed to evaluate the RMS of patients with acute stroke compared with predicted values and to relate this to anthropometric variables, risk factors, and neurologic severity. This is a cross-sectional study in the acute phase of stroke. After admission, RMS was evaluated by maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP); anthropometric data were collected; and neurologic severity was evaluated by the National Institutes of Health Stroke Scale. The analysis of MIP and MEP with predicted values was performed by chi-square test, and the relationship between anthropometric variables, risk factors, and neurologic severity was determined through multiple linear regression followed by residue analysis by the Shapiro-Wilk test; P < .05 was considered statistically significant. In the 32 patients studied, MIP and MEP were reduced when compared with the predicted values. MIP declined significantly by 4.39 points for each 1 kg/m 2 increase in body mass index (BMI), and MEP declined significantly by an average of 3.89 points for each 1 kg/m 2 increase in BMI. There was no statistically significant relationship between MIP or MEP and risk factors, and between MIP or MIP and neurologic severity in acute phase of stroke. There is a reduction of RMS in the acute phase of stroke, and RMS was lower in individuals with increased age and BMI. Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Hemiparesis and Epilepsy Are Associated With Worse Reported Health Status Following Unilateral Stroke in Children

PubMed Central

Smith, Sabrina E.; Vargas, Gray; Cucchiara, Andrew J.; Zelonis, Sarah J.; Beslow, Lauren A.

2015-01-01

BACKGROUND Perinatal and childhood stroke result in neurological impairment in the majority of survivors, but less is known about patient and parent perception of function following stroke in children. Our aim was to characterize parent-proxy and child-reported health status in children following unilateral arterial ischemic stroke or intraparenchymal hemorrhage. METHODS Fifty-nine children 2–18 years (30 girls, 29 boys) with unilateral arterial ischemic stroke or spontaneous intraparenchymal hemorrhage at least 6 months before evaluation were enrolled from a single center. The PedsQL version 4.0 Generic Short Form and PedsQL version 3.0 Cerebral Palsy Module were administered to childhood stroke subjects and parents. Generic PedsQL Inventory scores were compared between children with stroke and published data from healthy children. Reported health status scores for children with varying degrees of hemiparesis were compared. RESULTS Children with stroke had lower reported health status scores on the Generic PedsQL Inventory than healthy children. Children with moderate-severe hemiparesis had worse scores than children without hemiparesis on several measures of the Cerebral Palsy Module as reported by both parents and children. The parents of children with epilepsy reported worse scores on several measures compared with children without epilepsy, and the parent scores were lower on several measures for children with lower intelligence quotients. Agreement between parent and child scores was better on the Cerebral Palsy Module than on the Generic Inventory. CONCLUSIONS Children with stroke have worse reported health status than healthy controls. Degree of hemiparesis, epilepsy, and lower intelligence quotient affect reported health status on some measures. Agreement between parent-proxy and child scores ranges from slight to good which suggests that both provide useful information. PMID:25559938

Hemiparesis and epilepsy are associated with worse reported health status following unilateral stroke in children.

PubMed

Smith, Sabrina E; Vargas, Gray; Cucchiara, Andrew J; Zelonis, Sarah J; Beslow, Lauren A

2015-04-01

Perinatal and childhood stroke result in neurological impairment in the majority of survivors, but less is known about patient and parent perception of function following stroke in children. Our aim was to characterize parent-proxy and child-reported health status in children following unilateral arterial ischemic stroke or intraparenchymal hemorrhage. Fifty-nine children 2-18 years (30 girls, 29 boys) with unilateral arterial ischemic stroke or spontaneous intraparenchymal hemorrhage at least 6 months before evaluation were enrolled from a single center. The PedsQL version 4.0 Generic Short Form and PedsQL version 3.0 Cerebral Palsy Module were administered to childhood stroke subjects and parents. Generic PedsQL Inventory scores were compared between children with stroke and published data from healthy children. Reported health status scores for children with varying degrees of hemiparesis were compared. Children with stroke had lower reported health status scores on the Generic PedsQL Inventory than healthy children. Children with moderate-severe hemiparesis had worse scores than children without hemiparesis on several measures of the Cerebral Palsy Module as reported by both parents and children. The parents of children with epilepsy reported worse scores on several measures compared with children without epilepsy, and the parent scores were lower on several measures for children with lower intelligence quotients. Agreement between parent and child scores was better on the Cerebral Palsy Module than on the Generic Inventory. Children with stroke have worse reported health status than healthy controls. Degree of hemiparesis, epilepsy, and lower intelligence quotient affect reported health status on some measures. Agreement between parent-proxy and child scores ranges from slight to good which suggests that both provide useful information. Copyright © 2015 Elsevier Inc. All rights reserved.

Resting Energy Expenditure in Patients with Stroke during the Subacute Phases - Relationships with Stroke Types, Location, Severity of Paresis, and Activities of Daily Living.

PubMed

Kawakami, Michiyuki; Liu, Meigen; Wada, Ayako; Otsuka, Tomoyoshi; Nishimura, Atsuko

2015-01-01

The energy demands in patients with stroke during the subacute phases are unclear. However, this information is essential for appropriate clinical and nutritional management. The aims of this study were to determine the resting energy expenditure (REE) during the subacute phases, examine its relationships with stroke types, location, severity of hemiparesis, and activities of daily living (ADL), and evaluate whether estimation of REE from the Harris-Benedict equation (HB) requires the addition of a 'stress factor' to capture possible additional REE imposed by stroke. We measured REE in 95 patients with subacute stroke (53.5 ± 16.6 days post-stroke) with indirect calorimetry, and compared it with predicted values of energy expenditure estimated from the HB (expressed as percentage). Patients were admitted for rehabilitation of their first ischemic or nonsurgical hemorrhagic stroke. The severity of hemiparesis was assessed with the motor items of the Stroke Impairment Assessment Set (SIAS). The ADL was assessed with the Functional Independence Measure (FIM). We compared REE and %HB of the two groups divided by hemiparesis severity and ADL limitation using the Student's t-test, and those of the five groups divided by stroke location. The correlations between REE and the motor items of the SIAS and the FIM score were assessed with the Spearman rank correlation test. A multiple regression analysis for REE was conducted. The average body weight (BW) was 57.1 ± 11.3 kg. The average body mass index (BMI) was 22.5 ± 4.0. The mean REE (%HB) was 1,271 ± 284 kcal/day (106.0 ± 17.3%). REE and %HB of the low ADL group was less than that of the high ADL group (p < 0.05). The REE had a positive correlation with the FIM score (rs = 0.51, p < 0.01). The motor items of the SIAS were not significantly correlated with REE. BW, FIM, and stroke location were independent predictors of REE. Analysis of energy expenditure suggests that stroke patients are not hypermetabolic during the subacute phase. The 'stress factor' in stroke patients during the subacute phase was 1.0-1.1. This finding provides important information for improving nutritional management during the subacute phase in patients with stroke. © 2015 S. Karger AG, Basel.

Telestroke 10 years later--'telestroke 2.0'.

PubMed

Switzer, Jeffrey A; Levine, Steven R; Hess, David C

2009-01-01

The lack of physicians with specialty stroke training represents a significant challenge to the future of stroke. This deficit limits both quality stroke care and clinical research initiatives. The use of telemedicine for stroke ('telestroke') has been an attempt to overcome this shortage and extend stroke expertise to locations which lack coverage. However, the initial telestroke systems required a point-to-point connection for transmission and only provided videoconferencing which limited their generalizability and usefulness. 'Telestroke 2.0' is the authors' vision of an integrative web-based telestroke system combining high-quality audiovideo transmission, the ability of consults and teleradiology to be carried out from any desktop or laptop computer with web-access, decision and technical support, creation of billable physician documentation and electronic medical record connectivity. These features will facilitate the development of statewide and regional telestroke call networks with an opportunity for physician supply companies to fill in coverage gaps. In addition, telestroke 2.0 may improve acute stroke research by increasing trial efficiency via the addition of non-academic recruitment sites, enhancing trial validity by centralizing neurologic examinations via recorded encounters, and generalizing clinical trial results to community hospital settings. Greater diffusion and long-term sustainability of telestroke systems will be dependent upon improvements in patient and hospital reimbursement for acute stroke and telestroke care. Copyright 2009 S. Karger AG, Basel.

An Economic Evaluation Comparing Stroke Telemedicine to Conventional Stroke Medicine

ERIC Educational Resources Information Center

Budhram, Stanley Chandra

2011-01-01

Stroke is not only a serious medical problem, but it also poses an enormous economic burden on society. Stroke ranks the third as the leading cause of death in the United States behind heart disease and cancer. The survivors of stroke suffer from various degrees of long-term disability which create a severe financial burden on society. University…

The relationship between pneumonia and Glasgow coma scale assessment on acute stroke patients

NASA Astrophysics Data System (ADS)

Ritarwan, K.; Batubara, C. A.; Dhanu, R.

2018-03-01

Pneumonia is one of the most frequent medical complications of a stroke. Despite the well-documented association of a stroke associated infections with increased mortality and worse long-term outcome, on the other hand, the limited data available on independent predictors of pneumonia in acute stroke patients in an emergency unit. To determine the independentrelationship between pneumonia and Glasgow Coma Scale assessment on acute stroke patients. The cohort retrospective study observed 55 acute stroke patients who stayed in intensive care unit Adam Malik General Hospital from January until August 2017. Pneumonia was more frequent in patients with Ischemic stroke (OR 5.40; 95% CI: 1.28 – 6.40, p=0.003), higher National Institute of Health Stroke Scale (NIHSS) (p=0.014) and lower Glasgow Coma Scale (p=0.0001). Analysis multivariate logistic regression identified NIHSS as an independent of predictors of pneumonia (95% CI : 1.047 – 1.326, p=0.001). Pneumonia was associated with severity and type of stroke and length of hospital stay. The severity of the deficits evaluated by the NIHSS was shown to be the only independent risk factor for pneumonia in acute stroke patients.

CCL11 (Eotaxin-1) Levels Predict Long-Term Functional Outcomes in Patients Following Ischemic Stroke.

PubMed

Roy-O'Reilly, Meaghan; Ritzel, Rodney M; Conway, Sarah E; Staff, Ilene; Fortunato, Gilbert; McCullough, Louise D

2017-12-01

Circulating levels of the pro-inflammatory cytokine C-C motif chemokine 11 (CCL11, also known as eotaxin-1) are increased in several animal models of neuroinflammation, including traumatic brain injury and Alzheimer's disease. Increased levels of CCL11 have also been linked to decreased neurogenesis in mice. We hypothesized that circulating CCL11 levels would increase following ischemic stroke in mice and humans, and that higher CCL11 levels would correlate with poor long-term recovery in patients. As predicted, circulating levels of CCL11 in both young and aged mice increased significantly 24 h after experimental stroke. However, ischemic stroke patients showed decreased CCL11 levels compared to controls 24 h after stroke. Interestingly, lower post-stroke CCL11 levels were predictive of increased stroke severity and independently predictive of poorer functional outcomes in patients 12 months after ischemic stroke. These results illustrate important differences in the peripheral inflammatory response to ischemic stroke between mice and human patients. In addition, it suggests CCL11 as a candidate biomarker for the prediction of acute and long-term functional outcomes in ischemic stroke patients.

The Japan Statin Treatment Against Recurrent Stroke (J-STARS): A Multicenter, Randomized, Open-label, Parallel-group Study.

PubMed

Hosomi, Naohisa; Nagai, Yoji; Kohriyama, Tatsuo; Ohtsuki, Toshiho; Aoki, Shiro; Nezu, Tomohisa; Maruyama, Hirofumi; Sunami, Norio; Yokota, Chiaki; Kitagawa, Kazuo; Terayama, Yasuo; Takagi, Makoto; Ibayashi, Setsuro; Nakamura, Masakazu; Origasa, Hideki; Fukushima, Masanori; Mori, Etsuro; Minematsu, Kazuo; Uchiyama, Shinichiro; Shinohara, Yukito; Yamaguchi, Takenori; Matsumoto, Masayasu

2015-09-01

Although statin therapy is beneficial for the prevention of initial stroke, the benefit for recurrent stroke and its subtypes remains to be determined in Asian, in whom stroke profiles are different from Caucasian. This study examined whether treatment with low-dose pravastatin prevents stroke recurrence in ischemic stroke patients. This is a multicenter, randomized, open-label, blinded-endpoint, parallel-group study of patients who experienced non-cardioembolic ischemic stroke. All patients had a total cholesterol level between 4.65 and 6.21 mmol/L at enrollment, without the use of statins. The pravastatin group patients received 10 mg of pravastatin/day; the control group patients received no statins. The primary endpoint was the occurrence of stroke and transient ischemic attack (TIA), with the onset of each stroke subtype set to be one of the secondary endpoints. Although 3000 patients were targeted, 1578 patients (491 female, age 66.2 years) were recruited and randomly assigned to pravastatin group or control group. During the follow-up of 4.9 ± 1.4 years, although total stroke and TIA similarly occurred in both groups (2.56 vs. 2.65%/year), onset of atherothrombotic infarction was less frequent in pravastatin group (0.21 vs. 0.64%/year, p = 0.0047, adjusted hazard ratio 0.33 [95%CI 0.15 to 0.74]). No significant intergroup difference was found for the onset of other stroke subtypes, and for the occurrence of adverse events. Although whether low-dose pravastatin prevents recurrence of total stroke or TIA still needs to be examined in Asian, this study has generated a hypothesis that it may reduce occurrence of stroke due to larger artery atherosclerosis. This study was initially supported by a grant from the Ministry of Health, Labour and Welfare, Japan. After the governmental support expired, it was conducted in collaboration between Hiroshima University and the Foundation for Biomedical Research and Innovation.

Feasibility, safety and cost of outpatient management of acute minor ischaemic stroke: a population-based study.

PubMed

Paul, Nicola L M; Koton, Silvia; Simoni, Michela; Geraghty, Olivia C; Luengo-Fernandez, Ramon; Rothwell, Peter M

2013-03-01

Outpatient management safely and effectively prevents early recurrent stroke after transient ischaemic attack (TIA), but this approach may not be safe in patients with acute minor stroke. To study outcomes of clinic and hospital-referred patients with TIA or minor stroke (National Institute of Health Stroke Scale score ≤3) in a prospective, population-based study (Oxford Vascular Study). Of 845 patients with TIA/stroke, 587 (69%) were referred directly to outpatient clinics and 258 (31%) directly to inpatient services. Of the 250 clinic-referred minor strokes (mean age 72.7 years), 237 (95%) were investigated, treated and discharged on the same day, of whom 16 (6.8%) were subsequently admitted to hospital within 30 days for recurrent stroke (n=6), sepsis (n=3), falls (n=3), bleeding (n=2), angina (n=1) and nursing care (n=1). The 150 patients (mean age 74.8 years) with minor stroke referred directly to hospital (median length-of-stay 9 days) had a similar 30-day readmission rate (9/150; 6.3%; p=0.83) after initial discharge and a similar 30-day risk of recurrent stroke (9/237 in clinic patients vs 8/150, OR=0.70, 0.27-1.80, p=0.61). Rates of prescription of secondary prevention medication after initial clinic/hospital discharge were higher in clinic-referred than in hospital-referred patients for antiplatelets/anticoagulants (p<0.05) and lipid-lowering agents (p<0.001) and were maintained at 1-year follow-up. The mean (SD) secondary care cost was £8323 (13 133) for hospital-referred minor stroke versus £743 (1794) for clinic-referred cases. Outpatient management of clinic-referred minor stroke is feasible and may be as safe as inpatient care. Rates of early hospital admission and recurrent stroke were low and uptake and maintenance of secondary prevention was high.

Telmisartan to prevent recurrent stroke and cardiovascular events.

PubMed

Yusuf, Salim; Diener, Hans-Christoph; Sacco, Ralph L; Cotton, Daniel; Ounpuu, Stephanie; Lawton, William A; Palesch, Yuko; Martin, Reneé H; Albers, Gregory W; Bath, Philip; Bornstein, Natan; Chan, Bernard P L; Chen, Sien-Tsong; Cunha, Luis; Dahlöf, Björn; De Keyser, Jacques; Donnan, Geoffrey A; Estol, Conrado; Gorelick, Philip; Gu, Vivian; Hermansson, Karin; Hilbrich, Lutz; Kaste, Markku; Lu, Chuanzhen; Machnig, Thomas; Pais, Prem; Roberts, Robin; Skvortsova, Veronika; Teal, Philip; Toni, Danilo; VanderMaelen, Cam; Voigt, Thor; Weber, Michael; Yoon, Byung-Woo

2008-09-18

Prolonged lowering of blood pressure after a stroke reduces the risk of recurrent stroke. In addition, inhibition of the renin-angiotensin system in high-risk patients reduces the rate of subsequent cardiovascular events, including stroke. However, the effect of lowering of blood pressure with a renin-angiotensin system inhibitor soon after a stroke has not been clearly established. We evaluated the effects of therapy with an angiotensin-receptor blocker, telmisartan, initiated early after a stroke. In a multicenter trial involving 20,332 patients who recently had an ischemic stroke, we randomly assigned 10,146 to receive telmisartan (80 mg daily) and 10,186 to receive placebo. The primary outcome was recurrent stroke. Secondary outcomes were major cardiovascular events (death from cardiovascular causes, recurrent stroke, myocardial infarction, or new or worsening heart failure) and new-onset diabetes. The median interval from stroke to randomization was 15 days. During a mean follow-up of 2.5 years, the mean blood pressure was 3.8/2.0 mm Hg lower in the telmisartan group than in the placebo group. A total of 880 patients (8.7%) in the telmisartan group and 934 patients (9.2%) in the placebo group had a subsequent stroke (hazard ratio in the telmisartan group, 0.95; 95% confidence interval [CI], 0.86 to 1.04; P=0.23). Major cardiovascular events occurred in 1367 patients (13.5%) in the telmisartan group and 1463 patients (14.4%) in the placebo group (hazard ratio, 0.94; 95% CI, 0.87 to 1.01; P=0.11). New-onset diabetes occurred in 1.7% of the telmisartan group and 2.1% of the placebo group (hazard ratio, 0.82; 95% CI, 0.65 to 1.04; P=0.10). Therapy with telmisartan initiated soon after an ischemic stroke and continued for 2.5 years did not significantly lower the rate of recurrent stroke, major cardiovascular events, or diabetes. (ClinicalTrials.gov number, NCT00153062.) 2008 Massachusetts Medical Society

Reliability in the parameterization of the functional reach test in elderly stroke patients: a pilot study.

PubMed

Merchán-Baeza, Jose Antonio; González-Sánchez, Manuel; Cuesta-Vargas, Antonio Ignacio

2014-01-01

Postural instability is one of the major complications found in stroke survivors. Parameterising the functional reach test (FRT) could be useful in clinical practice and basic research. To analyse the reliability, sensitivity, and specificity in the FRT parameterisation using inertial sensors for recording kinematic variables in patients who have suffered a stroke. Cross-sectional study. While performing FRT, two inertial sensors were placed on the patient's back (lumbar and trunk). Five subjects over 65 who suffer from a stroke. FRT measures, lumbosacral/thoracic maximum angular displacement, maximum time of lumbosacral/thoracic angular displacement, time return initial position, and total time. Speed and acceleration of the movements were calculated indirectly. FRT measure is  12.75±2.06 cm. Intrasubject reliability values range from 0.829 (time to return initial position (lumbar sensor)) to 0.891 (lumbosacral maximum angular displacement). Intersubject reliability values range from 0.821 (time to return initial position (lumbar sensor)) to 0.883 (lumbosacral maximum angular displacement). FRT's reliability was 0.987 (0.983-0.992) and 0.983 (0.979-0.989) intersubject and intrasubject, respectively. The main conclusion could be that the inertial sensors are a tool with excellent reliability and validity in the parameterization of the FRT in people who have had a stroke.

Incorporating Stroke Severity Into Hospital Measures of 30-Day Mortality After Ischemic Stroke Hospitalization.

PubMed

Schwartz, Jennifer; Wang, Yongfei; Qin, Li; Schwamm, Lee H; Fonarow, Gregg C; Cormier, Nicole; Dorsey, Karen; McNamara, Robert L; Suter, Lisa G; Krumholz, Harlan M; Bernheim, Susannah M

2017-11-01

The Centers for Medicare & Medicaid Services publicly reports a hospital-level stroke mortality measure that lacks stroke severity risk adjustment. Our objective was to describe novel measures of stroke mortality suitable for public reporting that incorporate stroke severity into risk adjustment. We linked data from the American Heart Association/American Stroke Association Get With The Guidelines-Stroke registry with Medicare fee-for-service claims data to develop the measures. We used logistic regression for variable selection in risk model development. We developed 3 risk-standardized mortality models for patients with acute ischemic stroke, all of which include the National Institutes of Health Stroke Scale score: one that includes other risk variables derived only from claims data (claims model); one that includes other risk variables derived from claims and clinical variables that could be obtained from electronic health record data (hybrid model); and one that includes other risk variables that could be derived only from electronic health record data (electronic health record model). The cohort used to develop and validate the risk models consisted of 188 975 hospital admissions at 1511 hospitals. The claims, hybrid, and electronic health record risk models included 20, 21, and 9 risk-adjustment variables, respectively; the C statistics were 0.81, 0.82, and 0.79, respectively (as compared with the current publicly reported model C statistic of 0.75); the risk-standardized mortality rates ranged from 10.7% to 19.0%, 10.7% to 19.1%, and 10.8% to 20.3%, respectively; the median risk-standardized mortality rate was 14.5% for all measures; and the odds of mortality for a high-mortality hospital (+1 SD) were 1.51, 1.52, and 1.52 times those for a low-mortality hospital (-1 SD), respectively. We developed 3 quality measures that demonstrate better discrimination than the Centers for Medicare & Medicaid Services' existing stroke mortality measure, adjust for stroke severity, and could be implemented in a variety of settings. © 2017 American Heart Association, Inc.

Effects of ischemic stroke on dynamics of cerebral autoregulation

NASA Astrophysics Data System (ADS)

Chen, Zhi; Ivanov, Plamen Ch; Hu, Kun; Stanley, Eugene; Novak, Vera

2004-03-01

Cerebral vasoregulation involves several complex mechanisms adapting blood flow to fluctuations of systemic blood pressure (BP). Autonomic BP and metabolic vasoregulation are impaired after stroke and cerebral blood flow depends on systemic BP. To probe the mechanisms of cerebral autoregulation we study levels of nonlinear synchronization between cerebral blood flow velocity (BFV) and peripheral BP. We quantify the instantaneous phase of each signal employing analytic signal approach and Hilbert transform. As a marker of synchronization, we introduce a measure of cross-correlation between the instantaneous phase increments of the BFV and BP signals at different time lags. We have studied 12 subjects with minor chronic ischemic stroke and 11 matched normotensive controls (age<65years). BFV and BP of these subjects are continuously recorded during supine baseline, head-up tilt, hyperventilation and CO2 rebreathing. For control subjects we find significant synchronization between cerebral BFV and peripheral BP only for short time lags of up to 5-6 seconds, suggesting a rapid return to a steady cerebral blood flow after initial blood pressure perturbations. In contrast, for stroke subjects BFV/BP we find enhanced synchronization over longer time lags of up to 20 seconds, suggesting entrainment of cerebral blood flow velocity by slow vasomotor rhythms. These findings suggest that cerebral vasoregulation is impaired and cerebral blood flow follows the fluctuations of systemic BP in a synchronous manner. Our analysis shows that cerebral autoregulation is impaired in 10 out of the 12 stroke subjects, which is typically difficult to diagnose with conventional methods. Thus, our novel synchronization approach offers a new tool sensitive for evaluation of changes in the dynamics of cerebral autoregulation under stroke.

Stroke echoscan protocol: a fast and accurate pathway to diagnose embolic strokes.

PubMed

Pagola, Jorge; González-Alujas, Teresa; Muchada, Marian; Teixidó, Gisela; Flores, Alan; De Blauwe, Sophie; Seró, Laia; Luna, David Rodríguez; Rubiera, Marta; Ribó, Marc; Boned, Sandra; Álvarez-Sabin, José; Evangelista, Arturo; Molina, Carlos A

2015-01-01

Cardiac Echoscan is the simplified transthoracic echocardiogram focused on the main source of emboli detection in the acute stroke diagnosis (Stroke Echoscan). We describe the clinical impact related to the Stroke Echoscan protocol in our Center. Acute stroke patients who underwent the Stroke Echoscan by a trained stroke neurologist were included (Echoscan group). All examinations were reviewed by cardiologists. The main embolic stroke etiologies were: ventricular akinesia (VA), severe aortic atheroma (AA) plaque and cardiac shunt (SHUNT). The rate of the embolic stroke etiologies and the median length of stay (LOS) were compared with a cohort of patients studied by cardiologist (Echo group). Eighty acute stroke patients were included. The sensitivity (S) and specificity (E) were: VA (S 98.6%, E 66.7%, k = .7), AA (S 93.3%, E 96.9%, k = .88) and SHUNT (S 100%, E 100%, k = 1), respectively. The rate of AA diagnosis was significantly higher in Echoscan group (18.8% vs. 8.9%; P = .05). Echoscan protocol significantly reduced the LOS: 6 days (IQR 3-10) versus Echo group 9 days (IQR 6-13; P < .001). The Echoscan protocol was an accurate quick test, which reduced the length of stay and increased the percentage of severe AA plaque diagnosis. Copyright © 2014 by the American Society of Neuroimaging.

Severe edentulism is a major risk factor influencing stroke incidence in rural Ecuador (The Atahualpa Project).

PubMed

Del Brutto, Oscar H; Mera, Robertino M; Zambrano, Mauricio; Del Brutto, Victor J

2017-02-01

Background There is no information on stroke incidence in rural areas of Latin America, where living conditions and cardiovascular risk factors are different from urban centers. Aim Using a population-based prospective cohort study design, we aimed to assess risk factors influencing stroke incidence in community-dwelling adults living in rural Ecuador. Methods First-ever strokes occurring from 1 June 2012 to 31 May 2016, in Atahualpa residents aged ≥40 years, were identified from yearly door-to-door surveys and other overlapping sources. Poisson regression models adjusted for demographics, cardiovascular risk factors, edentulism and the length of observation time per subject were used to estimate stroke incidence rate ratio as well as factors influencing such incidence. Results Of 807 stroke-free individuals prospectively enrolled in the Atahualpa Project, follow-up was achieved in 718 (89%), contributing 2,499 years of follow-up (average 3.48 ± 0.95 years). Overall stroke incidence rate was 2.97 per 100 person-years of follow-up (95% CI: 1.73-4.2), which increased to 4.77 (95% CI: 1.61-14.1) when only persons aged ≥57 years were considered. Poisson regression models, adjusted for relevant confounders, showed that high blood pressure (IRR: 5.24; 95% CI: 2.55-7.93) and severe edentulism (IRR: 5.06; 95% CI: 2.28-7.85) were the factors independently increasing stroke incidence. Conclusions Stroke incidence in this rural setting is comparable to that reported from the developed world. Besides age and high blood pressure, severe edentulism is a major factor independently predicting incident strokes. Public awareness of the consequences of poor dental care might reduce stroke incidence in rural settings.

Compensatory Versus Noncompensatory Shoulder Movements Used for Reaching in Stroke.

PubMed

Levin, Mindy F; Liebermann, Dario G; Parmet, Yisrael; Berman, Sigal

2016-08-01

Background The extent to which the upper-limb flexor synergy constrains or compensates for arm motor impairment during reaching is controversial. This synergy can be quantified with a minimal marker set describing movements of the arm-plane. Objectives To determine whether and how (a) upper-limb flexor synergy in patients with chronic stroke contributes to reaching movements to different arm workspace locations and (b) reaching deficits can be characterized by arm-plane motion. Methods Sixteen post-stroke and 8 healthy control subjects made unrestrained reaching movements to targets located in ipsilateral, central, and contralateral arm workspaces. Arm-plane, arm, and trunk motion, and their temporal and spatial linkages were analyzed. Results Individuals with moderate/severe stroke used greater arm-plane movement and compensatory trunk movement compared to those with mild stroke and control subjects. Arm-plane and trunk movements were more temporally coupled in stroke compared with controls. Reaching accuracy was related to different segment and joint combinations for each target and group: arm-plane movement in controls and mild stroke subjects, and trunk and elbow movements in moderate/severe stroke subjects. Arm-plane movement increased with time since stroke and when combined with trunk rotation, discriminated between different subject groups for reaching the central and contralateral targets. Trunk movement and arm-plane angle during target reaches predicted the subject group. Conclusions The upper-limb flexor synergy was used adaptively for reaching accuracy by patients with mild, but not moderate/severe stroke. The flexor synergy, as parameterized by the amount of arm-plane motion, can be used by clinicians to identify levels of motor recovery in patients with stroke. © The Author(s) 2015.

Socioeconomic status and transient ischaemic attack/stroke: a prospective observational study.

PubMed

Kerr, Gillian D; Higgins, Peter; Walters, Matthew; Ghosh, Sandip K; Wright, Fiona; Langhorne, Peter; Stott, David J

2011-01-01

Lower socioeconomic status (SES) is associated with an increased risk of stroke but the mechanisms are unclear. We aimed to determine whether low-SES stroke/transient ischaemic attack (TIA) patients have a greater burden of vascular risk factors/co-morbidity and reduced health care access. We prospectively studied 467 consecutive stroke and TIA patients from 3 Scottish hospitals (outpatients and inpatients) during 2007/2008. We recorded vascular risk factors, stroke severity, co-morbidity measures, investigations and health service utilisation. SES was derived from postcodes using Scottish Neighbourhood Statistics and analysed in quartiles. TIA/stroke patients in the lowest SES quartile were younger (64 years, SD 14.1) than those in the highest quartile (72 years, SD 12.9; p < 0.0001). They were more likely to be current smokers (42 vs. 22%; p = 0.001) but there was no association with other vascular risk factors/co-morbidity. There was a trend for those with lower SES to have a more severe stroke [modified National Institutes of Health Stroke Scale score and interquartile range: 4 (2-6) vs. 3 (1-5); multivariate p = 0.05]. Lower SES groups were less likely to have neuro-imaging (82 vs. 90%; p = 0.036) or an electrocardiogram (72 vs. 87%; p = 0.003), but differences were no longer significant on multivariate analysis. However, there was equal access to stroke unit care. Low-SES TIA and stroke patients are younger and have a more severe deficit; an increased prevalence of smoking is likely to be a major contributor. We found equal access to stroke unit care for low-SES patients. Copyright © 2010 S. Karger AG, Basel.

Periodontal Disease Associated with Aortic Arch Atheroma in Patients with Stroke or Transient Ischemic Attack.

PubMed

Sen, Souvik; Chung, Matthew; Duda, Viktoriya; Giamberardino, Lauren; Hinderliter, Alan; Offenbacher, Steven

2017-10-01

Periodontal disease (PD) is associated with recurrent vascular event in stroke or transient ischemic attack (TIA). In this study, we investigated whether PD is independently associated with aortic arch atheroma (AA). We also explored the relationship PD has with AA plaque thickness and other characteristics associated with atheroembolic risk among patients with stroke or TIA. Finally, we confirmed the association between AA and recurrent vascular event in patients with stroke or TIA. In this prospective longitudinal hospital-based cohort study, PD was assessed in patients with stroke and TIA. Patients with confirmed stroke and TIA (n = 106) were assessed by calibrated dental examiners to determine periodontal status and were followed over a median of 24 months for recurrent vascular events (stroke, myocardial infarction, and death). The extent of AA and other plaque characteristics was assessed by transesophageal echocardiography. Within our patient cohort, 27 of the 106 participants had recurrent vascular events (including 16 with stroke or TIA) over the median of 24-month follow-up. Severe PD was associated with increased AA plaque thickness and calcification. The results suggest that PD may be a risk factor for AA. In this cohort, we confirm the association of severe AA with recurrent vascular events. In patients with stroke or TIA, severe PD is associated with increased AA plaque thickness, a risk factor for recurrent events. Further studies are needed to confirm this finding and to determine whether treatment of PD can reduce the rate of AA plaque progression and recurrent vascular events. Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Wake-up stroke: Clinical characteristics, sedentary lifestyle, and daytime sleepiness.

PubMed

Diniz, Deborath Lucia de Oliveira; Barreto, Pedro Rodrigues; Bruin, Pedro Felipe Carvalhedo de; Bruin, Veralice Meireles Sales de

2016-10-01

Wake-up stroke (WUS) is defined when the exact time of the beginning of the symptoms cannot be determined, for the deficits are perceived upon awakening. Sleep alterations are important risk factors for stroke and cardiovascular diseases. This study evaluates the characteristics of patients with and without WUS, the presence of daytime sleepiness, and associated risk factors. Patients with ischemic stroke were investigated about the presence of WUS. Clinical and demographic characteristics were evaluated. Stroke severity was studied by the National Institutes of Health Stroke Scale (NIHSS) and the Modified Rankin Scale (MRS), and daytime sleepiness severity was studied by the Epworth Sleepiness Scale (ESS). Seventy patients (57.1% men) aged from 32 to 80 years (58.5±13.3) were studied. WUS was observed in 24.3%. Arterial hypertension (67.1%), type 2 diabetes (27.1%), and hyperlipidemia (22.8%) were frequent. Type 2 diabetes and sedentary lifestyle were more common in patients with WUS (p<0.05). Overall, mild, moderate or very few symptoms of stroke (NIHSS<5) were predominant (62.3%). Among all cases, 20% had excessive daytime sleepiness (ESS>10). No differences were found between patients with and without WUS as regards stroke severity or excessive daytime sleepiness. Patients with excessive daytime sleepiness were younger and had more sedentary lifestyle (p<0.05). Individuals with previous history of heavy drinking had more daytime sleepiness (p=0.03). Wake-up stroke occurs in approximately 25% of stroke cases. In this study, patients with WUS had more diabetes and sedentary lifestyle. Daytime sleepiness is frequent and is associated with sedentary lifestyle and heavy drinking.

Effect of infusion pump fill-stroke flow interruption on response to sodium nitroprusside in surgical patients.

PubMed

Mann, H J; Fuhs, D W; Cerra, F B

1988-03-01

The influence of the piston-cassette pump fill stroke on the pharmacodynamic response to sodium nitroprusside was evaluated prospectively in 10 adult patients in the surgical intensive-care unit. Simultaneous analog recordings of blood pressure and fill stroke were made over three complete pump fill cycles in each patient. Sodium nitroprusside flow rates and concentrations were recorded throughout the data-collection period. Analysis was based on the maximum pressure obtained during the two-minute baseline period before a fill stroke (Pmax baseline), the pressure at the initiation of the fill stroke (P initial), and the maximum pressure obtained during the two-minute period after the fill stroke (Pmax postfill). The maximum systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean blood pressure (MBP) during the baseline and post-fill-stroke periods were significantly different. The mean (+/- S.D.) variability in pressure between the time periods Pmax baseline and Pmax postfill was 3.9 +/- 5.8 mm Hg for SBP (range, -8 to +16), 3.5 +/- 5.7 mm Hg for DBP (range, -7 to +13), and 3.6 +/- 5.6 mm Hg for MBP (range, -7 to +14). The likelihood of a pharmacodynamic change was inconsistent both between and within patients. Within patients the difference between cycles for the variability between time periods ranged from a minimum of 2 mm Hg to a maximum of 16 mm Hg for SBP, 2 mm Hg to 17 mm Hg for DBP, and 1 mm Hg to 17 mm Hg for MBP. The variability within the baseline period (Pmax baseline - P initial) in SBP was significantly greater than the variability between the time periods, while the differences for DBP and MBP were not significant.(ABSTRACT TRUNCATED AT 250 WORDS)

Mobile Interventional Stroke Teams Lead to Faster Treatment Times for Thrombectomy in Large Vessel Occlusion.

PubMed

Wei, Daniel; Oxley, Thomas J; Nistal, Dominic A; Mascitelli, Justin R; Wilson, Natalie; Stein, Laura; Liang, John; Turkheimer, Lena M; Morey, Jacob R; Schwegel, Claire; Awad, Ahmed J; Shoirah, Hazem; Kellner, Christopher P; De Leacy, Reade A; Mayer, Stephan A; Tuhrim, Stanley; Paramasivam, Srinivasan; Mocco, J; Fifi, Johanna T

2017-12-01

Endovascular recanalization treatment for acute ischemic stroke is a complex, time-sensitive intervention. Trip-and-treat is an interhospital service delivery model that has not previously been evaluated in the literature and consists of a shared mobile interventional stroke team that travels to primary stroke centers to provide on-site interventional capability. We compared treatment times between the trip-and-treat model and the traditional drip-and-ship model. We performed a retrospective analysis on 86 consecutive eligible patients with acute ischemic stroke secondary to large vessel occlusion who received endovascular treatment at 4 hospitals in Manhattan. Patients were divided into 2 cohorts: trip-and-treat (n=39) and drip-and-ship (n=47). The primary outcome was initial door-to-puncture time, defined as the time between arrival at any hospital and arterial puncture. We also recorded and analyzed the times of last known well, IV-tPA (intravenous tissue-type plasminogen activator) administration, transfer, and reperfusion. Mean initial door-to-puncture time was 143 minutes for trip-and-treat and 222 minutes for drip-and-ship ( P <0.0001). Although there was a trend in longer puncture-to-recanalization times for trip-and-treat ( P =0.0887), initial door-to-recanalization was nonetheless 79 minutes faster for trip-and-treat ( P <0.0001). There was a trend in improved admission-to-discharge change in National Institutes of Health Stroke Scale for trip-and-treat compared with drip-and-ship ( P =0.0704). Compared with drip-and-ship, the trip-and-treat model demonstrated shorter treatment times for endovascular therapy in our series. The trip-and-treat model offers a valid alternative to current interhospital stroke transfers in urban environments. © 2017 American Heart Association, Inc.

