Early rehabilitation outcome in patients with middle cerebral artery stroke.

PubMed

Balaban, Birol; Tok, Fatih; Yavuz, Ferdi; Yaşar, Evren; Alaca, Rıdvan

2011-07-12

Although important data on the prognosis and rehabilitation outcome in stroke patients have been reported, data on functional recovery according to stroke subtypes are limited. This retrospective study aimed to evaluate functional outcome in patients with middle cerebral artery (MCA) stroke-the most common subtype of ischemic stroke. The records of stroke patients that underwent the rehabilitation program at our brain injury rehabilitation service between January 2007 and December 2008 were reviewed, and those with MCA stroke were included in the study. Patient demographic and clinical data, and Barthel Index (BI) and Functional Independence Measure (FIM) scores at admission and discharge were collected. The study included 80 MCA stroke patients with a mean age of 63.54 years. FIM and BI scores improved significantly post rehabilitation (P<0.05). Age was negatively correlated with both BI and FIM scores at admission and discharge. Length of stay was not correlated with improvement in BI or FIM scores during hospitalization. The patients that had ≤1 month of inpatient rehabilitation had similar outcomes as those that had >1 month of inpatient rehabilitation (P>0.05). Length of time after stroke onset was not correlated with BI or FIM scores at admission. Regardless of initial functional status, prediction of discharge functional status was misleading. Physiatrists should keep in mind that functional improvement does not always increase with duration of inpatient therapy. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.

Statin Treatment and Functional Outcome after Ischemic Stroke: Case-control and Meta-analysis

PubMed Central

Biffi, A; Devan, WJ; Anderson, CD; Cortellini, L; Furie, KL; Rosand, J; Rost, NS

2011-01-01

Background and Purpose Multiple studies suggest that statin use prior to acute ischemic stroke (AIS) is associated with improved functional outcome. However, available evidence is conflicting, and several published reports are limited by small sample sizes. We therefore investigated the effect of antecedent use of statins on stroke outcome by performing a meta-analysis of all results from published studies as well as our own unpublished data. Methods We performed a systematic literature search and meta-analysis of studies investigating the association between pre-stroke statin use and clinical outcome, and included additional data from 126 pre-stroke statin users and 767 non-users enrolled at our Institution. A total of 12 studies, comprising 2013 statin users and 9682 non- users were meta-analyzed using a random effects model. We also meta-analyzed results for individual TOAST stroke subtypes to determine whether the effect of statin use differed across subtypes, using the Breslow-Day (BD) test. Results Meta-analysis of all available data identified an association between pre-stroke statin use and improved functional outcome (Odds Ratio = 1.62, 95% Confidence Interval: 1.39 -1.88), but we uncovered evidence of publication bias. The effect of statin use on functional outcome was found to be larger for small vessel strokes compared to other subtypes (BD p = 0.008). Conclusions Antecedent use of statins is associated with improved outcome in AIS patients. This association appears to be stronger in patients with small vessel stroke subtype. However, evidence of publication bias in the existing literature suggests these findings should be interpreted with caution. PMID:21415396

Aphasia As a Predictor of Stroke Outcome.

PubMed

Lazar, Ronald M; Boehme, Amelia K

2017-09-19

Aphasia is a common feature of stroke, affecting 21-38% of acute stroke patients and an estimated 1 million stroke survivors. Although stroke, as a syndrome, is the leading cause of disability in the USA, less is known about the independent impact of aphasia on stroke outcomes. During the acute stroke period, aphasia has been found to increase length of stay, inpatient complications, overall neurological disability, mortality, and to alter discharge disposition. Outcomes during the sub-acute and chronic stroke periods show that aphasia is associated with lower Functional Independence Measures (FIM) scores, longer stays in rehabilitation settings, poorer function in activities of daily living, and mortality. Factors that complicate the analysis of aphasia on post-stroke outcomes, however, include widely different systems of care across international settings that result in varying admission patterns to acute stroke units, allowable length of stays based on reimbursement, and criteria for rehabilitation placement. Aphasia arising from stroke is associated with worse outcomes both in the acute and chronic periods. Future research will have to incorporate disparate patterns in analytic models, and to take into account specific aphasia profiles and evolving methods of post-stroke speech-language therapy.

Type-2 diabetes mellitus reduces cortical thickness and decreases oxidative metabolism in sensorimotor regions after stroke.

PubMed

Ferris, Jennifer K; Peters, Sue; Brown, Katlyn E; Tourigny, Katherine; Boyd, Lara A

2018-05-01

Individuals with type-2 diabetes mellitus experience poor motor outcomes after ischemic stroke. Recent research suggests that type-2 diabetes adversely impacts neuronal integrity and function, yet little work has considered how these neuronal changes affect sensorimotor outcomes after stroke. Here, we considered how type-2 diabetes impacted the structural and metabolic function of the sensorimotor cortex after stroke using volumetric magnetic resonance imaging (MRI) and magnetic resonance spectroscopy (MRS). We hypothesized that the combination of chronic stroke and type-2 diabetes would negatively impact the integrity of sensorimotor cortex as compared to individuals with chronic stroke alone. Compared to stroke alone, individuals with stroke and diabetes had lower cortical thickness bilaterally in the primary somatosensory cortex, and primary and secondary motor cortices. Individuals with stroke and diabetes also showed reduced creatine levels bilaterally in the sensorimotor cortex. Contralesional primary and secondary motor cortex thicknesses were negatively related to sensorimotor outcomes in the paretic upper-limb in the stroke and diabetes group such that those with thinner primary and secondary motor cortices had better motor function. These data suggest that type-2 diabetes alters cerebral energy metabolism, and is associated with thinning of sensorimotor cortex after stroke. These factors may influence motor outcomes after stroke.

Relationships between brain and body temperature, clinical and imaging outcomes after ischemic stroke

PubMed Central

Karaszewski, Bartosz; Carpenter, Trevor K; Thomas, Ralph G R; Armitage, Paul A; Lymer, Georgina Katherine S; Marshall, Ian; Dennis, Martin S; Wardlaw, Joanna M

2013-01-01

Pyrexia soon after stroke is associated with severe stroke and poor functional outcome. Few studies have assessed brain temperature after stroke in patients, so little is known of its associations with body temperature, stroke severity, or outcome. We measured temperatures in ischemic and normal-appearing brain using 1H-magnetic resonance spectroscopy and its correlations with body (tympanic) temperature measured four-hourly, infarct growth by 5 days, early neurologic (National Institute of Health Stroke Scale, NIHSS) and late functional outcome (death or dependency). Among 40 patients (mean age 73 years, median NIHSS 7, imaged at median 17 hours), temperature in ischemic brain was higher than in normal-appearing brain on admission (38.6°C-core, 37.9°C-contralateral hemisphere, P=0.03) but both were equally elevated by 5 days; both were higher than tympanic temperature. Ischemic lesion temperature was not associated with NIHSS or 3-month functional outcome; in contrast, higher contralateral normal-appearing brain temperature was associated with worse NIHSS, infarct expansion and poor functional outcome, similar to associations for tympanic temperature. We conclude that brain temperature is higher than body temperature; that elevated temperature in ischemic brain reflects a local tissue response to ischemia, whereas pyrexia reflects the systemic response to stroke, occurs later, and is associated with adverse outcomes. PMID:23571281

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.

Improving cognitive outcomes for pediatric stroke.

PubMed

Greenham, Mardee; Anderson, Vicki; Mackay, Mark T

2017-04-01

The past 20 years have seen a 35% increase in prevalence of pediatric stroke. Contrary to widely held views, children do not recover better than adults. This review explores the impact of pediatric stroke on cognitive domains, including intellectual and executive functions, memory and behavior, and the influence of age, lesion characteristics, and comorbidities on outcome. Cognitive problems occur in up to half of ischemic and hemorrhagic stroke survivors. Single-center studies have shown intelligence quotient scores skewed to the lower end of the average range, with greater impairment in performance than verbal domains. Executive function, such as attention and processing speed are particularly vulnerable to the effects of pediatric stroke. Age at stroke, larger infarct size, cortical/subcortical lesion location, epilepsy, and comorbid physical deficits are associated with poorer cognitive outcomes. Cognitive impairment occurs relatively frequently following pediatric stroke but the nature, severity, and predictors of specific deficits are not well defined. Improving understanding of outcomes following pediatric stroke is a key priority for families but a paucity of data limits the ability to develop targeted disease, and age-specific pediatric rehabilitation strategies to optimize cognitive outcomes following pediatric stroke.