Lower NIH stroke scale scores are required to accurately predict a good prognosis in posterior circulation stroke.

PubMed

Inoa, Violiza; Aron, Abraham W; Staff, Ilene; Fortunato, Gilbert; Sansing, Lauren H

2014-01-01

The NIH stroke scale (NIHSS) is an indispensable tool that aids in the determination of acute stroke prognosis and decision making. Patients with posterior circulation (PC) strokes often present with lower NIHSS scores, which may result in the withholding of thrombolytic treatment from these patients. However, whether these lower initial NIHSS scores predict better long-term prognoses is uncertain. We aimed to assess the utility of the NIHSS at presentation for predicting the functional outcome at 3 months in anterior circulation (AC) versus PC strokes. This was a retrospective analysis of a large prospectively collected database of adults with acute ischemic stroke. Univariate and multivariate analyses were conducted to identify factors associated with outcome. Additional analyses were performed to determine the receiver operating characteristic (ROC) curves for NIHSS scores and outcomes in AC and PC infarctions. Both the optimal cutoffs for maximal diagnostic accuracy and the cutoffs to obtain >80% sensitivity for poor outcomes were determined in AC and PC strokes. The analysis included 1,197 patients with AC stroke and 372 with PC stroke. The median initial NIHSS score for patients with AC strokes was 7 and for PC strokes it was 2. The majority (71%) of PC stroke patients had baseline NIHSS scores ≤4, and 15% of these 'minor' stroke patients had a poor outcome at 3 months. ROC analysis identified that the optimal NIHSS cutoff for outcome prediction after infarction in the AC was 8 and for infarction in the PC it was 4. To achieve >80% sensitivity for detecting patients with a subsequent poor outcome, the NIHSS cutoff for infarctions in the AC was 4 and for infarctions in the PC it was 2. The NIHSS cutoff that most accurately predicts outcomes is 4 points higher in AC compared to PC infarctions. There is potential for poor outcomes in patients with PC strokes and low NIHSS scores, suggesting that thrombolytic treatment should not be withheld from these patients based solely on the NIHSS. © 2014 S. Karger AG, Basel. © 2014 S. Karger AG, Basel.

40 CFR 63.6590 - What parts of my plant does this subpart cover?

Code of Federal Regulations, 2012 CFR

2012-07-01

... initial notification requirements: (i) Existing spark ignition 2 stroke lean burn (2SLB) stationary RICE... spark ignition 4 stroke lean burn (4SLB) stationary RICE with a site rating of more than 500 brake HP... spark ignition 4 stroke rich burn (4SRB) stationary RICE with a site rating of less than or equal to 500...

Contralaterally Controlled Functional Electrical Stimulation for Stroke Rehabilitation

PubMed Central

Knutson, Jayme S.; Harley, Mary Y.; Hisel, Terri Z.; Makowski, Nathaniel S.; Fu, Michael J.; Chae, John

2012-01-01

Contralaterally controlled functional electrical stimulation (CCFES) is an innovative method of delivering neuromuscular electrical stimulation for rehabilitation of paretic limbs after stroke. It is being studied to evaluate its efficacy in improving recovery of arm and hand function and ankle dorsiflexion in chronic and subacute stroke patients. The initial studies provide preliminary evidence supporting the efficacy of CCFES. PMID:23365893

Burden of Stroke in Qatar.

PubMed

Ibrahim, Faisal; Deleu, Dirk; Akhtar, Naveed; Al-Yazeedi, Wafa; Mesraoua, Boulenouar; Kamran, Sadaat; Shuaib, Ashfaq

2015-12-01

Qatar is located on the northeastern coast of the Arabian Peninsula. The total population is over 2.1 million with around 15% being Qatari citizens. Hamad General Hospital (HGH) is the only tertiary referral governmental hospital in Qatar which admits acute (thrombolysis-eligible) stroke patients. To provide an overview of the burden of stroke in Qatar. Data from literature databases, online sources and our stroke registry were collated to identify information on the burden of stroke in Qatar. Overall, over 80% of all stroke patients in Qatar are admitted in HGH. In 2010, the age-standardized incidence for first-ever ischemic stroke was 51.88/100,000 person-years. To date our stroke registry reveals that 79% of all stroke patients are male and almost 50% of stroke patients are 50 years or less. Hypertension, diabetes and dyslipidemia are the main predisposing factors for stroke, with ischemic stroke being more common (87%) than hemorrhagic stroke (13%). Despite the lack of a stroke unit, 9% of ischemic stroke patients are being thrombolyzed. However the presence of a stroke ward allows swift turnover of patients with a length of stay of less than 5 days before discharge or, if required, transfer to the fully-equipped hospital-based rehabilitation service. Several community awareness programs are ongoing, in addition to several research programs funded by the Qatar National Research Fund and Hamad Medical Corporation. In a country where over 15% of the population suffers from diabetes there is continuous need for national community-based awareness campaigns, prevention and educational programs particularly targeting patients and health care workers. Copyright © 2015 National Stroke Association. Published by Elsevier Inc. All rights reserved.

A Piano Training Program to Improve Manual Dexterity and Upper Extremity Function in Chronic Stroke Survivors

PubMed Central

Villeneuve, Myriam; Penhune, Virginia; Lamontagne, Anouk

2014-01-01

Objective: Music-supported therapy was shown to induce improvements in motor skills in stroke survivors. Whether all stroke individuals respond similarly to the intervention and whether gains can be maintained over time remain unknown. We estimated the immediate and retention effects of a piano training program on upper extremity function in persons with chronic stroke. Methods: Thirteen stroke participants engaged in a 3-week piano training comprising supervised sessions (9 × 60 min) and home practice. Fine and gross manual dexterity, movement coordination, and functional use of the upper extremity were assessed at baseline, pre-intervention, post-intervention, and at a 3-week follow-up. Results: Significant improvements were observed for all outcomes at post-intervention and follow-up compared to pre-intervention scores. Larger magnitudes of change in manual dexterity and functional use of the upper extremity were associated with higher initial levels of motor recovery. Conclusion: Piano training can result in sustainable improvements in upper extremity function in chronic stroke survivors. Individuals with a higher initial level of motor recovery at baseline appear to benefit the most from this intervention. PMID:25202258

Spontaneous Swallowing Frequency [Has Potential to] Identify Dysphagia in Acute Stroke

PubMed Central

Carnaby, Giselle D; Sia, Isaac; Khanna, Anna; Waters, Michael

2014-01-01

Background and Purpose Spontaneous swallowing frequency has been described as an index of dysphagia in various health conditions. This study evaluated the potential of spontaneous swallow frequency analysis as a screening protocol for dysphagia in acute stroke. Methods In a cohort of 63 acute stroke cases swallow frequency rates (swallows per minute: SPM) were compared to stroke and swallow severity indices, age, time from stroke to assessment, and consciousness level. Mean differences in SPM were compared between patients with vs. without clinically significant dysphagia. ROC analysis was used to identify the optimal threshold in SPM which was compared to a validated clinical dysphagia examination for identification of dysphagia cases. Time series analysis was employed to identify the minimally adequate time period to complete spontaneous swallow frequency analysis. Results SPM correlated significantly with stroke and swallow severity indices but not with age, time from stroke onset, or consciousness level. Patients with dysphagia demonstrated significantly lower SPM rates. SPM differed by dysphagia severity. ROC analysis yielded a threshold of SPM ≤ 0.40 which identified dysphagia (per the criterion referent) with 0.96 sensitivity, 0.68 specificity, and 0.96 negative predictive value. Time series analysis indicated that a 5 to 10 minute sampling window was sufficient to calculate spontaneous swallow frequency to identify dysphagia cases in acute stroke. Conclusions Spontaneous swallowing frequency presents high potential to screen for dysphagia in acute stroke without the need for trained, available personnel. PMID:24149008

Movement Kinematics of the Ipsilesional Upper Extremity in Persons With Moderate or Mild Stroke.

PubMed

Bustrén, Eva-Lena; Sunnerhagen, Katharina Stibrant; Alt Murphy, Margit

2017-04-01

An increasing number of studies have indicated that the ipsilesional arm may be impaired after stroke. There is, however, a lack of knowledge whether ipsilesional deficits influence movement performance during purposeful daily tasks. The aim of this study was to investigate whether, and to what extent, movement impairments are present while performing an ipsilesional upper extremity task during the first 3 months after stroke. Movement kinematics describing movement time, smoothness, velocity, strategy, and pattern were captured during a standardized drinking task in 40 persons with first-ever stroke and 20 controls. Kinematics were measured early and at 3 months poststroke, and sensorimotor impairment was assessed with Fugl-Meyer Assessment in stroke. Half of the ipsilesional kinematics showed significant deficits early after stroke compared to controls, and the stroke severity had a significant impact on the kinematics. Movements of the ipsilesional arm were slower, less smooth, demonstrated prolonged relative time in deceleration, and increased arm abduction during drinking. Kinematics improved over time and reached a level comparable with controls at 3 months, except for angular velocity of the elbow and deceleration time in reaching for those with more severe motor impairment. This study demonstrates that movements of the ipsilesional arm, during a purposeful daily task, are impaired after stroke. These deficits are more prominent early after stroke and when the motor impairment is more severe. In clinical studies and praxis, the use of less-affected arm as a reference may underestimate the level of impairment and extent of recovery.

Spontaneous swallowing frequency has potential to identify dysphagia in acute stroke.

PubMed

Crary, Michael A; Carnaby, Giselle D; Sia, Isaac; Khanna, Anna; Waters, Michael F

2013-12-01

Spontaneous swallowing frequency has been described as an index of dysphagia in various health conditions. This study evaluated the potential of spontaneous swallow frequency analysis as a screening protocol for dysphagia in acute stroke. In a cohort of 63 acute stroke cases, swallow frequency rates (swallows per minute [SPM]) were compared with stroke and swallow severity indices, age, time from stroke to assessment, and consciousness level. Mean differences in SPM were compared between patients with versus without clinically significant dysphagia. Receiver operating characteristic curve analysis was used to identify the optimal threshold in SPM, which was compared with a validated clinical dysphagia examination for identification of dysphagia cases. Time series analysis was used to identify the minimally adequate time period to complete spontaneous swallow frequency analysis. SPM correlated significantly with stroke and swallow severity indices but not with age, time from stroke onset, or consciousness level. Patients with dysphagia demonstrated significantly lower SPM rates. SPM differed by dysphagia severity. Receiver operating characteristic curve analysis yielded a threshold of SPM≤0.40 that identified dysphagia (per the criterion referent) with 0.96 sensitivity, 0.68 specificity, and 0.96 negative predictive value. Time series analysis indicated that a 5- to 10-minute sampling window was sufficient to calculate spontaneous swallow frequency to identify dysphagia cases in acute stroke. Spontaneous swallowing frequency presents high potential to screen for dysphagia in acute stroke without the need for trained, available personnel.

Pre-operative stroke and neurological disability do not independently affect short- and long-term mortality in infective endocarditis patients.

PubMed

Diab, Mahmoud; Guenther, Albrecht; Sponholz, Christoph; Lehmann, Thomas; Faerber, Gloria; Matz, Anna; Franz, Marcus; Witte, Otto W; Pletz, Mathias W; Doenst, Torsten

2016-10-01

Infective endocarditis (IE) is still associated with high morbidity and mortality. The impact of pre-operative stroke on mortality and long-term survival is controversial. In addition, data on the severity of neurological disability due to pre-operative stroke are scarce. We analysed the impact of pre-operative stroke and the severity of its related neurological disability on short- and long-term outcome. We retrospectively reviewed our data from patients operated for left-sided IE between 01/2007 and 04/2013. We performed univariate (Chi-Square and independent samples t test) and multivariate analyses. Among 308 consecutive patients who underwent cardiac surgery for left-sided IE, pre-operative stroke was present in 87 (28.2 %) patients. Patients with pre-operative stroke had a higher pre-operative risk profile than patient without it: higher Charlson comorbidity index (8.1 ± 2.6 vs. 6.6 ± 3.3) and higher incidence of Staphylococcus aureus infection (43 vs. 17 %) and septic shock (37 vs. 19 %). In-hospital mortality was equal but 5-year survival was significantly worse with pre-operative stroke (33.1 % vs. 45 %, p = 0.006). 5-year survival was worst in patients with severe neurological disability compared to mild disability (19.0 vs. 0.58 %, p = 0.002). However, neither pre-operative stroke nor the degree of neurological disability appeared as an independent risk factor for short or long-term mortality by multivariate analysis. Pre-operative stroke and the severity of neurological disability do not independently affect short- and long-term mortality in patients with infective endocarditis. It appears that patients with pre-operative stroke present with a generally higher risk profile. This information may substantially affect decision-making.

Frequency of and Factors Associated With Obstructive Sleep Apnea and Periodic Limb Movements in Stroke and TIA Patients.

PubMed

Gadodia, Gaurav; Rangaraju, Srikant; Raza, Syed A; Razzak, Ammar; Marmarchi, Labib; Davis, Brittaine; Henriquez, Laura; Trotti, Lynn M; Rye, David; Nahab, Fadi

2018-03-01

Obstructive sleep apnea (OSA) and periodic limb movements (PLMs) have been associated with an increased risk of cardiovascular disease. There is limited data on the relationship between OSA and PLMs with atrial fibrillation and resistant hypertension in stroke and transient ischemic attack (TIA) patients. Consecutive stroke and TIA patients referred by a vascular neurologist for diagnostic polysomnography (PSG) from September 1, 2012 to August 31, 2015 were included in a retrospective analysis. Baseline clinical characteristics, PSG results and outcomes were collected to identify the frequency of and factors associated with PLMs (mild 5 to 10/h; severe ≥15/h), PLM arousals (≥5/h) and moderate-severe OSA (apna-hypopnea Index ≥15) including atrial fibrillation and resistant hypertension. Among 103 patients (mean age, 60±15 y; 50% female; 61% nonwhites; 77% ischemic stroke; 23% resistant hypertension) who underwent PSG, 20% had mild PLMs, 28% had severe PLMs, 14% had PLM arousals, and 22% had moderate-severe OSA. Factors associated with moderate-severe OSA included older age (odds ratio, 1.06; 95% confidence interval, 1.02-1.11) and presence of atrial fibrillation (odds ratio, 4.26; 95% confidence interval, 1.17-15.44). Nonwhite race was associated with lower likelihood of mild and severe PLMs, whereas female sex was associated with lower likelihood of PLM arousals. OSA and PLMs were not associated with resistant hypertension. A significant number of stroke and TIA patients who underwent PSG have PLMs and moderate-severe OSA. Stroke and TIA patients with atrial fibrillation are more likely to have moderate-severe OSA and may benefit from PSG evaluation.

Characteristics of Hemorrhagic Stroke following Spine and Joint Surgeries.

PubMed

Yang, Fei; Zhao, Jianning; Xu, Haidong

2017-01-01

Hemorrhagic stroke can occur after spine and joint surgeries such as laminectomy, lumbar spinal fusion, tumor resection, and total joint arthroplasty. Although this kind of stroke rarely happens, it may cause severe consequences and high mortality rates. Typical clinical symptoms of hemorrhagic stroke after spine and joint surgeries include headache, vomiting, consciousness disturbance, and mental disorders. It can happen several hours after surgeries. Most bleeding sites are located in cerebellar hemisphere and temporal lobe. A cerebrospinal fluid (CSF) leakage caused by surgeries may be the key to intracranial hemorrhages happening. Early diagnosis and treatments are very important for patients to prevent the further progression of intracranial hemorrhages. Several patients need a hematoma evacuation and their prognosis is not optimistic.

The mediating effect of psychological distress on functional dependence in stroke patients.

PubMed

Huang, Hui-Chuan; Huang, Li-Kai; Hu, Chaur-Jong; Chang, Chien-Hung; Lee, Hsin-Chien; Chi, Nai-Fang; Shyu, Meei-Ling; Chang, Hsiu-Ju

2014-12-01

To explore varied forms of psychological distress and to determine the mediating influence of psychological distress on functional outcomes in stroke patients. Previous studies attest to the influence of depression on poststroke functional recovery. While there is evidence for neuropathological deficits that occur after stroke to be associated with psychological distress, few studies have explored the effect of various types of psychological distress on functional recovery. A cross-sectional study was used. Data were collected from 178 first-time stroke patients. Study variables included demographic and disease characteristics (stroke location and stroke syndrome classification), psychological distress (the Chinese language version of the Emotional and Social Dysfunction Questionnaire) and functional outcome (Barthel index). Regression and mediation models were used to evaluate the effect of psychological distress on functional outcome. Results revealed that stroke patients experience various forms of mild psychological distress, including anger, helplessness, emotional dyscontrol, indifference, inertia and euphoria, after stroke. Regression and mediation analyses further confirmed that various forms of psychological distress significantly mediated the effect of severe stroke syndromes on functional dependence. The various forms of psychological distress after stroke might play a mediating role in functional recovery and explain how stroke severity affects functional dependence. By understanding the nature of various forms of psychological distress, healthcare professionals should adopt appropriate assessment instruments and design effective interventions to help improve mental and physical function of stroke patients. © 2014 John Wiley & Sons Ltd.

Quality of care and outcomes for in-hospital ischemic stroke: findings from the National Get With The Guidelines-Stroke.

PubMed

Cumbler, Ethan; Wald, Heidi; Bhatt, Deepak L; Cox, Margueritte; Xian, Ying; Reeves, Mathew; Smith, Eric E; Schwamm, Lee; Fonarow, Gregg C

2014-01-01

Analysis of quality of care for in-hospital stroke has not been previously performed at the national level. This study compares patient characteristics, process measures of quality, and outcomes for in-hospital strokes with those for community-onset strokes in a national cohort. We performed a retrospective cohort study of the Get With The Guidelines-Stroke (GWTG-Stroke) database of The American Heart Association from January 2006 to April 2012, using data from 1280 sites that reported ≥1 in-hospital stroke. Patient characteristics, comorbid illnesses, medications, quality of care measures, and outcomes were analyzed for 21 349 in-hospital ischemic strokes compared with 928 885 community-onset ischemic strokes. Patients with in-hospital stroke had more thromboembolic risk factors, including atrial fibrillation, prosthetic heart valves, carotid stenosis, and heart failure (P<0.0001), and experienced more severe strokes (median National Institutes of Health Stroke Score 9.0 versus 4.0; P<0.0001). Using GWTG-Stroke achievement measures, the proportion of patients with defect-free care was lower for in-hospital strokes (60.8% versus 82.0%; P<0.0001). After accounting for patient and hospital characteristics, patients with in-hospital strokes were less likely to be discharged home (adjusted odds ratio 0.37; 95% confidence intervals [0.35-0.39]) or be able to ambulate independently at discharge (adjusted odds ratio 0.42; 95% confidence intervals [0.39-0.45]). In-hospital mortality was higher for in-hospital stroke (adjusted odds ratio 2.72; 95% confidence intervals [2.57-2.88]). Compared with community-onset ischemic stroke, patients with in-hospital stroke experienced more severe strokes, received lower adherence to process-based quality measures, and had worse outcomes. These findings suggest there is an important opportunity for targeted quality improvement efforts for patients with in-hospital stroke.

Relationship of white matter lesions and severity of pushing behavior after stroke.

PubMed

Fujino, Yuji; Amimoto, Kazu; Sugimoto, Satoshi; Fukata, Kazuhiro; Inoue, Masahide; Uchino, Akira; Takahashi, Hidetoshi; Makita, Shigeru

2017-12-01

[Purpose] The relationship between white matter lesions (WMLs) and pushing behavior (PB) is still poorly understood. The purpose of this study was to investigate whether damage from WMLs affects the functional outcome of PB after acute stroke. [Subjects and Methods] In total, 37 patients were included. PB was assessed using the standardized Scale for Contraversive Pushing (SCP). Stroke types were classified as total anterior circulation infarct (TACI), partial anterior circulation infarct (PACI), or lacunar syndrome using the Bamford classification. WML severity was categorized into four groups using the Fazekas visual scale. Thereafter, patients were divided into 4 groups according to the stroke type and/or presence of WMLs. The SCP, Trunk Control Test (TCT), Stroke Impairment Assessment Set (SIAS), and Barthel Index were the outcome measures. [Results] The SCP and TCT in patients with PACI without WMLs were better than those in patients with TACI with or without WMLs. Regarding SCP, TCT, and SIAS, patients with TACI had poorer values compared with PACI, regardless of WML severity. Barthel Index efficiency was not significantly different between the groups. [Conclusion] Our results suggest that moderate to severe WMLs and PACI had a relationship with PB severity and truncal balance.

Relationship between functional disability and costs one and two years post stroke

PubMed Central

Lekander, Ingrid; Willers, Carl; von Euler, Mia; Lilja, Mikael; Sunnerhagen, Katharina S.; Pessah-Rasmussen, Hélène; Borgström, Fredrik

2017-01-01

Background and purpose Stroke affects mortality, functional ability, quality of life and incurs costs. The primary objective of this study was to estimate the costs of stroke care in Sweden by level of disability and stroke type (ischemic (IS) or hemorrhagic stroke (ICH)). Method Resource use during first and second year following a stroke was estimated based on a research database containing linked data from several registries. Costs were estimated for the acute and post-acute management of stroke, including direct (health care consumption and municipal services) and indirect (productivity losses) costs. Resources and costs were estimated per stroke type and functional disability categorised by Modified Rankin Scale (mRS). Results The results indicated that the average costs per patient following a stroke were 350,000SEK/€37,000–480,000SEK/€50,000, dependent on stroke type and whether it was the first or second year post stroke. Large variations were identified between different subgroups of functional disability and stroke type, ranging from annual costs of 100,000SEK/€10,000–1,100,000SEK/€120,000 per patient, with higher costs for patients with ICH compared to IS and increasing costs with more severe functional disability. Conclusion Functional outcome is a major determinant on costs of stroke care. The stroke type associated with worse outcome (ICH) was also consistently associated to higher costs. Measures to improve function are not only important to individual patients and their family but may also decrease the societal burden of stroke. PMID:28384164

Embolic strokes of undetermined source in a cohort of Polish stroke patients.

PubMed

Bembenek, Jan Pawel; Karlinski, Michal Adam; Kurkowska-Jastrzebska, Iwona; Czlonkowska, Anna

2018-03-19

We aimed to provide a descriptive analysis of embolic stroke of undetermined etiology (ESUS) population based on a long-term prospective stroke registry. We retrospectively analyzed data collected in a detailed registry regarding consecutive patients admitted for first-ever ischemic stroke (IS) between January 2001 and December 2015. We used Org 10172 in Acute Stroke Treatment classification supplemented with ESUS criteria proposed by the Cryptogenic Stroke/ESUS International Working Group. Within the ESUS group, we additionally compared patients ≤ 60 and > 60 years of age. During the study period, there was a total of 3008 (1615 females and 1393 males) admissions of first-ever strokes. The most frequent cause was undetermined (38.7%), followed by cardioembolic (27.7%), large artery atherosclerosis (18.2%), small vessel disease (11.9%), and other determined (3.6%). We identified 326 patients as ESUS, which accounted for 10.8% of all strokes and 28% of strokes of undetermined etiology. ESUS patients were the youngest. Compared to all types of stroke but for those with small vessel disease, ESUS patients were most often independent before stroke and had the least severe neurological deficit at admission and the best outcome at discharge. ESUS patients ≤ 60 years were more frequently independent at discharge than ESUS patients > 60 years. Approximately 11% of patients from our registry met ESUS criteria. ESUS patients were younger when compared to all other stroke etiologies, suffered less severe strokes, and had more favorable outcome at discharge than other groups except for those with small vessel disease strokes.

Stroke epidemiology, prevention, and management strategies at a regional level: Latin America and the Caribbean.

PubMed

Lavados, Pablo M; Hennis, Anselm J M; Fernandes, Jefferson G; Medina, Marco T; Legetic, Branca; Hoppe, Arnold; Sacks, Claudio; Jadue, Liliana; Salinas, Rodrigo

2007-04-01

Stroke is a major health problem in Latin American and Caribbean countries. In this paper, we review the epidemiology, aetiology, and management of stroke in the region based on a systematic search of articles published in Spanish, Portuguese, and English. Stroke mortality is higher than in developed countries but rates are declining. Population-based studies show variations in incidence of strokes: lower rates of ischaemic stroke and similar rates of intracranial haemorrhages, compared with other regions. A significant proportion of strokes in these populations can be attributed to a few preventable risk factors. Some countries have published national clinical guidelines, although much needs to be done in the organisation of care and rehabilitation. Even though the burden of stroke is high, there is a paucity of information for implementing evidence-based management. The Global Stroke Initiative, the WHO STEPS Stroke surveillance, and WHO-PREMISE projects provide opportunities for surveillance at institutional and community levels.

The propagation speed of a positive lightning return stroke

NASA Technical Reports Server (NTRS)

Idone, Vincent P.; Orville, Richard E.; Mach, Douglas M.; Rust, W. David

1987-01-01

The first direct determination of the propagation speed of a lightning return stroke lowering positive charge to ground has been made. This stroke was the third of eight otherwise negative strokes in a triggered lightning flash initiated at the Kennedy Space Center, FL. Two independent optical systems, one photographic and the other photoelectric, yielded common recordings for the third and fourth strokes; the respective two-dimensional return stroke propagation speeds were 1.0 vs 0.93 x 10 to the 8th m/s for the positive (third) stroke and 1.0 vs 1.0 x 10 to the 8th m/s for the fourth stroke. Using fast electric-field data, the positive stroke peak current was estimated to be 21 kA. Photoelectric data only yielded propagation speeds of 1.4, 1.6, 1.2, 1.3, 1.0 and 0.90 x 10 to the 8th m/s for the first, second and fifth through eighth return strokes, respectively.

[Cost analysis of telemedical treatment of stroke].

PubMed

Schenkel, J; Reitmeir, P; Von Reden, S; Holle, R; Boy, S; Haberl, R; Audebert, H

2013-07-01

Telemedicine-enabled stroke networks increase the probability of a good clinical outcome. There is a shortage of evidence about the effects of this new approach on costs for inpatient care and nursing care. We analysed health insurance and nursing care fund data of a statutory health insurance company (AOK Bayern). Data from stroke patients initially treated in a TeleStroke network (TEMPiS - telemedical project for integrative stroke care) between community hospitals and academic stroke centres were compared to data of matched hospitals without specialised stroke care and telemedical support. Costs for nursing care were obtained over a 30-month period after the initial stroke. To rule out pre-existing differences between network and control hospitals, costs of stroke care were also analysed during a time period before network implementation. 1 277 patients (767 in intervention, 510 in control hospitals) were analysed in the post-implementation period. An increased proportion of patients treated in intervention hospitals had a favourable outcome concerning the level of required nursing care. Patients in intervention hospitals had higher costs for acute inpatient care (5 309 € vs. 4 901 €, p=0.04), but lower nursing care fund costs (3 946 € vs. 5 132 €; p=0.04). There was no difference in relation to absolute total costs obtained in the post-implementation period. However, nursing care costs per survived year were significantly lower in intervention hospitals (1 953 € vs. 2 635 €; p=0.005). No significant differences were found in the pre-implementation period. Considering both health insurance and nursing care fund costs, the incremental costs for TeleStroke network care in hospitals are compensated by savings in outpatient care. © Georg Thieme Verlag KG Stuttgart · New York.

Atrial fibrillation detected by continuous electrocardiographic monitoring using implantable loop recorder to prevent stroke in individuals at risk (the LOOP study): Rationale and design of a large randomized controlled trial.

PubMed

Diederichsen, Søren Zöga; Haugan, Ketil Jørgen; Køber, Lars; Højberg, Søren; Brandes, Axel; Kronborg, Christian; Graff, Claus; Holst, Anders Gaarsdal; Nielsen, Jonas Bille; Krieger, Derk; Svendsen, Jesper Hastrup

2017-05-01

Atrial fibrillation (AF) increases the rate of stroke 5-fold, and AF-related strokes have a poorer prognosis compared with non-AF-related strokes. Atrial fibrillation and stroke constitute an intensifying challenge, and health care organizations are calling for awareness on the topic. Previous studies have demonstrated that AF is often asymptomatic and consequently undiagnosed. The implantable loop recorder (ILR) allows for continuous, long-term electrocardiographic monitoring with daily transmission of arrhythmia information, potentially leading to improvement in AF detection and stroke prevention. The LOOP study is an investigator-initiated, randomized controlled trial with 6,000 participants randomized 3:1 to a control group or to receive an ILR with continuous electrocardiographic monitoring. Participants are identified from Danish registries and are eligible for inclusion if 70years or older and previously diagnosed as having at least one of the following conditions: hypertension, diabetes mellitus, heart failure, or previous stroke. Exclusion criteria include history of AF and current oral anticoagulation treatment. When an AF episode lasting ≥6minutes is detected, oral anticoagulation will be initiated according to guidelines. Expected follow-up is 4years. The primary end point is time to stroke or systemic embolism, whereas secondary end points include time to AF diagnosis and death. The LOOP study will evaluate health benefits and cost-effectiveness of ILR as a screening tool for AF to prevent stroke in patients at risk. Secondary objectives include identification of risk factors for the development of AF and characterization of arrhythmias in the population. The trial holds the potential to influence the future of stroke prevention. Copyright © 2017 Elsevier Inc. All rights reserved.

White Matter Hyperintensities Improve Ischemic Stroke Recurrence Prediction.

PubMed

Andersen, Søren Due; Larsen, Torben Bjerregaard; Gorst-Rasmussen, Anders; Yavarian, Yousef; Lip, Gregory Y H; Bach, Flemming W

2017-01-01

Nearly one in 5 patients with ischemic stroke will invariably experience a second stroke within 5 years. Stroke risk stratification schemes based solely on clinical variables perform only modestly in non-atrial fibrillation (AF) patients and improvement of these schemes will enhance their clinical utility. Cerebral white matter hyperintensities are associated with an increased risk of incident ischemic stroke in the general population, whereas their association with the risk of ischemic stroke recurrence is more ambiguous. In a non-AF stroke cohort, we investigated the association between cerebral white matter hyperintensities and the risk of recurrent ischemic stroke, and we evaluated the predictive performance of the CHA2DS2VASc score and the Essen Stroke Risk Score (clinical scores) when augmented with information on white matter hyperintensities. In a registry-based, observational cohort study, we included 832 patients (mean age 59.6 (SD 13.9); 42.0% females) with incident ischemic stroke and no AF. We assessed the severity of white matter hyperintensities using MRI. Hazard ratios stratified by the white matter hyperintensities score and adjusted for the components of the CHA2DS2VASc score were calculated based on the Cox proportional hazards analysis. Recalibrated clinical scores were calculated by adding one point to the score for the presence of moderate to severe white matter hyperintensities. The discriminatory performance of the scores was assessed with the C-statistic. White matter hyperintensities were significantly associated with the risk of recurrent ischemic stroke after adjusting for clinical risk factors. The hazard ratios ranged from 1.65 (95% CI 0.70-3.86) for mild changes to 5.28 (95% CI 1.98-14.07) for the most severe changes. C-statistics for the prediction of recurrent ischemic stroke were 0.59 (95% CI 0.51-0.65) for the CHA2DS2VASc score and 0.60 (95% CI 0.53-0.68) for the Essen Stroke Risk Score. The recalibrated clinical scores showed improved C-statistics: the recalibrated CHA2DS2VASc score 0.62 (95% CI 0.54-0.70; p = 0.024) and the recalibrated Essen Stroke Risk Score 0.63 (95% CI 0.56-0.71; p = 0.031). C-statistics of the white matter hyperintensities score were 0.62 (95% CI 0.52-0.68) to 0.65 (95% CI 0.58-0.73). An increasing burden of white matter hyperintensities was independently associated with recurrent ischemic stroke in a cohort of non-AF ischemic stroke patients. Recalibration of the CHA2DS2VASc score and the Essen Stroke Risk Score with one point for the presence of moderate to severe white matter hyperintensities led to improved discriminatory performance in ischemic stroke recurrence prediction. Risk scores based on white matter hyperintensities alone were at least as accurate as the established clinical risk scores in the prediction of ischemic stroke recurrence. © 2016 S. Karger AG, Basel.

Selection for inpatient rehabilitation after severe stroke: what factors influence rehabilitation assessor decision-making?

PubMed

Hakkennes, Sharon; Hill, Keith D; Brock, Kim; Bernhardt, Julie; Churilov, Leonid

2013-01-01

This study aimed to identify factors that assessors considered important in decision-making regarding suitability for inpatient rehabilitation after acute severe stroke. Multi-site prospective observational cohort study. Consecutive acute, severe stroke patients and their assessors for inpatient rehabilitation. Rehabilitation assessors completed a questionnaire, rating the importance (10 point visual analogue scale) and direction (positive, negative or neutral) of 15 patient related and 2 organisational items potentially affecting their decision regarding patients' acceptance to rehabilitation. Of the 75 patients referred to rehabilitation and included in this study 61 (81.3%) were accepted for inpatient rehabilitation. The items considered to be most important in the decision to accept the patient for rehabilitation were pre-morbid cognition, pre-morbid mobility and pre-morbid communication. For those not accepted the most important items were current mobility, social support and current cognition. Factor analysis revealed 3 underlying factors, interpreted as post-stroke status, pre-morbid status, and social attributes, accounting for 61.8% of the total variance. All were independently associated with acceptance for rehabilitation (p < 0.05). This study highlights the importance of pre-morbid function and social factors in addition to post-stroke function in the decision making process for acceptance to rehabilitation following severe stroke. Future models for selection for rehabilitation should consider inclusion of these factors.

Severity of post-stroke aphasia according to aphasia type and lesion location in Koreans.

PubMed

Kang, Eun Kyoung; Sohn, Hae Min; Han, Moon-Ku; Kim, Won; Han, Tai Ryoon; Paik, Nam-Jong

2010-01-01

To determine the relations between post-stroke aphasia severity and aphasia type and lesion location, a retrospective review was undertaken using the medical records of 97 Korean patients, treated within 90 days of onset, for aphasia caused by unilateral left hemispheric stroke. Types of aphasia were classified according to the validated Korean version of the Western Aphasia Battery (K-WAB), and severities of aphasia were quantified using WAB Aphasia Quotients (AQ). Lesion locations were classified as cortical or subcortical, and were determined by magnetic resonance imaging. Two-step cluster analysis was performed using AQ values to classify aphasia severity by aphasia type and lesion location. Cluster analysis resulted in four severity clusters: 1) mild; anomic type, 2) moderate; Wernicke's, transcortical motor, transcortical sensory, conduction, and mixed transcortical types, 3) moderately severe; Broca's aphasia, and 4) severe; global aphasia, and also in three lesion location clusters: 1) mild; subcortical 2) moderate; cortical lesions involving Broca's and/or Wernicke's areas, and 3) severe; insular and cortical lesions not in Broca's or Wernicke's areas. These results revealed that within 3 months of stroke, global aphasia was the more severely affected type and cortical lesions were more likely to affect language function than subcortical lesions.

Electrification in winter storms and the analysis of thunderstorm overflight data

NASA Technical Reports Server (NTRS)

Brook, Marx

1993-01-01

We have been focusing our study of electrification in winter storms on the lightning initiation process, making inferences about the magnitude of the electric fields from the initial pulses associated with breakdown, i.e., with the formation of the initial streamers. The essence of the most significant finding is as follows: (1) initial breakdown radiation pulses from stepped leaders prior to the first return stroke are very large, reaching values of 20-30 Volts/meter, comparable to return stroke radiation; and (2) the duration of the stepped leader, from the initial detectable radiation pulse to the return stroke onset, is very-short-ranging from a minimum 1.5 ms to a maximum of 4.5 ms. This past summer (June-August of 1991) we participated in the CAPE program at the Kennedy Space Center in order to acquire data on stepped leaders in summer storms with the same equipment used to get the winter storm data. We discovered that the vigorous leaders seen in winter so frequently were present in summer storms, although not as large in amplitude and certainly not as frequent.

Left ventricular hypertrophy assessed by electrocardiogram is associated with more severe stroke and with higher in-hospital mortality in patients with acute ischemic stroke.

PubMed

Tziomalos, Konstantinos; Sofogianni, Areti; Angelopoulou, Stella-Maria; Christou, Konstantinos; Kostaki, Stavroula; Papagianni, Marianthi; Satsoglou, Sarantis; Spanou, Marianna; Savopoulos, Christos; Hatzitolios, Apostolos I

2018-07-01

Left ventricular hypertrophy (LVH), assessed by electrocardiogram (ECG), is associated with increased risk for stroke. However, few studies that evaluated whether ECG-detected LVH predicts ischemic stroke severity and outcome. We aimed to evaluate these associations. We prospectively studied 922 patients consecutively admitted with acute ischemic stroke (age 79.6 ± 6.9 years). Stroke severity was assessed at admission with the National Institutes of Health Stroke Scale (NIHSS). Severe stroke was defined as NIHSS≥5. LVH was evaluated with the Sokolow-Lyon index and the Cornell voltage-duration product criteria in an ECG obtained at admission. The outcome was assessed with dependency at discharge (modified Rankin scale 2-5) and in-hospital mortality. Independent predictors of severe stroke were age (relative risk (RR) per year 1.07, 95% confidence interval (CI) 1.03-1.11, p<0.001), female gender (RR 0.36, 95% CI 0.17-0.76, p<0.01), atrial fibrillation (RR 2.07, 95% CI 1.30-3.29, p<0.005), chronic kidney disease (RR 2.38, 95% CI 1.04-5.44, p<0.05), heart rate (RR per 1/min 1.02, 95% CI 1.01-1.04, p<0.005), glucose levels (RR 1.012, 95% CI 1.006-1.018, p<0.001), high-density lipoprotein cholesterol levels (RR 0.976, 95% CI 0.960-0.993, p<0.005) and LVH defined according to the Cornell voltage-duration product criteria (RR 2.08, 95% CI 1.12-3.86, p<0.05). Independent predictors of dependency at discharge were age (RR per year 1.08, 95% CI 1.03-1.13, p<0.001), past smoking (RR versus no smoking 0.42, 95% 0.19-0.89, p<0.05), history of ischemic stroke (RR 2.13, 95% CI 1.23-3.71, p<0.01) and NIHSS at admission (RR 1.48, 95% CI 1.35-1.63, p<0.001). Independent predictors of in-hospital mortality were glucose levels (RR 1.014, 95% CI 1.003-1.025, p<0.05), NIHSS at admission (RR 1.29, 95% CI 1.19-1.41, p<0.001) and LVH according to the Cornell voltage-duration product criteria (RR 4.95, 95% CI 1.09-22.37, p<0.05). LVH according to the Cornell voltage-duration product criteria appears to be associated with more severe stroke and with higher in-hospital mortality in patients with acute ischemic stroke. Copyright © 2018 Elsevier B.V. All rights reserved.