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.

Effect of renal function status on the prognostic value of heart rate in acute ischemic stroke patients.

PubMed

Zhu, Zhengbao; Zhong, Chongke; Xu, Tian; Wang, Aili; Peng, Yanbo; Xu, Tan; Peng, Hao; Chen, Chung-Shiuan; Wang, Jinchao; Ju, Zhong; Li, Qunwei; Geng, Deqin; Sun, Yingxian; Du, Qingjuan; Li, Yongqiu; Chen, Jing; Zhang, Yonghong; He, Jiang

2017-08-01

The association between heart rate and prognosis of ischemic stroke remains debatable, and whether renal function status influences the relationship between them is still not elucidated. A total of 3923 ischemic stroke patients were included in this prospective multicenter study from the China Antihypertensive Trial in Acute Ischemic Stroke (CATIS). The primary outcome was a combination of death and major disability (modified Rankin Scale score ≥3) at 3 months after stroke. Secondary outcomes were, separately, death and major disability. The association between heart rate tertiles and primary outcome was appreciably modified by renal function status (p interaction  = 0.037). After multivariate adjustment, high heart rate was associated with increased risk of primary outcome in patients with abnormal renal function (odds ratio, 1.61; 95% confidence interval, 1.02-2.54; p trend  = 0.039) but not in patients with normal renal function (odds ratio, 0.96; 95% confidence interval, 0.75-1.23; p trend  = 0.741), when two extreme tertiles were compared. Each 10 bpm increase of heart rate was associated with 21% (95% CI: 1%-44%) increased risk of primary outcome, and a linear association between heart rate and risk of primary outcome was observed among patients with abnormal renal function (p for linearity = 0.002). High heart rate may be merely a strong predictor of poor prognosis in acute ischemic stroke patients with abnormal renal function, suggesting that heart rate reduction should be applied to ischemic stroke patients with abnormal renal function to improve their prognosis. Copyright © 2017 Elsevier B.V. All rights reserved.

Statin treatment and functional outcome after ischemic stroke: case-control and meta-analysis.

PubMed

Biffi, Alessandro; Devan, William J; Anderson, Christopher D; Cortellini, Lynelle; Furie, Karen L; Rosand, Jonathan; Rost, Natalia S

2011-05-01

Multiple studies suggest that statin use before acute ischemic stroke is associated with improved functional outcome. However, available evidence is conflicting, and several published reports are limited by small sample sizes. We therefore investigated the effect of antecedent use of statins on stroke outcome by performing a meta-analysis of all results from published studies as well as our own unpublished data. We performed a systematic literature search and meta-analysis of studies investigating the association between prestroke statin use and clinical outcome and included additional data from 126 prestroke statin users and 767 nonusers enrolled at our institution. A total of 12 studies, comprising 2013 statin users and 9682 nonusers, was meta-analyzed using a random effects model. We also meta-analyzed results for individual Trial of ORG 10172 in Acute Stroke Treatment stroke subtypes to determine whether the effect of statin use differed across subtypes using the Breslow-Day test. Meta-analysis of all available data identified an association between prestroke statin use and improved functional outcome (OR, 1.62; 95% CI, 1.39 to 1.88), but we uncovered evidence of publication bias. The effect of statin use on functional outcome was found to be larger for small vessel strokes compared with other subtypes (Breslow-Day P=0.008). Antecedent use of statins is associated with improved outcome in patients with acute ischemic stroke. This association appears to be stronger in patients with small vessel stroke subtype. However, evidence of publication bias in the existing literature suggests these findings should be interpreted with caution.

Insulin resistance and clinical outcomes after acute ischemic stroke.

PubMed

Ago, Tetsuro; Matsuo, Ryu; Hata, Jun; Wakisaka, Yoshinobu; Kuroda, Junya; Kitazono, Takanari; Kamouchi, Masahiro

2018-04-24

In this study, we aimed to determine whether insulin resistance is associated with clinical outcomes after acute ischemic stroke. We enrolled 4,655 patients with acute ischemic stroke (aged 70.3 ± 12.5 years, 63.5% men) who had been independent before admission; were hospitalized in 7 stroke centers in Fukuoka, Japan, from April 2009 to March 2015; and received no insulin therapy during hospitalization. The homeostasis model assessment of insulin resistance (HOMA-IR) score was calculated using fasting blood glucose and insulin levels measured 8.3 ± 7.8 days after onset. Study outcomes were neurologic improvement (≥4-point decrease in NIH Stroke Scale score or 0 at discharge), poor functional outcome (modified Rankin Scale score of ≥3 at 3 months), and 3-month prognosis (stroke recurrence and all-cause mortality). Logistic regression analysis was used to evaluate the association of the HOMA-IR score with clinical outcomes. The HOMA-IR score was associated with neurologic improvement (odds ratio, 0.68 [95% confidence interval, 0.56-0.83], top vs bottom quintile) and with poor functional outcome (2.02 [1.52-2.68], top vs bottom quintile) after adjusting for potential confounding factors, including diabetes and body mass index. HOMA-IR was not associated with stroke recurrence or mortality within 3 months of onset. The associations were maintained in nondiabetic or nonobese patients. No heterogeneity was observed according to age, sex, stroke subtype, or stroke severity. These findings suggest that insulin resistance is independently associated with poor functional outcome after acute ischemic stroke apart from the risk of short-term stroke recurrence or mortality. © 2018 American Academy of Neurology.

Association of Leukoaraiosis With Convalescent Rehabilitation Outcome in Patients With Ischemic Stroke.

PubMed

Senda, Joe; Ito, Keiichi; Kotake, Tomomitsu; Kanamori, Masahiko; Kishimoto, Hideo; Kadono, Izumi; Suzuki, Yoshiro; Katsuno, Masahisa; Nishida, Yoshihiro; Ishiguro, Naoki; Sobue, Gen

2016-01-01

We investigated the factors influencing inpatient convalescent rehabilitation outcomes in patients with ischemic stroke, particularly severity of leukoaraiosis on magnetic resonance imaging. Participants included 520 patients with ischemic stroke (317 men and 203 women; mean age, 72.8±8.4 years) who were transferred from acute care hospitals for inpatient convalescent rehabilitation. Ischemic stroke subtypes included lacunar infarction (n=41), atherothrombosis (n=223), artery-to-artery embolism (n=67), cardiogenic embolism (n=97), undetermined embolism (n=76), and uncategorized ischemic stroke (n=16). Leukoaraiosis was graded according to periventricular hyperintensity (PVH) and deep white matter hyperintensity on magnetic resonance imaging. Functional Independence Measure scores were assessed on admission and at discharge. Multiple regression analysis revealed that rehabilitation outcomes, measured as total Functional Independence Measure scores, were significantly associated with leukoaraiosis estimated by PVH grade. This association was observed after adjustment for factors such as severity, age, and poststroke history. In all patients, PVH grades were associated with Functional Independence Measure motor scores (P<0.001), whereas in patients with artery-to-artery embolism or cardiogenic embolism and deep white matter hyperintensity grades were associated with Functional Independence Measure cognitive scores (P<0.05). Our study revealed that the degree of leukoaraiosis was associated with inpatient convalescent rehabilitation outcome in patients with ischemic stroke. Furthermore, the PVH grade was associated with motor function outcome, whereas the deep white matter hyperintensity grade correlated with cognitive function outcome, likely because the progression patterns and anatomic backgrounds of PVH and deep white matter hyperintensity differ according to ischemic stroke subtype. © 2015 American Heart Association, Inc.

Update of the Preventive Antibiotics in Stroke Study (PASS): statistical analysis plan.