Cardiovascular, Rheumatologic, and Pharmacologic Predictors of Stroke in Patients With Rheumatoid Arthritis: A Nested, Casee–Control Study

PubMed Central

Nadareishvili, Zurab; Michaud, Kaleb; Hallenbeck, John M.; Wolfe, Frederick

2009-01-01

Objective To determine the risk of stroke in patients with rheumatoid arthritis (RA) and risk factors associated with stroke. Methods We performed nested case–control analyses within a longitudinal databank, matching up to 20 controls for age, sex, and time of cohort entry to each patient with stroke. Conditional logistic regression was performed as an estimate of the relative risk of stroke in RA patients compared with those with noninflammatory rheumatic disorders, and to examine severity and anti–tumor necrosis factor (anti-TNF) treatment effects in RA. Results We identified 269 patients with first-ever all-category strokes and 67 with ischemic stroke, including 41 in RA patients. The odds ratio (OR) for the risk of all-category stroke in RA was 1.64 (95% confidence interval [95% CI] 1.16–2.30, P = 0.005), and for ischemic stroke was 2.66 (95% CI 1.24–5.70, P = 0.012). Ischemic stroke was predicted by hypertension, myocardial infarction, low-dose aspirin, comorbidity score, Health Assessment Questionnaire score, and presence of total joint replacement, but not by diabetes, smoking, exercise, or body mass index. Adjusted for cardiovascular and RA risk factors, ischemic stroke was associated with rofecoxib (P = 0.060, OR 2.27 [95% CI 0.97–5.28]), and possibly with corticosteroid use. Anti-TNF therapy was not associated with ischemic stroke (P = 0.584, OR 0.80 [95% CI 0.34–1.82]). Conclusion RA is associated with increased risk of stroke, particularly ischemic stroke. Stroke is predicted by RA severity, certain cardiovascular risk factors, and comorbidity. Except for rofecoxib, RA treatment does not appear to be associated with stroke, although the effect of corticosteroids remains uncertain. PMID:18668583

The Role of Citicoline in Neuroprotection and Neurorepair in Ischemic Stroke

PubMed Central

Álvarez-Sabín, José; Román, Gustavo C.

2013-01-01

Advances in acute stroke therapy resulting from thrombolytic treatment, endovascular procedures, and stroke units have improved significantly stroke survival and prognosis; however, for the large majority of patients lacking access to advanced therapies stroke mortality and residual morbidity remain high and many patients become incapacitated by motor and cognitive deficits, with loss of independence in activities of daily living. Therefore, over the past several years, research has been directed to limit the brain lesions produced by acute ischemia (neuroprotection) and to increase the recovery, plasticity and neuroregenerative processes that complement rehabilitation and enhance the possibility of recovery and return to normal functions (neurorepair). Citicoline has therapeutic effects at several stages of the ischemic cascade in acute ischemic stroke and has demonstrated efficiency in a multiplicity of animal models of acute stroke. Long-term treatment with citicoline is safe and effective, improving post-stroke cognitive decline and enhancing patients’ functional recovery. Prolonged citicoline administration at optimal doses has been demonstrated to be remarkably well tolerated and to enhance endogenous mechanisms of neurogenesis and neurorepair contributing to physical therapy and rehabilitation. PMID:24961534

[Progressive cerebral infraction initially presenting with pseudo-ulnar nerve palsy in a patient with severe internal carotid artery stenosis].

PubMed

Kakinuma, Kanako; Nakajima, Masashi; Hieda, Soutarou; Ichikawa, Hiroo; Kawamura, Mitsuru

2010-09-01

A 63-year-old man with hypercholesterolemia developed sensory and motor disturbances in the ulnar side of the right hand, and over three days the weakness evolved to entire right arm. Examination on the 6th day after onset showed mild lower facial palsy in addition to the upper limb weakness on the right. The weakness involved entire right arm sparing shoulder girdle muscles, which was worse in the 4th and 5th digits with claw hand deformity of the hand. Magnetic resonance imaging showed multiple small infracts in the centrum semiovale as well as in the medial side of the precentral knob on the left. Magnetic resonance angiography, ultrasonography, and 3D-CT angiography of the neck showed severe stenosis associated with unstable plaque of the left internal carotid artery. Hemodynamic mechanisms including microemboli and hypoperfusion associated with severe internal carotid artery stenosis are likely to cause stroke in evolution after initial presentation of pseudo-ulnar palsy in the present case.

Task-oriented treadmill exercise training in chronic hemiparetic stroke

PubMed Central

Ivey, Frederick M.; Hafer-Macko, Charlene E.; Macko, Richard F.

2010-01-01

Patients with stroke have elevated hemiparetic gait costs secondary to low activity levels and are often severely deconditioned. Decrements in peak aerobic capacity affect functional ability and cardiovascular-metabolic health and may be partially mediated by molecular changes in hemiparetic skeletal muscle. Conventional rehabilitation is time delimited in the subacute stroke phase and does not provide adequate aerobic intensity to reverse the profound detriments to fitness and function that result from stroke. Hence, we have studied progressive full body weight-support treadmill (TM) training as an adjunct therapy in the chronic stroke phase. Task-oriented TM training has produced measurable changes in fitness, function, and indices of cardiovascular-metabolic health after stroke, but the precise mechanisms for these changes remain under investigation. Further, the optimal dose of this therapy has yet to be identified for individuals with stroke and may vary as a function of deficit severity and outcome goals. This article summarizes the functional and metabolic decline caused by inactivity after stroke and provides current evidence that supports the use of TM training during the chronic stroke phase, with protocols and inclusion/exclusion criteria described. Our research findings are discussed in relation to associated research. PMID:18566943

Correlation between Sleep Duration and Risk of Stroke.

PubMed

Patyar, Sazal; Patyar, Rakesh Raman

2015-05-01

Modern lifestyle and job requirements have changed the sleep habits of most of the adult population. Various population-based studies have associated an increase in mortality with either shortened sleep or long sleep duration. Thus a U-shaped relationship between sleep duration and all-cause mortality in both men and women has been suggested. Several studies have found an association between sleep duration and risk of cardiovascular diseases also. Efforts to understand the etiology of stroke have indicated an association between sleep and stroke too. Obstructive sleep apnea, a sleep-related disorder, has been reported to significantly increase the risk of stroke. Moreover, many studies have shown that both short and long sleep durations are related to increased likelihood of diabetes and hypertension, which themselves are risk factors for stroke. Therefore, this review focuses on the correlation between sleep duration and risk of stroke based on the experimental and epidemiologic studies. Although a few experimental studies have reported that partial sleep deprivation may reduce stroke incidence and severity, yet, most experimental and observational studies have indicated a strong association between short/long sleep durations and higher risk of stroke. Copyright © 2015 National Stroke Association. Published by Elsevier Inc. All rights reserved.

78 FR 39299 - National Institute of Neurological Disorders and Stroke; Notice of Closed Meetings

Federal Register 2010, 2011, 2012, 2013, 2014

2013-07-01

... Disorders and Stroke Special, Emphasis Panel, International Traumatic Brain Injury Research Initiative. Date... Traumatic Encephalopathy and Delayed Effects of Traumatic Brain Injury. Date: July 19, 2013. Time: 1:30 p.m...

Lightning Step Leader and Return Stroke Spectra at 100,000 fps

NASA Astrophysics Data System (ADS)

Harley, J.; McHarg, M.; Stenbaek-Nielsen, H. C.; Haaland, R. K.; Sonnenfeld, R.; Edens, H. E.; Cummer, S.; Lapierre, J. L.; Maddocks, S.

2017-12-01

A fundamental understanding of lightning can be inferred from the spectral emissions resulting from the leader and return stroke channels. We examine events recorded at 00:58:07 on 19 July 2015 and 06:44:24 on 23 July 2017, both at Langmuir Laboratory. Analysis of both events is supplemented by data from the Lightning Mapping Array at Langmuir. The 00:58:07 event spectra was recorded using a 100 line per mm grating in front of a Phantom V2010 camera with an 85mm (9o FOV) Nikon lens recording at 100,000 frames per second. Coarse resolution spectra (approximately 5 nm resolution) are produced from approximately 400 nm to 800 nm for each frame. We analyze several nitrogen and oxygen lines to understand step leader temperature behavior between cloud and ground. The 06:44:24 event spectra was recorded using a 300 line per mm grating (approximately 1.5 nm resolution) in front of a Phantom V2010 camera with an 50mm (32o FOV) Nikon lens also recording at 100,000 frames per second. Two ionized atomic nitrogen lines at 502 nm and 569 nm appear upon attachment and disappear as the return stroke travels from ground to cloud in approximately 5 frames. We analyze these lines to understand initial return stroke temperature and species behavior.

Functional changes of neural circuits in stroke patients with dysphagia: A meta-analysis.

PubMed

Liu, Lu; Xiao, Yuan; Zhang, Wenjing; Yao, Li; Gao, Xin; Chandan, Shah; Lui, Su

2017-08-01

Dysphagia is a common problem in stroke patients with unclear pathogenesis. Several recent functional magnetic resonance imaging (fMRI) studies had been carried out to explore the cerebral functional changes in dysphagic stroke patients. The aim of this study was to analysis these imaging findings using a meta-analysis. We used seed-based d mapping (SDM) to conduct a meta-analysis for dysphagic stroke patients prior to any kind of special treatment for dysphagia. A systematic search was conducted for the relevant studies. SDM meta-analysis method was used to examine regions of increased and decreased functional activation between dysphagic stroke patients and healthy controls. Finally, six studies including 81 stroke patients with dysphagia and 78 healthy controls met the inclusion standards. When compared with healthy controls, stroke patients with dysphagia showed hyperactivation in left cingulate gyrus, left precentral gyrus and right posterior cingulate gyrus, and hypoactivation in right cuneus and left middle frontal gyrus. The hyperactivity of precentral gyrus is crucial in stroke patients with dysphagia and may be associated with the severity of stroke. Besides the motor areas, the default-mode network regions (DMN) and affective network regions (AN) circuits are also involved in dysphagia after stroke. © 2017 Chinese Cochrane Center, West China Hospital of Sichuan University and John Wiley & Sons Australia, Ltd.

Presentation and outcomes of "wake-up strokes" in a large randomized stroke trial: analysis of data from the International Stroke Trial.

PubMed

Moradiya, Yogesh; Janjua, Nazli

2013-11-01

Recent studies comparing the outcomes of wake-up stroke (WUS) and stroke while awake (SWA) patients reveal better outcomes among SWA patients, attributable in part to their higher rates of thrombolysis. Patients with WUS are largely excluded from therapy. Earlier analyses, conducted before the approval of alteplase for acute stroke, show the true divergence of natural histories between these 2 groups. We analyzed 17,398 patients with ischemic stroke from the International Stroke Trial and compared both presentations and outcomes between the WUS and SWA groups. Severity was assessed by level of consciousness, Oxfordshire Community Stroke Project (OCSP) stroke classification, number of neurologic deficits, and predicted probability of dependency or death. Outcomes were assessed at day 14 and at 6 months. Outcome assessments were controlled for potential confounders. WUS represented 29.6% of all ischemic strokes. More severe OSCP stroke type (total anterior circulation syndrome) was less common in WUS. Although more patients with WUS were alert at presentation with a lower predicted probability of dependency, the 14-day mortality rates and rates of poor outcome at 6 months were similar between the 2 groups. WUS patients comprise one quarter to one third of ischemic stroke patients. Despite their more benign presentations, they deteriorate to outcome rates similar to SWA. Although they are typically excluded from time-dependent acute interventions, patients with WUS may benefit from acute intervention to prevent this worsening natural history. Copyright © 2013 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Neural correlates of brain state in chronic ischemia and stroke: combined resting state electroencephalogram and transcranial Doppler ultrasonographic study.

PubMed

Martynova, Olga V; Portnova, Galina V; Gladun, Ksenya V

2017-02-08

Clinical neurology is constantly searching for reliable indices of ischemic brain damage to prevent a possible development of stroke. We suggest that resting state electroencephalogram (rsEEG) with respect to other clinical data may provide important information about the severity of ischemia. We carried out correlation analysis of rsEEG, data of transcranial Doppler ultrasonography of head vessels, and clinical assessment scores collected from healthy volunteers and four groups of patients with mild chronic microvascular ischemia (CMI-1), moderate CMI (CMI-2), severe atrophy of the cerebral hemisphere, ischemic stroke in the left middle cerebral artery stroke, and ischemic stroke in the right middle cerebral artery stroke. Using independent component analysis and k-mean clustering of EEG data, we observed prominent changes in rsEEG reflected in specific distributions of spectral peaks in all groups of patients. We found a significant correlation of EEG spectral distribution and the blood flow velocity in coronal arteries, which was also affected by the severity of ischemia and the localization of stroke. Moreover, EEG spectral distribution was more indicative of early stages of ischemia than the blood flow velocity. Our data support the hypothesis that rsEEG may reflect altered neural activity caused by ischemic brain damage.

Some properties of negative cloud-to-ground flashes from observations of a local thunderstorm based on accurate-stroke-count studies

NASA Astrophysics Data System (ADS)

Zhu, Baoyou; Ma, Ming; Xu, Weiwei; Ma, Dong

2015-12-01

Properties of negative cloud-to-ground (CG) lightning flashes, in terms of number of strokes per flash, inter-stroke intervals and the relative intensity of subsequent and first strokes, were presented by accurate-stroke-count studies based on all 1085 negative flashes from a local thunderstorm. The percentage of single-stroke flashes and stroke multiplicity evolved significantly during the whole life cycle of the study thunderstorm. The occurrence probability of negative CG flashes decreased exponentially with the increasing number of strokes per flash. About 30.5% of negative CG flashes contained only one stroke and number of strokes per flash averaged 3.3. In a subset of 753 negative multiple-stroke flashes, about 41.4% contained at least one subsequent stroke stronger than the corresponding first stroke. Subsequent strokes tended to decrease in strength with their orders and the ratio of subsequent to first stroke peaks presented a geometric mean value of 0.52. Interestingly, negative CG flashes of higher multiplicity tended to have stronger initial strokes. 2525 inter-stroke intervals showed a more or less log-normal distribution and gave a geometric mean value of 62 ms. For CG flashes of particular multiplicity geometric mean inter-stroke intervals tended to decrease with the increasing number of strokes per flash, while those intervals associated with higher order strokes tended to be larger than those associated with low order strokes.

Why a polysomnogram should become part of the diagnostic evaluation of stroke and transient ischemic attack.

PubMed

Grigg-Damberger, Madeleine

2006-02-01

Neurologists need to recognize, diagnose, and treat obstructive sleep apnea (OSA) in patients with stroke or transient ischemic attack (TIA). Increasing medical evidence suggests that OSA is an independent risk factor for stroke and TIA. Stroke (or TIA) is more likely a cause, rather than a consequence, of OSA because PSG studies have shown: 1) apneas in stroke are typically obstructive, not central or Cheyne-Stokes in type; 2) apneas are just as frequent and severe in patients with either TIA or stroke; 3) OSA severity is not influenced by the acuteness or location of the stroke; 4) untreated OSA patients have more strokes, stroke morbidity, and mortality than those who are treated. OSA alone can induce hypertension, especially in younger men. A causal relationship has recently been demonstrated between OSA and hypertension. A distinctive feature of OSA-induced hypertension is loss of the normal nighttime fall in blood pressure ("nondippers"). Data from the Sleep Heart Health Study showed a dose-response association between OSA severity and the presence of hypertension 4 years later. Hypertension or ischemic heart disease usually develops in untreated patients with OSA over time without particular worsening of OSA. Studies have shown sleep itself is not a risk factor for stroke because most stroke and TIAs begin between 6 am and noon, while the individual is awake. However, OSA promptly be considered in stroke beginning during sleep because 88% of strokes that develop during sleep occur in "nondippers." Premature death in OSA patients is most often cardiovascular, but occurs while the patients are awake. The risk of myocardial infarction is increased 20-fold in untreated OSA. Treating OSA patients with continuous positive airway pressure can prevent or improve hypertension, reduce abnormal elevations of inflammatory cytokines and adhesion molecules, reduce excessive sympathetic tone, avoid increased vascular oxidative stress, reverse coagulation abnormalities, and reduce leptin levels. If all this can be achieved by a polysomnogram, then this test should become part of a neurologist's armamentarium for stroke and TIA.

Location and severity of spasticity in the first 1-2 weeks and at 3 and 18 months after stroke.

PubMed

Welmer, A-K; Widén Holmqvist, L; Sommerfeld, D K

2010-05-01

There is no consensus concerning the location or severity of spasticity, or how this changes with time after stroke. The purpose was to describe: the location and severity of spasticity, in different muscle groups, during the first 1-2 weeks and at 3 and 18 months after stroke; the association between the severity of spasticity and control of voluntary movements; and the occurrence of spasticity in younger versus older patients. In a cohort of consecutive patients, the following parameters were assessed during the first 1-2 weeks (n = 109) and at 3 (n = 95) and 18 (n = 66) months after first-ever stroke: spasticity, by the Modified Ashworth Scale in different muscle groups; plantar-flexor clonus, by physical examination; and movement function, by the Lindmark Motor Assessment Scale. During the first 1-2 weeks and at 3 months after stroke, spasticity was most common in the anti-gravity muscles. The severity of upper extremity spasticity increased over time (P < 0.05). Upper extremity spasticity and movement scores were moderately associated (r = -0.61, P < 0.05). At 3 months, spasticity was more common amongst the younger patients (P < 0.05). The results confirm that spasticity is most common in the anti-gravity muscles and is associated with the control of voluntary movements. As the severity of spasticity also increased after 3 months, when neurally mediated spasticity is expected to have passed its peak, intrinsic muscle changes may play a larger role than neural components with the passage of time after stroke.

Mirror therapy in chronic stroke survivors with severely impaired upper limb function: a randomized controlled trial.

PubMed

Colomer, Carolina; NOé, Enrique; Llorens, Roberto

2016-06-01

Mirror therapy (MT) has been proposed to improve the motor function of chronic individuals with stroke with mild to moderate impairment. With regards to severe upper limb paresis, MT has shown to provide limited motor improvement in the acute or sub-acute phase. However, no previous research has described the effects of MT in chronic individuals with stroke with severely impaired upper limb function. The aim of this study was to determine the effectiveness of MT on chronic stroke survivors with severe upper-limb impairment in comparison with passive mobilization. A randomized controlled trial. Rehabilitative outpatient unit. A total of 31 chronic subjects poststroke with severely impaired upper limb function were randomly assigned to either an experimental group (N.=15), or a control group (N.=16). Twenty-four intervention sessions were performed for both groups. Each session included 45-minute period of MT (experimental group) or passive mobilization (control group), administered three days a week. Participants were assessed before and after the intervention with the Wolf Motor Function Test, the Fugl-Meyer Assessment, and the Nottingham Sensory Assessment. Improvement in motor function was observed in both groups on the time (P=0.002) and ability (P=0.001) subscales of the Wolf Motor Function Test. No differences were detected in kinesthesis or stereognosis. However, the experimental group showed a significant improvement in tactile sensation that was mainly observed as an increased sensitivity to light touches. In comparison with passive mobilization, MT in chronic stroke survivors with severely impaired upper-limb function may provide a limited but positive effect on light touch sensitivity while providing similar motor improvement. MT is a therapeutic approach that can be used in the rehabilitation of severely impaired upper limb in chronic stroke survivors, specifically to address light touch sensitivity deficits.

Novel Screening Tool for Stroke Using Artificial Neural Network.

PubMed

Abedi, Vida; Goyal, Nitin; Tsivgoulis, Georgios; Hosseinichimeh, Niyousha; Hontecillas, Raquel; Bassaganya-Riera, Josep; Elijovich, Lucas; Metter, Jeffrey E; Alexandrov, Anne W; Liebeskind, David S; Alexandrov, Andrei V; Zand, Ramin

2017-06-01

The timely diagnosis of stroke at the initial examination is extremely important given the disease morbidity and narrow time window for intervention. The goal of this study was to develop a supervised learning method to recognize acute cerebral ischemia (ACI) and differentiate that from stroke mimics in an emergency setting. Consecutive patients presenting to the emergency department with stroke-like symptoms, within 4.5 hours of symptoms onset, in 2 tertiary care stroke centers were randomized for inclusion in the model. We developed an artificial neural network (ANN) model. The learning algorithm was based on backpropagation. To validate the model, we used a 10-fold cross-validation method. A total of 260 patients (equal number of stroke mimics and ACIs) were enrolled for the development and validation of our ANN model. Our analysis indicated that the average sensitivity and specificity of ANN for the diagnosis of ACI based on the 10-fold cross-validation analysis was 80.0% (95% confidence interval, 71.8-86.3) and 86.2% (95% confidence interval, 78.7-91.4), respectively. The median precision of ANN for the diagnosis of ACI was 92% (95% confidence interval, 88.7-95.3). Our results show that ANN can be an effective tool for the recognition of ACI and differentiation of ACI from stroke mimics at the initial examination. © 2017 American Heart Association, Inc.

Development of a novel translation micromirror for adaptive optics

NASA Astrophysics Data System (ADS)

He, Siyuan; Ben Mrad, Ridha

2003-10-01

Conventional translation micromirrors for adaptive optics use attractive electrostatic force and therefore have two limitations: 1) the stroke is limited to less than one third of the initial gap distance between the mirror plate and the substrate. Normally the stroke is in the range of submicrometers; 2) stiction happens during operation. A novel translation micromirror, which uses a repulsive electrostatic force, is presented in this paper. This novel translation micromirror completely overcomes the limitations associated with conventional translation micromirrors and its stroke is not limited by the initial gap distance between the mirror plate and the substrate and therefore is able to achieve a much larger vertical stroke to modulate lights over a wider spectrum than that achieved by conventional translation micromirrors. The novel translation micromirror has no stiction problem and is highly compatible with mature surface micromachining technology. An analytical model is derived for the novel translation micromirror and prototypes are fabricated. The prototype of the novel translation micromirror, which is deliberately not optimized so it could be fabricated using MUMPS, achieved a vertical stroke of 1.75μm using a driving voltage of 50 volts, which is three times the stroke of conventional MUMPS translation micromirrors. It is expected that if standard surface micromachining is used instead of MUMPs, the design of the novel translation micromirror can be optimized and a much larger vertical stroke can be achieved.

Streamlining Workflow for Endovascular Mechanical Thrombectomy: Lessons Learned from a Comprehensive Stroke Center.

PubMed

Wang, Hongjin; Thevathasan, Arthur; Dowling, Richard; Bush, Steven; Mitchell, Peter; Yan, Bernard

2017-08-01

Recently, 5 randomized controlled trials confirmed the superiority of endovascular mechanical thrombectomy (EMT) to intravenous thrombolysis in acute ischemic stroke with large-vessel occlusion. The implication is that our health systems would witness an increasing number of patients treated with EMT. However, in-hospital delays, leading to increased time to reperfusion, are associated with poor clinical outcomes. This review outlines the in-hospital workflow of the treatment of acute ischemic stroke at a comprehensive stroke center and the lessons learned in reduction of in-hospital delays. The in-hospital workflow for acute ischemic stroke was described from prehospital notification to femoral arterial puncture in preparation for EMT. Systematic review of literature was also performed with PubMed. The implementation of workflow streamlining could result in reduction of in-hospital time delays for patients who were eligible for EMT. In particular, time-critical measures, including prehospital notification, the transfer of patients from door to computed tomography (CT) room, initiation of intravenous thrombolysis in the CT room, and the mobilization of neurointervention team in parallel with thrombolysis, all contributed to reduction in time delays. We have identified issues resulting in in-hospital time delays and have reported possible solutions to improve workflow efficiencies. We believe that these measures may help stroke centers initiate an EMT service for eligible patients. Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Is It Acute Stroke or Not - A Prospective Observational Study from a Multidisciplinary Emergency Department.

PubMed

Wolf, Marc E; Chatzikonstantinou, Anastasios; Grüttner, Joachim; Ebert, Anne D; Walter, Thomas; Hennerici, Michael G; Fatar, Marc

2016-01-01

Acute stroke is a medical emergency with various clinical presentations. Since the introduction of systemic thrombolytic treatment, stroke diagnosis has been made quickly and with great caution, and the trend of rapid presentation at hospitals has increased. In our multidisciplinary Emergency Department, we prospectively collected and analysed data of consecutive patients presenting with suspected acute stroke (SAS) or transient ischemic attack (TIA). Four hundred ten patients (200 men, mean age 68 ± 16, range 17-93 years) with SAS were admitted of which 105 were prehospitally announced as within the time-window for thrombolytic treatment (TW). Diagnosis of acute stroke/TIA was retained in 147 (35.9%). The initially reported TW <4.5 h was wrong in 35.3%. Thrombolysis was performed in 27 patients (23.5% of ischemic stroke patients; 6.6% of all SAS). Diagnosis of another neurologic disease was made in 62 (15.1%). Major differential diagnoses came from the field of internal medicine, psychiatry or otorhinolaryngology. One hundred fifty patients (36.6%) were rapidly discharged. About half the number of our patients admitted for SAS did not suffer from an acute neurologic disease. Residual symptoms post-stroke might be partly responsible for initial misinterpretation. The crucial difference between symptom onset and symptom recognition needs to be emphasized to improve the prehospital assessment of the TW. © 2016 S. Karger AG, Basel.

Choosing a particular oral anticoagulant and dose for stroke prevention in individual patients with non-valvular atrial fibrillation: part 2

PubMed Central

Diener, Hans-Christoph; Aisenberg, James; Ansell, Jack; Atar, Dan; Breithardt, Günter; Eikelboom, John; Ezekowitz, Michael D.; Granger, Christopher B.; Halperin, Jonathan L.; Hohnloser, Stefan H.; Hylek, Elaine M.; Kirchhof, Paulus; Lane, Deirdre A.; Verheugt, Freek W.A.; Veltkamp, Roland; Lip, Gregory Y.H.

2017-01-01

The choice of oral anticoagulant (OAC) for patients with atrial fibrillation (AF) may be influenced by individual clinical features or by patterns of risk factors and comorbidities. We reviewed analyses of subgroups of patients from trials of vitamin K antagonists vs. non-vitamin K oral anticoagulants (NOACs) for stroke prevention in AF with the aim to identify patient groups who might benefit from a particular OAC more than from another. In addition, we discuss the timing of initiation of anticoagulation. In the second of a two-part review, we discuss the use of NOAC for stroke prevention in the following subgroups of patients with AF: (vii) secondary stroke prevention in patients after stroke or transient ischaemic attack (TIA), (viii) patients with acute stroke requiring thrombolysis or thrombectomy, (ix) those initiating or restarting OAC treatment after stroke or TIA, (x) those with renal impairment on dialysis, (xi) the elderly, (xii) those at high risk of gastrointestinal bleeding, and (xiii) those with hypertension. In addition, we discuss adherence and compliance. Finally, we present a summary of treatment suggestions. In specific subgroups of patients with AF, evidence supports the use of particular NOACs and/or particular doses of anticoagulant. The appropriate choice of treatment for these subgroups will help to promote optimal clinical outcomes. PMID:26848150

Attachment process in rocket-triggered lightning strokes

NASA Astrophysics Data System (ADS)

Wang, D.; Rakov, V. A.; Uman, M. A.; Takagi, N.; Watanabe, T.; Crawford, D. E.; Rambo, K. J.; Schnetzer, G. H.; Fisher, R. J.; Kawasaki, Z.-I.

1999-01-01

In order to study the lightning attachment process, we have obtained highly resolved (about 100 ns time resolution and about 3.6 m spatial resolution) optical images, electric field measurements, and channel-base current recordings for two dart leader/return-stroke sequences in two lightning flashes triggered using the rocket-and-wire technique at Camp Blanding, Florida. One of these two sequences exhibited an optically discernible upward-propagating discharge that occurred in response to the approaching downward-moving dart leader and connected to this descending leader. This observation provides the first direct evidence of the occurrence of upward connecting discharges in triggered lightning strokes, these strokes being similar to subsequent strokes in natural lightning. The observed upward connecting discharge had a light intensity one order of magnitude lower than its associated downward dart leader, a length of 7-11 m, and a duration of several hundred nanoseconds. The speed of the upward connecting discharge was estimated to be about 2 × 107 m/s, which is comparable to that of the downward dart leader. In both dart leader/return-stroke sequences studied, the return stroke was inferred to start at the point of junction between the downward dart leader and the upward connecting discharge and to propagate in both upward and downward directions. This latter inference provides indirect evidence of the occurrence of upward connecting discharges in both dart leader/return-stroke sequences even though one of these sequences did not have a discernible optical image of such a discharge. The length of the upward connecting discharges (observed in one case and inferred from the height of the return-stroke starting point in the other case) is greater for the event that is characterized by the larger leader electric field change and the higher return-stroke peak current. For the two dart leader/return-stroke sequences studied, the upward connecting discharge lengths are estimated to be 7-11 m and 4-7 m, with the corresponding return-stroke peak currents being 21 kA and 12 kA, and the corresponding leader electric field changes 30 m from the rocket launcher being 56 kV/m and 43 kV/m. Additionally, we note that the downward dart leader light pulse generally exhibits little variation in its 10-90% risetime and peak value over some tens of meters above the return-stroke starting point, while the following return-stroke light pulse shows an appreciable increase in risetime and a decrease in peak value while traversing the same section of the lightning channel. Our findings regarding (1) the initially bidirectional development of return-stroke process and (2) the relatively strong attenuation of the upward moving return-stroke light (and by inference current) pulse over the first some tens of meters of the channel may have important implications for return-stroke modeling.

Unilateral spatial neglect in the acute phase of ischemic stroke can predict long-term disability and functional capacity.

PubMed

Luvizutto, Gustavo José; Moliga, Augusta Fabiana; Rizzatti, Gabriela Rizzo Soares; Fogaroli, Marcelo Ortolani; Moura Neto, Eduardo de; Nunes, Hélio Rubens de Carvalho; Resende, Luiz Antônio de Lima; Bazan, Rodrigo

2018-05-21

The aim of this study was to assess the relationship between the degree of unilateral spatial neglect during the acute phase of stroke and long-term functional independence. This was a prospective study of right ischemic stroke patients in which the independent variable was the degree of spatial neglect and the outcome that was measured was functional independence. The potential confounding factors included sex, age, stroke severity, topography of the lesion, risk factors, glycemia and the treatment received. Unilateral spatial neglect was measured using the line cancellation test, the star cancellation test and the line bisection test within 48 hours of the onset of symptoms. Functional independence was measured using the modified Rankin and Barthel scales at 90 days after discharge. The relationship between unilateral spatial neglect and functional independence was analyzed using multiple logistic regression that was corrected for confounding factors. We studied 60 patients with a median age of 68 (34-89) years, 52% of whom were male and 74% of whom were Caucasian. The risk for moderate to severe disability increased with increasing star cancellation test scores (OR=1.14 [1.03-1.26], p=0.01) corrected for the stroke severity, which was a confounding factor that had a statistically positive association with disability (OR=1.63 [1.13-2.65], p=0.01). The best chance of functional independence decreased with increasing star cancellation test scores (OR=0.86 [0.78-0.96], p=0.006) corrected for the stroke severity, which was a confounding factor that had a statistically negative association with independence (OR=0.66 [0.48-0.92], p=0.017). The severity of unilateral spatial neglect in acute stroke worsens the degree of long-term disability and functional independence.

Trends in Ten-Year Survival of Stroke Patients Hospitalized between 1980 and 2000: The Minnesota Stroke Survey

PubMed Central

Lakshminarayan, Kamakshi; Berger, Alan K; Fuller, Candace C.; Jacobs, David R.; Anderson, David C.; Steffen, Lyn M; Sillah, Arthur; Luepker, Russell V.

2014-01-01

Background & Purpose We report on trends in post-stroke survival, both in the early period after stroke and over the long-term. We examine these trends by stroke sub-type. Methods The Minnesota Stroke Survey (MSS) is a study of all hospitalized acute stroke patients aged 30–74 years in the Minneapolis-St. Paul metropolis. Validated stroke events were sampled for survey years 1980, 1985, 1990, 1995 and 2000 and subtyped as ischemic or hemorrhagic by neuroimaging for survey years 1990, 1995 and 2000. Survival was obtained by linkage to vital statistics data through the year 2010. Results There were 3773 acute stroke events. Age-adjusted 10-year survival improved from 1980 to 2000 (men 29.5% to 46.5%, p < 0.0001; women 32.6% to 50.5%, p < 0.0001). Ten-year ischemic stroke survival (n = 1667) improved from 1990 to 2000 (men 35.3% to 50%, p = 0.0001; women 38% to 55.3%, p < 0.0001). Ten-year hemorrhagic stroke survival showed a trend toward improvement but this (n = 489) did not reach statistical significance, perhaps because of their smaller number (men 29.7% to 45.8%, p=0.06; women 39.2% to 49.6%, p=0.2). Markers of stroke severity including unconsciousness or major neurological deficits at admission declined from 1980 to 2000 while neuroimaging use increased. Conclusions These post-stroke survival trends are likely due to multiple factors including more sensitive case ascertainment shifting the case-mix toward less severe strokes, improved stroke care and risk factor management, and overall improvements in population health and longevity. PMID:25028450

Predicting recovery of voluntary upper extremity movement in subacute stroke patients with severe upper extremity paresis.

PubMed

Koh, Chia-Lin; Pan, Shin-Liang; Jeng, Jiann-Shing; Chen, Bang-Bin; Wang, Yen-Ho; Hsueh, I-Ping; Hsieh, Ching-Lin

2015-01-01

Prediction of voluntary upper extremity (UE) movement recovery is largely unknown in patients with little voluntary UE movement at admission. The present study aimed to investigate (1) the extent and variation of voluntary UE movement recovery, and (2) the best predictive model of the recovery of voluntary UE movement by clinical variables in patients with severe UE paresis. Prospective cohort study. 140 (out of 590) stroke patients with severe UE paresis completed all assessments. Voluntary UE movement was assessed using the UE subscale of the Stroke Rehabilitation Assessment of Movement (STREAM-UE). Two outcome measures, STREAM-UE scores at discharge (DC(STREAM-UE)) and changes between admission and discharge (Δ(STREAM-UE)), were investigated to represent the final states and improvement of the recovery of voluntary UE movement. Stepwise regression analyses were used to investigate 19 clinical variables and to find the best predictive models of the two outcome measures. The participants showed wide variation in both DC(STREAM-UE) and Δ(STREAM-UE). 3.6% of the participants almost fully recovered at discharge (DC(STREAM-UE) > 15). A large improvement (Δ(STREAM-UE) >= 10) occurred in 16.4% of the participants, while 32.9% of the participants did not have any improvement. The four predictors for the DC(STREAM-UE) (R(2) = 35.0%) were 'baseline STREAM-UE score', 'hemorrhagic stroke', 'baseline National Institutes of Health Stroke Scale (NIHSS) score', and 'cortical lesion excluding primary motor cortex'. The three predictors for the Δ(STREAM-UE) (R(2) = 22.0%) were 'hemorrhagic stroke', 'baseline NIHSS score', and 'cortical lesion excluding primary motor cortex'. Recovery of voluntary UE movement varied widely in patients with severe UE paresis after stroke. The predictive power of clinical variables was poor. Both results indicate the complex nature of voluntary UE movement recovery in patients with severe UE paresis after stroke.

Sensitivity and Specificity of an Adult Stroke Screening Tool in Childhood Ischemic Stroke.

PubMed

Neville, Kerri; Lo, Warren

2016-05-01

There are frequent delays in the diagnosis of acute pediatric ischemic stroke. A screening tool that could increase the suspicion of acute ischemic stroke could aid early recognition and might improve initial care. An earlier study reported that children with acute ischemic stroke have signs that can be recognized with two adult stroke scales. We tested the hypothesis that an adult stroke scale could distinguish children with acute ischemic stroke from children with acute focal neurological deficits not due to stroke. We retrospectively applied an adult stroke scale to the recorded examinations of 53 children with acute symptomatic acute ischemic stroke and 53 age-matched control subjects who presented with focal neurological deficits. We examined the sensitivity and specificity of the stroke scale and the occurrence of acute seizures as predictors of stroke status. The total stroke scale did not differentiate children with acute ischemic stroke from those who had acute deficits from nonstroke causes; however, the presence of arm weakness was significantly associated with stroke cases. Acute seizures were significantly associated with stroke cases. An adult stroke scale is not sensitive or specific to distinguish children with acute ischemic stroke from those with nonstroke focal neurological deficits. The development of a pediatric acute ischemic stroke screening tool should include arm weakness and perhaps acute seizures as core elements. Such a scale must account for the limitations of language in young or intellectually disabled children. Copyright © 2016 Elsevier Inc. All rights reserved.

Use of acupuncture therapy as a supplement to conventional medical treatments for acute ischaemic stroke patients in an academic medical centre in Korea.