PubMed

Westendorp, Willeke F; Vermeij, Jan-Dirk; Dippel, Diederik W J; Dijkgraaf, Marcel G W; van der Poll, Tom; Prins, Jan M; Vermeij, Frederique H; Roos, Yvo B W E M; Brouwer, Matthijs C; Zwinderman, Aeilko H; van de Beek, Diederik; Nederkoorn, Paul J

2014-10-01

Infections occur in 30% of stroke patients and are associated with unfavorable outcomes. Preventive antibiotic therapy lowers the infection rate after stroke, but the effect of preventive antibiotic treatment on functional outcome in patients with stroke is unknown. The PASS is a multicenter, prospective, phase three, randomized, open-label, blinded end-point (PROBE) trial of preventive antibiotic therapy in acute stroke. Patients are randomly assigned to either ceftriaxone at a dose of 2 g, given every 24 h intravenously for 4 days, in addition to standard stroke-unit care, or standard stroke-unit care without preventive antibiotic therapy. The aim of this study is to assess whether preventive antibiotic treatment improves functional outcome at 3 months by preventing infections. This paper presents in detail the statistical analysis plan (SAP) of the Preventive Antibiotics in Stroke Study (PASS) and was submitted while the investigators were still blinded for all outcomes. The primary outcome is the score on the modified Rankin Scale (mRS), assessed by ordinal logistic regression analysis according to a proportional odds model. Secondary analysis of the primary outcome is the score on the mRS dichotomized as a favorable outcome (mRS 0 to 2) versus unfavorable outcome (mRS 3 to 6). Secondary outcome measures are death rate at discharge and 3 months, infection rate during hospital admission, length of hospital admission, volume of post-stroke care, use of antibiotics during hospital stay, quality-adjusted life years and costs. Complications of treatment, serious adverse events (SAEs) and suspected unexpected serious adverse reactions (SUSARs) are reported as safety outcomes. The data from PASS will establish whether preventive antibiotic therapy in acute stroke improves functional outcome by preventing infection and will be analyzed according to this pre-specified SAP. Current controlled trials; ISRCTN66140176. Date of registration: 6 April 2010.

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

Prestroke physical activity is associated with good functional outcome and arterial recanalization after stroke due to a large vessel occlusion.

PubMed

Ricciardi, Ana Clara; López-Cancio, Elena; Pérez de la Ossa, Natalia; Sobrino, Tomás; Hernández-Pérez, María; Gomis, Meritxell; Munuera, Josep; Muñoz, Lucía; Dorado, Laura; Millán, Mónica; Dávalos, Antonio; Arenillas, Juan F

2014-01-01

Although multiple studies and meta-analyses have consistently suggested that regular physical activity (PhA) is associated with a decreased stroke risk and recurrence, there is limited data on the possible preconditioning effect of prestroke PhA on stroke severity and prognosis. We aimed to study the association of prestroke PhA with different outcome variables in patients with acute ischemic stroke due to an anterior large vessel occlusion. The Prestroke Physical Activity and Functional Recovery in Patients with Ischemic Stroke and Arterial Occlusion trial is an observational and longitudinal study that included consecutive patients with acute ischemic stroke admitted to a single tertiary stroke center. Main inclusion criteria were: anterior circulation ischemic stroke within 12 h from symptom onset; presence of a confirmed anterior large vessel occlusion, and functional independence previous to stroke. Prestroke PhA was evaluated with the International Physical Activity Questionnaire and categorized into mild, moderate and high levels by means of metabolic equivalent (MET) minutes per week thresholds. The primary outcome measure was good functional outcome at 3 months (modified Rankin scale ≤2). Secondary outcomes were severity of stroke at admission, complete early recanalization, early dramatic neurological improvement and final infarct volume. During the study period, 159 patients fulfilled the above criteria. The mean age was 68 years, 62% were men and the baseline NIHSS score was 17. Patients with high levels of prestroke PhA were younger, had more frequently distal occlusions and had lower levels of blood glucose and fibrinogen at admission. After multivariate analysis, a high level of prestroke PhA was associated with a good functional outcome at 3 months. Regarding secondary outcome variables and after adjustment for relevant factors, a high level of prestroke PhA was independently associated with milder stroke severity at admission, early dramatic improvement, early arterial recanalization after intravenous thrombolysis and lower final infarct volume. The beneficial association of prestroke PhA with stroke outcomes was already present with a cutoff point of 1,000 MET min/week, a level of PhA easily achieved by walking 1 h/day during 5 days or by doing a vigorous aerobic activity 1 h/day twice a week. Prestroke PhA is independently associated with favorable stroke outcomes after a large vessel occlusion. Future research on the underlying mechanisms is needed to understand this neuroprotective effect of PhA. © 2014 S. Karger AG, Basel.

Autonomic Dysfunction Predicts Clinical Outcomes After Acute Ischemic Stroke: A Prospective Observational Study.

PubMed

Xiong, Li; Tian, Ge; Leung, Howan; Soo, Yannie O Y; Chen, Xiangyan; Ip, Vincent H L; Mok, Vincent C T; Chu, Winnie C W; Wong, Ka Sing; Leung, Thomas W H

2018-01-01

Central autonomic dysfunction increases stroke morbidity and mortality. We aimed to investigate whether poststroke autonomic dysfunction graded by Ewing battery can predict clinical outcome. In this prospective observational study, we assessed autonomic function of ischemic stroke patients within 7 days from symptom onset by Ewing battery. On the basis of the magnitude of autonomic dysfunction, we stratified patients into significant (definite, severe, or atypical) or minor (normal or early) autonomic function impairment groups and correlated the impairment with the 3-month modified Rankin Scale score (good outcome: modified Rankin Scale score 0≈2; poor outcome: modified Rankin Scale score 3≈6). Among the 150 patients enrolled (mean age, 66.4±9.9 years; 70.7% males), minor autonomic dysfunction was identified in 36 patients (24.0%), and significant autonomic dysfunction was identified in 114 patients (76.0%) based on Ewing battery. In 3 months, a poor functional outcome was found in 32.5% of significant group patients compared with 13.9% in the minor group ( P =0.031). Crude odds ratios of the magnitude of autonomic dysfunction and 3-month unfavorable functional outcome after acute ischemic stroke were 2.979 (95% confidence interval, 1.071-8.284; P =0.036). After adjusting for confounding variables with statistical significance between the 2 functional outcome subgroups identified in univariate analysis (including sex and National Institutes of Health Stroke Scale score on admission), the magnitude of autonomic dysfunction still independently predicted an unfavorable outcome, with an odds ratio of 3.263 (95% confidence interval, 1.141-9.335; P =0.027). Autonomic dysfunction gauged by Ewing battery predicts poor functional outcome after acute ischemic stroke. © 2017 American Heart Association, Inc.

Clinical prediction of functional outcome after ischemic stroke: the surprising importance of periventricular white matter disease and race.

PubMed

Kissela, Brett; Lindsell, Christopher J; Kleindorfer, Dawn; Alwell, Kathleen; Moomaw, Charles J; Woo, Daniel; Flaherty, Matthew L; Air, Ellen; Broderick, Joseph; Tsevat, Joel

2009-02-01

We sought to build models that address questions of interest to patients and families by predicting short- and long-term mortality and functional outcome after ischemic stroke, while allowing for risk restratification as comorbid events accumulate. A cohort of 451 ischemic stroke subjects in 1999 were interviewed during hospitalization, at 3 months, and at approximately 4 years. Medical records from the acute hospitalization were abstracted. All hospitalizations for 3 months poststroke were reviewed to ascertain medical and psychiatric comorbidities, which were categorized for analysis. Multivariable models were derived to predict mortality and functional outcome (modified Rankin Scale) at 3 months and 4 years. Comorbidities were included as modifiers of the 3-month models, and included in 4-year predictions. Poststroke medical and psychiatric comorbidities significantly increased short-term poststroke mortality and morbidity. Severe periventricular white matter disease (PVWMD) was significantly associated with poor functional outcome at 3 months, independent of other factors, such as diabetes and age; inclusion of this imaging variable eliminated other traditional risk factors often found in stroke outcomes models. Outcome at 3 months was a significant predictor of long-term mortality and functional outcome. Black race was a predictor of 4-year mortality. We propose that predictive models for stroke outcome, as well as analysis of clinical trials, should include adjustment for comorbid conditions. The effects of PVWMD on short-term functional outcomes and black race on long-term mortality are findings that require confirmation.

Impact of nutritional status on long-term functional outcomes of post-acute stroke patients in Taiwan.

PubMed

Shen, Hsiu-Chu; Chen, Hsueh-Fen; Peng, Li-Ning; Lin, Ming-Hsien; Chen, Liang-Kung; Liang, Chih-Kuang; Lo, Yuk-Keung; Hwang, Shinn-Jang

2011-01-01

Nutritional status is important in stroke care, but little is known regarding to the prognostic role of nutritional status on long-term functional outcomes among stroke survivors. The main purpose of this study was to evaluate to the prognostic role of nutritional status on long-term functional outcomes among stroke survivors. Data of acute stroke registry in Kaohsiung Veterans General Hospital were retrieved for analysis. Overall, 483 patients (mean age = 70.7 ± 10.3 years) with first-ever stroke were found. Among them, 95 patients (19.7%) were malnourished at admission, 310 (mean age = 70.4 ± 10.1 years, 63.5% males) survived for 6 months, and 244 (78.7%) had good functional outcomes. Subjects with poor functional outcomes were older (74.7 ± 8.9 vs. 69.0 ± 10.1 years, p < 0.001), more likely to be malnourished (56.2% vs. 26.6%, p < 0.001), to develop pneumonia upon admission (23.3% vs. 12.7%, p = 0.027), had a longer hospital stay (23.5 ± 13.9 vs. 12.5 ± 8.2 days, p < 0.001), had a higher National Institutes of Health Stroke Scale (NIHSS) score (12.9 ± 9.3 vs. 4.9 ± 4.3, p < 0.001), poorer stroke recovery (NIHSS improvement: 6.9% vs. 27.4%, p = 0.005), and poorer functional improvement (Barthel index = BI improvement in the first month: 31.4% vs. 138%, p < 0.001). Older age (odds ratio = OR) = 1.07, 95% confidence interval (CI = 1.03-1.11, p<0.001), baseline NIHSS score (OR = 1.23, 95%CI = 1.15-1.31, p < 0.001) and malnutrition at acute stroke (OR = 2.57, 95%CI: 1.29-5.13, p<0.001) were all independent risk factors for poorer functional outcomes. In conclusion, as a potentially modifiable factor, more attentions should be paid to malnutrition to promote quality of stroke care since the acute stage. Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.

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.

Characterizing speech and language pathology outcomes in stroke rehabilitation.

PubMed

Hatfield, Brooke; Millet, Deborah; Coles, Janice; Gassaway, Julie; Conroy, Brendan; Smout, Randall J

2005-12-01

Hatfield B, Millet D, Coles J, Gassaway J, Conroy B, Smout RJ. Characterizing speech and language pathology outcomes in stroke rehabilitation. To describe a subset of speech-language pathology (SLP) patients in the Post-Stroke Rehabilitation Outcomes Project and to examine outcomes for patients with low admission FIM levels of auditory comprehension and verbal expression. Observational cohort study. Five inpatient rehabilitation hospitals. Patients (N=397) receiving post-stroke SLP with admission FIM cognitive components at levels 1 through 5. Not applicable. Increase in comprehension and expression FIM scores from admission to discharge. Cognitively and linguistically complex SLP activities (problem-solving and executive functioning skills) were associated with greater likelihood of success in low- to mid-level functioning communicators in the acute post-stroke rehabilitation period. The results challenge common clinical practice by suggesting that use of high-level cognitively and linguistically complex SLP activities early in a patient's stay may result in more efficient practice and better outcomes regardless of the patient's functional communication severity level on admission.

Predictors of functional outcome among stroke patients in Lima, Peru.

PubMed

Abanto, Carlos; Ton, Thanh G N; Tirschwell, David L; Montano, Silvia; Quispe, Yrma; Gonzales, Isidro; Valencia, Ana; Calle, Pilar; Garate, Arturo; Zunt, Joseph

2013-10-01

Because of the aging population in low- and middle-income countries, cerebrovascular disease is expected to remain a leading cause of death. Little has been published about stroke in Peru. We conducted a retrospective cohort study of hospitalized stroke patients at a referral center hospital in Lima, Peru to explore factors associated with functional outcome among stroke patients. We identified 579 patients hospitalized for ischemic stroke or intracerebral hemorrhage stroke at the National Institute of Neurologic Sciences in Lima, Peru in 2008 and 2009. A favorable outcome was defined as a modified Rankin scale score of ≤ 2 at discharge. The mean age was 63.3 years; 75.6% had ischemic stroke; the average duration of stay was 17.3 days. At hospital discharge, 231 (39.9%) had a favorable outcome. The overall mortality rate was 5.2%. In multivariate models, the likelihood of having a favorable outcome decreased linearly with increasing age (P = .02) and increasing National Institutes of Health Stroke Scale (NIHSS) score (P = .02). Favorable outcome was also associated with male gender (relative risk [RR] 1.2; 95% confidence interval [CI] 1.0-1.5) and divorced status (RR 1.3; 95% CI 1.1-1.7). Patients on Salud Integral de Salud (SIS; public assistance-type insurance; RR 0.7; 95% CI 0.5-1.0) were also less likely to have a favorable outcome. Favorable outcome after stroke was independently associated with younger age, a lower NIHSS score, male gender, being divorced, and not being on SIS insurance. These findings suggest that additional study of worse functional outcomes in patients with SIS insurance be conducted and confirm the importance of risk adjustment for age, stroke severity (according to the NIHSS scale), and other socioeconomic factors in outcomes studies. Future studies should preferentially assess outcome at 30 days and 6 months to provide more reliable comparisons and allow additional study of Peruvian end-of-life decision-making and care. Copyright © 2013 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Effect of stress hyperglycemia and intensive rehabilitation therapy in non-diabetic hemorrhagic stroke: Korean Stroke Cohort for Functioning and Rehabilitation.

PubMed

Yoon, J A; Kim, D Y; Sohn, M K; Lee, J; Lee, S-G; Lee, Y-S; Han, E Y; Joo, M C; Oh, G-J; Han, J; Lee, S W; Park, M; Chang, W H; Shin, Y-I; Kim, Y-H

2016-11-01

We investigated the effect of stress hyperglycemia on the functional outcomes of non-diabetic hemorrhagic stroke. In addition, we investigated the usefulness of intensive rehabilitation for improving functional outcomes in patients with stress hyperglycemia. Non-diabetic hemorrhagic stroke patients were recruited and divided into two groups: intracerebral hemorrhage (ICH) (n = 165) and subarachnoid hemorrhage (SAH) (n = 156). Each group was divided into non-diabetics with or without stress hyperglycemia. Functional assessments were performed at 7 days and 3, 6 and 12 months after stroke onset. The non-diabetic with stress hyperglycemia groups were again divided into two groups who either received or did not receive intensive rehabilitation treatment. Serial functional outcome was compared between groups. For the ICH group, patients with stress hyperglycemia had worse modified Rankin Scale, National Institutes of Health Stroke Scale, Functional Ambulatory Category and Korean Mini-Mental State Examination scores than patients without stress hyperglycemia. For the SAH group, patients with stress hyperglycemia had worse scores on all functional assessments than patients without stress hyperglycemia at all time-points. After intensive rehabilitation treatment of patients with stress hyperglycemia, the ICH group had better scores on Functional Ambulatory Category and the SAH group had better scores on all functional assessments than patients without intensive rehabilitation treatment. Stress hyperglycemia affects the long-term prognosis of non-diabetic hemorrhagic stroke patients. Among stress hyperglycemia patients, intensive rehabilitation can enhance functional improvement after stroke. © 2016 EAN.

Outcome measurement of hand function following mirror therapy for stroke rehabilitation: A systematic review.

PubMed

Cantero-Téllez, Raquel; Naughton, Nancy; Algar, Lori; Valdes, Kristin

2018-02-28

Systematic review. Mirror therapy is a treatment used to address hand function following a stroke. Measurement of outcomes using appropriate assessment tools is crucial; however, many assessment options exist. The purpose of this study is to systematically review outcome measures that are used to assess hand function following mirror therapy after stroke and, in addition, to identify the psychometric and descriptive properties of the included measures and through the linking process determine if the outcome measures are representative of the International Classification of Functioning, Disability and Health (ICF). Following a comprehensive literature search, outcome measures used in the included studies were linked to the ICF and analyzed based on descriptive information and psychometric properties. Eleven studies met inclusion criteria and included 24 different assessment tools to measure hand or upper limb function. Most outcome measures used in the selected studies (63%) were rated by the evaluating therapist. Thirteen outcome measures (54%) linked to the ICF body function category and 10 measures (42%) linked to activities and participation. One outcome measure was linked to not defined, and all other ICF categories were not represented. A majority of outcome measures have been assessed for validity, reliability, and responsiveness, but responsiveness was the least investigated psychometric property. Current studies on mirror therapy after stroke are not consistent in the assessment tools used to determine hand function. Understanding of study outcomes requires analysis of the assessment tools. The outcome measures used in the included studies are not representative of personal and environmental factors, but tools linking to body functions and activities and participations provide important information on functional outcome. Integrating a combination of measures that are psychometrically sound and reflective of the ICF should be considered for assessment of hand function after mirror therapy after stroke. Copyright © 2018 Hanley & Belfus. Published by Elsevier Inc. All rights reserved.

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.

Embolic Strokes of Undetermined Source in the Athens Stroke Registry: An Outcome Analysis.