PubMed

Chang, Hyejung; Kwon, Young Dae; Yoon, Sung Sang

2011-10-01

Acupuncture has served as a major complementary and alternative therapy that supplements conventional medicine and is the subject of growing public interest. This study was conducted to estimate the usage rate of acupuncture as a supplemental treatment in acute ischaemic stroke patients and to identify factors associated with the choice to use this therapy. Using the registry of stroke patients admitted to an academic medical centre in Korea, the use of acupuncture therapy was recorded and analysed, along with the patients' socio-demographic characteristics, hospital access variables, risk factors for ischaemic stroke and clinical characteristics. The data were analysed using descriptive statistics, chi-square tests and multiple logistic regression analyses. Of 2167 patients, 18% received acupuncture therapy. The choice of acupuncture therapy was significantly associated with stroke severity as well as gender, age, geographical residence and previous history of stroke. After controlling for other significant factors, there was an approximately 3.4-fold greater usage in patients with moderately severe strokes (95% confidence interval (CI)=2.5-4.6) and 4.1-fold greater usage in patients with severe strokes (95% CI=2.7-6.4). The findings provide a better understanding of patients' utilization of acupuncture therapy as a supplement to conventional medical treatments and of factors associated with the utilization of acupuncture in patients with acute ischemic stroke. Strategic implications of acupuncture therapy are suggested for both health-care providers and policy makers. Copyright © 2011 Elsevier Ltd. All rights reserved.

Rethinking the continuum of stroke rehabilitation.

PubMed

Teasell, Robert W; Murie Fernandez, Manuel; McIntyre, Amanda; Mehta, Swati

2014-04-01

Suffering a stroke can be a devastating and life-changing event. Although there is a large evidence base for stroke rehabilitation in the acute and subacute stages, it has been long accepted that patients with stroke reach a plateau in their rehabilitation recovery relatively early. We have recently published the results of a systematic review designed to identify all randomized controlled trials (RCTs) where a rehabilitation intervention was initiated more than 6 months after the onset of the stroke. Of the trials identified, 339 RCTs met inclusion criteria, demonstrating an evidence base for stroke rehabilitation in the chronic phase as well. This seems at odds with the assumption that further recovery is unlikely and the subsequent lack of resources devoted to chronic stroke rehabilitation and management. Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.

Heart Rate and Initial Presentation of Cardiovascular Diseases (Caliber)

ClinicalTrials.gov

2013-09-17

Abdominal Aortic Aneurysm; Coronary Heart Disease NOS; Unheralded Coronary Death; Intracerebral Haemorrhage; Heart Failure; Ischemic Stroke; Myocardial Infarction; Stroke; Peripheral Arterial Disease; Stable Angina Pectoris; Subarachnoid Haemorrhage; Transient Ischemic Attack; Unstable Angina; Cardiac Arrest, Sudden Cardiac Death

Non-fluent speech following stroke is caused by impaired efference copy.

PubMed

Feenaughty, Lynda; Basilakos, Alexandra; Bonilha, Leonardo; den Ouden, Dirk-Bart; Rorden, Chris; Stark, Brielle; Fridriksson, Julius

2017-09-01

Efference copy is a cognitive mechanism argued to be critical for initiating and monitoring speech: however, the extent to which breakdown of efference copy mechanisms impact speech production is unclear. This study examined the best mechanistic predictors of non-fluent speech among 88 stroke survivors. Objective speech fluency measures were subjected to a principal component analysis (PCA). The primary PCA factor was then entered into a multiple stepwise linear regression analysis as the dependent variable, with a set of independent mechanistic variables. Participants' ability to mimic audio-visual speech ("speech entrainment response") was the best independent predictor of non-fluent speech. We suggest that this "speech entrainment" factor reflects integrity of internal monitoring (i.e., efference copy) of speech production, which affects speech initiation and maintenance. Results support models of normal speech production and suggest that therapy focused on speech initiation and maintenance may improve speech fluency for individuals with chronic non-fluent aphasia post stroke.

[NDT-Bobath method used in the rehabilitation of patients with a history of ischemic stroke].

PubMed

Klimkiewicz, Paulina; Kubsik, Anna; Woldańska-Okońska, Marta

2012-01-01

Ischemic stroke is the third leading cause of death and disability in human. The vitally important problem after ischemic stroke is hemiparesis of the body. The most common methods used in improving the mobility of patients after ischemic stroke is a Bobath-NDT (Neuro-Developmental Treatment - Bobath), which initiated the Berta and Karel Bobath for children with cerebral palsy. It is a method designed to neurophysiological recovery of these vital functions that the patient was lost due to illness, and wants it back.

Wingspan stenting can effectively prevent long-term strokes for patients with severe symptomatic atherosclerotic basilar stenosis

PubMed Central

Bai, Wei-Xing; Gao, Bu-Lang; Wang, Zi-Liang; Cai, Dong-Yang; Zhu, Liang-Fu; Xue, Jiang-Yu; Li, Zhao-Shuo

2016-01-01

Objective To investigate the safety and long-term effect of using the Wingspan stent for severe symptomatic atherosclerotic basilar artery stenosis (≥70%). Materials and methods Between July 2007 and April 2013, we had 91 consecutive patients (age range 41–82 years old) with symptomatic severe basilar stenosis (70–99%) who underwent Wingspan stenting at our center. All patients had stenosis-related temporary ischemic attack or strokes. We analyzed the demographic data, pre- and post-procedural cerebral angiography, technical success rate, peri-procedural complications, and clinical and imaging follow-ups. Results The Wingspan stenting procedure was successful in all patients: The stenosis was reduced from 82.2% ± 5.8% pre-stenting to 15.9% ± 5.7% post-stenting. The 30-day peri-operative rate for stroke or death was 14.3%, which included ischemic stroke in 12 cases (12/91 = 13.2%) and subarachnoid hemorrhage in one case (1/91 = 1.1%), with a fatal or disabling stroke rate of 2.2%. Among the 77 patients with clinical follow-up assessment within 7–60 months (mean 31.3 ± 15.1 months) after stenting, four patients (5.2%) had posterior ischemia, including one patient with disabling ischemic stroke (1.3%) and three patients (3.9%) with temporary ischemic attack. The 2-year cumulative stroke rate was 16% (95% CI: 8.2–23.8%). Among 46 patients with imaging assessments at 3–45 months (mean, 9.5 ± 8.3) post-stenting, six (13.0%) patients had restenosis, including two (2/46 = 4.3%) with symptomatic restenosis. Conclusions The benefit of stenting for patients with severe basilar artery stenosis (> 70%) may lie in lowering the long-term fatal and disabling stroke rate; and as long as the peri-operative stroke rate can be kept at a relatively lower level, patients with severe basilar stenosis can benefit from basilar artery stenting. PMID:26823331

Benefits and Risks of Postmenopausal Hormone Therapy When It Is Initiated Soon After Menopause

PubMed Central

Manson, JoAnn E.; Langer, Robert D.; Anderson, Garnet L.; Pettinger, Mary; Jackson, Rebecca D.; Johnson, Karen C.; Kuller, Lewis H.; Lane, Dorothy S.; Wactawski-Wende, Jean; Brzyski, Robert; Allison, Matthew; Ockene, Judith; Sarto, Gloria; Rossouw, Jacques E.

2009-01-01

The authors further analyzed results from the Women's Health Initiative randomized trials (1993–2004) of conjugated equine estrogens, with or without medroxyprogesterone acetate, focusing on health benefits versus risks among women who initiated hormone therapy soon after menopause. Data from the Women's Health Initiative observational study (1993–2004) were included in some analyses for additional precision. Results are presented here for incident coronary heart disease, stroke, venous thromboembolism, breast cancer, colorectal cancer, endometrial cancer, or hip fracture; death from other causes; a summary global index; total cancer; and total mortality. Hazard ratios for breast cancer and total cancer were comparatively higher (P < 0.05) among women who initiated hormone therapy soon after menopause, for both regimens. Among these women, use of conjugated equine estrogens appeared to produce elevations in venous thromboembolism and stroke and a reduction in hip fracture. Estrogen plus progestin results among women who initiated use soon after menopause were similar for venous thromboembolism, stroke, and hip fracture but also included evidence of longer-term elevations in breast cancer, total cancer, and the global index. These analyses provide little support for the hypothesis of favorable effects among women who initiate postmenopausal estrogen use soon after menopause, either for coronary heart disease or for health benefits versus risk indices considered. PMID:19468079

Modeling Dynamic Regulatory Processes in Stroke.

DOE Office of Scientific and Technical Information (OSTI.GOV)

McDermott, Jason E.; Jarman, Kenneth D.; Taylor, Ronald C.

2012-10-11

The ability to examine in silico the behavior of biological systems can greatly accelerate the pace of discovery in disease pathologies, such as stroke, where in vivo experimentation is lengthy and costly. In this paper we describe an approach to in silico examination of blood genomic responses to neuroprotective agents and subsequent stroke through the development of dynamic models of the regulatory processes observed in the experimental gene expression data. First, we identified functional gene clusters from these data. Next, we derived ordinary differential equations (ODEs) relating regulators and functional clusters from the data. These ODEs were used to developmore » dynamic models that simulate the expression of regulated functional clusters using system dynamics as the modeling paradigm. The dynamic model has the considerable advantage of only requiring an initial starting state, and does not require measurement of regulatory influences at each time point in order to make accurate predictions. The manipulation of input model parameters, such as changing the magnitude of gene expression, made it possible to assess the behavior of the networks through time under varying conditions. We report that an optimized dynamic model can provide accurate predictions of overall system behavior under several different preconditioning paradigms.« less

Animal Robot Assisted-therapy for Rehabilitation of Patient with Post-Stroke Depression

NASA Astrophysics Data System (ADS)

Zikril Zulkifli, Winal; Shamsuddin, Syamimi; Hwee, Lim Thiam

2017-06-01

Recently, the utilization of therapeutic animal robots has expanded. This research aims to explore robotics application for mental healthcare in Malaysia through human-robot interaction (HRI). PARO, the robotic seal PARO was developed to give psychological effects on humans. Major Depressive Disorder (MDD) is a common but severe mood disorder. This study focuses on the interaction protocol between PARO and patients with MDD. Initially, twelve rehabilitation patients gave subjective evaluation on their first interaction with PARO. Next, therapeutic interaction environment was set-up with PARO in it to act as an augmentation strategy with other psychological interventions for post-stroke depression. Patient was exposed to PARO for 20 minutes. The results of behavioural analysis complemented with information from HRI survey question. The analysis also observed that the individual interactors engaged with the robot in diverse ways based on their needs Results show positive reaction toward the acceptance of an animal robot. Next, therapeutic interaction is set-up for PARO to contribute as an augmentation strategy with other psychological interventions for post-stroke depression. The outcome is to reduce the stress level among patients through facilitated therapy session with PARO

Determinants of Health-Related Quality of Life in Taiwanese Middle-Aged Women Stroke Survivors.

PubMed

Pai, Hsiang-Chu; Wu, Ming-Hsiu; Chang, Mei-Yueh

Female stroke victims have a higher survival rate and experience a greater loss of quality of life than do male stroke victims. The aim of this study was to evaluate the determinants of health-related quality of life in middle-aged women stroke survivors. This study is a cross-sectional design. This cross-sectional research uses a descriptive, prospective, and correlational study design to investigate the associations between latent variables. Participants included women stroke survivors, aged 45-65 years, who were patients at a medical center in Taiwan. Participants completed an interview and a six-part questionnaire comprising the Short-Form Health Survey (SF-36), National Institutes of Health Stroke Scale, Modified Rankin Scale, Burden Scale, Chinese Health Questionnaire, and five items that pertain to the survivor's cognitive appraisal of coping. Structural equation modeling (SEM), with the use of the partial least squares (PLS) method, was used to examine the proposed conceptual model. A total of 48 dyad samples (48 female stroke survivors, mean age = 55.29; 48 caregivers, mean age = 42.71) participated in the study. Overall, women's physical functioning (PF; stroke severity), cognitive appraisal of coping, and caregiver's psychosocial functioning were the predictors, explaining 43.3% of the variance in women's health-related quality of life. We found that female stroke survivors' level of stroke severity and negative appraisal-impact of stroke are significant predictors of the stroke survivor's quality of life. In addition to assisting women in their PF rehabilitation, rehabilitation nurses also should help to develop survivors' self-care confidence as a means to avoid the recurrence of stroke.

Synergy effects of combined multichannel EMG-triggered electrical stimulation and mirror therapy in subacute stroke patients with severe or very severe arm/hand paresis.

PubMed

Schick, Thomas; Schlake, Hans-Peter; Kallusky, Juliane; Hohlfeld, Günter; Steinmetz, Maria; Tripp, Florian; Krakow, Karsten; Pinter, Michaela; Dohle, Christian

2017-01-01

Neurorehabilitation requires the development of severity-dependent and successful therapies for arm/hand rehabilitation in stroke patients. To evaluate the effectiveness of adding mirror therapy to bilateral EMG-triggered multi-channel electrostimulation for the treatment of severe arm/hand paresis in stroke patients. The subjects of this randomized, controlled, multicentre study were stroke patients who had suffered their first insult between 1 and 6 months before study start and had severe or very severe arm/hand paresis, as classified by Fugl-Meyer-Assessment. Subjects were randomly allocated to an intervention group (n = 16) or control group (n = 17). Both groups were treated for 3 weeks (5x week, 30 minutes) with bilateral EMG-triggered multi-channel electrostimulation. The intervention group additionally received mirror feedback of the unaffected limb. The primary outcome measure was motor recovery of the upper extremities, as measured by the Fugl-Meyer Assessment. The Intervention Group with very severe paresis had significantly better motor recovery in total Fugl-Meyer Assessment (p = 0.017) at a medium effect size (Cohen) of d = 0.7, due to a significant recovery of shoulder and elbow function (p = 0.003) in the Fugl-Meyer Assessment Part A subtest. For subjects with severe paresis, additional mirror therapy did not significantly influence outcome. Additional mirror therapy in combination with EMG-triggered multi-channel electrostimulation is therapeutically beneficial for post-acute stroke patients with very severe arm/hand paresis.

Lesion site patterns in severe, nonverbal aphasia to predict outcome with a computer-assisted treatment program.

PubMed

Naeser, M A; Baker, E H; Palumbo, C L; Nicholas, M; Alexander, M P; Samaraweera, R; Prete, M N; Hodge, S M; Weissman, T

1998-11-01

To test whether lesion site patterns in patients with chronic, severe aphasia who have no meaningful spontaneous speech are predictive of outcome following treatment with a nonverbal, icon-based computer-assisted visual communication (C-ViC) program. Retrospective study in which computed tomographic scans performed 3 months after onset of stroke and aphasia test scores obtained before C-ViC therapy were reviewed for patients after receiving C-ViC treatment. A neurology department and speech pathology service of a Department of Veterans Affairs medical center and a university aphasia research center. Seventeen patients with stroke and severe aphasia who began treatment with C-ViC from 3 months to 10 years after onset of stroke. Level of ability to use C-ViC on a personal computer to communicate. All patients with bilateral lesions failed to learn C-ViC. For patients with unilateral left hemisphere lesion sites, statistical analyses accurately discriminated between those who could initiate communication with C-ViC from those who were only able to answer directed questions. The critical lesion areas involved temporal lobe structures (Wernicke cortical area and the subcortical temporal isthmus), supraventricular frontal lobe structures (supplementary motor area or cingulate gyrus 24), and the subcortical medial subcallosal fasciculus, deep to the Broca area. Specific lesion sites were also identified for appropriate candidacy for C-ViC. Lesion site patterns on computed tomographic scans are helpful to define candidacy for C-ViC training, and to predict outcome level. A practical method is presented for clinical application of these lesion site results in combination with aphasia test scores.

Effect of anterior cervical osteophyte in poststroke dysphagia: a case-control study.

PubMed

Kim, Youngkook; Park, Geun-Young; Seo, Yu Jung; Im, Sun

2015-07-01

To investigate whether the concomitant presence of anterior cervical osteophytes can influence the severity and outcome of patients with poststroke dysphagia. Retrospective case-control study. Hospital. A total of 40 participants were identified (N=40). Patients with poststroke dysphagia with anterior cervical osteophytes (n=20) were identified and matched by age, sex, location, and laterality of the stroke lesion to a poststroke dysphagia control group with no anterior cervical osteophytes (n=20). Not applicable. Videofluoroscopic swallowing study, Functional Oral Intake Scale (FOIS), and Penetration-Aspiration Scale results assessed within the first month of stroke were analyzed. The FOIS at 6 months was recorded, and severity of dysphagia was compared between the 2 groups. The case group had larger degrees of postswallow residues in the valleculae and pyriform sinuses (P=.020 and P<.001, respectively), with more patients showing postswallow aspiration (62.5%) than the control group (0%; P<.001), along with a higher risk of being on enteral nutrition feeding (odds ratio [OR]=13.933; 95% confidence interval [CI], 2.863-infinity) within the first month of stroke. At the 6-month follow-up, the case group had significantly lower mean FOIS scores (3.8±1.7) than the control group (6.1±1.3; P<.001), with an increased risk of having persistent dysphagia (OR=15.375; 95% CI, 3.195-infinity). The presence of anterior cervical osteophytes, which may cause mechanical obstruction and interfere with residue clearance at the valleculae and pyriform sinuses and result in more postswallow aspiration, may influence initial severity and outcome of poststroke dysphagia. The presence of anterior cervical osteophytes may be considered an important clinical condition that may affect poststroke dysphagia rehabilitation. Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.

Poststroke aphasia : epidemiology, pathophysiology and treatment.

PubMed

Berthier, Marcelo L

2005-01-01

Aphasia, the loss or impairment of language caused by brain damage, is one of the most devastating cognitive impairments of stroke. Aphasia is present in 21-38% of acute stroke patients and is associated with high short- and long-term morbidity, mortality and expenditure. Recovery from aphasia is possible even in severe cases. While speech-language therapy remains the mainstay treatment of aphasia, the effectiveness of conventional therapies has not been conclusively proved. This has motivated attempts to integrate knowledge from several domains in an effort to plan more rational therapies and to introduce other therapeutic strategies, including the use of intensive language therapy and pharmacological agents. Several placebo-controlled trials suggest that piracetam is effective in recovery from aphasia when started soon after the stroke, but its efficacy vanishes in patients with chronic aphasia. Drugs acting on catecholamine systems (bromocriptine, dexamfetamine) have shown varying degrees of efficacy in case series, open-label studies and placebo-controlled trials. Bromocriptine is useful in acute and chronic aphasias, but its beneficial action appears restricted to nonfluent aphasias with reduced initiation of spontaneous verbal messages. Dexamfetamine improves language function in subacute aphasia and the beneficial effect is maintained in the long term, but its use is restricted to highly selected samples. Pharmacological agents operating on the cholinergic system (e.g. donepezil) have shown promise. Data from single-case studies, case series and an open-label study suggest that donepezil may have beneficial effects on chronic poststroke aphasia. Preliminary evidence suggests that donepezil is well tolerated and its efficacy is maintained in the long term. Randomised controlled trials of donepezil and other cholinergic agents in poststroke aphasia are warranted.

Hospital financing of ischaemic stroke: determinants of funding and usefulness of DRG subcategories based on severity of illness.

PubMed

Dewilde, Sarah; Annemans, Lieven; Pincé, Hilde; Thijs, Vincent

2018-05-11

Several Western and Arab countries, as well as over 30 States in the US are using the "All-Patient Refined Diagnosis-Related Groups" (APR-DRGs) with four severity-of-illness (SOI) subcategories as a model for hospital funding. The aim of this study is to verify whether this is an adequate model for funding stroke hospital admissions, and to explore which risk factors and complications may influence the amount of funding. A bottom-up analysis of 2496 ischaemic stroke admissions in Belgium compares detailed in-hospital resource use (including length of stay, imaging, lab tests, visits and drugs) per SOI category and calculates total hospitalisation costs. A second analysis examines the relationship between the type and location of the index stroke, medical risk factors, patient characteristics, comorbidities and in-hospital complications on the one hand, and the funding level received by the hospital on the other hand. This dataset included 2513 hospitalisations reporting on 35,195 secondary diagnosis codes, all medically coded with the International Classification of Disease (ICD-9). Total costs per admission increased by SOI (€3710-€16,735), with severe patients costing proportionally more in bed days (86%), and milder patients costing more in medical imaging (24%). In all resource categories (bed days, medications, visits and imaging and laboratory tests), the absolute utilisation rate was higher among severe patients, but also showed more variability. SOI 1-2 was associated with vague, non-specific stroke-related ICD-9 codes as primary diagnosis (71-81% of hospitalisations). 24% hospitalisations had, in addition to the primary diagnosis, other stroke-related codes as secondary diagnoses. Presence of lung infections, intracranial bleeding, severe kidney disease, and do-not-resuscitate status were each associated with extreme SOI (p < 0.0001). APR-DRG with SOI subclassification is a useful funding model as it clusters stroke patients in homogenous groups in terms of resource use. The data on medical care utilisation can be used with unit costs from other countries with similar healthcare set-ups to 1) assess stroke-related hospital funding versus actual costs; 2) inform economic models on stroke prevention and treatment. The data on diagnosis codes can be used to 3) understand which factors influence hospital funding; 4) raise awareness about medical coding practices.

Code stroke in Asturias.

PubMed

Benavente, L; Villanueva, M J; Vega, P; Casado, I; Vidal, J A; Castaño, B; Amorín, M; de la Vega, V; Santos, H; Trigo, A; Gómez, M B; Larrosa, D; Temprano, T; González, M; Murias, E; Calleja, S

2016-04-01

Intravenous thrombolysis with alteplase is an effective treatment for ischaemic stroke when applied during the first 4.5 hours, but less than 15% of patients have access to this technique. Mechanical thrombectomy is more frequently able to recanalise proximal occlusions in large vessels, but the infrastructure it requires makes it even less available. We describe the implementation of code stroke in Asturias, as well as the process of adapting various existing resources for urgent stroke care in the region. By considering these resources, and the demographic and geographic circumstances of our region, we examine ways of reorganising the code stroke protocol that would optimise treatment times and provide the most appropriate treatment for each patient. We distributed the 8 health districts in Asturias so as to permit referral of candidates for reperfusion therapies to either of the 2 hospitals with 24-hour stroke units and on-call neurologists and providing IV fibrinolysis. Hospitals were assigned according to proximity and stroke severity; the most severe cases were immediately referred to the hospital with on-call interventional neurology care. Patient triage was provided by pre-hospital emergency services according to the NIHSS score. Modifications to code stroke in Asturias have allowed us to apply reperfusion therapies with good results, while emphasising equitable care and managing the severity-time ratio to offer the best and safest treatment for each patient as soon as possible. Copyright © 2015 Sociedad Española de Neurología. Published by Elsevier España, S.L.U. All rights reserved.

Delayed-onset dementia after stroke or transient ischemic attack.

PubMed

Mok, Vincent C T; Lam, Bonnie Y K; Wang, Zhaolu; Liu, Wenyan; Au, Lisa; Leung, Eric Y L; Chen, Sirong; Yang, Jie; Chu, Winnie C W; Lau, Alexander Y L; Chan, Anne Y Y; Shi, Lin; Fan, Florence; Ma, Sze H; Ip, Vincent; Soo, Yannie O Y; Leung, Thomas W H; Kwok, Timothy C Y; Ho, Chi L; Wong, Lawrence K S; Wong, Adrian

2016-11-01

Patients surviving stroke without immediate dementia are at high risk of delayed-onset dementia. Mechanisms underlying delayed-onset dementia are complex and may involve vascular and/or neurodegenerative diseases. Dementia-free patients with stroke and/or transient ischemic attack (TIA; n = 919) were studied for 3 years prospectively, excluding those who developed dementia 3 to 6 months after stroke and/or TIA. Forty subjects (4.4%) developed dementia during the study period. Imaging markers of severe small vessel disease (SVD), namely presence of ≥3 lacunes and confluent white matter changes; history of hypertension and diabetes mellitus independently predicted delayed-onset dementia after adjustment for age, gender, and education. Only 6 of 31 (19.4%) subjects with delayed cognitive decline harbored Alzheimer's disease-like Pittsburg compound B (PiB) retention. Most PiB cases (16/25, 64%) had evidence of severe SVD. Severe SVD contributes importantly to delayed-onset dementia after stroke and/or TIA. Future clinical trials aiming to prevent delayed-onset dementia after stroke and/or TIA should target this high-risk group. Copyright © 2016 The Alzheimer's Association. Published by Elsevier Inc. All rights reserved.

[In-hospital stroke care in Catalonia [Spain]. Results of the "First Clinical Audit of Stroke. Catalonia, 2005/2006"].

PubMed

Abilleira, Sònia; Ribera, Aida; Sánchez, Emília; Roquer, Jaume; Duarte, Esther; Tresserras, Ricard; Gallofré, Miquel

2008-01-01

To determine the quality of in-hospital stroke care in public acute care hospitals in Catalonia before the implementation of a clinical practice guideline (CPG) on stroke by determining adherence to specific recommendations of the CPG. We retrospectively reviewed the case notes of consecutive patients with stroke (defined with ICD-9 codes: 431, 433.x1, 434.x1, and 436) admitted to 48 Catalan hospitals within the first half of 2005. Data were collected on indicators of the healthcare process selected on the basis of their scientific evidence and/or clinical relevance. The participating hospitals included 20, 40 or 60 stroke cases according to their annual stroke caseload. After random selection, up to 9.3% of all cases recruited at each study center were externally monitored to assess the quality of the data gathered. Indicators were grouped into six different dimensions related to distinct aspects of clinical practice. We analyzed data from 1,791 stroke cases (53.9% men, mean age: 75.6 [12.4] years). Overall inter-observer agreement was 0.7. Compliance with the six dimensions was as follows (mean percentage [95%CI]): quality of medical records, 78.5% (77.5-79.4); initial interventions, 92.4% (91.5-93.2); neurological assessment, 38.3% (37.3-39.3); assessment of rehabilitation needs, 44.9% (43.2-46.7); prevention and management of medical complications, 68.4% (66.9-70), and initial preventive measures, 78.9% (77.3-80.4). In the first half of 2005, in-hospital stroke care in Catalonia showed room for improvement particularly in aspects related to the neurological assessment and follow-up of patients and their rehabilitation process.

Association of antidepressant medication therapy with inpatient rehabilitation outcomes for stroke, traumatic brain injury, or traumatic spinal cord injury.

PubMed

Weeks, Douglas L; Greer, Christopher L; Bray, Brenda S; Schwartz, Catrina R; White, John R

2011-05-01

To study whether outcomes in patients who have undergone inpatient rehabilitation for stroke, traumatic brain injury (TBI), or traumatic spinal cord injury (TSCI) differ based on antidepressant medication (ADM) use. Retrospective cohort study of 867 electronic medical records of patients receiving inpatient rehabilitation for stroke, TBI, or TSCI. Four cohorts were formed within each rehabilitation condition: patients with no history of ADM use and no indication of history of depression; patients with no history of ADM use but with a secondary diagnostic code for a depressive illness; patients with a history of ADM use prior to and during inpatient rehabilitation; and patients who began ADM therapy in inpatient rehabilitation. Freestanding inpatient rehabilitation facility (IRF). Patients diagnosed with stroke (n=625), TBI (n=175), and TSCI (n=67). Not applicable. FIM, rehabilitation length of stay (LOS), deviation between actual LOS and expected LOS, and functional gain per day. In each impairment condition, patients initiating ADM therapy in inpatient rehabilitation had longer LOS than patients in the same impairment condition on ADM at IRF admission, and had significantly longer LOS than patients with no history of ADM use and no diagnosis of depression (P<.05). LOS for patients initiating ADM therapy as inpatients even exceeded LOS for patients without ADM history, but who had a diagnosis for a depressive disorder. Deviation in LOS was significantly larger in the stroke and TBI groups initiating ADM in IRF than their counterparts with no history of ADM use, illustrating that the group initiating ADM therapy in rehabilitation significantly exceeded expected LOS. Increased LOS did not translate into functional gains, and in fact, functional gain per day was lower in the group initiating ADM therapy in IRF. Explanations for unexpectedly long LOS in patients initiating ADM in inpatient rehabilitation focus on the potential for ADM to inhibit therapy-driven remodeling of the nervous system when initiated close in time to nervous system injury, or the possibility that untreated sequelae (eg, depressive symptoms or fatigue) were limiting progress in therapy, which triggered ADM treatment. Copyright © 2011 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.

Phosphorylated recombinant HSP27 protects the brain and attenuates blood-brain barrier disruption following stroke in mice receiving intravenous tissue-plasminogen activator.

PubMed

Shimada, Yoshiaki; Shimura, Hideki; Tanaka, Ryota; Yamashiro, Kazuo; Koike, Masato; Uchiyama, Yasuo; Urabe, Takao; Hattori, Nobutaka

2018-01-01

Loss of integrity of the blood-brain barrier (BBB) in ischemic stroke victims initiates a devastating cascade of events causing brain damage. Maintaining the BBB is important to preserve brain function in ischemic stroke. Unfortunately, recombinant tissue plasminogen activator (tPA), the only effective fibrinolytic treatment at the acute stage of ischemic stroke, also injures the BBB and increases the risk of brain edema and secondary hemorrhagic transformation. Thus, it is important to identify compounds that maintain BBB integrity in the face of ischemic injury in patients with stroke. We previously demonstrated that intravenously injected phosphorylated recombinant heat shock protein 27 (prHSP27) protects the brains of mice with transient middle cerebral artery occlusion (tMCAO), an animal stroke-model. Here, we determined whether prHSP27, in addition to attenuating brain injury, also decreases BBB damage in hyperglycemic tMCAO mice that had received tPA. After induction of hyperglycemia and tMCAO, we examined 4 treatment groups: 1) bovine serum albumin (BSA), 2) prHSP27, 3) tPA, 4) tPA plus prHSP27. We examined the effects of prHSP27 by comparing the BSA and prHSP27 groups and the tPA and tPA plus prHSP27 groups. Twenty-four hours after injection, prHSP27 reduced infarct volume, brain swelling, neurological deficits, the loss of microvessel proteins and endothelial cell walls, and mortality. It also reduced the rates of hemorrhagic transformation, extravasation of endogenous IgG, and MMP-9 activity, signs of BBB damage. Therefore, prHSP27 injection attenuated brain damage and preserved the BBB in tPA-injected, hyperglycemic tMCAO experimental stroke-model mice, in which the BBB is even more severely damaged than in simple tMCAO mice. The attenuation of brain damage and BBB disruption in the presence of tPA suggests the effectiveness of prHSP27 and tPA as a combination therapy. prHSP27 may be a novel therapeutic agent for ischemic stroke patients whose BBBs are injured following tPA injections.

A measure of early physical functioning (EPF) post-stroke.

PubMed

Finch, Lois E; Higgins, Johanne; Wood-Dauphinee, Sharon; Mayo, Nancy E

2008-07-01

To develop a comprehensive measure of Early Physical Functioning (EPF) post-stroke quantified through Rasch analysis and conceptualized using the International Classification of Functioning Disability and Health (ICF). An observational cohort study. A cohort of 262 subjects (mean age 71.6 (standard deviation 12.5) years) hospitalized post-acute stroke. Functional assessments were made within 3 days of stroke with items from valid and reliable indices commonly utilized to evaluate stroke survivors. Information on important variables was also collected. Principal component and Rasch analysis confirmed the factor structure, and dimensionality of the measure. Rasch analysis combined items across ICF components to develop the measure. Items were deleted iteratively, those retained fit the model and were related to the construct; reliability and validity were assessed. A 38-item unidimensional measure of the EPF met all Rasch model requirements. The item difficulty matched the person ability (mean person measure: -0.31; standard error 0.37 logits), reliability of the person-item-hierarchy was excellent at 0.97. Initial validity was adequate. The 38-item EPF measure was developed. It expands the range of assessment post acute stroke; it covers a broad spectrum of difficulty with good initial psychometric properties that, once revalidated, can assist in planning and evaluating early interventions.

Electrification in winter storms and the analysis of thunderstorm overflight

NASA Technical Reports Server (NTRS)

Brook, Marx

1991-01-01

The emergence of 24 hr operational lightning detection networks has led to the finding that positive lightning strokes, although still much fewer in number than the normal negative strokes, are present in summer and winter storms. Recent papers address the importance of understanding the meteorological conditions which lead to a dominance of one polarity of stroke over another; the appearance of positive strokes at the end of a storm appeared to presage the end-of-storm downdraft and subsidence leading to downburst activity. It is beginning to appear that positive strokes may be important meteorological indicators. Significant research accomplishments on the following topics are addressed: (1) a study to verify that the black boxes used in the lightning networks to detect both negative and positive strokes to ground were accurate; (2) the use of slow tails to determine the polarity of distant lightning; (3) lightning initiation in winter vs. summer storms; (4) the upgrade of sensors for the measurement of electric field signals associated with lightning; (5) the analysis of lightning flash records from storms between 40 and 125 km from the sensor; and (6) an interesting aspect of the initiation process which involves the physical processes driving the stepped leader. The focus of current research and future research plans are presented.

On the Nature of Cloud Lightning

NASA Astrophysics Data System (ADS)

Betz, H. D.; Schmidt, K.; Oettinger, W. P.; Montag, B.; Wuerl, A.

2009-04-01

Studies of lightning discharges generally deal with electrical activities that occur both inside thunderclouds (IC) and may involve a ground connection (CG). Even though CG has been studied more extensively than IC, it is known that the two types of discharges are accompanied by emission of qualitatively similar radiation. Less well recognized is the observation that relatively strong strokes are produced not only in connection with CG, but also by discharge processes that do not connect to ground. These IC strokes tend to exhibit somewhat smaller field amplitudes than CG strokes, but they produce thunder and the field records often resemble the ones known from CG. In fact, the number of these IC-strokes is large enough to allow efficient monitoring of cloud activity with the same technique as one applies for CG detection (VLF/LF). Very frequently, IC-strokes are produced during the initial breakdown phase, whereby initiation is probably caused by electron runaway processes that extend over hundreds of meters. Further prominent discharge phases can be effectively observed, most important are stepped leaders with copious emission of VHF radio signals. Experimental data for the various cloud processes are discussed and evaluated with respect to theoretical and practical significance. Open questions on the production mechanisms are elucidated, and the relative occurrence of IC versus CG strokes is illustrated.

Social Deprivation and Initial Presentation of 12 Cardiovascular Diseases: a CALIBER Study

ClinicalTrials.gov

2013-09-03

Abdominal Aortic Aneurysm; Coronary Heart Disease NOS; Unheralded Corronary Death; Intracerebral Haemorrhage; Heart Failure; Ischemic Stroke; Myocardial Infarction; Stroke; Peripheral Arterial Disease; Stable Angina Pectoris; Subarachnoid Haemorrhage; Transient Ischemic Attack; Unstable Angina; Cardiac Arrest, Sudden Cardiac Death

Burden of stroke in Bangladesh.

PubMed

Islam, Md Nazmul; Moniruzzaman, Mohammed; Khalil, Md Ibrahim; Basri, Rehana; Alam, Mohammad Khursheed; Loo, Keat Wei; Gan, Siew Hua

2013-04-01

Stroke is the third leading cause of death in Bangladesh. The World Health Organization ranks Bangladesh's mortality rate due to stroke as number 84 in the world. The reported prevalence of stroke in Bangladesh is 0.3%, although no data on stroke incidence have been recorded. Hospital-based studies conducted in past decades have indicated that hypertension is the main cause of ischaemic and haemorrhagic stroke in Bangladesh. The high number of disability-adjusted life-years lost due to stroke (485 per 10,000 people) show that stroke severely impacts Bangladesh's economy. Although two non-governmental organizations, BRAC and the Centre for the Rehabilitation of the Paralysed, are actively involved in primary stroke prevention strategies, the Bangladeshi government needs to emphasize healthcare development to cope with the increasing population density and to reduce stroke occurrence. © 2012 The Authors. International Journal of Stroke © 2012 World Stroke Organization.

C-reactive protein concentration and risk of coronary heart disease, stroke, and mortality: an individual participant meta-analysis.

PubMed

Kaptoge, Stephen; Di Angelantonio, Emanuele; Lowe, Gordon; Pepys, Mark B; Thompson, Simon G; Collins, Rory; Danesh, John

2010-01-09

Associations of C-reactive protein (CRP) concentration with risk of major diseases can best be assessed by long-term prospective follow-up of large numbers of people. We assessed the associations of CRP concentration with risk of vascular and non-vascular outcomes under different circumstances. We meta-analysed individual records of 160 309 people without a history of vascular disease (ie, 1.31 million person-years at risk, 27 769 fatal or non-fatal disease outcomes) from 54 long-term prospective studies. Within-study regression analyses were adjusted for within-person variation in risk factor levels. Log(e) CRP concentration was linearly associated with several conventional risk factors and inflammatory markers, and nearly log-linearly with the risk of ischaemic vascular disease and non-vascular mortality. Risk ratios (RRs) for coronary heart disease per 1-SD higher log(e) CRP concentration (three-fold higher) were 1.63 (95% CI 1.51-1.76) when initially adjusted for age and sex only, and 1.37 (1.27-1.48) when adjusted further for conventional risk factors; 1.44 (1.32-1.57) and 1.27 (1.15-1.40) for ischaemic stroke; 1.71 (1.53-1.91) and 1.55 (1.37-1.76) for vascular mortality; and 1.55 (1.41-1.69) and 1.54 (1.40-1.68) for non-vascular mortality. RRs were largely unchanged after exclusion of smokers or initial follow-up. After further adjustment for fibrinogen, the corresponding RRs were 1.23 (1.07-1.42) for coronary heart disease; 1.32 (1.18-1.49) for ischaemic stroke; 1.34 (1.18-1.52) for vascular mortality; and 1.34 (1.20-1.50) for non-vascular mortality. CRP concentration has continuous associations with the risk of coronary heart disease, ischaemic stroke, vascular mortality, and death from several cancers and lung disease that are each of broadly similar size. The relevance of CRP to such a range of disorders is unclear. Associations with ischaemic vascular disease depend considerably on conventional risk factors and other markers of inflammation. British Heart Foundation, UK Medical Research Council, BUPA Foundation, and GlaxoSmithKline. Copyright 2010 Elsevier Ltd. All rights reserved.