PubMed

Ntaios, George; Papavasileiou, Vasileios; Milionis, Haralampos; Makaritsis, Konstantinos; Vemmou, Anastasia; Koroboki, Eleni; Manios, Efstathios; Spengos, Konstantinos; Michel, Patrik; Vemmos, Konstantinos

2015-08-01

Information about outcomes in Embolic Stroke of Undetermined Source (ESUS) patients is unavailable. This study provides a detailed analysis of outcomes of a large ESUS population. Data set was derived from the Athens Stroke Registry. ESUS was defined according to the Cryptogenic Stroke/ESUS International Working Group criteria. End points were mortality, stroke recurrence, functional outcome, and a composite cardiovascular end point comprising recurrent stroke, myocardial infarction, aortic aneurysm rupture, systemic embolism, or sudden cardiac death. We performed Kaplan-Meier analyses to estimate cumulative probabilities of outcomes by stroke type and Cox-regression to investigate whether stroke type was outcome predictor. 2731 patients were followed-up for a mean of 30.5±24.1months. There were 73 (26.5%) deaths, 60 (21.8%) recurrences, and 78 (28.4%) composite cardiovascular end points in the 275 ESUS patients. The cumulative probability of survival in ESUS was 65.6% (95% confidence intervals [CI], 58.9%-72.2%), significantly higher compared with cardioembolic stroke (38.8%, 95% CI, 34.9%-42.7%). The cumulative probability of stroke recurrence in ESUS was 29.0% (95% CI, 22.3%-35.7%), similar to cardioembolic strokes (26.8%, 95% CI, 22.1%-31.5%), but significantly higher compared with all types of noncardioembolic stroke. One hundred seventy-two (62.5%) ESUS patients had favorable functional outcome compared with 280 (32.2%) in cardioembolic and 303 (60.9%) in large-artery atherosclerotic. ESUS patients had similar risk of composite cardiovascular end point as all other stroke types, with the exception of lacunar strokes, which had significantly lower risk (adjusted hazard ratio, 0.70 [95% CI, 0.52-0.94]). Long-term mortality risk in ESUS is lower compared with cardioembolic strokes, despite similar rates of recurrence and composite cardiovascular end point. Recurrent stroke risk is higher in ESUS than in noncardioembolic strokes. © 2015 American Heart Association, Inc.

Web-based tool for dynamic functional outcome after acute ischemic stroke and comparison with existing models.

PubMed

Ji, Ruijun; Du, Wanliang; Shen, Haipeng; Pan, Yuesong; Wang, Penglian; Liu, Gaifen; Wang, Yilong; Li, Hao; Zhao, Xingquan; Wang, Yongjun

2014-11-25

Acute ischemic stroke (AIS) is one of the leading causes of death and adult disability worldwide. In the present study, we aimed to develop a web-based risk model for predicting dynamic functional status at discharge, 3-month, 6-month, and 1-year after acute ischemic stroke (Dynamic Functional Status after Acute Ischemic Stroke, DFS-AIS). The DFS-AIS was developed based on the China National Stroke Registry (CNSR), in which eligible patients were randomly divided into derivation (60%) and validation (40%) cohorts. Good functional outcome was defined as modified Rankin Scale (mRS) score ≤ 2 at discharge, 3-month, 6-month, and 1-year after AIS, respectively. Independent predictors of each outcome measure were obtained using multivariable logistic regression. The area under the receiver operating characteristic curve (AUROC) and plot of observed and predicted risk were used to assess model discrimination and calibration. A total of 12,026 patients were included and the median age was 67 (interquartile range: 57-75). The proportion of patients with good functional outcome at discharge, 3-month, 6-month, and 1-year after AIS was 67.9%, 66.5%, 66.9% and 66.9%, respectively. Age, gender, medical history of diabetes mellitus, stroke or transient ischemic attack, current smoking and atrial fibrillation, pre-stroke dependence, pre-stroke statins using, admission National Institutes of Health Stroke Scale score, admission blood glucose were identified as independent predictors of functional outcome at different time points after AIS. The DFS-AIS was developed from sets of predictors of mRS ≤ 2 at different time points following AIS. The DFS-AIS demonstrated good discrimination in the derivation and validation cohorts (AUROC range: 0.837-0.845). Plots of observed versus predicted likelihood showed excellent calibration in the derivation and validation cohorts (all r = 0.99, P < 0.001). When compared to 8 existing models, the DFS-AIS showed significantly better discrimination for good functional outcome and mortality at discharge, 3-month, 6-month, and 1-year after AIS (all P < 0.0001). The DFS-AIS is a valid risk model to predict functional outcome at discharge, 3-month, 6-month, and 1-year after AIS.

Low free triiodothyronine predicts poor functional outcome after acute ischemic stroke.

PubMed

Suda, Satoshi; Muraga, Kanako; Kanamaru, Takuya; Okubo, Seiji; Abe, Arata; Aoki, Junya; Suzuki, Kentaro; Sakamoto, Yuki; Shimoyama, Takashi; Nito, Chikako; Kimura, Kazumi

2016-09-15

The aim of this study was to investigate the association of admission serum thyroid hormone concentration with clinical characteristics and functional outcomes in patients after acute ischemic stroke. We retrospectively enrolled 398 consecutive patients admitted to our stroke center between July 2010 and April 2012. Serum thyroid stimulating hormone (TSH), free triiodothyronine (FT3), and free thyroxine (FT4) were evaluated upon admission. Neurological severity was evaluated using the National Institutes of Health Stroke Scale (NIHSS) upon admission and the modified Rankin Scale (mRS) upon discharge. Poor outcome was defined as a mRS score of 3-5 or death (mRS score 6). Separate analyses were conducted according to outcome and quartile serum FT3 concentration. In total, 164 patients (41.2%) demonstrated a poor outcome. Age, male gender, blood glucose level, arterial fibrillation, dyslipidemia, smoking, NIHSS score, cardioembolic stroke type, and periventricular hyperintensities, but not FT4 or TSH, were significantly associated with poor functional outcome. Furthermore, poor functional outcome was independently associated with low FT3 (<2.29pg/mL). In comparisons between FT3 quartiles (Q1 [≤2.11pg/mL], Q2 [2.12-2.45pg/mL], Q3 [2.46-2.77pg/mL], Q4 [≥2.78pg/mL]), patients with poor outcomes were more frequent in Q1 than in Q4 after multivariate adjustment. Death was more frequent in Q1 than in Q4 after adjustment for risk factors and comorbidities, but this difference was non-significant after additional adjustment for age and NIHSS score. Our data suggest that a lower FT3 value upon admission may predict a poor functional outcome in patients with acute ischemic stroke. Further large-scale prospective studies are required to clarify the role of thyroid hormone in the acute phase of ischemic stroke. Copyright © 2016 Elsevier B.V. All rights reserved.

Elevated Fasting Blood Glucose Is Predictive of Poor Outcome in Non-Diabetic Stroke Patients: A Sub-Group Analysis of SMART.

PubMed

Yao, Ming; Ni, Jun; Zhou, Lixin; Peng, Bin; Zhu, Yicheng; Cui, Liying

2016-01-01

Although increasing evidence suggests that hyperglycemia following acute stroke adversely affects clinical outcome, whether the association between glycaemia and functional outcome varies between stroke patients with\\without pre-diagnosed diabetes remains controversial. We aimed to investigate the relationship between the fasting blood glucose (FBG) and the 6-month functional outcome in a subgroup of SMART cohort and further to assess whether this association varied based on the status of pre-diagnosed diabetes. Data of 2862 patients with acute ischemic stroke (629 with pre-diagnosed diabetics) enrolled from SMART cohort were analyzed. Functional outcome at 6-month post-stroke was measured by modified Rankin Scale (mRS) and categorized as favorable (mRS:0-2) or poor (mRS:3-5). Binary logistic regression model, adjusting for age, gender, educational level, history of hypertension and stroke, baseline NIHSS and treatment group, was used in the whole cohort to evaluate the association between admission FBG and functional outcome. Stratified logistic regression analyses were further performed based on the presence/absence of pre-diabetes history. In the whole cohort, multivariable logistical regression showed that poor functional outcome was associated with elevated FBG (OR1.21 (95%CI 1.07-1.37), p = 0.002), older age (OR1.64 (95% CI1.38-1.94), p<0.001), higher NIHSS (OR2.90 (95%CI 2.52-3.33), p<0.001) and hypertension (OR1.42 (95%CI 1.13-1.98), p = 0.04). Stratified logistical regression analysis showed that the association between FBG and functional outcome remained significant only in patients without pre-diagnosed diabetes (OR1.26 (95%CI 1.03-1.55), p = 0.023), but not in those with premorbid diagnosis of diabetes (p = 0.885). The present results demonstrate a significant association between elevated FBG after stroke and poor functional outcome in patients without pre-diagnosed diabetes, but not in diabetics. This finding confirms the importance of glycemic control during acute phase of ischemic stroke especially in patients without pre-diagnosed diabetes. Further investigation for developing optimal strategies to control blood glucose level in hyperglycemic setting is therefore of great importance. ClinicalTrials.gov NCT00664846.

The impact of early specialist management on outcomes of patients with in-hospital stroke.

PubMed

Manawadu, Dulka; Choyi, Jithesh; Kalra, Lalit

2014-01-01

Delays in treatment of in-hospital stroke (IHS) adversely affect patient outcomes. We hypothesised that early referral and specialist management of IHS patients will improve outcomes at 90 days. Baseline characteristics, assessment delays, thrombolysis eligibility, 90-day functional outcomes and all-cause mortality were compared between IHS patients referred for specialist stroke management within 3 hours of symptom onset (early referrals) and later referrals. Patients were identified from a prospective stroke registry between January 2009 and December 2010. Inclusion criteria were primary admission with a non-stroke diagnosis, onset of new neurological deficits after admission and early ischaemic changes on CT or MR imaging. Eighty four (4.6%) of 1836 stroke patients had IHS (mean age 74 year; 51% male, median NIHSS score 10). There were no significant differences in baseline characteristics between 53 (63%) early and 31 (37%) late referrals. Thrombolysis was performed in 29 (76%) of the 37/78 (47%) potentially eligible patients; 7 patients were excluded because specialist referral was delayed beyond 4.5 hours despite symptom recognition within 3 hours of onset. Early referral improved functional outcomes (modified Rankin Scale 0-2 at 90 days 40% v 7%, p = 0.001) and was an independent predictor of mRS 0-2 at 90 days after adjusting for age, pre-morbid function, primary cause for hospital admission and stroke severity [OR 1.13 (95% C.I.  = 1.10-1.27), p = 0.002]. Early referral and specialist management of IHS patients that includes thrombolysis is associated with better functional outcomes at 90 days.

Poststroke Shoulder Pain in Turkish Stroke Patients: Relationship with Clinical Factors and Functional Outcomes

ERIC Educational Resources Information Center

Barlak, Aysegul; Unsal, Sibel; Kaya, Kurtulus; Sahin-Onat, Sule; Ozel, Sumru

2009-01-01

The objective of this study was to assess the possible causes of hemiplegic shoulder pain (HSP) in Turkish patients with stroke, to identify the correlation between HSP and clinical factors, and to review the effects of HSP on functional outcomes. A total of 187 consecutive patients with stroke were evaluated for the presence of HSP and for the…

Association Between Brain-Derived Neurotrophic Factor Genotype and Upper Extremity Motor Outcome After Stroke.

PubMed

Chang, Won Hyuk; Park, Eunhee; Lee, Jungsoo; Lee, Ahee; Kim, Yun-Hee

2017-06-01

The identification of intrinsic factors for predicting upper extremity motor outcome could aid the design of individualized treatment plans in stroke rehabilitation. The aim of this study was to identify prognostic factors, including intrinsic genetic factors, for upper extremity motor outcome in patients with subacute stroke. A total of 97 patients with subacute stroke were enrolled. Upper limb motor impairment was scored according to the upper limb of Fugl-Meyer assessment score at 3 months after stroke. The prediction of upper extremity motor outcome at 3 months was modeled using various factors that could potentially influence this impairment, including patient characteristics, baseline upper extremity motor impairment, functional and structural integrity of the corticospinal tract, and brain-derived neurotrophic factor genotype. Multivariate ordinal logistic regression models were used to identify the significance of each factor. The independent predictors of motor outcome at 3 months were baseline upper extremity motor impairment, age, stroke type, and corticospinal tract functional integrity in all stroke patients. However, in the group with severe motor impairment at baseline (upper limb score of Fugl-Meyer assessment <25), the number of Met alleles in the brain-derived neurotrophic factor genotype was also an independent predictor of upper extremity motor outcome 3 months after stroke. Brain-derived neurotrophic factor genotype may be a potentially useful predictor of upper extremity motor outcome in patients with subacute stroke with severe baseline motor involvement. © 2017 American Heart Association, Inc.

A retrospective observational study of functional outcomes, length of stay, and discharge disposition after an inpatient stroke rehabilitation program in Saudi Arabia.

PubMed

Bindawas, Saad M; Mawajdeh, Hussam; Vennu, Vishal; Alhaidary, Hisham

2016-08-01

Functional outcomes, length of stay (LOS), and discharge disposition have become frequent outcome measures among stroke patients after rehabilitation programs. To examine the trends of changes in functional outcomes, LOS, and discharge disposition in stroke patients discharged from an inpatient rehabilitation facility.All patients (n = 432) were admitted to a tertiary inpatient rehabilitation hospital in Riyadh, Saudi Arabia with stroke diagnoses from November 2008 to December 2014. The functional independence measure (FIM) instrument used to assess the patient's functional status. The LOS was measured as the number of days the patients spent in the hospital from the day of admission to the day of discharge. The FIM efficiency was used to measure the patient's rehabilitation progress. All of the variables of the prospectively collected data were retrospectively analyzed.There were significant changes by years in the total FIM ranging from 23 to 29 (P < 0.001) and subscores: FIM motor ranging from 20 to 26 (P < 0.001); FIM cognitive ranging from 1.8 to 3 (P < 0.001). The mean LOS remained constant, from 52 days in 2011 to 40 days in 2013. The FIM efficiency was stable between years and ranged from 0.52 to 0.72. The rates of discharge (to home) were significantly unstable and ranged from 100% in 2010 and 2011 to 92% in 2013.Our results suggest that functional outcomes in patients with stroke have improved after an inpatient stroke rehabilitation program between 2008 and 2014 even with a constant LOS. Discharge disposition has remained unstable over this period. To improve the efficiency of the stroke rehabilitation program in Saudi Arabia, there is a need to decrease the LOS and emphasize a comprehensive interdisciplinary approach.

Association between PTGS1 polymorphisms and functional outcomes in Chinese patients with stroke during aspirin therapy: Interaction with smoking.

PubMed

Cai, Huan; Cai, Biyang; Sun, Lingli; Zhang, Hao; Zhou, Shuyu; Cao, Liping; Guo, Hongquan; Sun, Wen; Yan, Bernard; Davis, Stephen M; Zhang, Zhizhong; Liu, Xinfeng

2017-05-15

Prostaglandin-Endoperoxide Synthase 1 (PTGS1) and smoking may play important roles in aspirin nonresponsiveness, but the effect of their interaction on stroke outcomes remains largely unknown. We examined the effects of PTGS1 polymorphisms, smoking status, and their interaction on functional outcomes in a cohort of Chinese Han patients with stroke during aspirin therapy. A total of 617 ischemic stroke patients taking aspirin were enrolled. Three single nucleotide polymorphisms (SNPs) rs1330344, rs3842788, and rs5788 in PTGS1 were determined for genotyping. Poor functional outcomes were defined as a modified Rankin Scale (mRS) of 3-6 at 90-day follow-up. The influence of PTGS1 gene-smoking interaction on functional outcomes was examined. Poor functional outcomes occurred in 145 (23.5%) patients. When adjusting multiple factors by logistic regression, CC genotype of rs1330344 was associated with poor functional outcomes (risk ratio [RR]=1.73; 95% confidence interval [CI]: 1.17-2.37). A similar connection was found in the CGC haplotype (RR=1.40; 95% CI: 1.08-1.77). Furthermore, we found a significant interaction between rs1330344 and smoking status (P interaction =0.018); the interaction effect between the PTGS1 haplotype and smoking also showed statistical significance (P interaction =0.040). In Chinese Han stroke patients with aspirin therapy, the adverse effect of PTGS1 polymorphisms on functional outcomes may be modulated by the smoking status. PTGS1 gene-smoking interaction might in part reflect the heterogeneity in the prognosis of patients treated with aspirin. Copyright © 2017 Elsevier B.V. All rights reserved.

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

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

The impact of patient's weight on post-stroke rehabilitation.