Which stroke symptoms prompt a 911 call? A population-based study.

PubMed

Kleindorfer, Dawn; Lindsell, Christopher J; Moomaw, Charles J; Alwell, Kathleen; Woo, Daniel; Flaherty, Matthew L; Adeoye, Opeolu; Zakaria, Tarek; Broderick, Joseph P; Kissela, Brett M

2010-06-01

Many studies show that a major barrier to short-term treatment of stroke is patient or bystander delay in responding to stroke symptoms. Most studies have found that less than half of stroke/transient ischemic attack (TIA) events result in a 911 call. We sought to determine which symptoms prompt the public to call 911. A population of 1.3 million within a 5-county region was screened for TIA and all strokes in 1999 using all local hospital International Classification of Diseases, Ninth Edition, codes for stroke (430-436) during 1999. Documented stroke symptoms were abstracted from the medical record. Symptoms were grouped as weakness, numbness, speech/language, confusion/decreased level of consciousness, headache, visual changes, and dizziness/vertigo/coordination. Cases included in this analysis had their strokes at home or work and presented to an emergency department. Logistic regression assessed which symptoms predicted a 911 call, adjusting for age, race, sex, prior stroke, baseline disability, overall stroke severity, home vs work, and stroke subtype. Two thousand nine hundred seventy-five stroke/TIA patients met inclusion criteria, of whom 40% used emergency medical services. After adjustment, symptoms that increased odds of a 911 call were weakness, confusion/decreased level of consciousness, speech/language, and dizziness/coordination/vertigo. Numbness was less likely to result in a 911 call as were visual changes. The presence of headache was not associated with the decision to call 911. The public appears to respond differently based on the type of stroke symptom, independent of overall severity. Public awareness messages regarding stroke warning signs should be designed with this in mind. Copyright (c) 2010 Elsevier Inc. All rights reserved.

Quantitation of aortic and mitral regurgitation in the pediatric population: evaluation by radionuclide angiocardiography

DOE Office of Scientific and Technical Information (OSTI.GOV)

Hurwitz, R.A.; Treves, S.; Freed, M.

The ability to quantitate aortic (AR) or mitral regurgitation (MR), or both, by radionuclide angiocardiography was evaluated in children and young adults at rest and during isometric exercise. Regurgitation was estimated by determining the ratio of left ventricular stroke volume to right ventricular stroke volume obtained during equilibrium ventriculography. The radionuclide measurement was compared with results of cineangiography, with good correlation between both studies in 47 of 48 patients. Radionuclide stroke volume ratio was used to classify severity: the group with equivocal regurgitation differed from the group with mild regurgitation (p less than 0.02); patients with mild regurgitation differed frommore » those with moderate regurgitation (p less than 0.001); and those with moderate regurgitation differed from those with severe regurgitation (p less than 0.01). The stroke volume ratio was responsive to isometric exercise, remaining constant or increasing in 16 of 18 patients. After surgery to correct regurgitation, the stroke volume ratio significantly decreased from preoperative measurements in all 7 patients evaluated. Results from the present study demonstrate that a stroke volume ratio greater than 2.0 is compatible with moderately severe regurgitation and that a ratio greater than 3.0 suggests the presence of severe regurgitation. Thus, radionuclide angiocardiography should be useful for noninvasive quantitation of AR or MR, or both, helping define the course of young patients with left-side valvular regurgitation.« less

Enhancing the development and approval of acute stroke therapies: Stroke Therapy Academic Industry roundtable.

PubMed

Fisher, Marc; Albers, Gregory W; Donnan, Geoffrey A; Furlan, Anthony J; Grotta, James C; Kidwell, Chelsea S; Sacco, Ralph L; Wechsler, Lawrence R

2005-08-01

Previous Stroke Therapy Academic Industry Roundtable (STAIR) meetings focused on preclinical evidence of drug efficacy and enhancing acute stroke trial design and performance. A fourth (STAIR-IV) was held to discuss relevant issues related to acute stroke drug development and regulatory approval. The STAIR-IV meeting had 3 main focus areas. The first topic was novel approaches to statistical design of acute stroke trials and appropriate outcome measures. The second focus was the need for better cooperation among participants in stroke therapy development that may be addressed through a national consortium of stroke trial centers in the United States and elsewhere. Lastly, regulatory issues related to the approval of novel mono and multiple acute stroke therapies were discussed. The development of additional acute stroke therapies represents a large unmet need with many remaining challenges and also opportunities to incorporate novel approaches to clinical trial design that will lead to regulatory approval. The STAIR-IV meeting explored new concepts of trial methodology and data analysis, initiatives for implementing a US clinical trialist consortium, and pertinent regulatory issues to expedite approval of novel therapies.

Stroke mortality in Tennessee: an eco-epidemiologic perspective.

PubMed

Flowers, Joanne; Vutla, Balaji; Aldrich, Tim E

2008-04-01

Prevention of stroke mortality in Tennessee is a statewide public health priority. These analyses describe how the distribution of Caucasian stroke mortality is greater among the state's Appalachian Counties. For African-American residents, the elevated stroke mortality risk is not distinctive for geographic regions, although Upper East Tennessee rates are elevated. If the Caucasian criteria for assigning "high" rates were used with African-American stroke mortality data, the entire state would be designated as having elevated levels for stroke mortality. Race-gender specific analyses at the county-level (ecological attributes) illustrate the greater risks for "high" county-level stroke mortality rates are present for urban and poor communities in our state. African-American males are a clear exception, where the poorer, rural communities show a protective effect for "high" county-level stroke mortality rates. We support implementing stroke prevention programming and public health interventions based on the mortality data distributions; compatible statewide initiatives are underway We recommend strategic over-sampling of the state's priority populations for stroke risk to facilitate the monitoring of prevention and intervention program impacts over time.

RApid Primary care Initiation of Drug treatment for Transient Ischaemic Attack (RAPID-TIA): study protocol for a pilot randomised controlled trial.

PubMed

Edwards, Duncan; Fletcher, Kate; Deller, Rachel; McManus, Richard; Lasserson, Daniel; Giles, Matthew; Sims, Don; Norrie, John; McGuire, Graham; Cohn, Simon; Whittle, Fiona; Hobbs, Vikki; Weir, Christopher; Mant, Jonathan

2013-07-02

People who have a transient ischaemic attack (TIA) or minor stroke are at high risk of a recurrent stroke, particularly in the first week after the event. Early initiation of secondary prevention drugs is associated with an 80% reduction in risk of stroke recurrence. This raises the question as to whether these drugs should be given before being seen by a specialist--that is, in primary care or in the emergency department. The aims of the RAPID-TIA pilot trial are to determine the feasibility of a randomised controlled trial, to analyse cost effectiveness and to ask: Should general practitioners and emergency doctors (primary care physicians) initiate secondary preventative measures in addition to aspirin in people they see with suspected TIA or minor stroke at the time of referral to a specialist? This is a pilot randomised controlled trial with a sub-study of accuracy of primary care physician diagnosis of TIA. In the pilot trial, we aim to recruit 100 patients from 30 general practices (including out-of-hours general practice centres) and 1 emergency department whom the primary care physician diagnoses with TIA or minor stroke and randomly assign them to usual care (that is, initiation of aspirin and referral to a TIA clinic) or usual care plus additional early initiation of secondary prevention drugs (a blood-pressure lowering protocol, simvastatin 40 mg and dipyridamole 200 mg m/r bd). The primary outcome of the main study will be the number of strokes at 90 days. The diagnostic accuracy sub-study will include these 100 patients and an additional 70 patients in whom the primary care physician thinks the diagnosis of TIA is possible, rather than probable. For the pilot trial, we will report recruitment rate, follow-up rate, a preliminary estimate of the primary event rate and occurrence of any adverse events. For the diagnostic study, we will calculate sensitivity and specificity of primary care physician diagnosis using the final TIA clinic diagnosis as the reference standard. This pilot study will be used to estimate key parameters that are needed to design the main study and to estimate the accuracy of primary care diagnosis of TIA. The planned follow-on trial will have important implications for the initial management of people with suspected TIA. ISRCTN62019087.

Eating difficulties among stroke patients in the acute state: a descriptive, cross-sectional, comparative study.

PubMed

Medin, Jörgen; Windahl, Jenny; von Arbin, Magnus; Tham, Kerstin; Wredling, Regina

2011-09-01

To examine eating difficulties among stroke patients - a comparison between women and men. Gender differences have been reported in studies of stroke, but the findings are inconclusive and few of these studies have specifically focused on gender differences in eating difficulties. This study was a descriptive, cross-sectional, comparative study. Patients with stroke were recruited at a general hospital in Sweden. To detect eating difficulties, individual observations of the patients were made during one meal using a structured observation protocol. Assessment also included measurements of nutritional and oral status, degree of independence, stroke severity, neglect and well-being. One hundred and four patients (53·8% women) were included in the study. The proportion of stroke patients with one or more eating difficulties was 81·7%. The most common eating difficulties were 'managing food on the plate' (66·3%), 'food consumption' (54·8%) and 'sitting position' (45·2%). Women had lower 'food consumption', more severe stroke (p = 0·003), worse functional status (p = 0·001) and lower quality of life (QoL) (p=0·038) than men. More women than men were malnourished and living alone. After adjustment for functional status and motor arm, the odds ratio of having difficulties with food consumption was four times higher among women than men (1·7-9·4, confidence interval 95%). More women than men with stroke suffered from inadequate food consumption. The women had more severe strokes, experienced poorer QoL and showed lower functional status than the men. In the rehabilitation process of women with stroke, these factors should be taken into consideration. Structured observation of meals, including assessment of food consumption, might be necessary in acute stroke care to detect patients, especially women, who might need closer supervision and nutritional intervention. © 2011 Blackwell Publishing Ltd.

Confounding by Pre-Morbid Functional Status in Studies of Apparent Sex Differences in Severity and Outcome of Stroke

PubMed Central

Coulombe, Janie; Li, Linxin; Ganesh, Aravind; Silver, Louise; Rothwell, Peter M.

2017-01-01

Background and Purpose— Several studies have reported unexplained worse outcomes after stroke in women but none included the full spectrum of symptomatic ischemic cerebrovascular events while adjusting for prior handicap. Methods— Using a prospective population-based incident cohort of all transient ischemic attack/stroke (OXVASC [Oxford Vascular Study]) recruited between April 2002 and March 2014, we compared pre-morbid and post-event modified Rankin Scale score (mRS) in women and men and change in mRS score 1 month, 6 months, 1 year, and 5 years after stroke. Baseline stroke-related neurological impairment was measured with the National Institutes of Health Stroke Scale. Results— Among 2553 patients (50.6% women) with a first transient ischemic attack/ischemic stroke, women had a worse handicap 1 month after ischemic stroke (age-adjusted odds ratio for mRS score, 1.35; 95% confidence interval, 1.12–1.63). However, women also had a higher pre-morbid mRS score compared with men (age-adjusted odds ratio, 1.58; 95% confidence interval, 1.36–1.84). There was no difference in stroke severity when adjusting for age and pre-morbid mRS (odds ratio, 1.10; 95% confidence interval, 0.90–1.35) and no difference in the pre-/poststroke change in mRS at 1 month (age-adjusted odds ratio, 1.00; 95% confidence interval, 0.82–1.21), 6 months, 1 year, and 5 years. Women had a lower mortality rate, and there was no sex difference in risk of recurrent stroke. Conclusions— We found no evidence of a worse outcome of stroke in women when adjusting for age and pre-morbid mRS. Failure to account for sex differences in pre-morbid handicap could explain contradictory findings in previous studies. Properties of the mRS may also contribute to these inconsistencies. PMID:28798261

Confounding by Pre-Morbid Functional Status in Studies of Apparent Sex Differences in Severity and Outcome of Stroke.

PubMed

Renoux, Christel; Coulombe, Janie; Li, Linxin; Ganesh, Aravind; Silver, Louise; Rothwell, Peter M

2017-10-01

Several studies have reported unexplained worse outcomes after stroke in women but none included the full spectrum of symptomatic ischemic cerebrovascular events while adjusting for prior handicap. Using a prospective population-based incident cohort of all transient ischemic attack/stroke (OXVASC [Oxford Vascular Study]) recruited between April 2002 and March 2014, we compared pre-morbid and post-event modified Rankin Scale score (mRS) in women and men and change in mRS score 1 month, 6 months, 1 year, and 5 years after stroke. Baseline stroke-related neurological impairment was measured with the National Institutes of Health Stroke Scale. Among 2553 patients (50.6% women) with a first transient ischemic attack/ischemic stroke, women had a worse handicap 1 month after ischemic stroke (age-adjusted odds ratio for mRS score, 1.35; 95% confidence interval, 1.12-1.63). However, women also had a higher pre-morbid mRS score compared with men (age-adjusted odds ratio, 1.58; 95% confidence interval, 1.36-1.84). There was no difference in stroke severity when adjusting for age and pre-morbid mRS (odds ratio, 1.10; 95% confidence interval, 0.90-1.35) and no difference in the pre-/poststroke change in mRS at 1 month (age-adjusted odds ratio, 1.00; 95% confidence interval, 0.82-1.21), 6 months, 1 year, and 5 years. Women had a lower mortality rate, and there was no sex difference in risk of recurrent stroke. We found no evidence of a worse outcome of stroke in women when adjusting for age and pre-morbid mRS. Failure to account for sex differences in pre-morbid handicap could explain contradictory findings in previous studies. Properties of the mRS may also contribute to these inconsistencies. Copyright © 2017 The Author(s).

Severity of Post-stroke Aphasia According to Aphasia Type and Lesion Location in Koreans

PubMed Central

Kang, Eun Kyoung; Sohn, Hae Min; Han, Moon-Ku; Kim, Won; Han, Tai Ryoon

2010-01-01

To determine the relations between post-stroke aphasia severity and aphasia type and lesion location, a retrospective review was undertaken using the medical records of 97 Korean patients, treated within 90 days of onset, for aphasia caused by unilateral left hemispheric stroke. Types of aphasia were classified according to the validated Korean version of the Western Aphasia Battery (K-WAB), and severities of aphasia were quantified using WAB Aphasia Quotients (AQ). Lesion locations were classified as cortical or subcortical, and were determined by magnetic resonance imaging. Two-step cluster analysis was performed using AQ values to classify aphasia severity by aphasia type and lesion location. Cluster analysis resulted in four severity clusters: 1) mild; anomic type, 2) moderate; Wernicke's, transcortical motor, transcortical sensory, conduction, and mixed transcortical types, 3) moderately severe; Broca's aphasia, and 4) severe; global aphasia, and also in three lesion location clusters: 1) mild; subcortical 2) moderate; cortical lesions involving Broca's and/or Wernicke's areas, and 3) severe; insular and cortical lesions not in Broca's or Wernicke's areas. These results revealed that within 3 months of stroke, global aphasia was the more severely affected type and cortical lesions were more likely to affect language function than subcortical lesions. PMID:20052357

The effect of the introduction of a case-mix-based funding model of rehabilitation for severe stroke: an Australian experience.

PubMed

Brock, Kim A; Vale, Stephen J; Cotton, Susan M

2007-07-01

To compare resource use of, and outcomes for, rehabilitation for severe stroke before and after the implementation of the Casemix and Rehabilitation Funding Tree case-mix-based funding model. Prospective, observational cohort study. Eight inpatient rehabilitation centers in Australia. Consecutive sample of 609 patients with severe stroke. Not applicable. Rehabilitation length of stay (LOS), discharge destination, and FIM instrument motor score at discharge. The average rehabilitation LOS changed significantly between the preimplementation year and the implementation year (Mann-Whitney U, P=.001). There were no significant differences in discharge destination. FIM motor score at discharge showed significant reduction in improvement (Mann-Whitney U, P=.001) between the preimplementation year and the implementation year. There were no significant correlations between LOS in rehabilitation and gain in function for either the preimplementation year (Spearman rho, P=.07) or the implementation year (P=.15). The change in funding model was associated with a decrease in inpatient costs and with an associated increase in disability at discharge. Our results suggest that the rate of improvement in severe stroke is variable; also, they support the use of funding models for stroke rehabilitation that allow flexibility in resource allocation.

Increased circulating leukocyte-derived microparticles in ischemic cerebrovascular disease.

PubMed

He, Zhangping; Tang, Yanyan; Qin, Chao

2017-06-01

Circulating leukocyte-derived microparticles act as proinflammatory mediators that reflect vascular inflammation. In this study, we examined the hypothesis that the quantity of leukocyte-derived microparticles is increased in patients with ischemic cerebrovascular diseases, and investigated utility of various phenotypes of leukocyte-derived microparticles as specific biomarkers of vascular inflammation injury. Additionally we focused on identifying leukocyte-derived microparticles that may be correlated with stroke severity in acute ischemic stroke patients. The plasma concentration of leukocyte-derived microparticles obtained by a series of centrifugations of 76 consecutive patients with ischemic cerebrovascular diseases and 70 age-, sex-, and race-matched healthy controls were determined by flow cytometry. Significantly elevated numbers of leukocyte (CD45+), monocyte (CD14+), lymphocyte (CD4+), granulocyte (CD15+) derived microparticles were found in the plasma samples of patients ischemic cerebrovascular diseases, compared to healthy controls (p<0.05). Furthermore, the plasma levels of CD14+ microparticles were significantly correlated with stroke severity (r=0.355, p=0.019), cerebral vascular stenosis severity (r=0.255, p=0.025) and stroke subtype (r=0.242, p=0.036). No association with stroke was observed for other leukocyte-derived phenotypes. These results demonstrate that circulating leukocyte-derived microparticles amounts are increased in patients with ischemic cerebrovascular diseases, compared with healthy controls. As proinflammatory mediators, leukocyte-derived microparticles may contribute to vascular inflammatory and the inflammatory process in acute ischemic stroke. Levels of CD14+ microparticles may be a promising biomarker of ischemic severity and outcome of stroke in the clinic. Copyright © 2017 Elsevier Ltd. All rights reserved.

Rehabilitation and education are underutilized for mild stroke and TIA sufferers.

PubMed

Faux, Steven G; Arora, Pooja; Shiner, Christine T; Thompson-Butel, Angelica G; Klein, Linda A

2018-06-01

Transient ischemic attack (TIA) and mild stroke represent a large proportion of cerebrovascular events, at high risk of being followed by recurrent, serious events. The importance of early education addressing risk management, secondary prevention and lifestyle modifications is the centerpiece of further stroke prevention. However, delivering education and rehabilitation to this population can be complex and challenging. Via synthesis of a narrative review and clinical experience, we explore the unique and inherent complexities of rehabilitation management and education provision for patients following mild stroke and TIA. A considerable proportion of TIA/mild stroke survivors have ongoing rehabilitation needs that are poorly addressed. The need for rehabilitation in these patients is often overlooked, and available assessment tools lack the sensitivity to identify common subtle impairments in cognition, mood, language and fatigue. Active and accessible education interventions need to be initiated early after the event, and integrated with ongoing rehabilitation management. Priority areas in need of future development in this field are highlighted and discussed. Implications for rehabilitation Survivors of mild stroke and TIA have ongoing unmet rehabilitation needs and require a unique approach to rehabilitation and education. Rehabilitation needs are difficult to assess and poorly addressed in this cohort, where available assessment tools lack the sensitivity required to identify subtle impairments. Education needs to be initiated early after the event and involve active engagement of the patient in order to improve stroke knowledge, mood and motivate adherence to lifestyle modifications and secondary prevention. Rehabilitation physicians are currently an underutilized resource, who should be more involved in the management of all patients following TIA or mild stroke.

Active ankle dorsiflexion and the Mingazzini manoeuvre: two clinical bedside tests related to prognosis of postural transferring, standing and walking ability in patients with stroke.

PubMed

Smania, N; Gambarin, M; Paolucci, S; Girardi, P; Bortolami, M; Fiaschi, A; Santilli, V; Picelli, A

2011-09-01

Lower limb paresis is one of the main determinants of postural transferring, standing and walking disability in patients with stroke. Early prognosis of recovery of lower limb function and of related functional disability is an important issue in neurorehabilitation clinical practice. Aim of this study was to assess the relationship between active ankle dorsiflexion and the Mingazzini manoeuvre with the prognosis of lower limb function and of postural transferring, standing and walking ability in patients with stroke. This was a longitudinal study with prospectively collected data. University hospital. The study included 53 patients with first unilateral brain ischemic stroke. Patients were evaluated initially (mean 4.02 days) and approximately at six months (mean 178.6 days) after stroke. Initial assessment included active ankle dorsiflexion and the Mingazzini manoeuvre. The assessment after six months included three outcome measures evaluating the rate of improvement of lower limb function and of postural transferring, standing and walking ability (Postural Assessment Scale for Stroke patients, Functional Ambulation Category, Motricity Index leg subtest). The active ankle dorsiflexion showed to be related with the prognosis of lower limb function and of walking ability, while the Mingazzini manoeuvre was related with the improvement of postural transferring and standing ability. Active ankle dorsiflexion and the Mingazzini manoeuvre are related with the prognosis of lower limb function and of postural transferring, standing and walking ability in patients with stroke. These simple bedside tests give a picture of improvement potential of motor activities connected to lower limb function in patients with acute stroke.

Antibody Levels to Persistent Pathogens and Incident Stroke in Mexican Americans

PubMed Central

Sealy-Jefferson, Shawnita; Gillespie, Brenda W.; Aiello, Allison E.; Haan, Mary N.; Morgenstern, Lewis B.; Lisabeth, Lynda D.

2013-01-01

Background Persistent pathogens have been proposed as risk factors for stroke; however, the evidence remains inconclusive. Mexican Americans have an increased risk of stroke especially at younger ages, as well as a higher prevalence of infections caused by several persistent pathogens. Methodology/Principal Findings Using data from the Sacramento Area Latino Study on Aging (n = 1621), the authors used discrete-time regression to examine associations between stroke risk and (1) immunoglobulin G antibody levels to Helicobacter pylori (H. pylori), Cytomegalovirus, Varicella Zoster Virus, Toxoplasma gondii and Herpes simplex virus 1, and (2) concurrent exposure to several pathogens (pathogen burden), defined as: (a) summed sero-positivity, (b) number of pathogens eliciting high antibody levels, and (c) average antibody level. Models were adjusted for socio-demographics and stroke risk factors. Antibody levels to H. pylori predicted incident stroke in fully adjusted models (Odds Ratio: 1.58; 95% Confidence Interval: 1.09, 2.28). No significant associations were found between stroke risk and antibody levels to the other four pathogens. No associations were found for pathogen burden and incident stroke in fully adjusted models. Conclusions/Significance Our results suggest that exposure to H. pylori may be a stroke risk factor in Mexican Americans and may contribute to ethnic differences in stroke risk given the increased prevalence of exposure to H. pylori in this population. Future studies are needed to confirm this association. PMID:23799066

Can we derive an 'exchange rate' between descriptive and preference-based outcome measures for stroke? Results from the transfer to utility (TTU) technique

PubMed Central

Mortimer, Duncan; Segal, Leonie; Sturm, Jonathan

2009-01-01

Background Stroke-specific outcome measures and descriptive measures of health-related quality of life (HRQoL) are unsuitable for informing decision-makers of the broader consequences of increasing or decreasing funding for stroke interventions. The quality-adjusted life year (QALY) provides a common metric for comparing interventions over multiple dimensions of HRQoL and mortality differentials. There are, however, many circumstances when – because of timing, lack of foresight or cost considerations – only stroke-specific or descriptive measures of health status are available and some indirect means of obtaining QALY-weights becomes necessary. In such circumstances, the use of regression-based transformations or mappings can circumvent the failure to elicit QALY-weights by allowing predicted weights to proxy for observed weights. This regression-based approach has been dubbed 'Transfer to Utility' (TTU) regression. The purpose of the present study is to demonstrate the feasibility and value of TTU regression in stroke by deriving transformations or mappings from stroke-specific and generic but descriptive measures of health status to a generic preference-based measure of HRQoL in a sample of Australians with a diagnosis of acute stroke. Findings will quantify the additional error associated with the use of condition-specific to generic transformations in stroke. Methods We used TTU regression to derive empirical transformations from three commonly used descriptive measures of health status for stroke (NIHSS, Barthel and SF-36) to a preference-based measure (AQoL) suitable for attaching QALY-weights to stroke disease states; based on 2570 observations drawn from a sample of 859 patients with stroke. Results Transformations from the SF-36 to the AQoL explained up to 71.5% of variation in observed AQoL scores. Differences between mean predicted and mean observed AQoL scores from the 'severity-specific' item- and subscale-based SF-36 algorithms and from the 'moderate to severe' index- and item-based Barthel algorithm were neither clinically nor statistically significant when 'low severity' SF-36 transformations were used to predict AQoL scores for patients in the NIHSS = 0 and NIHSS = 1–5 subgroups and when 'moderate to severe severity' transformations were used to predict AQoL scores for patients in the NIHSS ≥ 6 subgroup. In contrast, the difference between mean predicted and mean observed AQoL scores from the NIHSS algorithms and from the 'low severity' Barthel algorithms reached levels that could mask minimally important differences on the AQoL scale. Conclusion While our NIHSS to AQoL transformations proved unsuitable for most applications, our findings demonstrate that stroke-relevant outcome measures such as the SF-36 and Barthel Index can be adequately transformed to preference-based measures for the purposes of economic evaluation. PMID:19371444

Parent and family impact of raising a child with perinatal stroke

PubMed Central

2014-01-01

Background Perinatal stroke is a leading cause of early brain injury, cerebral palsy, and lifelong neurological morbidity. No study to date has examined the impact of raising a child with perinatal stroke on parents and families. However, a large breadth of research suggests that parents, especially mothers, may be at increased risk for psychological concerns. The primary aim of this study was to examine the impact of raising a child with perinatal stroke on mothers’ wellbeing. A secondary aim was to examine how caring for a child with perinatal stroke differentially affects mothers and fathers. Methods In Study I, a matched case-control design was used to compare the wellbeing of mothers of children with perinatal stroke and mothers of children with typical development. In Study II, a matched case-control design was used to compare mother-father dyads. Participants completed validated measures of anxiety and depression, stress, quality of life and family functioning, marital satisfaction, and marital distress. Parents of children with perinatal stroke also completed a recently validated measure of the psychosocial impact of perinatal stroke including guilt and blame outcomes. Disease severity was categorized by parents, validated by the Pediatric Stroke Outcome Measure (PSOM), and compared across the above outcomes in Study I. Results A total of 112 mothers participated in Study I (n = 56 per group; mean child age = 7.42 years), and 56 parents participated in Study II (n = 28 per group; mean child age = 8.25 years). In Study I, parent assessment of disease severity was correlated with PSOM scores (γ = 0.75, p < .001) and associated with parent outcomes. Mothers of children with mild conditions were indistinguishable from controls on the outcome measures. However, mothers of children with moderate/severe conditions had poorer outcomes on measures of depression, marital satisfaction, quality of life, and family functioning. In Study II, mothers and fathers had similar outcomes except mothers demonstrated a greater burden of guilt and higher levels of anxiety. Conclusions Although most mothers of children with perinatal stroke adapt well, mothers of children with moderate/severe conditions appear to be at higher risk for psychological concerns. PMID:25018138

Parent and family impact of raising a child with perinatal stroke.

PubMed

Bemister, Taryn B; Brooks, Brian L; Dyck, Richard H; Kirton, Adam

2014-07-14

Perinatal stroke is a leading cause of early brain injury, cerebral palsy, and lifelong neurological morbidity. No study to date has examined the impact of raising a child with perinatal stroke on parents and families. However, a large breadth of research suggests that parents, especially mothers, may be at increased risk for psychological concerns. The primary aim of this study was to examine the impact of raising a child with perinatal stroke on mothers' wellbeing. A secondary aim was to examine how caring for a child with perinatal stroke differentially affects mothers and fathers. In Study I, a matched case-control design was used to compare the wellbeing of mothers of children with perinatal stroke and mothers of children with typical development. In Study II, a matched case-control design was used to compare mother-father dyads. Participants completed validated measures of anxiety and depression, stress, quality of life and family functioning, marital satisfaction, and marital distress. Parents of children with perinatal stroke also completed a recently validated measure of the psychosocial impact of perinatal stroke including guilt and blame outcomes. Disease severity was categorized by parents, validated by the Pediatric Stroke Outcome Measure (PSOM), and compared across the above outcomes in Study I. A total of 112 mothers participated in Study I (n = 56 per group; mean child age = 7.42 years), and 56 parents participated in Study II (n = 28 per group; mean child age = 8.25 years). In Study I, parent assessment of disease severity was correlated with PSOM scores (γ = 0.75, p < .001) and associated with parent outcomes. Mothers of children with mild conditions were indistinguishable from controls on the outcome measures. However, mothers of children with moderate/severe conditions had poorer outcomes on measures of depression, marital satisfaction, quality of life, and family functioning. In Study II, mothers and fathers had similar outcomes except mothers demonstrated a greater burden of guilt and higher levels of anxiety. Although most mothers of children with perinatal stroke adapt well, mothers of children with moderate/severe conditions appear to be at higher risk for psychological concerns.

["Healthy Region Lower Rhine ... against Stroke": the concept and implementation of an intersectoral public health programme 2003-2008].

PubMed

Rau, Rüdiger; Rumpeltin, Carsten; Hoop, Renate; Pfeiffer, Holger; Drees, Jeannette; Paas, Birgit; Schmitz-Buhl, Gabriele; Geraedts, Max

2009-01-01

When the Public Health Service Act of North Rhine-Westphalia (OGDG-NRW) came into effect local health conferences (KGK) were established in both rural and urban districts. These conferences are designed to optimize medical and social healthcare at the local level. In 2001 KGK managers from six neighbouring districts founded the Network Healthy Lower Rhine. From 2003 to 2008 this network was able to implement the "Healthy Lower Rhine ... against Stroke" programme. The initiative primarily aims at improving community knowledge of stroke with regard to 1) proper action ("Stroke is a medical emergency, so call the emergency number 112!") and 2) stroke warning signs. Eventually these steps are intended 3) to reduce prehospital delays. Before the program started a project plan was developed including evaluation approaches. The central elements of the concept include local health targets, intersectoral collaboration and networking, 5-year programme duration, social marketing and a communication strategy. Initially, a needs assessment was conducted using local expert panels, surveys on community knowledge, and clinical data sampling to assess healthcare quality. Subsequently, a package of measures with a "two-level implementation model" was prepared. Normative evaluation consisted of self-reflection within the network-team. The summative evaluation was based on two approaches: surveys on community knowledge of stroke (city of Düsseldorf and district of Wesel) as well as data sample collection in hospitals on health care quality. The central elements of the concepts were implemented. Community surveys revealed similar deficits in community knowledge of stroke in the city of Dusseldorf (2000 and 2004) and in the district of Wesel (2002 and 2008). Knowledge of proper action (call 112 in case of stroke) significantly improved in the Dusseldorf community from 32.5% of correct statements in 2000 to 50.6% correct answers in 2004 and, finally, in 2008 to 69% correct answers in the Wesel district. Hospitals in the district of Wesel collected three-month samples of data on prehospital times in 2003 (before the initiative was started) and in 2005. There was no significant change: the portion of 28% of patients being hospitalized within a three-hour window after the onset of stroke symptoms remained unchanged. Due to medical progress and demographic changes stroke remains a paramount issue of public health in Germany. With its programme "Healthy Lower Rhine ... against Stroke" the Network Healthy Lower Rhine provides a strategy for launching and implementing a complex and intersectoral public health intervention.

Cross-Cultural Adaptation and Initial Validation of the Stroke-Specific Quality of Life Scale into the Yoruba Language

ERIC Educational Resources Information Center

Akinpelu, Aderonke O.; Odetunde, Marufat O.; Odole, Adesola C.

2012-01-01

Stroke-Specific Quality of Life 2.0 (SS-QoL 2.0) scale is used widely and has been cross-culturally adapted to many languages. This study aimed at the cross-cultural adaptation of SS-QoL 2.0 to Yoruba, the indigenous language of south-western Nigeria, and to carry out an initial investigation on its validity. English SS-QoL 2.0 was first adapted…

Literature and art therapy in post-stroke psychological disorders.

PubMed

Eum, Yeongcheol; Yim, Jongeun

2015-01-01

Stroke is one of the leading causes of morbidity and long-term disability worldwide, and post-stroke depression (PSD) is a common and serious psychiatric complication of stroke. PSD makes patients have more severe deficits in activities of daily living, a worse functional outcome, more severe cognitive deficits and increased mortality as compared to stroke patients without depression. Therefore, to reduce or prevent mental problems of stroke patients, psychological treatment should be recommended. Literature and art therapy are highly effective psychological treatment for stroke patients. Literature therapy divided into poetry and story therapy is an assistive tool that treats neurosis as well as emotional or behavioral disorders. Poetry can add impression to the lethargic life of a patient with PSD, thereby acting as a natural treatment. Story therapy can change the gloomy psychological state of patients into a bright and healthy story, and therefore can help stroke patients to overcome their emotional disabilities. Art therapy is one form of psychological therapy that can treat depression and anxiety in stroke patients. Stroke patients can express their internal conflicts, emotions, and psychological status through art works or processes and it would be a healing process of mental problems. Music therapy can relieve the suppressed emotions of patients and add vitality to the body, while giving them the energy to share their feelings with others. In conclusion, literature and art therapy can identify the emotional status of patients and serve as a useful auxiliary tool to help stroke patients in their rehabilitation process.

Issues post-stroke for Muslim people in maintaining the practice of salat (prayer): A qualitative study.

PubMed

Mohamed, Che Rabiaah; Nelson, Katherine; Wood, Pamela; Moss, Cheryle

2015-01-01

Muslims throughout the world perform salat (prayer) five times a day; salat involves a person reciting the Holy Qur'an while being in several positions. There are several steps that should be carried out before prayer, including wudhu (ablution) and covering one's awrah (body). To identify educational needs for stroke patients and their caregivers in Malaysia. Another purpose is to report on the needs identified by stroke patients and their families related to salat. Descriptive qualitative study. Phase 1 involved semi-structured interviews with stroke patients (n = 5), family caregivers (n = 5) and health professionals (n = 12) in Kelantan Malaysia. Phase 2 involved presenting the findings from Phase 1 to the health professionals with the aim of establishing priorities and processes to develop education strategies for stroke patients and their families. Preparing for and performing salat was challenging for both patient and family carers to do following a stroke. Themes identified were prayer and the meaning of the stroke events for participants, difficulties praying post-stroke, prayer as part of rehabilitation therapy. Providing culturally safe care should include how nurses assess and support patients and their caregivers post stroke to meet their prayer needs. Nurses have a role in discussing with stroke patients and their families how in addition to its spiritual and customary benefits, prayer and for Muslims reciting the Holy Qur'an can have cognitive and rehabilitation benefits, as well as being a source of psychological support for stroke patients.

Inequities in access to inpatient rehabilitation after stroke: an international scoping review.

PubMed

Lynch, Elizabeth A; Cadilhac, Dominique A; Luker, Julie A; Hillier, Susan L

2017-12-01

Background Inequities in accessing inpatient rehabilitation after stroke have been reported in many countries and impact on patient outcomes. Objective To explore variation in international recommendations regarding which patients should receive inpatient rehabilitation after stroke and to describe reported access to rehabilitation. Methods A scoping review was conducted to identify clinical guidelines with recommendations regarding which patients should access inpatient rehabilitation after stroke, and data regarding the proportion of patients accessing stroke rehabilitation. Four bibliographic databases and grey literature were searched. Results Twenty-eight documents were included. Selection criteria for post-acute inpatient rehabilitation were identified for 14 countries or regions and summary data on the proportion of patients receiving inpatient rehabilitation were identified for 14 countries. In Australia, New Zealand, and the United Kingdom, it is recommended that all patients with stroke symptoms should access rehabilitation, whereas guidelines from the United States, Canada, and Europe did not consistently recommend rehabilitation for people with severe stroke. Access to inpatient rehabilitation ranged from 13% in Sweden to 57% in Israel. Differences in availability of early supported discharge/home rehabilitation programs and variations in reporting methods may influence the ability to reliably compare access to rehabilitation between regions. Conclusion Recommendations regarding which patients with moderate and severe strokes should access ongoing rehabilitation are inconsistent. Clinical practice guidelines from different countries regarding post-stroke rehabilitation do not always reflect the evidence regarding the likely benefits to people with stroke. Inequity in access to rehabilitation after stroke is an international issue.

Cardioembolic Stroke

PubMed Central

Kamel, Hooman; Healey, Jeff S.

2017-01-01

Cardiac embolism accounts for an increasing proportion of ischemic strokes, and might multiply several-fold over the next decades. However, research points to several potential strategies to stem this expected rise in cardioembolic stroke. First, although one-third of strokes are of unclear cause, it is increasingly accepted that many of these cryptogenic strokes arise from a distant embolism rather than in-situ cerebrovascular disease, leading to the recent formulation of “embolic stroke of undetermined source” (ESUS) as a distinct target for investigation. Second, recent clinical trials have indicated that ESUS may often stem from subclinical atrial fibrillation (AF) which can be diagnosed with prolonged heart-rhythm monitoring. Third, emerging evidence indicates that a thrombogenic atrial substrate can lead to atrial thromboembolism even in the absence of AF. Such an atrial cardiopathy may explain many cases of ESUS, and oral anticoagulant drugs may prove to reduce stroke risk from atrial cardiopathy given its parallels to AF. Non-vitamin K antagonist oral anticoagulant (NOAC) drugs have recently expanded therapeutic options for preventing cardioembolic stroke and are currently being tested for stroke prevention in patients with ESUS, including specifically those with atrial cardiopathy. Fourth, increasing appreciation of thrombogenic atrial substrate and the common co-existence of cardiac and extra-cardiac stroke risk factors suggests benefits from global vascular risk factor management in addition to anticoagulation. Finally, improved imaging of ventricular thrombus plus the availability of NOAC drugs may lead to better prevention of stroke from acute myocardial infarction and heart failure. PMID:28154101

Comparing Prognostic Strength of Acute Corticospinal Tract Injury Measured by a New Diffusion Tensor Imaging Based Template Approach Versus Common Approaches

PubMed Central

Hirai, Kelsi K.; Groisser, Benjamin N.; Copen, William A.; Singhal, Aneesh B.; Schaechter, Judith D.

2015-01-01

Background Long-term motor outcome of acute stroke patients with severe motor impairment is difficult to predict. While measure of corticospinal tract (CST) injury based on diffusion tensor imaging (DTI) in subacute stroke patients strongly predicts motor outcome, its predictive value in acute stroke patients is unclear. Using a new DTI-based, density-weighted CST template approach, we demonstrated recently that CST injury measured in acute stroke patients with moderately-severe to severe motor impairment of the upper limb strongly predicts motor outcome of the limb at 6 months. New Method The current study compared the prognostic strength of CST injury measured in 10 acute stroke patients with moderately-severe to severe motor impairment of the upper limb by the new density-weighted CST template approach versus several variants of commonly used DTI-based approaches. Results and Comparison with Existing Methods Use of the density-weighted CST template approach yielded measurements of acute CST injury that correlated most strongly, in absolute magnitude, with 6-month upper limb strength (rs = 0.93), grip (rs = 0.94) and dexterity (rs = 0.89) compared to all other 11 approaches. Formal statistical comparison of correlation coefficients revealed that acute CST injury measured by the density-weighted CST template approach correlated significantly more strongly with 6-month upper limb strength, grip and dexterity than 9, 10 and 6 of the 11 alternative measurements, respectively. Conclusions Measurements of CST injury in acute stroke patients with substantial motor impairment by the density-weighted CST template approach may have clinical utility for anticipating healthcare needs and improving clinical trial design. PMID:26386285

Changes in arm-hand function and arm-hand skill performance in patients after stroke during and after rehabilitation.

PubMed

Franck, Johan Anton; Smeets, Rob Johannes Elise Marie; Seelen, Henk Alexander Maria

2017-01-01

Arm-hand rehabilitation programs applied in stroke rehabilitation frequently target specific populations and thus are less applicable in heterogeneous patient populations. Besides, changes in arm-hand function (AHF) and arm-hand skill performance (AHSP) during and after a specific and well-described rehabilitation treatment are often not well evaluated. This single-armed prospective cohort study featured three subgroups of stroke patients with either a severely, moderately or mildly impaired AHF. Rehabilitation treatment consisted of a Concise_Arm_and_hand_ Rehabilitation_Approach_in_Stroke (CARAS). Measurements at function and activity level were performed at admission, clinical discharge, 3, 6, 9 and 12 months after clinical discharge. Eighty-nine stroke patients (M/F:63/23; mean age:57.6yr (+/-10.6); post-stroke time:29.8 days (+/-20.1)) participated. All patients improved on AHF and arm-hand capacity during and after rehabilitation, except on grip strength in the severely affected subgroup. Largest gains occurred in patients with a moderately affected AHF. As to self-perceived AHSP, on average, all subgroups improved over time. A small percentage of patients declined regarding self-perceived AHSP post-rehabilitation. A majority of stroke patients across the whole arm-hand impairment severity spectrum significantly improved on AHF, arm-hand capacity and self-perceived AHSP. These were maintained up to one year post-rehabilitation. Results may serve as a control condition in future studies.

Post-stroke fatigue and its dimensions within first 3 months after stroke.

PubMed

Delva, Iryna I; Lytvynenko, Nataliya V; Delva, Mykhaylo Y

Post-stroke fatigue (PSF) is a common stroke complication with long-term negative consequences. Assess the qualitative and quantitative PSF characteristics during 3 month post-stroke period. There were examined 141 patients with acute ischemic or hemorrhagic strokes at hospital stay, in 1, 2 and 3 months after stroke. PSF was measured by fatigue assessment scale (FAS), multidimensional fatigue inventory-20 (MFI-20) and fatigue severity scale (FSS). 116 (82.3%) patients had ischemic strokes, 25 (17.7%) had hemorrhagic strokes. According to FAS and MFI-20 "global fatigue" sub-scale, PSF was present, respectively, in 22.0% and 25.5% cases at hospital stay, in 38.3% and 35.5% cases in 3 month after stroke. The growing prevalence of PSF was based on significantly increasing the rates of PSD physical domain (from 28.4% to 41.1%) and the rates of PSF mental domain (from 19.1% to 31.9%). On the other hand, the rates of PSF activity-related component had been significantly reduced from 36.2% to 17.0% within observation period. Moreover, according to MFI-20, it had been revealed significant increasing of PSF intensities in global, physical and mental domains during first 3 post-stroke months. According to FSS value ranks, proportions of patients with "no PSF" had been decreased in 1.5 times due to simultaneously rising rates of "moderate" as well as "severe" PSF impacts on daily life. The PSF spreading is significantly increased during the first 3 post-stroke months due to increasing of rates and intensities of physical and mental PSF domains.

ALTERED PHALANX FORCE DIRECTION DURING POWER GRIP FOLLOWING STROKE

PubMed Central

Enders, Leah R.

2015-01-01

Many stroke survivors with severe impairment can grasp only with a power grip. Yet, little knowledge is available on altered power grip after stroke, other than reduced power grip strength. This study characterized stroke survivors’ static power grip during 100% and 50% maximum grip. Each phalanx force’s angular deviation from the normal direction and its contribution to total normal force was compared for 11 stroke survivors and 11 age-matched controls. Muscle activities and skin coefficient of friction (COF) were additionally compared for another 20 stroke and 13 age-matched control subjects. The main finding was that stroke survivors gripped with a 34% greater phalanx force angular deviation of 19±2° compared to controls of 14±1° (p<.05). Stroke survivors’ phalanx force angular deviation was closer to the 23° threshold of slippage between the phalanx and grip surface, which may explain increased likelihood of object dropping in stroke survivors. In addition, this altered phalanx force direction decreases normal grip force by tilting the force vector, indicating a partial role of phalanx force angular deviation in reduced grip strength post stroke. Greater phalanx force angular deviation may biomechanically result from more severe underactivation of stroke survivors’ first dorsal interosseous (FDI) and extensor digitorum communis (EDC) muscles compared to their flexor digitorum superficialis (FDS) or somatosensory deficit. While stroke survivors’ maximum power grip strength was approximately half of the controls’, the distribution of their remaining strength over the fingers and phalanges did not differ, indicating evenly distributed grip force reduction over the entire hand. PMID:25795079

Improved lower extremity pedaling mechanics in individuals with stroke under maximal workloads.

PubMed

Linder, Susan M; Rosenfeldt, Anson B; Bazyk, Andrew S; Koop, Mandy Miller; Ozinga, Sarah; Alberts, Jay L

2018-05-01

Background Individuals with stroke present with motor control deficits resulting in the abnormal activation and timing of agonist and antagonist muscles and inefficient movement patterns. The analysis of pedaling biomechanics provides a window into understanding motor control deficits, which vary as a function of workload. Understanding the relationship between workload and motor control is critical when considering exercise prescription during stroke rehabilitation. Objectives To characterize pedaling kinematics and motor control processes under conditions in which workload was systematically increased to an eventual patient-specific maximum. Methods A cohort study was conducted in which 18 individuals with chronic stroke underwent a maximal exertion cardiopulmonary exercise test on a stationary cycle ergometer, during which pedaling torque was continuously recorded. Measures of force production, pedaling symmetry, and pedaling smoothness were obtained. Results Mean Torque increased significantly (p < 0.05) for both legs from initial to terminal workloads. Mean torque Symmetry Index, calculated for down and upstroke portions of the pedaling action, improved from 0.37(0.29) to 0.29(0.35) during downstroke (p = 0.007), and worsened during the upstroke: -0.37(0.38) to -0.62(0.46) (p < 0.001) from initial to terminal workloads. Low Torque Duration improved from initial to terminal workloads, decreasing from 121.1(52.9) to 58.1(39.6) degrees (p < 0.001), respectively. Smoothness of pedaling improved significantly from initial to terminal workloads (p < 0.001). Conclusions Improved pedaling kinematics at terminal workloads indicate that individuals with stroke demonstrate improved motor control with respect to the timing, sequencing, and activation of hemiparetic lower extremity musculature compared to lower workloads. Therapeutic prescription involving higher resistance may be necessary to sufficiently engage and activate the paretic lower extremity.

Quantifying Selection Bias in National Institute of Health Stroke Scale Data Documented in an Acute Stroke Registry.

PubMed

Thompson, Michael P; Luo, Zhehui; Gardiner, Joseph; Burke, James F; Nickles, Adrienne; Reeves, Mathew J

2016-05-01

As a measure of stroke severity, the National Institutes of Health Stroke Scale (NIHSS) is an important predictor of patient- and hospital-level outcomes, yet is often undocumented. The purpose of this study is to quantify and correct for potential selection bias in observed NIHSS data. Data were obtained from the Michigan Stroke Registry and included 10 262 patients with ischemic stroke aged ≥65 years discharged from 23 hospitals from 2009 to 2012, of which 74.6% of patients had documented NIHSS. We estimated models predicting NIHSS documentation and NIHSS score and used the Heckman selection model to estimate a correlation coefficient (ρ) between the 2 model error terms, which quantifies the degree of selection bias in the documentation of NIHSS. The Heckman model found modest, but significant, selection bias (ρ=0.19; 95% confidence interval: 0.09, 0.29; P<0.001), indicating that because NIHSS score increased (ie, strokes were more severe), the probability of documentation also increased. We also estimated a selection bias-corrected population mean NIHSS score of 4.8, which was substantially lower than the observed mean NIHSS score of 7.4. Evidence of selection bias was also identified using hospital-level analysis, where increased NIHSS documentation was correlated with lower mean NIHSS scores (r=-0.39; P<0.001). We demonstrate modest, but important, selection bias in documented NIHSS data, which are missing more often in patients with less severe stroke. The population mean NIHSS score was overestimated by >2 points, which could significantly alter the risk profile of hospitals treating patients with ischemic stroke and subsequent hospital risk-adjusted outcomes. © 2016 American Heart Association, Inc.

Pre-hospital Delay as Determinant of Ischemic Stroke Outcome in an Italian Cohort of Patients Not Receiving Thrombolysis.

PubMed

Denti, Licia; Artoni, Andrea; Scoditti, Umberto; Gatti, Elisa; Bussolati, Chiara; Ceda, Gian Paolo

2016-06-01

Pre-hospital delay in acute stroke is critical to the administration of thrombolysis and affects patients' clinical outcome. In this study, the impact of pre-hospital delay on the outcome of ischemic stroke was investigated in an Italian cohort of patients who did not receive thrombolysis. Data from a cohort of 1847 patients, suffering from first-ever ischemic stroke and referred to an in-hospital clinical pathway were analyzed retrospectively. The relationship between pre-hospital delay and 1-month mortality was assessed with adjustment for demographics, premorbid disability, and stroke severity, which was graded according to the Scandinavian Stroke Scale, with higher scores indicating less severity. Five hundred and twelve patients (27.7%) arrived at hospital within 2 hours of symptom onset. A significant correlation was found between early arrival and a reduced risk of 1-month mortality (hazard ratio .65; 95% confidence interval .48-.89; P = .02). There was a significant interaction (P = .01) between pre-hospital delay and the neurological score on mortality in the multivariate model, and the survival advantage of early admission was significant only for patients with scores on the Scandinavian Stroke Scale less than 18 (hazard ratio .54; 95% confidence interval .34-.85; P = .008). Our study suggests that reducing pre-hospital delay can increase the probability of survival in patients with ischemic stroke, especially those who are most severely affected. Even if the patients cannot benefit from thrombolysis, survival rates can be increased provided that they are managed according to standardized care processes. Copyright © 2016 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Comparative effectiveness of dabigatran and rivaroxaban versus warfarin for the treatment of non-valvular atrial fibrillation

PubMed Central

Bengtson, Lindsay GS; Lutsey, Pamela L.; Chen, Lin Y.; MacLehose, Richard F.; Alonso, Alvaro

2016-01-01

Background Effectiveness data on novel oral anticoagulants (NOACs) versus warfarin for stroke prevention in non-valvular atrial fibrillation (NVAF) by prior warfarin use are limited. Methods We used data from the US MarketScan databases from 2009–2012. NVAF patients initiating dabigatran or rivaroxaban were matched with up to 5 warfarin users. Propensity score-adjusted Cox regression was used to calculate hazard ratios (HR) and 95% confidence intervals (95%CI) for relevant endpoints in NOACs versus warfarin users. Separate analyses were conducted to compare anticoagulant-naïve users of NOACs and those switching from warfarin. Results Among 32,918 dabigatran, 3,301 rivaroxaban, and 109,447 warfarin users with NVAF, 225 intracranial bleeds, 1035 ischemic strokes, 958 myocardial infarctions, and 1842 gastrointestinal bleeds were identified. Compared to warfarin users, patients initiating NOACs had similar ischemic stroke rates and lower intracranial bleeding rates, while the gastrointestinal bleeding rate was higher in dabigatran users than warfarin users. Associations of dabigatran with ischemic stroke risk differed between anticoagulant-naïve initiators and patients switching from warfarin; dabigatran was associated with lower ischemic stroke rates in naïve users (HR 0.65, 95%CI 0.52–0.82) but not in switchers (HR 1.20, 95%CI 0.95–1.51), compared to warfarin. Risk of stroke and bleeding was not different between rivaroxaban and warfarin users. Conclusions Real-world effectiveness of NOACs (compared to warfarin) for diverse outcomes was comparable to efficacy reported in published clinical trials. However, harms and benefits of switching from warfarin to dabigatran need to be evaluated. PMID:27889397

Factors associated with antithrombotic treatment decisions for stroke prevention in atrial fibrillation in the Stockholm region after the introduction of NOACs.

PubMed

Komen, Joris; Forslund, Tomas; Hjemdahl, Paul; Wettermark, Björn

2017-10-01

The purpose of this study was to investigate the influence of patient characteristics such as age and stroke and bleeding risks on decisions for antithrombotic treatment in patients with atrial fibrillation (AF). This was a retrospective, population-based study including AF patients initiated with either warfarin, dabigatran, rivaroxaban, apixaban, or low-dose aspirin (ASA) between March 2015 and February 2016. Multivariate models were used to calculate adjusted odds ratios (aOR) for factors associated with treatment decisions. A total of 6765 newly initiated patients were included, most with apixaban (46.4%) and least with ASA (6.7%). There were more comorbidities in patients initiated with ASA or warfarin compared to the cohort average. Patients with high stroke risks had higher chances of receiving ASA (CHA 2 DS 2 -VASc ≥5 vs 0; aOR 2.01; 95% confidence interval (CI) 1.12-3.33). Among patients receiving oral anticoagulants, patients with high bleeding risks more often received warfarin (ATRIA score 5-10 vs 0-3; aOR 1.40; CI 1.20-1.64). Among NOACs, apixaban was preferred for patients with higher stroke risks (aOR 1.78; CI 1.31-2.41), high bleeding risks (aOR 1.54; CI 1.26-1.88) and high age (age group ≥85 vs 0-65; aOR 1.84; CI 1.44-2.35). Conversely, dabigatran treatment was associated with lower ages and lower risks. High stroke and bleeding risks favored choices of warfarin or ASA. Among patients receiving NOACs, apixaban was favored for elderly and high-risk patients whereas dabigatran was used in lower risk patients. The inadvertent use of ASA, especially among those with high stroke risks, should be further discouraged.

A randomized controlled trial on providing ankle-foot orthoses in patients with (sub-)acute stroke: Short-term kinematic and spatiotemporal effects and effects of timing.

PubMed

Nikamp, Corien D M; Hobbelink, Marte S H; van der Palen, Job; Hermens, Hermie J; Rietman, Johan S; Buurke, Jaap H

2017-06-01

Initial walking function is often limited after stroke, and regaining walking ability is an important goal in rehabilitation. Various compensatory movement strategies to ensure sufficient foot-clearance are reported. Ankle-foot orthoses (AFOs) are often prescribed to improve foot-clearance and may influence these strategies. However, research studying effects of actual AFO-provision early after stroke is limited. We conducted an explorative randomized controlled trial and aimed to study the short-term effects of AFO-provision on kinematic and spatiotemporal parameters in patients early after stroke. In addition, we studied whether timing of AFO-provision influenced these effects. Unilateral hemiparetic patients maximal six weeks post-stroke were randomly assigned to AFO-provision: early (at inclusion) or delayed (eight weeks later). Three-dimensional gait-analysis with and without AFO in randomized order was performed within two weeks after AFO-provision. Twenty subjects (8 early, 12 delayed) were analyzed. We found significant positive effects of AFO-provision for ankle dorsiflexion at initial contact, foot-off and during swing (-3.6° (7.3) vs 3.0° (3.9); 0.0° (7.4) vs 5.2° (3.7); and -6.1° (7.8) vs 2.6° (3.5), respectively), all p<0.001. No changes in knee, hip and pelvis angles were found after AFO-provision, except for knee (+2.3°) and hip flexion (+1.6°) at initial contact, p≤0.001. Significant effects of AFO-provision were found for cadence (+2.1 steps/min, p=0.026), stride duration (-0.08s, p=0.015) and single support duration (+1.0%, p=0.002). Early or delayed AFO-provision after stroke did not affect results. In conclusion, positive short-term effects of AFO-provision were found on ankle kinematics early after stroke. Timing of AFO-provision did not influence the results. NTR1930. Copyright © 2017 Elsevier B.V. All rights reserved.

Risk of stroke/systemic embolism, major bleeding and associated costs in non-valvular atrial fibrillation patients who initiated apixaban, dabigatran or rivaroxaban compared with warfarin in the United States Medicare population.

PubMed

Amin, Alpesh; Keshishian, Allison; Trocio, Jeffrey; Dina, Oluwaseyi; Le, Hannah; Rosenblatt, Lisa; Liu, Xianchen; Mardekian, Jack; Zhang, Qisu; Baser, Onur; Vo, Lien

2017-09-01

To compare the risk and cost of stroke/systemic embolism (SE) and major bleeding between each direct oral anticoagulant (DOAC) and warfarin among non-valvular atrial fibrillation (NVAF) patients. Patients (≥65 years) initiating warfarin or DOACs (apixaban, rivaroxaban, and dabigatran) were selected from the Medicare database from 1 January 2013 to 31 December 2014. Patients initiating each DOAC were matched 1:1 to warfarin patients using propensity score matching to balance demographics and clinical characteristics. Cox proportional hazards models were used to estimate the risks of stroke/SE and major bleeding of each DOAC vs. warfarin. Two-part models were used to compare the stroke/SE- and major-bleeding-related medical costs between matched cohorts. Of the 186,132 eligible patients, 20,803 apixaban-warfarin pairs, 52,476 rivaroxaban-warfarin pairs, and 16,731 dabigatran-warfarin pairs were matched. Apixaban (hazard ratio [HR] = 0.40; 95% confidence interval [CI] 0.31, 0.53) and rivaroxaban (HR = 0.72; 95% CI 0.63, 0.83) were significantly associated with lower risk of stroke/SE compared to warfarin. Apixaban (HR = 0.51; 95% CI 0.44, 0.58) and dabigatran (HR = 0.79; 95% CI 0.69, 0.91) were significantly associated with lower risk of major bleeding; rivaroxaban (HR = 1.17; 95% CI 1.10, 1.26) was significantly associated with higher risk of major bleeding compared to warfarin. Compared to warfarin, apixaban ($63 vs. $131) and rivaroxaban ($93 vs. $139) had significantly lower stroke/SE-related medical costs; apixaban ($292 vs. $529) and dabigatran ($369 vs. $450) had significantly lower major bleeding-related medical costs. Among the DOACs in the study, only apixaban is associated with a significantly lower risk of stroke/SE and major bleeding and lower related medical costs compared to warfarin.

Planning of Ballistic Movement following Stroke: Insights from the Startle Reflex

PubMed Central

Honeycutt, Claire Fletcher; Perreault, Eric Jon

2012-01-01

Following stroke, reaching movements are slow, segmented, and variable. It is unclear if these deficits result from a poorly constructed movement plan or an inability to voluntarily execute an appropriate plan. The acoustic startle reflex provides a means to initiate a motor plan involuntarily. In the presence of a movement plan, startling acoustic stimulus triggers non-voluntary early execution of planned movement, a phenomenon known as the startReact response. In unimpaired individuals, the startReact response is identical to a voluntarily initiated movement, except that it is elicited 30–40 ms. As the startReact response is thought to be mediated by brainstem pathways, we hypothesized that the startReact response is intact in stroke subjects. If startReact is intact, it may be possible to elicit more task-appropriate patterns of muscle activation than can be elicited voluntarily. We found that startReact responses were intact following stroke. Responses were initiated as rapidly as those in unimpaired subjects, and with muscle coordination patterns resembling those seen during unimpaired volitional movements. Results were striking for elbow flexion movements, which demonstrated no significant differences between the startReact responses elicited in our stroke and unimpaired subject groups. The results during planned extension movements were less straightforward for stroke subjects, since the startReact response exhibited task inappropriate activity in the flexors. This inappropriate activity diminished over time. This adaptation suggests that the inappropriate activity was transient in nature and not related to the underlying movement plan. We hypothesize that the task-inappropriate flexor activity during extension results from an inability to suppress the classic startle reflex, which primarily influences flexor muscles and adapts rapidly with successive stimuli. These results indicate that stroke subjects are capable of planning ballistic elbow movements, and that when these planned movements are involuntarily executed they can be as rapid and appropriate as those in unimpaired individuals. PMID:22952634

Functional and motor outcome 5 years after stroke is equivalent to outcome at 2 months: follow-up of the collaborative evaluation of rehabilitation in stroke across Europe.

PubMed

Meyer, Sarah; Verheyden, Geert; Brinkmann, Nadine; Dejaeger, Eddy; De Weerdt, Willy; Feys, Hilde; Gantenbein, Andreas R; Jenni, Walter; Laenen, Annouschka; Lincoln, Nadina; Putman, Koen; Schuback, Birgit; Schupp, Wilfried; Thijs, Vincent; De Wit, Liesbet

2015-06-01

Recovery of patients within the first 6 months after stroke is well documented, but there has been little research on long-term recovery. The aim of this study was to analyze functional and motor recovery between admission to rehabilitation centres and 5 years after stroke. This follow-up of the Collaborative Evaluation of Rehabilitation in Stroke Across Europe study, included patients from 4 European rehabilitation centres. Patients were assessed on admission, at 2 and 6 months, and 5 years after stroke, using the Barthel Index, Rivermead Motor Assessment Gross Function, Leg and Trunk function, and Arm function. Linear mixed models were used, corrected for baseline characteristics. To account for the drop-out during follow-up, the analysis is likelihood-based (assumption of missingness at random). A total of 532 patients were included in this study, of which 238 were followed up at 5 years post stroke. Mean age at stroke onset was 69 (±10 SD) years, 53% were men, 84% had ischemic strokes, and 53% had left-sided motor impairment. Linear mixed model analysis revealed a significant deterioration for all 4 outcomes between 6 months and 5 years (P<0.0001). Scores at 2 months were not statistically significant different from scores at 5 years after stroke. Higher age (P<0.0001) and increasing stroke severity on admission (P<0.0001) negatively affected long-term functional and motor recovery. Five-year follow-up revealed deterioration in functional and motor outcome, with a return to the level measured at 2 months. Increasing age and increasing stroke severity negatively affected recovery up to 5 years after stroke. © 2015 American Heart Association, Inc.

Influence of cerebral white matter lesions on the activities of daily living of older patients with mild stroke.

PubMed

Yamashita, Yutaka; Wada, Ikuo; Horiba, Mitsuya; Sahashi, Kento

2016-08-01

Neurological symptom severity is a prognostic factor for post-stroke activities of daily living (ADL). Recently, it has been reported that white matter lesions indicate poor functional prognosis in patients with stroke. The present study investigated the influence of white matter lesions on the ADL of older patients with stroke who have mild neurological symptoms. We investigated ADL at discharge in 44 patients with stroke (men, n = 27; women, n = 17; mean age 78 years [range 71-85 years]) aged ≥65 years with National Institutes of Health Stroke Scale scores of ≤5 (cerebral infarction, n = 37; cerebral hemorrhage, n = 7). We used single correlation analysis and multiple regression analysis to investigate factors that correlated with ADL at discharge. ADL at discharge was also evaluated on the basis of white matter lesion severity (Fazekas classification, grades 0-3). Single correlation analysis showed that age (r = -0.36, P = 0.016), male sex (r = 0.362, P = 0.016), neurological symptom severity (r = -0.361, P = 0.016), ADL on starting rehabilitation (r = 0.685, P < 0.001) and white matter lesion severity (r = -0.361, P = 0.016) significantly correlated with ADL at discharge. Multiple regression analysis showed that ADL on starting rehabilitation (β = 0.519, t = 4.723, P < 0.001) and white matter lesion severity (β = -0.309, t = -3.057, P < 0.01) were statistically significant prognostic factors for ADL at discharge. ADL at discharge score was significantly lower in the group with high white matter lesion severity (Fazekas, grade 2) than in the other two groups (Fazekas, grade 0, P < 0.01; Fazekas, grade 1, P < 0.05). Severe white matter lesions are a prognostic factor for poor ADL at discharge in older patients with stroke who have mild neurological symptoms. Geriatr Gerontol Int 2016; 16: 942-947. © 2015 Japan Geriatrics Society.

Cheyne-Stokes Respiration in Patients with First-Ever Lacunar Stroke

PubMed Central

Bonnin-Vilaplana, Marc; Arboix, Adrià; Parra, Olga; García-Eroles, Luis; Montserrat, Josep M.; Massons, Joan

2012-01-01

The aim of this single-center prospective study was to assess the presence of Cheyne-Stokes respiration (CSR) and CSR-related variables in 68 consecutive patients with radiologically proven first-ever lacunar stroke undergoing a respiratory sleep study using a portable respiratory polygraph within the first 48 hours of stroke onset. CSR was diagnosed in 14 patients (20.6%). Patients with CSR as compared with those without CSR showed a significantly higher mean (standard deviation, SD) apnea-hypopnea index (AHI) (34.9 (21.7) versus 18.5 (14.4), P = 0.001) and central apnea index (13.1 (13.8) versus 1.8 (3.4), P = 0.0001) as well as higher scores of the Barthel index and the Canadian Neurological scale as a measure of stroke severity, and longer hospital stay. CSR was present in one of each five patients with lacunar stroke. The presence of CSR was associated with a trend towards a higher functional stroke severity and worse prognosis. PMID:23471518

[The consequences of stroke for the artist Lovis Corinth].

PubMed

Bäzner, H; Hennerici, M G

2006-09-01

The artist Lovis Corinth suffered a right-hemispheric stroke at the age of 53 years but only died 14 years later. The huge amount of work he produced after this life threatening disease allows detailed analysis of his post-stroke artwork in comparison to pre-stroke. When performing this analysis as a neurologist, an enormous diversity of subtle stroke sequelae can be discovered that are mostly explained by left-sided hemi-neglect. These findings clearly go far beyond pure psychological processes. Moreover, Corinth is a motivating example for disabled patients because he was able to produce great artwork after his stroke. He was struggling against a motor disability admittedly not severely affecting his artistic production, but also against severe neuropsychological deficits that did have clear consequences. Lovis Corinth left us the credo "True art means to use unreality". Taken together with the often cited phrase "Drawing means to leave out (details)", a clear-cut interpretation for neurologists can be derived from the understanding of right-hemisphere lesions and subsequent left-sided neglect.

Exploring barriers and facilitators to the clinical use of virtual reality for post-stroke unilateral spatial neglect assessment.

PubMed

Ogourtsova, Tatiana; Archambault, Philippe S; Lamontagne, Anouk

2017-11-07

Hemineglect, defined as a failure to attend to the contralesional side of space, is a prevalent and disabling post-stroke deficit. Conventional hemineglect assessments lack sensitivity as they contain mainly non-functional tasks performed in near-extrapersonal space, using static, two-dimensional methods. This is of concern given that hemineglect is a strong predictor for functional deterioration, limited post-stroke recovery, and difficulty in community reintegration. With the emerging field of virtual reality, several virtual tools have been proposed and have reported better sensitivity in neglect-related deficits detection than conventional methods. However, these and future virtual reality-based tools are yet to be implemented in clinical practice. The present study aimed to explore the barriers/facilitators perceived by clinicians in the use of virtual reality for hemineglect assessment; and to identify features of an optimal virtual assessment. A qualitative descriptive process, in the form of focus groups, self-administered questionnaire and individual interviews was used. Two focus groups (n = 11 clinicians) were conducted and experts in the field (n = 3) were individually interviewed. Several barriers and facilitators, including personal, institutional, client suitability, and equipment factors, were identified. Clinicians and experts in the field reported numerous features for the virtual tool optimization. Factors identified through this study lay the foundation for the development of a knowledge translation initiative towards an implementation of a virtual assessment for hemineglect. Addressing the identified barriers/facilitators during implementation and incorporating the optimal features in the design of the virtual assessment could assist and promote its eventual adoption in clinical settings. Implications for rehabilitation A multimodal and active knowledge translation intervention built on the presently identified modifiable factors is suggested to be implemented to support the clinical integration of a virtual reality-based assessment for post-stroke hemineglect. To amplify application and usefulness of a virtual-reality based tool in the assessment of post-stroke hemineglect, optimal features identified in the present study should be incorporated in the design of such technology.

Blood pressure and stroke: an overview of published reviews.

PubMed

Lawes, Carlene M M; Bennett, Derrick A; Feigin, Valery L; Rodgers, Anthony

2004-04-01

The last few years have seen a considerable increase in the amount of information available concerning blood pressure (BP) and stroke associations. This article provides an overview of published reviews of the effects on stroke seen in trials of BP-lowering drugs and compares these with the results available from cohort studies. We present a review of major overviews of prospective cohort studies and an updated meta-analysis of >40 randomized controlled trials of BP lowering, which included >188 000 participants and approximately 6800 stroke events. Cohort studies now indicate that in the Asia Pacific region as well as in North America and Western Europe, each 10 mm Hg lower systolic BP is associated with a decrease in risk of stroke of approximately one third in subjects aged 60 to 79 years. The association is continuous down to levels of at least 115/75 mm Hg and is consistent across sexes, regions, and stroke subtypes and for fatal and nonfatal events. The proportional association is age dependent but is still strong and positive in those aged 80 years. Data from randomized controlled trials, in which mean age at event was approximately 70 years, indicate that a 10 mm Hg reduction in systolic BP is associated with a reduction in risk of stroke of approximately one third. Per mm Hg systolic BP reduction, the relative benefits for stroke appear similar between agents, by baseline BP levels, and whether or not individuals have a past history of cardiovascular disease. There is, however, evidence of greater benefit with a larger BP reduction. The epidemiologically expected benefits of BP lowering for stroke risk reduction are broadly consistent across a range of different population subgroups. There are greater benefits from larger BP reductions, and initiating and maintaining BP reduction for stroke prevention is a more important issue than choice of initial agent.

Is Transient Ischemic Attack a Medical Emergency? An Evidence-Based Analysis

PubMed Central

Sehatzadeh, S

2015-01-01

Background Transient ischemic attack (TIA) is a brief episode of dysfunction in a confined area of the brain. The risk of stroke following TIA is approximately 4% within the first 2 days and 9% within the first month. Therefore, early diagnosis and treatment is critical to reduce mortality and risk of stroke in patients who have experienced a TIA. Objectives This systematic review aimed to investigate the impact of the urgent evaluation and initiation of treatment of patients with TIA on the risk of subsequent stroke and death. Data Sources A literature search was performed for studies published from January 1, 2007, until December 21, 2012. The search was updated monthly to April 1, 2013. Results All identified studies showed that urgent assessment and initiation of treatment of TIA is an effective strategy in reducing the incidence of stroke. Among these, a large observational study found a large effect in that the risk of stroke was reduced by 80%, and a Canadian study found that providing urgent care significantly reduced the rate of stroke in high-risk patients. Another Canadian study reported a significant reduction in the rate of death among patients referred to stroke prevention clinics, compared to patients not referred to such services. One study showed that patients discharged from an emergency department with standard care had significantly higher rates of stroke and subsequent TIA in the first month, compared to those who were hospitalized. However, another study showed that for patients at low to moderate risk, rate of stroke was similar between inpatients and those managed in a TIA clinic. Limitations Our analysis was restricted to the effect of the combined interventions. The magnitude of benefit of each individual component of the intervention cannot be determined through this review. Conclusions The results of this systematic review have important clinical and health system implications. Urgent management of TIA patients in specialized TIA clinics rather than regular practice results in a lower rate of stroke and disability. PMID:26355823

Predicting Discharge to Institutional Long-Term Care After Stroke: A Systematic Review and Metaanalysis.

PubMed

Burton, Jennifer K; Ferguson, Eilidh E C; Barugh, Amanda J; Walesby, Katherine E; MacLullich, Alasdair M J; Shenkin, Susan D; Quinn, Terry J

2018-01-01

Stroke is a leading cause of disability worldwide, and a significant proportion of stroke survivors require long-term institutional care. Understanding who cannot be discharged home is important for health and social care planning. Our aim was to establish predictive factors for discharge to institutional care after hospitalization for stroke. We registered and conducted a systematic review and meta-analysis (PROSPERO: CRD42015023497) of observational studies. We searched MEDLINE, EMBASE, and CINAHL Plus to February 2017. Quantitative synthesis was performed where data allowed. Acute and rehabilitation hospitals. Adults hospitalized for stroke who were newly admitted directly to long-term institutional care at the time of hospital discharge. Factors associated with new institutionalization. From 10,420 records, we included 18 studies (n = 32,139 participants). The studies were heterogeneous and conducted in Europe, North America, and East Asia. Eight studies were at high risk of selection bias. The proportion of those surviving to discharge who were newly discharged to long-term care varied from 7% to 39% (median 17%, interquartile range 12%), and the model of care received in the long-term care setting was not defined. Older age and greater stroke severity had a consistently positive association with the need for long-term care admission. Individuals who had a severe stroke were 26 times as likely to be admitted to long-term care than those who had a minor stroke. Individuals aged 65 and older had a risk of stroke that was three times as great as that of younger individuals. Potentially modifiable factors were rarely examined. Age and stroke severity are important predictors of institutional long-term care admission directly from the hospital after an acute stroke. Potentially modifiable factors should be the target of future research. Stroke outcome studies should report discharge destination, defining the model of care provided in the long-term care setting. © 2017 The Authors. Journal of the American Geriatrics Society published by Wiley Periodicals, Inc. on behalf of The American Geriatrics Society.

Proportional Recovery From Lower Limb Motor Impairment After Stroke.

PubMed

Smith, Marie-Claire; Byblow, Winston D; Barber, P Alan; Stinear, Cathy M

2017-05-01

In people with preserved corticospinal tract (CST) function after stroke, upper limb impairment resolves by ≈70% within 3 months. This is known as the proportional recovery rule. Patients without CST function do not fit this rule and have worse upper limb outcomes. This study investigated resolution of motor impairment in the lower limb (LL). Patients with stroke and LL weakness were assessed 3 days and 3 months after stroke with the LL Fugl-Meyer. CST integrity was determined in a subset of patients using transcranial magnetic stimulation to test for LL motor-evoked potentials and magnetic resonance imaging to measure CST lesion load. Linear regression analyses were conducted to predict resolution of motor impairment (ΔFugl-Meyer) including factors initial impairment, motor-evoked potential status, CST lesion load, and LL therapy dose. Thirty-two patients completed 3-month follow-up and recovered 74% (95% confidence interval, 60%-88%) of initial LL motor impairment. Initial impairment was the only significant predictor of resolution of motor impairment. There was no identifiable cluster of patients who did not fit the proportional recovery rule. Measures of CST integrity did not predict proportional LL recovery. LL impairment resolves by ≈70% within 3 months after stroke. The absence of a nonfitter group may be because of differences in the neuroanatomical organization of descending motor tracts to the upper limb and LL. Proportional recovery of the LL is not influenced by therapy dose providing further evidence that it reflects a fundamental biological process. © 2017 American Heart Association, Inc.

Validation of simplified centre of mass models during gait in individuals with chronic stroke.

PubMed

Huntley, Andrew H; Schinkel-Ivy, Alison; Aqui, Anthony; Mansfield, Avril

2017-10-01

The feasibility of using a multiple segment (full-body) kinematic model in clinical gait assessment is difficult when considering obstacles such as time and cost constraints. While simplified gait models have been explored in healthy individuals, no such work to date has been conducted in a stroke population. The aim of this study was to quantify the errors of simplified kinematic models for chronic stroke gait assessment. Sixteen individuals with chronic stroke (>6months), outfitted with full body kinematic markers, performed a series of gait trials. Three centre of mass models were computed: (i) 13-segment whole-body model, (ii) 3 segment head-trunk-pelvis model, and (iii) 1 segment pelvis model. Root mean squared error differences were compared between models, along with correlations to measures of stroke severity. Error differences revealed that, while both models were similar in the mediolateral direction, the head-trunk-pelvis model had less error in the anteroposterior direction and the pelvis model had less error in the vertical direction. There was some evidence that the head-trunk-pelvis model error is influenced in the mediolateral direction for individuals with more severe strokes, as a few significant correlations were observed between the head-trunk-pelvis model and measures of stroke severity. These findings demonstrate the utility and robustness of the pelvis model for clinical gait assessment in individuals with chronic stroke. Low error in the mediolateral and vertical directions is especially important when considering potential stability analyses during gait for this population, as lateral stability has been previously linked to fall risk. Copyright © 2017 Elsevier Ltd. All rights reserved.