PubMed

Kalichman, Leonid; Alperovitch-Najenson, Deborah; Treger, Iuly

2016-08-01

Purpose To evaluate the influence of patient's weight on rehabilitation outcomes in first-event stroke patients. Design Retrospective, observational comparative study. 102 first-time stroke male and female patients admitted to the 52-bed neurology rehabilitation department in a rehabilitation hospital were included in the study. Body mass index (BMI), Functional Independence Measure (FIM) on admission and at discharge, as well as the delta-FIM (FIM on admission - FIM at discharge) were evaluated. The Kruskal-Wallis test was used to compare the FIM and the NIHSS scores between BMI groups (normal, overweight, moderate and severe obesity). Results A statistically significant negative correlation (rho = -0.20, p = 0.049) was found between FIM change and BMI, that remained significant after adjustments for age, sex and hospitalisation days. No difference was found between groups in FIM or NIHSS change between BMI groups. Conclusions In sub-acute post-stroke patients undergoing rehabilitation in rehabilitation hospital, BMI was negatively associated with the improvement of functional parameters. Patients' BMI should be taken into consideration when predicting rehabilitation outcome for stroke patients. Further investigations are needed to identify the functional parameters affected by the patients' BMI. Implications for Rehabilitation In sub-acute post-stroke patients undergoing rehabilitation in rehabilitation hospital, BMI was negatively associated with the improvement of functional parameters. Patients' BMI should be taken into consideration when predicting rehabilitation outcome for stroke patients. New rehabilitation strategies should be designed to improve the functional outcomes of rehabilitation of obese patients.

Measure of functional independence dominates discharge outcome prediction after inpatient rehabilitation for stroke.

PubMed

Brown, Allen W; Therneau, Terry M; Schultz, Billie A; Niewczyk, Paulette M; Granger, Carl V

2015-04-01

Identifying clinical data acquired at inpatient rehabilitation admission for stroke that accurately predict key outcomes at discharge could inform the development of customized plans of care to achieve favorable outcomes. The purpose of this analysis was to use a large comprehensive national data set to consider a wide range of clinical elements known at admission to identify those that predict key outcomes at rehabilitation discharge. Sample data were obtained from the Uniform Data System for Medical Rehabilitation data set with the diagnosis of stroke for the years 2005 through 2007. This data set includes demographic, administrative, and medical variables collected at admission and discharge and uses the FIM (functional independence measure) instrument to assess functional independence. Primary outcomes of interest were functional independence measure gain, length of stay, and discharge to home. The sample included 148,367 people (75% white; mean age, 70.6±13.1 years; 97% with ischemic stroke) admitted to inpatient rehabilitation a mean of 8.2±12 days after symptom onset. The total functional independence measure score, the functional independence measure motor subscore, and the case-mix group were equally the strongest predictors for any of the primary outcomes. The most clinically relevant 3-variable model used the functional independence measure motor subscore, age, and walking distance at admission (r(2)=0.107). No important additional effect for any other variable was detected when added to this model. This analysis shows that a measure of functional independence in motor performance and age at rehabilitation hospital admission for stroke are predominant predictors of outcome at discharge in a uniquely large US national data set. © 2015 American Heart Association, Inc.

One-year outcome after first-ever stroke according to stroke subtype, severity, risk factors and pre-stroke treatment. A population-based study from Tartu, Estonia.

PubMed

Vibo, R; Kõrv, J; Roose, M

2007-04-01

The aim of the current study was to evaluate the outcome at 1 year following a first-ever stroke based on a population-based registry from 2001 to 2003 in Tartu, Estonia. The outcome of first-ever stroke was assessed in 433 patients by stroke risk factors, demographic data and stroke severity at onset using the Barthel Index (BI) score and the modified Rankin Score (mRS) at seventh day, 6 months and 1 year. Female sex, older age, blood glucose value >10 mmol/l on admission and more severe stroke on admission were the best predictors of dependency 1 year following the first-ever stroke. At 1 year, the percentage of functionally dependent patients was 20% and the survival rate was 56%. The use of antihypertensive/antithrombotic medication prior to stroke did not significantly affect the outcome. The survival rate of stroke patients in Tartu is lower compared with other studied populations. The outcome of stroke was mainly determined by the initial severity of stroke and by elevated blood glucose value on admission. Patients with untreated hypertension had more severe stroke and trend for unfavourable outcome compared with those who were on treatment.

Effect of Core Stability Training on Trunk Function, Standing Balance, and Mobility in Stroke Patients.

PubMed

Haruyama, Koshiro; Kawakami, Michiyuki; Otsuka, Tomoyoshi

2017-03-01

Trunk function is important for standing balance, mobility, and functional outcome after stroke, but few studies have evaluated the effects of exercises aimed at improving core stability in stroke patients. To investigate the effectiveness of core stability training on trunk function, standing balance, and mobility in stroke patients. An assessor-blinded, randomized controlled trial was undertaken in a stroke rehabilitation ward, with 32 participants randomly assigned to an experimental group or a control group (n = 16 each). The experimental group received 400 minutes of core stability training in place of conventional programs within total training time, while the control group received only conventional programs. Primary outcome measures were evaluated using the Trunk Impairment Scale (TIS), which reflects trunk function. Secondary outcome measures were evaluated by pelvic tilt active range of motion in the sagittal plane, the Balance Evaluation Systems Test-brief version (Brief-BESTest), Functional Reach test, Timed Up-and-Go test (TUG), and Functional Ambulation Categories (FAC). A general linear repeated-measures model was used to analyze the results. A treatment effect was found for the experimental group on the dynamic balance subscale and total score of the TIS ( P = .002 and P < .001, respectively), pelvic tilt active range of motion ( P < .001), Brief-BESTest ( P < .001), TUG ( P = .008), and FAC ( P = .022). Core stability training has beneficial effects on trunk function, standing balance, and mobility in stroke patients. Our findings might provide support for introducing core stability training in stroke rehabilitation.

High Dietary Glycemic Load is Associated with Poor Functional Outcome in Patients with Acute Cerebral Infarction.

PubMed

Song, Tae Jin; Chang, Yoonkyung; Chun, Min Young; Lee, Chan Young; Kim, A Ram; Kim, Yuri; Kim, Yong Jae

2018-04-01

Elevated postprandial blood glucose is a critical risk factor for stroke. The dietary glycemic load (GL) and glycemic index (GI) are frequently used as markers of the postprandial blood glucose response to estimate the overall glycemic effect of diets. We hypothesized that high dietary GL, GI, or total carbohydrate intake is associated with a poor functional outcome in patients with acute ischemic stroke. We prospectively included 263 first-ever ischemic stroke patients who completed a semiquantitative food-frequency questionnaire. The dietary GL, GI, and total carbohydrate intake were investigated by examining the average frequency of intake during the previous year based on reference amounts for various food items. Poor functional outcome was defined as a score on the modified Rankin Scale (mRS) of ≥3 at 3 months after stroke. The patients were aged 65.4±11.7 years (mean±standard deviation), and 58.2% of them were male. A multivariate analysis adjusted for age, sex, marital status, prestroke mRS score, diabetes mellitus, hyperlipidemia, body mass index, triglycerides, low-density lipoprotein, hemoglobin A1c, stroke classification, and National Institutes of Health Stroke Scale score, early neurological deterioration, and high-grade white-matter hyperintensities revealed that the dietary GL and total carbohydrate intake were associated with a poor functional outcome, with odds ratios for the top quartile relative to the bottom quartile of 28.93 (95% confidence interval=2.82-296.04) and 36.84 (95% confidence interval=2.99-453.42), respectively (p for trend=0.002 and 0.002, respectively). In contrast, high dietary GI was not associated with a poor functional outcome (p for trend=0.481). Increased dietary GL and carbohydrate intake were associated with a poor short-term functional outcome after an acute ischemic stroke. Copyright © 2018 Korean Neurological Association.