A randomized trial evaluation of the Oswestry Standing Frame for patients after stroke.

PubMed

Bagley, Pam; Hudson, Mary; Forster, Anne; Smith, Jane; Young, John

2005-06-01

Standing is believed to have benefits in addressing motor and sensory impairments after stroke. One device to facilitate standing for severely disabled patients is the Oswestry Standing Frame. To evaluate the effectiveness of the Oswestry Standing Frame for severely disabled stroke patients. A single centre, randomized controlled trial. An inpatient stroke rehabilitation unit. Patients were recruited if they had a clinical diagnosis of stroke, were medically stable and unable to achieve any score on the Trunk Control Test or unable to stand in mid-line without the assistance of two therapists. The intervention (n = 71) and control (n = 69) groups both received usual stroke unit care but the intervention group also received a minimum of 14 consecutive days' treatment using the standing frame. The primary outcome measure was the Rivermead Mobility Index (RMI). Secondary measures included the Barthel Index; the Rivermead Motor Assessment; the balanced sitting and sitting to standing components of the Motor Assessment Scale; the Trunk Control Test and the Hospital Anxiety and Depression Scale. Blind assessment was undertaken at baseline, six weeks, 12 weeks and six months post stroke. Information on resource use was also collected. There was no statistically significant difference between groups in any of the outcome measures or for resource use. Mann-Whitney U-tests for the RMI change from baseline scores to six weeks, 12 weeks and six months post stroke were p = 0.310; p = 0.970 and p = 0.282, respectively. Use of the Oswestry Standing Frame did not improve clinical outcome or provide resource savings for this severely disabled patient group.

Diagnosis and initial management of cerebellar infarction.

PubMed

Edlow, Jonathan A; Newman-Toker, David E; Savitz, Sean I

2008-10-01

Cerebellar infarction is an important cause of stroke that often presents with common and non-specific symptoms such as dizziness, nausea and vomiting, unsteady gait, and headache. Accurate diagnosis frequently relies on careful attention to patients' coordination, gait, and eye movements--components of the neurological physical examination that are sometimes omitted or abridged if cerebellar stroke is not specifically being considered. The differential diagnosis is broad, and includes many common and benign causes. Furthermore, early-stage posterior fossa ischaemia is rarely seen with brain CT--the most commonly available initial imaging test that is used for stroke. Insufficient examination and imaging can result in misdiagnosis. However, early correct diagnosis is crucial to help prevent treatable but potentially fatal complications, such as brainstem compression and obstructive hydrocephalus. The identification and treatment of the underlying vascular lesions at an early stage can also prevent subsequent occurrences of stroke and improve patients' outcomes. Here, we review the clinical presentation of cerebellar infarction, from diagnosis and misdiagnosis to patients' monitoring, treatment, and potential complications.

Multiple recurrent ischaemic strokes in a patient with cancer: is there a role for the initiation of anticoagulation therapy for secondary stroke prevention?

PubMed Central

Suero-Abreu, Giselle Alexandra; Cheng, Jia Zhen; Then, Ryna Karina

2017-01-01

A 52-year-old woman with a medical history of cervical and thyroid cancer, hypertension, dyslipidaemia, uncontrolled diabetes and heavy smoking was diagnosed with a new metastatic cholangiocarcinoma. While undergoing palliative chemotherapy, she developed dysarthria and left-sided weakness. Imaging studies showed multiple bilateral ischaemic strokes. On hospital days 2 and 5, she developed worsening neurological symptoms and imaging studies revealed new areas of ischaemia on respective days. Subsequent workup did not revealed a clear aetiology for the multiple ischaemic events and hypercoagulability studies were only significant for a mildly elevated serum D-dimer level. Although guidelines are unclear, full-dose anticoagulation with low molecular weight heparin was initiated given her high risk of stroke recurrence. She was discharged to acute rehabilitation but, within a month, she experienced complications of her malignant disease progression and a new pulmonary thromboembolism. The patient died soon after being discharged home with hospice care. PMID:28578306

Cardioembolic Stroke.

PubMed

O'Carroll, Cumara B; Barrett, Kevin M

2017-02-01

Cardioembolic stroke is common and disproportionately more disabling than nonembolic mechanisms of stroke. Its incidence is expected to rise because of the age-related incidence of atrial fibrillation and an aging population. This article summarizes the different causes of cardioembolism and outlines current management guidelines. Since cardioembolic stroke is not a single disease entity, its diagnosis requires initial clinical suspicion and a comprehensive evaluation, including ECG, echocardiography, brain imaging, and cardiac monitoring. Atrial fibrillation is the most common cause of cardioembolic stroke, and anticoagulation is usually recommended. This article reviews risk stratification models to assist in the decision-making process and highlights the increased use of novel oral anticoagulants for stroke prevention in atrial fibrillation. New data support the importance of prolonged cardiac monitoring for diagnosing occult atrial fibrillation. Current data on other mechanisms of cardioembolic stroke, such as prosthetic heart valves and aortic arch atherosclerosis, are also presented, and the available evidence regarding patent foramen ovale closure in cryptogenic stroke is summarized. Cardioembolism is an important cause of ischemic stroke, with diverse underlying mechanisms requiring a tailored approach to diagnosis, management, and prevention.

How I treat and manage strokes in sickle cell disease

PubMed Central

Kassim, Adetola A.; Galadanci, Najibah A.; Pruthi, Sumit

2015-01-01

Neurologic complications are a major cause of morbidity and mortality in sickle cell disease (SCD). In children with sickle cell anemia, routine use of transcranial Doppler screening, coupled with regular blood transfusion therapy, has decreased the prevalence of overt stroke from ∼11% to 1%. Limited evidence is available to guide acute and chronic management of individuals with SCD and strokes. Current management strategies are based primarily on single arm clinical trials and observational studies, coupled with principles of neurology and hematology. Initial management of a focal neurologic deficit includes evaluation by a multidisciplinary team (a hematologist, neurologist, neuroradiologist, and transfusion medicine specialist); prompt neuro-imaging and an initial blood transfusion (simple followed immediately by an exchange transfusion or only exchange transfusion) is recommended if the hemoglobin is >4 gm/dL and <10 gm/dL. Standard therapy for secondary prevention of strokes and silent cerebral infarcts includes regular blood transfusion therapy and in selected cases, hematopoietic stem cell transplantation. A critical component of the medical care following an infarct is cognitive and physical rehabilitation. We will discuss our strategy of acute and long-term management of strokes in SCD. PMID:25824688

Frontal lobe atrophy is associated with small vessel disease in ischemic stroke patients.

PubMed

Chen, Yangkun; Chen, Xiangyan; Xiao, Weimin; Mok, Vincent C T; Wong, Ka Sing; Tang, Wai Kwong

2009-12-01

The pathogenesis of frontal lobe atrophy (FLA) in stroke patients is unclear. We aimed to ascertain whether subcortical ischemic changes were more associated with FLA than with parietal lobe atrophy (PLA) and temporal lobe atrophy (TLA). Brain magnetic resonance images (MRIs) from 471 Chinese ischemic stroke patients were analyzed. Lobar atrophy was defined by a widely used visual rating scale. All patients were divided into non-severe, mild-moderate, and severe atrophy of the frontal, parietal, and temporal lobe groups. The severity of white matter lesions (WMLs) was rated with the Fazekas' scale. Clinical and radiological features were compared among the groups. Subsequent logistic regressions were performed to determine the risk factors of atrophy and severe atrophy of the frontal, parietal and temporal lobes. The frequency of FLA in our cohort was 36.9% (174/471). Severe FLA occurred in 30 (6.4%) patients. Age, previous stroke, and periventricular hyperintensities (PVH) (odds ratio (OR)=1.640, p=0.039) were independent risk factors of FLA. Age and deep white matter hyperintensities (DWMH) (OR=3.634, p=0.002) were independent risk factors of severe FLA. PVH and DWMH were not independent risk factors of PLA and TLA. Frontal lobe atrophy in ischemic stroke patients may be associated with small vessel disease. The association between WMLs and FLA was predominant over atrophy of the parietal and temporal lobes, which suggests that the frontal lobe may be vulnerable to subcortical ischemic changes.

Case report: severe heat stroke with multiple organ dysfunction – a novel intravascular treatment approach

PubMed Central

Broessner, Gregor; Beer, Ronny; Franz, Gerhard; Lackner, Peter; Engelhardt, Klaus; Brenneis, Christian; Pfausler, Bettina; Schmutzhard, Erich

2005-01-01

Introduction We report the case of a patient who developed a severe post-exertional heat stroke with consecutive multiple organ dysfunction resistant to conventional antipyretic treatment, necessitating the use of a novel endovascular device to combat hyperthermia and maintain normothermia. Methods A 38-year-old male suffering from severe heat stroke with predominant signs and symptoms of encephalopathy requiring acute admission to an intensive care unit, was admitted to a ten-bed neurological intensive care unit of a tertiary care hospital. The patient developed consecutive multiple organ dysfunction with rhabdomyolysis, and hepatic and respiratory failure. Temperature elevation was resistant to conventional treatment measures. Aggressive intensive care treatment included forced diuresis and endovascular cooling to combat hyperthermia and maintain normothermia. Results Analyses of serum revealed elevation of proinflammatory cytokines (TNF alpha, IL-6), cytokines (IL-2R), anti-inflammatory cytokines (IL-4) and chemokines (IL-8) as well as signs of rhabdomyolysis and hepatic failure. Aggressive intensive care treatment as forced diuresis and endovascular cooling (CoolGard® and CoolLine®) to combat hyperthermia and maintain normothermia were used successfully to treat this severe heat stroke. Conclusion In this case of severe heat stroke, presenting with multiple organ dysfunction and elevation of cytokines and chemokines, which was resistant to conventional cooling therapies, endovascular cooling may have contributed significantly to the reduction of body temperature and, possibly, avoided a fatal result. PMID:16285034

Oxygen uptake response to cycle ergometry in post-acute stroke patients with different severity of hemiparesis.

PubMed

Chen, Chun-Kai; Weng, Ming-Cheng; Chen, Tien-Wen; Huang, Mao-Hsiung

2013-11-01

This study evaluated the impact of severity of hemiparesis on oxygen uptake (VO2) response in post-acute stroke patients. Sixty-four patients with a mean poststroke interval of 8.6 ± 3.8 days underwent a ramp cardiopulmonary exercise test on a cycling ergometer to volitional termination. Mean peak VO2 (VO2peak) and work efficiency (ΔVO2/ΔWR) were measured by open-circuit spirometry during standard upright ergometer cycling. Severity of the hemiparetic lower limb was assessed by Brunnstrom's motor recovery stages lower extremity (BMRSL). VO2peak was 10% lower in hemiparetic leg with BMRSL V than in that with BMRSL VI, 20% lower in BMRSL IV, and 50% lower in BMRSL III. ΔVO2/ΔWR was higher for the group with increased BMRSL. The relations were consistent after adjustment for age, sex, body mass index, stroke type, hemiparetic side, modified Ashworth Scale, time poststroke, comorbidities, and medications. Our findings revealed that O2peak is dependent on the severity of hemiparesis in leg, and along with ΔO2/ΔWR closely related to the severity of hemiparesis in post-acute stroke patients, regardless of the types and locations of lesion after stroke, as well as the differences in comorbidities and medications. Copyright © 2013. Published by Elsevier B.V.

RecoverNow: Feasibility of a Mobile Tablet-Based Rehabilitation Intervention to Treat Post-Stroke Communication Deficits in the Acute Care Setting

PubMed Central

Corbett, Dale; Finestone, Hillel M.; Hatcher, Simon; Lumsden, Jim; Momoli, Franco; Shamy, Michel C. F.; Stotts, Grant; Swartz, Richard H.; Yang, Christine

2016-01-01

Background Approximately 40% of patients diagnosed with stroke experience some degree of aphasia. With limited health care resources, patients’ access to speech and language therapies is often delayed. We propose using mobile-platform technology to initiate early speech-language therapy in the acute care setting. For this pilot, our objective was to assess the feasibility of a tablet-based speech-language therapy for patients with communication deficits following acute stroke. Methods We enrolled consecutive patients admitted with a stroke and communication deficits with NIHSS score ≥1 on the best language and/or dysarthria parameters. We excluded patients with severe comprehension deficits where communication was not possible. Following baseline assessment by a speech-language pathologist (SLP), patients were provided with a mobile tablet programmed with individualized therapy applications based on the assessment, and instructed to use it for at least one hour per day. Our objective was to establish feasibility by measuring recruitment rate, adherence rate, retention rate, protocol deviations and acceptability. Results Over 6 months, 143 patients were admitted with a new diagnosis of stroke: 73 had communication deficits, 44 met inclusion criteria, and 30 were enrolled into RecoverNow (median age 62, 26.6% female) for a recruitment rate of 68% of eligible participants. Participants received mobile tablets at a mean 6.8 days from admission [SEM 1.6], and used them for a mean 149.8 minutes/day [SEM 19.1]. In-hospital retention rate was 97%, and 96% of patients scored the mobile tablet-based communication therapy as at least moderately convenient 3/5 or better with 5/5 being most “convenient”. Conclusions Individualized speech-language therapy delivered by mobile tablet technology is feasible in acute care. PMID:28002479

Stroke presentation and outcome in developing countries: a prospective study in the Gambia.

PubMed

Garbusinski, Johanne M; van der Sande, Marianne A B; Bartholome, Emmanuel J; Dramaix, Michèle; Gaye, Alieu; Coleman, Rosalind; Nyan, Ousman A; Walker, Richard W; McAdam, Keith P W J; Walraven, Gys E

2005-07-01

Despite increasing burden of stroke in Africa, prospective descriptive data are rare. Our objective was to describe, in The Gambia, the clinical outcome of stroke patients admitted to the Royal Victoria Teaching Hospital in the capital Banjul, to assess mortality and morbidity, and propose preventive and therapeutic measures. Prospective data were collected on consecutive patients older than 15 years old admitted between February 2000 and February 2001 with the diagnosis of nonsubarachnoid stroke. Risk factors, clinical characteristics, and social consequences were assessed using a modified National Institutes of Health Stroke Scale (mNIHSS), the Barthel Activity in Daily Living scale, the Siriraj score for subtypes, and the Bamford criteria for location/extension. Patients were followed-up at home up to 1 year after discharge. Ninety-one percent (148/162) of eligible patients were enrolled and followed-up. Hypertension and smoking were the most prevalent risk factors. Severity was high at admission, especially in women, and was strongly correlated to the outcome. mNIHSS and consciousness level on admission were strong predictors of the mortality risk. Swallowing difficulties at admission, fever, lung infection, and no aspirin treatment were, independently, risk factors for a lethal outcome susceptible to being addressed by treatment. Mortality was 41% in-hospital and 62% after 1 year. In survivors, autonomy levels improved over time. Drug compliance was poor. At home, family members provided care. Long-term socioeconomic and cultural activities were affected in most patients. Case-fatality was high compared with Western cohorts. Preventive measures can be developed. Rational treatment, in the absence of head imaging for initial assessment, requires adapted protocols. Providers should be trained, both at hospital and community levels.

Anosognosia, neglect, extinction and lesion site predict impairment of daily living after right-hemispheric stroke.

PubMed

Vossel, Simone; Weiss, Peter H; Eschenbeck, Philipp; Fink, Gereon R

2013-01-01

Right-hemispheric stroke can give rise to manifold neuropsychological deficits, in particular, impairments of spatial perception which are often accompanied by reduced self-awareness of these deficits (anosognosia). To date, the specific contribution of these deficits to a patient's difficulties in daily life activities remains to be elucidated. In 55 patients with right-hemispheric stroke we investigated the predictive value of different neglect-related symptoms, visual extinction and anosognosia for the performance of standardized activities of daily living (ADL). The additional impact of lesion location was examined using voxel-based lesion-symptom mapping. Step-wise linear regression revealed that anosognosia for visuospatial deficits was the most important predictor for performance in standardized ADL. In addition, motor-intentional and perceptual-attentional neglect, extinction and cancellation task performance significantly predicted ADL performance. Lesions comprising the right frontal and cingulate cortex and adjacent white matter explained additional variance in the performance of standardized ADL, in that damage to these areas was related to lower performance than predicted by the regression model only. Our data show a decisive role of anosognosia for visuospatial deficits for impaired ADL and therefore outcome/disability after stroke. The findings further demonstrate that the severity of neglect and extinction also predicts ADL performance. Our results thus strongly suggest that right-hemispheric stroke patients should not only be routinely assessed for neglect and extinction but also for anosognosia to initiate appropriate rehabilitative treatment. The observation that right frontal lesions explain additional variance in ADL most likely reflects that dysfunction of the supervisory system also significantly impacts upon rehabilitation. Copyright © 2012 Elsevier Ltd. All rights reserved.

RecoverNow: Feasibility of a Mobile Tablet-Based Rehabilitation Intervention to Treat Post-Stroke Communication Deficits in the Acute Care Setting.

PubMed

Mallet, Karen H; Shamloul, Rany M; Corbett, Dale; Finestone, Hillel M; Hatcher, Simon; Lumsden, Jim; Momoli, Franco; Shamy, Michel C F; Stotts, Grant; Swartz, Richard H; Yang, Christine; Dowlatshahi, Dar

2016-01-01

Approximately 40% of patients diagnosed with stroke experience some degree of aphasia. With limited health care resources, patients' access to speech and language therapies is often delayed. We propose using mobile-platform technology to initiate early speech-language therapy in the acute care setting. For this pilot, our objective was to assess the feasibility of a tablet-based speech-language therapy for patients with communication deficits following acute stroke. We enrolled consecutive patients admitted with a stroke and communication deficits with NIHSS score ≥1 on the best language and/or dysarthria parameters. We excluded patients with severe comprehension deficits where communication was not possible. Following baseline assessment by a speech-language pathologist (SLP), patients were provided with a mobile tablet programmed with individualized therapy applications based on the assessment, and instructed to use it for at least one hour per day. Our objective was to establish feasibility by measuring recruitment rate, adherence rate, retention rate, protocol deviations and acceptability. Over 6 months, 143 patients were admitted with a new diagnosis of stroke: 73 had communication deficits, 44 met inclusion criteria, and 30 were enrolled into RecoverNow (median age 62, 26.6% female) for a recruitment rate of 68% of eligible participants. Participants received mobile tablets at a mean 6.8 days from admission [SEM 1.6], and used them for a mean 149.8 minutes/day [SEM 19.1]. In-hospital retention rate was 97%, and 96% of patients scored the mobile tablet-based communication therapy as at least moderately convenient 3/5 or better with 5/5 being most "convenient". Individualized speech-language therapy delivered by mobile tablet technology is feasible in acute care.

Ischemic Volume and Neurological Deficit: Correlation of Computed Tomography Perfusion with the National Institutes of Health Stroke Scale Score in Acute Ischemic Stroke.

PubMed

Furlanis, Giovanni; Ajčević, Miloš; Stragapede, Lara; Lugnan, Carlo; Ridolfi, Mariana; Caruso, Paola; Naccarato, Marcello; Ukmar, Maja; Manganotti, Paolo

2018-04-30

The National Institutes of Health Stroke Scale (NIHSS) is the most adopted stroke patients' evaluation tool in emergency settings to assess the severity of stroke and to determine the patients' eligibility for specific treatments. Computed tomography perfusion (CTP) is crucial to identify salvageable tissue that can benefit from the reperfusion treatment. The aim of this study is to identify the relation between the NIHSS scores and the hypoperfused volumes evaluated by CTP in patients with hyperacute ischemic stroke. This retrospective study was conducted on 105 patients with ischemic stroke who underwent NIHSS assessment and CTP in the hyperacute phase. Hypoperfused volume was evaluated by CTP maps processed with semi-automatic algorithm. An analysis was conducted to determine the degree of correlation between the NIHSS scores and the ischemic lesion volumes and to investigate the relation between the anterior and the posterior circulation strokes, as well as between the right and the left hemispheric strokes. A significant correlation was found between ischemic volume and NIHSS score at baseline (r = .82; P < .0001) in the entire cohort. A high NIHSS-volume correlation was identified in the anterior circulation stroke (r = .76; P < .0001); whereas, it was nonsignificant in the posterior circulation stroke. NIHSS score and volume correlated for the left and the right hemispheric strokes (r = .83 and .81; P < .0001), showing a slightly higher slope in the left. This study showed a strong correlation between the baseline NIHSS score and the ischemic volume estimated by CTP. We confirmed that NIHSS is a reliable predictor of perfusion deficits in acute ischemic stroke. CTP allows fast imaging assessment in the hyperacute phase. The results highlight the importance of these diagnostic tools in the assessment of stroke severity and in acute decision-making. Copyright © 2018 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Epidemiologic features, risk factors, and outcome of sepsis in stroke patients treated on a neurologic intensive care unit.

PubMed

Berger, Benjamin; Gumbinger, Christoph; Steiner, Thorsten; Sykora, Marek

2014-04-01

Because of the immune-suppressive effect of cerebral damage, stroke patients are at high risk for infections. These might result in sepsis, which is the major contributor to intensive care unit (ICU) mortality. Although there are numerous studies on infections in stroke patients, the role of sepsis as a poststroke complication is unknown. We retrospectively analyzed incidence of and risk factors for sepsis acquisition as well as outcome parameters of 238 patients with ischemic or hemorrhagic strokes consecutively admitted to the neurologic ICU in a tertiary university hospital between January 1, 2009, and December 31, 2010. Basic demographic and clinical data including microbiological parameters as well as factors describing stroke severity (eg, lesion volume and National Institute of Health stroke scale score) were recorded and included into the analysis. The diagnosis of sepsis was based on the criteria of the German Sepsis Society. We identified 30 patients (12.6%) with sepsis within the first 7 days from stroke onset. The lungs were the most frequent source of infection (93.3%), and gram-positive organisms were dominating the microbiologic spectrum (52.4%). Comorbidities (chronic obstructive pulmonary disease and immunosuppressive disorders) and Simplified Acute Physiology Score II but none of the factors describing stroke severity were independent predictors of sepsis acquisition. Sepsis was associated with a significantly worse prognosis, leading to a 2-fold increased mortality rate during in-hospital care (36.7% vs 18.8%) and after 3 months (56.5% vs 28.5%), but only in the subgroup of supratentorial hemorrhages, it was an independent predictor of in-hospital and 3-month mortality. Other factors significantly associated with death in a multivariate analysis were chronic obstructive pulmonary disease, malignancies (in-hospital mortality only), and Simplified Acute Physiology Score II (3-month mortality only) for ischemia and heart failure (in-hospital mortality only), National Institute of Health stroke scale score (in-hospital mortality only), and stroke volume for hemorrhages, respectively. Sepsis seems to be a frequent complication of stroke patients requiring neurologic ICU treatment. Predictors of sepsis acquisition in our study were comorbidities and severity of deterioration of physiological status, but not stroke severity. A better understanding of risk factors is important for prevention and early recognition, whereas knowledge of outcome may help in prognosis prediction. Further studies are needed to clarify the optimal preventive treatment for these patients. Copyright © 2014 Elsevier Inc. All rights reserved.

Smoking and stroke: the more you smoke the more you stroke

PubMed Central

Shah, Reena S; Cole, John W

2010-01-01

Cigarette smoking is a well-established risk factor for all forms of stroke. While both the general public and the global healthcare system are aware of the vascular risks associated with smoking, the prevalence of tobacco use has remained largely unchanged over the last quarter of a century. Approximately one in five US adults are classified as regular smokers, with the initiation of smoking typically occurring during the teenage years. Although the increased risk of stroke associated with smoking is generally acknowledged, it is less well recognized that considerable scientific evidence implicates a strong dose–response relationship between smoking and stroke risk. In this article, we summarize the literature regarding smoking-related stroke risk, the dose–response relationship, and the costs of this detrimental habit to both the individual and society as a whole. PMID:20602553

Influence of Inflammation on Poststroke Plasticity

PubMed Central

Kossut, Malgorzata

2013-01-01

Age-related brain injuries including stroke are a leading cause of morbidity and mental disability worldwide. Most patients who survive stroke experience some degree of recovery. The restoration of lost functions can be explained by neuronal plasticity, understood as brain ability to reorganize and remodel itself in response to changed environmental requirements. However, stroke triggers a cascade of events which may prevent the normal development of the plastic changes. One of them may be inflammatory response initiated immediately after stroke, which has been found to contribute to neuronal injury. Some recent evidence though has suggested that inflammatory reaction can be also neuroprotective. This paper attempts to discuss the influence of poststroke inflammatory response on brain plasticity and stroke outcome. We also describe the recent anti-inflammatory strategies that have been effective for recovery in experimental stroke. PMID:23533818

Usability test of a hand exoskeleton for activities of daily living: an example of user-centered design.

PubMed

Almenara, Maria; Cempini, Marco; Gómez, Cristina; Cortese, Mario; Martín, Cristina; Medina, Josep; Vitiello, Nicola; Opisso, Eloy

2017-01-01

(1) To assess a robotic device (Handexos) during the design process with regard to usability, end user satisfaction and safety, (2) to determine whether Handexos can improve the activities of daily living (ADLs) of spinal cord injury (SCI) patients and stroke patients with upper-limb dysfunction. During a 2-year development stage of the device, a total of 37 participants (aged 22-68), 28 clinicians (experts) and nine patients with SCI or stroke (end users) were included in a user-centered design process featuring usability tests. They performed five grasps wearing the device. The assessments were obtained at the end of the session by filling out a questionnaire and making suggestions. The experts' opinion was that the modified device was an improvement over the preliminary version, although this was not reflected in the scores. Whereas end user scores for comfort, grasp, performance and safety were above the sufficiency threshold, the scores for year 2 were lower than those for year 1. The findings demonstrate that although Handexos meets the initial functional requirements and underlines the potential for assisting SCI and post-stroke subjects in ADLs, several aspects such as mechanical complexity and low adaptability to different hand sizes need to be further addressed. Implications for Rehabilitation Wearable robotics devices could improve the activities of daily living in patients with spinal cord injury or stroke. They could be a tool for rehabilitation of the upper limb. Further usability tests to improve this type of tools are recommended.

Personality differences among patients with chronic aphasia predict improvement in speech-language therapy.

PubMed

Votruba, Kristen L; Rapport, Lisa J; Whitman, R Douglas; Johnson, Alex; Langenecker, Scott

2013-01-01

Negative affectivity and neurocognitive deficits including executive dysfunction have been shown to be detrimental to rehabilitation therapies. However, research on the relationship between neuropsychological deficits and improvement in speech-language therapy (SLT) for aphasia is sparse. To examine the relationships among neurocognitive and psychological functioning and improvement in SLT following aphasia due to stroke. Fifty patients who were ≥ 9 months post stroke and enrolled in outpatient SLT to treat aphasia participated. Using standard language assessment measures, the authors evaluated language functioning at initiation of the study and after participants completed various SLT protocols. Executive functioning, visuospatial skills, attention, and memory also were assessed to provide indices of convergent and discriminant validity. Participants' mood and affectivity were evaluated by self-report, and their functional abilities and recovery of function since stroke were assessed via caregiver report. A multiple regression model testing the combined powers of neurocognitive and psychological variables was significant (P = .004, R2 = 0.33), with psychological and neurocognitive functioning accounting for 15% of the variance in relative language change beyond that accounted for by stroke severity and gross cognitive functioning. Negative affectivity expressed on the Positive and Negative Affectivity Scale made unique contributions to the model. Improvement in SLT is substantially related to neurocognitive and psychological functioning, particularly affectivity. Assessment of these characteristics may assist in identifying patients who are likely to improve and in tailoring treatment programs to yield optimal outcomes.

Optimal Transport Destination for Ischemic Stroke Patients With Unknown Vessel Status: Use of Prehospital Triage Scores.

PubMed

Schlemm, Eckhard; Ebinger, Martin; Nolte, Christian H; Endres, Matthias; Schlemm, Ludwig

2017-08-01

Patients with acute ischemic stroke (AIS) and large vessel occlusion may benefit from direct transportation to an endovascular capable comprehensive stroke center (mothership approach) as opposed to direct transportation to the nearest stroke unit without endovascular therapy (drip and ship approach). The optimal transport strategy for patients with AIS and unknown vessel status is uncertain. The rapid arterial occlusion evaluation scale (RACE, scores ranging from 0 to 9, with higher scores indicating higher stroke severity) correlates with the National Institutes of Health Stroke Scale and was developed to identify patients with large vessel occlusion in a prehospital setting. We evaluate how the RACE scale can help to inform prehospital triage decisions for AIS patients. In a model-based approach, we estimate probabilities of good outcome (modified Rankin Scale score of ≤2 at 3 months) as a function of severity of stroke symptoms and transport times for the mothership approach and the drip and ship approach. We use these probabilities to obtain optimal RACE cutoff scores for different transfer time settings and combinations of treatment options (time-based eligibility for secondary transfer under the drip and ship approach, time-based eligibility for thrombolysis at the comprehensive stroke center under the mothership approach). In our model, patients with AIS are more likely to benefit from direct transportation to the comprehensive stroke center if they have more severe strokes. Values of the optimal RACE cutoff scores range from 0 (mothership for all patients) to >9 (drip and ship for all patients). Shorter transfer times and longer door-to-needle and needle-to-transfer (door out) times are associated with lower optimal RACE cutoff scores. Use of RACE cutoff scores that take into account transport times to triage AIS patients to the nearest appropriate hospital may lead to improved outcomes. Further studies should examine the feasibility of translation into clinical practice. © 2017 American Heart Association, Inc.

Regional Evaluation of the Severity-Based Stroke Triage Algorithm for Emergency Medical Services Using Discrete Event Simulation.

PubMed

Bogle, Brittany M; Asimos, Andrew W; Rosamond, Wayne D

2017-10-01

The Severity-Based Stroke Triage Algorithm for Emergency Medical Services endorses routing patients with suspected large vessel occlusion acute ischemic strokes directly to endovascular stroke centers (ESCs). We sought to evaluate different specifications of this algorithm within a region. We developed a discrete event simulation environment to model patients with suspected stroke transported according to algorithm specifications, which varied by stroke severity screen and permissible additional transport time for routing patients to ESCs. We simulated King County, Washington, and Mecklenburg County, North Carolina, distributing patients geographically into census tracts. Transport time to the nearest hospital and ESC was estimated using traffic-based travel times. We assessed undertriage, overtriage, transport time, and the number-needed-to-route, defined as the number of patients enduring additional transport to route one large vessel occlusion patient to an ESC. Undertriage was higher and overtriage was lower in King County compared with Mecklenburg County for each specification. Overtriage variation was primarily driven by screen (eg, 13%-55% in Mecklenburg County and 10%-40% in King County). Transportation time specifications beyond 20 minutes increased overtriage and decreased undertriage in King County but not Mecklenburg County. A low- versus high-specificity screen routed 3.7× more patients to ESCs. Emergency medical services spent nearly twice the time routing patients to ESCs in King County compared with Mecklenburg County. Our results demonstrate how discrete event simulation can facilitate informed decision making to optimize emergency medical services stroke severity-based triage algorithms. This is the first step toward developing a mature simulation to predict patient outcomes. © 2017 American Heart Association, Inc.

Visual Aids for Improving Patient Decision Making in Severe Symptomatic Carotid Stenosis.

PubMed

Fridman, Sebastian; Saposnik, Gustavo; Sposato, Luciano A

2017-12-01

Because of the large amount of information to process and the limited time of a clinical consult, choosing between carotid endarterectomy (CEA) and carotid angioplasty with stenting (CAS) can be confusing for patients with severe symptomatic internal carotid stenosis (ICA). We aim to develop a visual aid tool to help clinicians and patients in the decision-making process of selecting between CEA and CAS. Based on pooled analysis from randomized controlled trials including patients with symptomatic and severe ICA (SSICA), we generated visual plots comparing CEA with CAS for 3 prespecified postprocedural time points: (1) any stroke or death at 4 months, and (2) any stroke or death in the first 30 days and ipsilateral stroke thereafter at 5 years and (3) at 10 years. A total of 4574 participants (2393 assigned to CAS, and 2361 to CEA) were included in the analyses. For every 100 patients with SSICA, 6 would develop any stroke or death in the CEA group compared with 9 undergoing CAS at 4 months (hazard ratio [HR] 1.53; 95%CI 1.20-1.95). At 5 years, 7 patients in the CEA group would develop any periprocedural stroke or death and ipsilateral stroke thereafter versus 12 undergoing CAS (HR 1.72; 95%CI 1.24-2.39), compared with 10 patients in the CEA and 13 in the CAS groups at 10 years (HR 1.17; 95%CI 0.82-1.66). Visual aids presented in this study could potentially help patients with severe symptomatic internal carotid stenosis to better weigh the risks and benefits of CEA versus CAS as a function of time, allowing for the prioritization of personal preferences, and should be prospectively assessed. Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Mental chronometry and mental rotation abilities in stroke patients with different degrees of sensory deficit.

PubMed

Liepert, Joachim; Büsching, Imke; Sehle, Aida; Schoenfeld, Mircea Ariel

2016-11-22

Motor imagery is used for treatment of motor deficits after stroke. Clinical observations suggested that motor imagery abilities might be reduced in patients with severe sensory deficits. This study investigated the influence of somatosensory deficits on temporal (mental chronometry, MC) and spatial aspects of motor imagery abilities. Stroke patients (n = 70; <6 months after stroke) were subdivided into 3 groups according to their somatosensory functions. Group 1 (n = 31) had no sensory deficits, group 2 (n = 27) had a mild to moderate sensory impairment and group 3 (n = 12) had severe sensory deficits. Patients and a healthy age-matched control group (n = 23) participated in a mental chronometry task (Box and Block Test, BBT) and a mental rotation task (Hand Identification Test, HIT). MC abilities were expressed as a ratio (motor execution time-motor imagery time/motor execution time). MC for the affected hand was significantly impaired in group 3 in comparison to stroke patients of group 1 (p = 0.006), group 2 (p = 0.005) and healthy controls (p < 0.001). For the non-affected hand MC was similar across all groups. Stroke patients had a slower BBT motor execution than healthy controls (p < 0.001), and group 1 executed the task faster than group 3 (p = 0.002). The percentage of correct responses in the HIT was similar for all groups. Severe sensory deficits impair mental chronometry abilities but have no impact on mental rotation abilities. Future studies should explore whether the presence of severe sensory deficits in stroke patients reduces the benefit from motor imagery therapy.

Current recommendations: what is the clinician to do?

PubMed

Manson, Joann E

2014-04-01

Menopausal hormone therapy (HT) has complex biologic effects but continues to have an important clinical role in the management of vasomotor and other menopausal symptoms. The rational use of menopausal HT requires balancing the potential benefits and risks of treatment. Findings from the Women's Health Initiative (WHI) and other randomized clinical trials have helped to clarify the benefits and risks of HT and have provided insights to improve decision making. Several clinical characteristics have utility in identifying women for whom benefits of HT are likely to outweigh the risks. Age and time since menopause are strong predictors of health outcomes and absolute risks associated with HT, and differences by age have been particularly apparent for estrogen alone. In the WHI trial of conjugated equine estrogens (CEE) alone, younger women (50-59 years) had more favorable results for all-cause mortality, myocardial infarction, and the global index, but not for stroke and venous thrombosis. Age trends were less clear for CEE + medroxyprogesterone acetate, owing to increased risks of breast cancer, stroke, and venous thrombosis in all age groups. Absolute risks of adverse events were lower in younger than in older women in both trials, however. Other predictors of lower vascular risk from HT include favorable lipid status and absence of the metabolic syndrome. Transdermal administration may be associated with lower risks of venous thrombosis and stroke, but additional research is needed. The use of risk stratification and personalized risk assessment offers promise for improved benefit-risk profile and safety of HT. One approach to decision making is presented. Key elements include: assessment of whether the patient has moderate to severe menopausal symptoms, the primary indication for initiating systemic HT (vaginal estrogen may be used to treat genitourinary symptoms in the absence of vasomotor symptoms); understanding the patient's own preference regarding therapy; evaluating the patient for the presence of any contraindications to HT, as well as the time since menopause onset and baseline risks of cardiovascular disease and breast cancer; reviewing carefully the benefits and risks of treatment with the patient, giving more emphasis to absolute than to relative measures of effect; and, if HT is initiated, regularly reviewing the patient's need for continued treatment. Copyright © 2014 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.

Incidence of Hospitalized Stroke in the Czech Republic: The National Registry of Hospitalized Patients.

PubMed

Sedova, Petra; Brown, Robert D; Zvolsky, Miroslav; Kadlecova, Pavla; Bryndziar, Tomas; Kubelka, Tomáš; Weiss, Viktor; Volný, Ondřej; Bednarik, Josef; Mikulik, Robert

2017-05-01

Contemporary stroke incidence data are not available in some countries and regions, including in Eastern Europe. Based on previous validation of the accuracy of the National Registry of Hospitalized Patients (NRHOSP), we report the incidence of hospitalized stroke in the Czech Republic (CR) using the NRHOSP. The results of the prior validation study assessing the accuracy of coding of stroke diagnoses in the NRHOSP were applied, and we calculated (1) the overall incidence of hospitalized stroke and (2) the incidence rates of hospitalized stroke for the three main stroke types: cerebral infarction (International Classification of Diseases Tenth Revision, CI I63), subarachnoid hemorrhage (SAH I60), and intracerebral hemorrhage (ICH I61). We calculated the average annual age- and sex-standardized incidence. The overall incidence of hospitalized stroke was 241 out of 100,000 individuals. The incidence of hospitalized stroke for the main stroke types was 8.2 cases in SAH, 29.5 in ICH, and 211 in CI per 100,000 individuals. The standardized annual stroke incidence adjusted to the 2000 World Health Organization population for overall stroke incidence of hospitalized stroke was 131 per 100,000 individuals. Standardized stroke incidence for stroke subtypes was 5.7 cases in SAH, 16.7 in ICH, and 113 in CI per 100,000 individuals. These studies provide an initial assessment of the burden of stroke in this part of the world. The estimates of hospitalized stroke in the CR and Eastern Europe suggest that ICH is about three times more common than SAH, and hemorrhagic stroke makes up about 18% of strokes. Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Complementary and alternative medicine treatments among stroke patients in India.

PubMed

Pandian, Jeyaraj Durai; Toor, Gagan; Arora, Rajni; Kaur, Paramdeep; Dheeraj, K V; Bhullar, Ranjeet Singh; Sylaja, Padmawati N

2012-01-01

Complementary and alternative medicine (CAM) is commonly used by persons with stroke throughout the world, particularly in Asia. The objectives of this study were to determine the frequency of CAM use and the factors that predict the use of CAM in stroke patients. This study was carried out in the stroke units of Christian Medical College, Ludhiana, and Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India, from June 2010 to December 2010. Participants were interviewed using a structured questionnaire (≥ 6 months post stroke). Outcomes were assessed using a modified Rankin Scale (mRS). Three hundred fourteen stroke patients were interviewed; mean age was 57.4 ± 12.9 years, and 230 (73.2%) patients were men. Of 314 patients, 114 (36.3%) had used the following CAM treatments: ayurvedic massage, 67 (59.3%); intravenous fluids, 22 (19.5%); herbal medicines, 17 (15%); homeopathy, 15 (13.3%); witchcraft, 3 (2.7%); acupuncture, 3 (2.7%); opium intake, 10 (8.8%); and other nonconventional treatments, 10 (8.8%). Patients with severe stroke (P < .0001), limb weakness (P < .0001), dysphagia (P = .02), dyslipidemia (P = .007), hypertension (P = .03), or hemorrhagic stroke (P<.0001) and patients with poor outcome (mRS >2;P < .0001) often used CAM treatments. More than one-third of the patients in this study opted for CAM. Presence of limb weakness, dysphagia, dyslipidemia, hypertension, hemorrhagic stroke, severe stroke, and poor outcome predicted the use of CAM.

The Christchurch earthquake stroke incidence study.

PubMed

Wu, Teddy Y; Cheung, Jeanette; Cole, David; Fink, John N

2014-03-01

We examined the impact of major earthquakes on acute stroke admissions by a retrospective review of stroke admissions in the 6 weeks following the 4 September 2010 and 22 February 2011 earthquakes. The control period was the corresponding 6 weeks in the previous year. In the 6 weeks following the September 2010 earthquake there were 97 acute stroke admissions, with 79 (81.4%) ischaemic infarctions. This was similar to the 2009 control period which had 104 acute stroke admissions, of whom 80 (76.9%) had ischaemic infarction. In the 6 weeks following the February 2011 earthquake, there were 71 stroke admissions, and 61 (79.2%) were ischaemic infarction. This was less than the 96 strokes (72 [75%] ischaemic infarction) in the corresponding control period. None of the comparisons were statistically significant. There was also no difference in the rate of cardioembolic infarction from atrial fibrillation between the study periods. Patients admitted during the February 2011 earthquake period were less likely to be discharged directly home when compared to the control period (31.2% versus 46.9%, p=0.036). There was no observable trend in the number of weekly stroke admissions between the 2 weeks leading to and 6 weeks following the earthquakes. Our results suggest that severe psychological stress from earthquakes did not influence the subsequent short term risk of acute stroke, but the severity of the earthquake in February 2011 and associated civil structural damages may have influenced the pattern of discharge for stroke patients. Copyright © 2013 Elsevier Ltd. All rights reserved.

Geomagnetic storms can trigger stroke: evidence from 6 large population-based studies in Europe and Australasia.

PubMed

Feigin, Valery L; Parmar, Priya G; Barker-Collo, Suzanne; Bennett, Derrick A; Anderson, Craig S; Thrift, Amanda G; Stegmayr, Birgitta; Rothwell, Peter M; Giroud, Maurice; Bejot, Yannick; Carvil, Phillip; Krishnamurthi, Rita; Kasabov, Nikola

2014-06-01

Although the research linking cardiovascular disorders to geomagnetic activity is accumulating, robust evidence for the impact of geomagnetic activity on stroke occurrence is limited and controversial. We used a time-stratified case-crossover study design to analyze individual participant and daily geomagnetic activity (as measured by Ap Index) data from several large population-based stroke incidence studies (with information on 11 453 patients with stroke collected during 16 031 764 person-years of observation) in New Zealand, Australia, United Kingdom, France, and Sweden conducted between 1981 and 2004. Hazard ratios and corresponding 95% confidence intervals (CIs) were calculated. Overall, geomagnetic storms (Ap Index 60+) were associated with 19% increase in the risk of stroke occurrence (95% CI, 11%-27%). The triggering effect of geomagnetic storms was most evident across the combined group of all strokes in those aged <65 years, increasing stroke risk by >50%: moderate geomagnetic storms (60-99 Ap Index) were associated with a 27% (95% CI, 8%-48%) increased risk of stroke occurrence, strong geomagnetic storms (100-149 Ap Index) with a 52% (95% CI, 19%-92%) increased risk, and severe/extreme geomagnetic storms (Ap Index 150+) with a 52% (95% CI, 19%-94%) increased risk (test for trend, P<2×10(-16)). Geomagnetic storms are associated with increased risk of stroke and should be considered along with other established risk factors. Our findings provide a framework to advance stroke prevention through future investigation of the contribution of geomagnetic factors to the risk of stroke occurrence and pathogenesis. © 2014 American Heart Association, Inc.

NEUROIMAGING CHARACTERISTICS AND POST-STROKE FATIGUE WITHIN THE FIRST 6 MONTHS AFTER ISCHEMIC STROKES.

PubMed

Delva, M; Delva, I

2017-10-01

Aim - identify neuroimaging characteristics associated with different post-stroke fatigue (PSF) domains within first 6 months after ischemic strokes. There were enrolled in the study 107 patients with acute ischemic strokes. General PSF and certain PSF domains (global, physical, mental, motivational, activity-related) were measured by multidimensional fatigue inventory-20 (MFI-20) scale at hospital stay, in 1, 3 and 6 months after stroke occurrence. Brain MRI studies included cerebral infarct localization, planimetric measurements of infarct volumes, measurement of brain atrophy indexes (bifrontal, bicaudate, cortical atrophy indexes, width of third ventricle) and evaluation of leukoaraiosis severity, according to Fazekas scale. In univariate logistic regression analysis infarcts volumes as well as brain atrophy indexes were not significantly associated with risk of any PSF domain at any time points within first 6 months after ischemic strokes. On the other hand, it had been found reliable associations between subcortical infarcts and increased risk of PSF domains which are related just to physical activity (physical PSF, activity-related PSF) in 1 month after stroke onset and later, as well as reliable associations between infratentorial infarcts and risk of global PSF domain in 3 months after stroke and later. Moreover, it have been revealed significant direct associations between severity of white matter lesions and risk of mental PSF in 3 months after stroke onset and later. Subcortical infarcts may be risk factors for development of physical PSF domain, infratentorial infarcts - risk factors for development of global PSF domain, leukoaraiosis extension - risk factor for development of mental PSF domain but not early than 1 month after stroke occurrence.

Lifestyle Factors and Early Clinical Outcome in Patients With Acute Stroke: A Population-Based Study.

PubMed

Ingeman, Annette; Andersen, Grethe; Thomsen, Reimar W; Hundborg, Heidi H; Rasmussen, Henrik H; Johnsen, Søren P

2017-03-01

We examined the associations of individual and combined lifestyle factors with early adverse stroke outcomes. A total of 82 597 patients were identified from nationwide registries. Lifestyle factors at the time of stroke admission included body mass index (kg/m 2 ), smoking habits, and alcohol intake, which were grouped (healthy, moderately healthy, moderately unhealthy, and unhealthy). The associations between lifestyle and outcomes were examined using multivariable regression. A total of 18.3% had a severe stroke, 7.8% pneumonia, 12.5% urinary tract infection, and 9.9% died within 30 days. The association between lifestyle, stroke severity, and mortality, respectively, differed according to sex. Unhealthy lifestyle was associated with lower risk of severe stroke (adjusted odds ratio [OR], 0.73; 95% confidence interval [CI], 0.63-0.84) and 30-day mortality among men (adjusted OR, 0.71; 95% CI, 0.58-0.87), but not among women (severe stroke: adjusted OR, 1.14; 95% CI, 0.85-1.55, and mortality: adjusted OR, 1.34; 95% CI, 0.90-1.99). No sex differences were found for pneumonia and urinary tract infection. Unhealthy lifestyle was not associated with a statistically significant increased risk of developing in-hospital pneumonia (adjusted OR, 1.30; 95% CI, 0.98-1.73) or urinary tract infection (adjusted OR, 0.98; 95% CI, 0.72-1.33). Underweight was associated with a higher 30-day mortality (men: adjusted OR, 1.71; 95% CI, 1.50-1.96, and women: adjusted OR, 1.46; 95% CI, 1.34-1.60). Healthy lifestyle was not associated with a lower risk of adverse stroke outcomes, in particularly among men. However, underweight may be a particular concern being associated with an increased risk of adverse outcomes among both sexes. © 2017 American Heart Association, Inc.

Biochemical and inflammatory biomarkers in ischemic stroke: translational study between humans and two experimental rat models

PubMed Central

2014-01-01

Background our objective was to examine the plasma levels of three biological markers involved in cerebral ischemia (IL-6, glutamate and TNF-alpha) in stroke patients and compare them with two different rat models of focal ischemia (embolic stroke model- ES and permanent middle cerebral artery occlusion ligation model-pMCAO) to evaluate which model is most similar to humans. Secondary objectives: 1) to analyze the relationship of these biological markers with the severity, volume and outcome of the brain infarction in humans and the two stroke models; and 2) to study whether the three biomarkers are also increased in response to damage in organs other than the central nervous system, both in humans and in rats. Methods Multi-center, prospective, case-control study including acute stroke patients (n = 58) and controls (n = 19) with acute non-neurological diseases Main variables: plasma biomarker levels on admission and at 72 h; stroke severity (NIHSS scale) and clinical severity (APACHE II scale); stroke volume; functional status at 3 months (modified Rankin Scale [mRS] and Barthel index [BI]). Experimental groups: ES (n = 10), pMCAO (n = 6) and controls (tissue stress by leg compression) (n = 6). Main variables: plasma biomarker levels at 3 and 72 h; volume of ischemic lesion (H&E) and cell death (TUNEL). Results in stroke patients, IL-6 correlated significantly with clinical severity (APACHE II scale), stroke severity (NIHSS scale), infarct volume (cm3) and clinical outcome (mRS) (r = 0.326, 0.497, 0.290 and 0.444 respectively; P < 0.05). Glutamate correlated with stroke severity, but not with outcome, and TNF-alpha levels with infarct volume. In animals, The ES model showed larger infarct volumes (median 58.6% vs. 29%, P < 0.001) and higher inflammatory biomarkers levels than pMCAO, except for serum glutamate levels which were higher in pMCAO. The ES showed correlations between the biomarkers and cell death (r = 0.928 for IL-6; P < 0.001; r = 0.765 for TNF-alpha, P < 0.1; r = 0.783 for Glutamate, P < 0.1) and infarct volume (r = 0.943 for IL-6, P < 0.0001) more similar to humans than pMCAO. IL-6, glutamate and TNF-α levels were not higher in cerebral ischemia than in controls. Conclusions Both models, ES and pMCAO, show differences that should be considered when conducting translational studies. IL-6, Glutamate and TNF-α are not specific for cerebral ischemia either in humans or in rats. PMID:25086655

Endocarditis and Stroke

PubMed Central

GRECU, Nicolae; TIU, Cristina; TERECOASA, Elena; BAJENARU, Ovidiu

2014-01-01

Endocarditis is an important, although less common, cause of cerebral embolism. All forms of endocarditis share an initial common pathophysiologic pathway, best illustrated by the non-bacterial thrombotic form, but also a final potential for embolization. Stroke associated with endocarditis has signifficant mortality and morbidity rates, especially due to the frequent concomitant multiple sites of brain embolization. In this article we aim to briefly review endocarditis with a focus on stroke as a complication, while also presenting case correlates from our department. PMID:25705308

Beat by beat stroke volume assessment by PDE in upright and supine exercise

NASA Technical Reports Server (NTRS)

1980-01-01

A 3.0 MHz pulse Doppler echocardiograph was used to estimate instantaneous stroke volume and cardiac output in 8 men during steady state supine and upright exercise at 300 kpm/min which were compared with other studies utilizing invasive procedures. The mean transients in heart rate and stroke volume and cardiac output for the first 20 sec of exercise in each posture were then determined. Centerline blood velocities were obtained in the ascending aorta with the transducer positioned manually in the suprasternal notch. Mean supine values for stroke volume and cardiac output at rest and exercise were 111 (6.4) and 112 ml (9.7 L/min), respectively, for supine. The corresponding results for upright were 76 (5.6) and 92 ml (8.4 L/min). These values compare favorably with prior studies. The transient response of cardiac output following the onset of upright was about twice as fast as in S because of the rapid and almost immediate upsurge in stroke volume. In supine, only heart rate served to augment cardiac output as stroke volume initially fell. The faster initial aortic flow in upright must represent the rapid mobilization of pooled venous blood from the leg veins which more than accounts for the additional volume (184 ml) of blood passing through the aorta during upright compared with supine in the first 20 sec.

Acute stroke care at rural hospitals in Idaho: challenges in expediting stroke care.

PubMed

Gebhardt, James G; Norris, Thomas E

2006-01-01

Thrombolytics are currently the most effective treatment for stroke. However, the National Institute for Neurological Disorders and Stroke criteria for initiation of thrombolytic therapy, most notably the 3-hour time limit from symptom onset, have proven challenging for many rural hospitals to achieve. To provide a snapshot of stroke care at rural hospitals in Idaho and to investigate the experiences of these hospitals in expediting stroke care. Using a standard questionnaire, a telephone survey of hospital staff at 21 rural hospitals in Idaho was performed. The survey focused on acute stroke care practices and strategies to expedite stroke care. The median number of stroke patients treated per year was 23.3. Patient delays were reported by 77.8% of hospitals, transport delays by 66.7%, in-hospital delays by 61.1%, equipment delays by 22.2%, and ancillary services delays by 61.1%. Approximately 67% of hospitals had implemented a clinical pathway for stroke and 80.0% had provided staff with stroke-specific training. No hospitals surveyed had a designated stroke team, and only 33.3% reported engaging in quality improvement efforts to expedite stroke care. Thrombolytics (tPA) were available and indicated for stroke at 55.6% of the hospitals surveyed. Rural hospitals in Idaho face many difficult challenges as they endeavor to meet the 3-hour deadline for thrombolytic therapy, including limited resources and experience in acute stroke care, and many different types of prehospital and in-hospital delays.

Satisfaction with rehabilitation in relation to self-perceived quality of life and function among patients with stroke - a 12 month follow-up.

PubMed

Hansson, Eva Ekvall; Beckman, Anders; Wihlborg, Anna; Persson, Sylvia; Troein, Margareta

2013-06-01

Stroke causes complex disability and function, and perceived quality of life has been shown to correlate with satisfaction with care as well as with life in general among stroke patients. The aim of this study was to study the relation of satisfaction with how rehabilitation was provided with self-perceived quality of life, self-perceived function and rehabilitation received, 12 months after the incidence. The subjects were assessed 12 months after the onset of stroke. The Barthel index was used to measure function, and the EuroQol-5D to measure quality of life. To measure satisfaction with how rehabilitation was provided, a questionnaire from the Swedish Stroke Register was used. Two hundred and eighty-three patients participated in the follow-up, 137 women and 146 men, aged between 42 and 95 years (mean age 75.2, SD 11.8). For the majority of patients rehabilitation was initiated at in-hospital care (directly after onset). One hundred and sixty-eight patients considered that rehabilitation was well provided for. Sixty-six regarded that the rehabilitation was only partly provided for and 35 that it was not provided for at all. High value on Barthel Index was associated with satisfaction with how rehabilitation was provided for (OR 2.81). Also, rehabilitation on three or more levels was negatively associated with satisfaction with rehabilitation provision (OR 0.24) and so was being male (OR 0.49). In this study, patients with higher values on Barthel Index were more satisfied with how rehabilitation was provided for. However, male patients and patients who received rehabilitation on three or more levels of care were less satisfied. Given the assumption that patients with more severe dysfunction after stroke are being rehabilitated on more levels, this might imply that it is not the amount of rehabilitation that gives satisfaction but the patients self-perceived function after rehabilitation. © 2012 Nordic College of Caring Science.

Predictors and Outcomes of Dysphagia Screening After Acute Ischemic Stroke.

PubMed

Joundi, Raed A; Martino, Rosemary; Saposnik, Gustavo; Giannakeas, Vasily; Fang, Jiming; Kapral, Moira K

2017-04-01

Guidelines advocate screening all acute stroke patients for dysphagia. However, limited data are available regarding how many and which patients are screened and how failing a swallowing screen affects patient outcomes. We sought to evaluate predictors of receiving dysphagia screening after acute ischemic stroke and outcomes after failing a screening test. We used the Ontario Stroke Registry from April 1, 2010, to March 31, 2013, to identify patients hospitalized with acute ischemic stroke and determine predictors of documented dysphagia screening and outcomes after failing the screening test, including pneumonia, disability, and death. Among 7171 patients, 6677 patients were eligible to receive dysphagia screening within 72 hours, yet 1280 (19.2%) patients did not undergo documented screening. Patients with mild strokes were significantly less likely than those with more severe strokes to have documented screening (adjusted odds ratio, 0.51; 95% confidence interval [CI], 0.41-0.64). Failing dysphagia screening was associated with poor outcomes, including pneumonia (adjusted odds ratio, 4.71; 95% CI, 3.43-6.47), severe disability (adjusted odds ratio, 5.19; 95% CI, 4.48-6.02), discharge to long-term care (adjusted odds ratio, 2.79; 95% CI, 2.11-3.79), and 1-year mortality (adjusted hazard ratio, 2.42; 95% CI, 2.09-2.80). Associations were maintained in patients with mild strokes. One in 5 patients with acute ischemic stroke did not have documented dysphagia screening, and patients with mild strokes were substantially less likely to have documented screening. Failing dysphagia screening was associated with poor outcomes, including in patients with mild strokes, highlighting the importance of dysphagia screening for all patients with acute ischemic stroke. © 2017 American Heart Association, Inc.

Effect of methylphenidate and/or levodopa coupled with physiotherapy on functional and motor recovery after stroke--a randomized, double-blind, placebo-controlled trial.

PubMed

Lokk, J; Salman Roghani, R; Delbari, A

2011-04-01

Amphetamine-like drugs are reported to enhance motor recovery and activities of daily living (ADL) in stroke rehabilitation, but results from trials with humans are inconclusive. This study is aimed at investigating whether levodopa (LD) and/or methylphenidate (MPH) in combination with physiotherapy could improve functional motor recovery and ADL in patients with stroke. A randomized, double-blind, placebo-controlled trial with ischemic stroke patients randomly allocated to one of four treatment groups of either MPH, LD or MPH+LD or placebo combined with physiotherapy was performed. Motor function, ADL, and stroke severity were assessed by Fugl-Meyer (FM), Barthel index (BI), and National Institute of Health Stroke Scale (NIHSS) at baseline, 15, 90, and 180 days respectively. All participants showed recovery of motor function and ADL during treatment and at 6-month follow-up. There were slightly but significant differences in BI and NIHSS compared to placebo at the 6-month follow-up. Ischemic chronic stroke patients having MPH and/or LD in combination with physiotherapy showed a slight ADL and stroke severity improvement over time. Future studies should address the issue of the optimal therapeutic window and dosage of medications to identify those patients who would benefit most. © 2010 John Wiley & Sons A/S.

Treadmill training with partial body weight support after stroke.

PubMed

Hesse, Stefan; Werner, Cordula; von Frankenberg, Sophie; Bardeleben, Anita

2003-02-01

Treadmill therapy with partial BWS is a promising new approach to improve gait ability after stroke. This task-specific approach enables nonambulatory patients the repetitive practice of complex gait cycles instead of single-limb gait-preparatory maneuvers. Patients walk more symmetrically with less spasticity and better cardiovascular efficiency on the treadmill than with floor walking. Several controlled, clinical studies have shown the potential of treadmill training as a therapeutic intervention for nonambulatory patients with chronic stroke-related hemiplegia. Furthermore, controlled trials in acute stroke survivors have shown that treadmill training is as effective as other physiotherapy approaches that stress the repetitive practice of gait. Controlled multicenter trials comparing locomotor training with conventional therapy will be forthcoming. An electromechanical gait trainer that relieves the strenuous effort of the therapists and provides control of the trunk in a phase-dependent manner is a new technical alternative for gait training in severely impaired stroke patients.

Improving Motor Corticothalamic Communication After Stroke Using Real-Time fMRI Connectivity-Based Neurofeedback.

PubMed

Liew, Sook-Lei; Rana, Mohit; Cornelsen, Sonja; Fortunato de Barros Filho, Marcos; Birbaumer, Niels; Sitaram, Ranganatha; Cohen, Leonardo G; Soekadar, Surjo R

2016-08-01

Two thirds of stroke survivors experience motor impairment resulting in long-term disability. The anatomical substrate is often the disruption of cortico-subcortical pathways. It has been proposed that reestablishment of cortico-subcortical communication relates to functional recovery. In this study, we applied a novel training protocol to augment ipsilesional cortico-subcortical connectivity after stroke. Chronic stroke patients with severe motor impairment were provided online feedback of blood-oxygenation level dependent signal connectivity between cortical and subcortical regions critical for motor function using real-time functional magnetic resonance imaging neurofeedback. In this proof of principle study, 3 out of 4 patients learned to voluntarily modulate cortico-subcortical connectivity as intended. Our results document for the first time the feasibility and safety for patients with chronic stroke and severe motor impairment to self-regulate and augment ipsilesional cortico-subcortical connectivity through neurofeedback using real-time functional magnetic resonance imaging. © The Author(s) 2015.

Evidence, education and practice.

PubMed

Kaste, Markku

2006-01-01

Stroke causes greater loss of quality-adjusted life years than any other disease and is also one of the most expensive disorders. The burden of stroke will increase in the future due to change in the age structure of populations. We have a vast body of evidence on how to prevent stroke and how to treat stroke patients. Good examples are treatment of hypertension, antithrombotic agents and carotid surgery in stroke prevention, thrombolysis in ischaemic stroke and stroke unit care for all stroke patients. We only have to translate scientific evidence into daily practice. If some pieces are missing, it is our duty to generate them through research. While taking part in randomized clinical trials (RCTs), the discipline, an essential part of RCTs, will improve the daily care of all stroke patients. Besides RCTs there are many other sources of scientific evidence for stroke management, one of which is the European Stroke Initiative (EUSI). The mission of the EUSI is to improve and optimize stroke management in Europe through education and by offering best practice guidelines. Also national and international societies and organizations play an important role in providing education. The human factor is one obstacle to more successful stroke management because to be more effective we must change our own clinical routine. We can make a difference by applying available evidence to our daily practice. Copyright (c) 2006 S. Karger AG, Basel.

Stroke-Related Stigma among West Africans: Patterns and Predictors

PubMed Central

Sarfo, Fred Stephen; Nichols, Michelle; Qanungo, Suparna; Teklehaimanot, Abeba; Singh, Arti; Mensah, Nathaniel; Saulson, Raelle; Gebregziabher, Mulugeta; Ezinne, Uvere; Owolabi, Mayowa; Jenkins, Carolyn; Ovbiagele, Bruce

2017-01-01

Background Disability-adjusted life-years lost after stroke in Low & Middle-Income Countries (LMICs) is almost seven times those lost in High-income countries. Although individuals living with chronic neurological and mental disorders are prone to stigma, there is a striking paucity of literature on stroke-related stigma particularly from LMICs. Objective To assess the prevalence, severity, determinants and psychosocial consequences of stigma among LMIC stroke survivors. Methods Between November 2015 and February 2016, we conducted a cross-sectional survey of 200 consecutive stroke survivors attending a neurology clinic in a tertiary medical center in Ghana. The validated 8-Item Stigma Scale for Chronic Illness (SSCI-8) questionnaire was administered to study participants to assess internalized and enacted domains of stigma at the personal dimension with further adaptation to capture family and community stigma experienced by stroke participants. Responses on the SSCI-8 were scored from 1–5 for each item, where 1=never, 2=rarely, 3=sometimes, 4=often and 5=always with a score range of 8–40. Demographic and clinical data on stroke type and severity as well as depression and health-related quality of life indicators were also collected. Predictors of stroke-related stigma were assessed using Linear Models (GLM) via Proc GENMOD in SAS 9.4. Results 105 (52.5%) subjects recruited were males and the mean ± SD age of stroke survivors in this survey was 62.0 ± 14.4 years. Mean SSCI-8 score was highest for personal stigma (13.7 ± 5.7), which was significantly higher than family stigma (11.9 ± 4.6; p=0.0005) and social/community stigma (11.4 ± 4.4; p<0.0001). Approximately 80% of the cohort reported experiencing mild-to-moderate degrees of stigma. A graded increase in scores on the Geriatric Depression Scale and Centre for Epidemiological Studies-Depression scale was observed across the three categories. Living in an urban setting was associated with higher SSCI-8 scores. Moreover, stroke subjects with more severe post-stroke residual symptom deficits reported a significantly higher frequency of stigma. Conclusion Four out of five stroke survivors in this Ghanaian cohort reported experiencing some form of stigma. Stigmatized individuals were also more likely to be depressed and have lower levels of quality of life. Further studies are required to assess the consequences of stigma from stroke in LMIC. PMID:28320146

Thrombolytic Treatment for Ischaemic Stroke: Could the Crisis of Confidence Have Been Avoided by Better Analysis of Trial Data?

PubMed

Barer, David; Berge, Eivind

2017-02-01

In many countries, thrombolysis with intravenous alteplase has become a central part of acute stroke care in recent years, requiring radical restructuring of services. However, a significant minority of emergency and stroke physicians have always had serious doubts about the safety and efficacy of thrombolytic treatment, and in 2015 these prompted a major review of the licensing status of alteplase by the UK regulatory authorities. Subsequent dramatic headlines and media stories have called into question the integrity of researchers and clinicians and undermined public faith in medical research. How did this situation arise and what should be done to prevent a repetition as we enter the era of intra-arterial treatment for stroke?Early intravenous alteplase increases the chances both of good recovery and of severe haemorrhage, so the risk/benefit balance must be assessed for individual patients according to stroke severity. For older patients and those with bigger strokes, the 'good recovery' criterion is an inefficient way of assessing treatment effects since few achieve full independence and differences between levels of functional impairment are ignored. This waste of information can be reduced by applying different criteria for 'good' and 'poor' outcomes in different prognostic groups (as clinicians do intuitively), hence increasing the number of patients contributing useful data. Such 'three-way prognosis-based outcome' analysis of existing and future trials could greatly increase the amount of relevant evidence to guide clinical decisions for individual patients across the range of stroke severity.

Changes in arm-hand function and arm-hand skill performance in patients after stroke during and after rehabilitation

PubMed Central

Smeets, Rob Johannes Elise Marie; Seelen, Henk Alexander Maria

2017-01-01

Background Arm-hand rehabilitation programs applied in stroke rehabilitation frequently target specific populations and thus are less applicable in heterogeneous patient populations. Besides, changes in arm-hand function (AHF) and arm-hand skill performance (AHSP) during and after a specific and well-described rehabilitation treatment are often not well evaluated. Method This single-armed prospective cohort study featured three subgroups of stroke patients with either a severely, moderately or mildly impaired AHF. Rehabilitation treatment consisted of a Concise_Arm_and_hand_ Rehabilitation_Approach_in_Stroke (CARAS). Measurements at function and activity level were performed at admission, clinical discharge, 3, 6, 9 and 12 months after clinical discharge. Results Eighty-nine stroke patients (M/F:63/23; mean age:57.6yr (+/-10.6); post-stroke time:29.8 days (+/-20.1)) participated. All patients improved on AHF and arm-hand capacity during and after rehabilitation, except on grip strength in the severely affected subgroup. Largest gains occurred in patients with a moderately affected AHF. As to self-perceived AHSP, on average, all subgroups improved over time. A small percentage of patients declined regarding self-perceived AHSP post-rehabilitation. Conclusions A majority of stroke patients across the whole arm-hand impairment severity spectrum significantly improved on AHF, arm-hand capacity and self-perceived AHSP. These were maintained up to one year post-rehabilitation. Results may serve as a control condition in future studies. PMID:28614403

Money is Brain: Financial Barriers and Consequences for Canadian Stroke Patients.

PubMed

Ganesh, Aravind; King-Shier, Kathryn; Manns, Braden J; Hill, Michael D; Campbell, David J T

2017-03-01

Stroke patients of lower socioeconomic status have worse outcomes. It remains poorly understood whether this is due to illness severity or personal or health system barriers. We explored the experiences of stroke patients with financial barriers in a qualitative descriptive pilot study, seeking to capture perceived challenges that interfere with their poststroke health and recovery. We interviewed six adults with a history of stroke and financial barriers in Alberta, Canada, inquiring about their: (1) experiences after stroke; (2) experience of financial barriers; (3) perceived reasons for financial barriers; (4) health consequences of financial barriers; and (5) mechanisms for coping with financial barriers. Two reviewers analyzed data using inductive thematic analysis. The participants developed new or worsened financial circumstances as a consequence of stroke-related disability. Poststroke impairments and financial barriers took a toll on their mental health. They struggled to access several aspects of long-term poststroke care, including allied health professional services, medications, and proper nutrition. They described opportunity costs and tradeoffs when accessing health services. In several cases, they were unaware of health resources available to them and were hesitant to disclose their struggles to their physicians and even their families. Some patients with financial barriers perceive challenges to accessing various aspects of poststroke care. They may have inadequate knowledge of resources available to them and may not disclose their concerns to their health care team. This suggests that providers themselves might consider asking stroke patients about financial barriers to optimize their long-term poststroke care.

Peripheral Frequency of CD4+ CD28− Cells in Acute Ischemic Stroke

PubMed Central

Tuttolomondo, Antonino; Pecoraro, Rosaria; Casuccio, Alessandra; Di Raimondo, Domenico; Buttà, Carmelo; Clemente, Giuseppe; Corte, Vittoriano della; Guggino, Giuliana; Arnao, Valentina; Maida, Carlo; Simonetta, Irene; Maugeri, Rosario; Squatrito, Rosario; Pinto, Antonio

2015-01-01

Abstract CD4+ CD28− T cells also called CD28 null cells have been reported as increased in the clinical setting of acute coronary syndrome. Only 2 studies previously analyzed peripheral frequency of CD28 null cells in subjects with acute ischemic stroke but, to our knowledge, peripheral frequency of CD28 null cells in each TOAST subtype of ischemic stroke has never been evaluated. We hypothesized that CD4+ cells and, in particular, the CD28 null cell subset could show a different degree of peripheral percentage in subjects with acute ischemic stroke in relation to clinical subtype and severity of ischemic stroke. The aim of our study was to analyze peripheral frequency of CD28 null cells in subjects with acute ischemic stroke in relation to TOAST diagnostic subtype, and to evaluate their relationship with scores of clinical severity of acute ischemic stroke, and their predictive role in the diagnosis of acute ischemic stroke and diagnostic subtype We enrolled 98 consecutive subjects admitted to our recruitment wards with a diagnosis of ischemic stroke. As controls we enrolled 66 hospitalized patients without a diagnosis of acute ischemic stroke. Peripheral frequency of CD4+ and CD28 null cells has been evaluated with a FACS Calibur flow cytometer. Subjects with acute ischemic stroke had a significantly higher peripheral frequency of CD4+ cells and CD28 null cells compared to control subjects without acute ischemic stroke. Subjects with cardioembolic stroke had a significantly higher peripheral frequency of CD4+ cells and CD28 null cells compared to subjects with other TOAST subtypes. We observed a significant relationship between CD28 null cells peripheral percentage and Scandinavian Stroke Scale and NIHSS scores. ROC curve analysis showed that CD28 null cell percentage may be useful to differentiate between stroke subtypes. These findings seem suggest a possible role for a T-cell component also in acute ischemic stroke clinical setting showing a different peripheral frequency of CD28 null cells in relation of each TOAST subtype of stroke. PMID:25997053

Red cell distribution width does not predict stroke severity or functional outcome.

PubMed

Ntaios, George; Gurer, Ozgur; Faouzi, Mohamed; Aubert, Carole; Michel, Patrik

2012-01-01

Red cell distribution width was recently identified as a predictor of cardiovascular and all-cause mortality in patients with previous stroke. Red cell distribution width is also higher in patients with stroke compared with those without. However, there are no data on the association of red cell distribution width, assessed during the acute phase of ischemic stroke, with stroke severity and functional outcome. In the present study, we sought to investigate this relationship and ascertain the main determinants of red cell distribution width in this population. We used data from the Acute Stroke Registry and Analysis of Lausanne for patients between January 2003 and December 2008. Red cell distribution width was generated at admission by the Sysmex XE-2100 automated cell counter from ethylene diamine tetraacetic acid blood samples stored at room temperature until measurement. An χ(2) -test was performed to compare frequencies of categorical variables between different red cell distribution width quartiles, and one-way analysis of variance for continuous variables. The effect of red cell distribution width on severity and functional outcome was investigated in univariate and multivariate robust regression analysis. Level of significance was set at 95%. There were 1504 patients (72±15·76 years, 43·9% females) included in the analysis. Red cell distribution width was significantly associated to NIHSS (β-value=0·24, P=0·01) and functional outcome (odds ratio=10·73 for poor outcome, P<0·001) at univariate analysis but not multivariate. Prehospital Rankin score (β=0·19, P<0·001), serum creatinine (β=0·008, P<0·001), hemoglobin (β=-0·009, P<0·001), mean platelet volume (β=0·09, P<0·05), age (β=0·02, P<0·001), low ejection fraction (β=0·66, P<0·001) and antihypertensive treatment (β=0·32, P<0·001) were independent determinants of red cell distribution width. Red cell distribution width, assessed during the early phase of acute ischemic stroke, does not predict severity or functional outcome. © 2011 The Authors. International Journal of Stroke © 2011 World Stroke Organization.

Platelet glycoprotein IIb/IIIa inhibitors in acute ischemic stroke.

PubMed

Kumar, Sudhir; Rajshekher, G; Prabhakar, Subhashini

2008-01-01

Acute ischemic stroke (AIS) is a common cause of morbidity and mortality worldwide. Thrombolytic therapy with tissue plasminogen activator, the only approved treatment for AIS, is received by less than 2% of patients. Moreover, there is a slight increase in hemorrhagic complications with thrombolysis. Therefore, there is a need for newer therapeutic modalities in AIS, which could be used in window periods beyond 3-6 h after stroke onset with fewer hemorrhagic complications. Glycoprotein IIb/IIIa inhibitors (GPI), after their initial success in patients with acute coronary syndromes, promised much in patients with AIS over the past decade or so. However, their exact role in patients with AIS, including the window periods and type of strokes, and the risk of symptomatic or asymptomatic hemorrhage are unclear at the moment. The current review focuses on the literature concerning the use of GPI in AIS and looks at the available evidence regarding their use. Abciximab thought to be safe and effective in initial case series and early trials, has not been shown to improve outcomes in AIS, and is associated with higher rates of hemorrhage. Tirofiban appears to be safe and effective in initial trials and there is a need to conduct further trials to establish its role in AIS.

From QASC to QASCIP: successful Australian translational scale-up and spread of a proven intervention in acute stroke using a prospective pre-test/post-test study design

PubMed Central

Lydtin, Anna; Comerford, Daniel; Cadilhac, Dominique A; McElduff, Patrick; Dale, Simeon; Hill, Kelvin; Longworth, Mark; Ward, Jeanette; Cheung, N Wah; D'Este, Cate

2016-01-01

Objectives To embed an evidence-based intervention to manage FEver, hyperglycaemia (Sugar) and Swallowing (the FeSS protocols) in stroke, previously demonstrated in the Quality in Acute Stroke Care (QASC) trial to decrease 90-day death and dependency, into all stroke services in New South Wales (NSW), Australia's most populous state. Design Pre-test/post-test prospective study. Setting 36 NSW stroke services. Methods Our clinical translational initiative, the QASC Implementation Project (QASCIP), targeted stroke services to embed 3 nurse-led clinical protocols (the FeSS protocols) into routine practice. Clinical champions attended a 1-day multidisciplinary training workshop and received standardised educational resources and ongoing support. Using the National Stroke Foundation audit collection tool and processes, patient data from retrospective medical record self-reported audits for 40 consecutive patients with stroke per site pre-QASCIP (1 July 2012 to 31 December 2012) were compared with prospective self-reported data from 40 consecutive patients with stroke per site post-QASCIP (1 November 2013 to 28 February 2014). Inter-rater reliability was substantial for 10 of 12 variables. Primary outcome measures Proportion of patients receiving care according to the FeSS protocols pre-QASCIP to post-QASCIP. Results All 36 (100%) NSW stroke services participated, nominating 100 site champions who attended our educational workshops. The time from start of intervention to completion of post-QASCIP data collection was 8 months. All (n=36, 100%) sites provided medical record audit data for 2144 patients (n=1062 pre-QASCIP; n=1082 post-QASCIP). Pre-QASCIP to post-QASCIP, proportions of patients receiving the 3 targeted clinical behaviours increased significantly: management of fever (pre: 69%; post: 78%; p=0.003), hyperglycaemia (pre: 23%; post: 34%; p=0.0085) and swallowing (pre: 42%; post: 51%; p=0.033). Conclusions We obtained unprecedented statewide scale-up and spread to all NSW stroke services of a nurse-led intervention previously proven to improve long-term patient outcomes. As clinical leaders search for strategies to improve quality of care, our initiative is replicable and feasible in other acute care settings. PMID:27154485