Race and Gender Differences in One-Year Outcomes for Community-Dwelling Stroke Survivors with Family Caregivers

PubMed Central

Roth, David L.; Haley, William E.; Clay, Olivio J.; Perkins, Martinique; Grant, Joan S.; Rhodes, J. David; Wadley, Virginia G.; Kissela, Brett; Howard, George

2011-01-01

Background and Purpose Previous research has reported worse outcomes after stroke for women and for African Americans, but few prospective, population-based studies have systematically examined demographic differences on long-term stroke outcomes. Race and gender differences on one-year stroke outcomes were examined using an epidemiologically-derived sample of first-time stroke survivors from the national REasons for Geographic and Racial Differences in Stroke (REGARDS) study. Methods Participants of REGARDS who reported a first-time stroke event during regular surveillance calls were interviewed by telephone and then completed an in-home evaluation approximately one year after the verified first-time stroke event (N = 112). A primary family caregiver was also enrolled and interviewed for each stroke survivor. Measures from the in-home evaluation included previously validated stroke outcomes assessments of neurological deficits, functional impairments, and patient-reported effects of stroke in multiple domains. Results African American stroke survivors were less likely to be living with their primary family caregivers than White participants. Analyses that controlled for age, education, and whether the stroke survivors lived with their primary family caregivers indicated that African Americans and women showed significantly greater deficits on multiple one-year outcome measures compared to Whites and men, respectively. Conclusions Among community-dwelling stroke survivors with family caregivers, women and African Americans are at heightened risk for poor long-term outcomes one year after first-time stroke events. Rehabilitation services and public health policies aimed at enhancing stroke recovery rates should address these disparities in post-stroke outcomes. PMID:21257820

Validation of the DRAGON Score in a Chinese Population to Predict Functional Outcome of Intravenous Thrombolysis-Treated Stroke Patients.

PubMed

Zhang, Xinmiao; Liao, Xiaoling; Wang, Chunjuan; Liu, Liping; Wang, Chunxue; Zhao, Xingquan; Pan, Yuesong; Wang, Yilong; Wang, Yongjun

2015-08-01

The DRAGON score predicts functional outcome of ischemic stroke patients treated with intravenous thrombolysis. Our aim was to evaluate its utility in a Chinese stroke population. Patients with acute ischemic stroke treated with intravenous thrombolysis were prospectively registered in the Thrombolysis Implementation and Monitor of acute ischemic Stroke in China. We excluded patients with basilar artery occlusion and missing data, leaving 970 eligible patients. We calculated the DRAGON score, and the clinical outcome was measured by the modified Rankin Scale at 3 months. Model discrimination was quantified by calculating the C statistic. Calibration was assessed using Pearson correlation coefficient. The C statistic was .73 (.70-.76) for good outcome and .75 (.70-.79) for miserable outcome. Proportions of patients with good outcome were 94%, 83%, 70%, and 0% for 0 to 1, 2, 3, and 8 to 10 score points, respectively. Proportions of patients with miserable outcome were 0%, 3%, 9%, and 50% for 0 to 1, 2, 3, and 8 to 10 points, respectively. There was high correlation between predicted and observed probability of 3-month favorable and miserable outcome in the external validation cohort (Pearson correlation coefficient, .98 and .98, respectively, both P < .0001). The DRAGON score showed good performance to predict functional outcome after tissue-type plasminogen activator treatment in the Chinese population. This study demonstrated the accuracy and usability of the DRAGON score in the Chinese population in daily practice. Copyright © 2015 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Effectiveness of Functional Electrical Stimulation in Improving Clinical Outcomes in the Upper Arm following Stroke: A Systematic Review and Meta-Analysis

PubMed Central

Vafadar, Amir K.; Côté, Julie N.; Archambault, Philippe S.

2015-01-01

Background. Different therapeutic methods are being used to prevent or decrease long-term impairments of the upper arm in stroke patients. Functional electrical stimulation (FES) is one of these methods, which aims to stimulate the nerves of the weakened muscles so that the resulting muscle contractions resemble those of a functional task. Objectives. The objective of this study was to review the evidence for the effect of FES on (1) shoulder subluxation, (2) pain, and (3) upper arm motor function in stroke patients, when added to conventional therapy. Methods. From the 727 retrieved articles, 10 (9 RCTs, 1 quasi-RCT) were selected for final analysis and were rated based on the PEDro (Physiotherapy Evidence Database) scores and the Sackett's levels of evidence. A meta-analysis was performed for all three considered outcomes. Results. The results of the meta-analyses showed a significant difference in shoulder subluxation in experimental groups compared to control groups, only if FES was applied early after stroke. No effects were found on pain or motor function outcomes. Conclusion. FES can be used to prevent or reduce shoulder subluxation early after stroke. However, it should not be used to reduce pain or improve upper arm motor function after stroke. PMID:25685805

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.

An International Standard Set of Patient-Centered Outcome Measures After Stroke.

PubMed

Salinas, Joel; Sprinkhuizen, Sara M; Ackerson, Teri; Bernhardt, Julie; Davie, Charlie; George, Mary G; Gething, Stephanie; Kelly, Adam G; Lindsay, Patrice; Liu, Liping; Martins, Sheila C O; Morgan, Louise; Norrving, Bo; Ribbers, Gerard M; Silver, Frank L; Smith, Eric E; Williams, Linda S; Schwamm, Lee H

2016-01-01

Value-based health care aims to bring together patients and health systems to maximize the ratio of quality over cost. To enable assessment of healthcare value in stroke management, an international standard set of patient-centered stroke outcome measures was defined for use in a variety of healthcare settings. A modified Delphi process was implemented with an international expert panel representing patients, advocates, and clinical specialists in stroke outcomes, stroke registers, global health, epidemiology, and rehabilitation to reach consensus on the preferred outcome measures, included populations, and baseline risk adjustment variables. Patients presenting to a hospital with ischemic stroke or intracerebral hemorrhage were selected as the target population for these recommendations, with the inclusion of transient ischemic attacks optional. Outcome categories recommended for assessment were survival and disease control, acute complications, and patient-reported outcomes. Patient-reported outcomes proposed for assessment at 90 days were pain, mood, feeding, selfcare, mobility, communication, cognitive functioning, social participation, ability to return to usual activities, and health-related quality of life, with mobility, feeding, selfcare, and communication also collected at discharge. One instrument was able to collect most patient-reported subdomains (9/16, 56%). Minimum data collection for risk adjustment included patient demographics, premorbid functioning, stroke type and severity, vascular and systemic risk factors, and specific treatment/care-related factors. A consensus stroke measure Standard Set was developed as a simple, pragmatic method to increase the value of stroke care. The set should be validated in practice when used for monitoring and comparisons across different care settings. © 2015 The Authors.

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.

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.

Astrocytes, therapeutic targets for neuroprotection and neurorestoration in ischemic stroke

PubMed Central

Liu, Zhongwu; Chopp, Michael

2015-01-01

Astrocytes are the most abundant cell type within the central nervous system. They play essential roles in maintaining normal brain function, as they are a critical structural and functional part of the tripartite synapses and the neurovascular unit, and communicate with neurons, oligodendrocytes and endothelial cells. After an ischemic stroke, astrocytes perform multiple functions both detrimental and beneficial, for neuronal survival during the acute phase. Aspects of the astrocytic inflammatory response to stroke may aggravate the ischemic lesion, but astrocytes also provide benefit for neuroprotection, by limiting lesion extension via anti-excitotoxicity effects and releasing neurotrophins. Similarly, during the late recovery phase after stroke, the glial scar may obstruct axonal regeneration and subsequently reduce the functional outcome; however, astrocytes also contribute to angiogenesis, neurogenesis, synaptogenesis, and axonal remodeling, and thereby promote neurological recovery. Thus, the pivotal involvement of astrocytes in normal brain function and responses to an ischemic lesion designates them as excellent therapeutic targets to improve functional outcome following stroke. In this review, we will focus on functions of astrocytes and astrocyte-mediated events during stroke and recovery. We will provide an overview of approaches on how to reduce the detrimental effects and amplify the beneficial effects of astrocytes on neuroprotection and on neurorestoration post stroke, which may lead to novel and clinically relevant therapies for stroke. PMID:26455456

A practical assessment of magnetic resonance diffusion-perfusion mismatch in acute stroke: observer variation and outcome.

PubMed

Kane, I; Hand, P J; Rivers, C; Armitage, P; Bastin, M E; Lindley, R; Dennis, M; Wardlaw, J M

2009-11-01

MR diffusion/perfusion mismatch may help identify patients for acute stroke treatment, but mixed results from clinical trials suggest that further evaluation of the mismatch concept is required. To work effectively, mismatch should predict prognosis on arrival at hospital. We assessed mismatch duration and associations with functional outcome in acute stroke. We recruited consecutive patients with acute stroke, recorded baseline clinical variables, performed MR diffusion and perfusion imaging and assessed 3-month functional outcome. We assessed practicalities, agreement between mismatch on mean transit time (MTT) or cerebral blood flow (CBF) maps, visually and with lesion volume, and the relationship of each to functional outcome. Of 82 patients starting imaging, 14 (17%) failed perfusion imaging. Overall, 42% had mismatch (56% at <6 h; 41% at 12-24 h; 23% at 24-48 h). Agreement for mismatch by visual versus volume assessment was fair using MTT (kappa 0.59, 95% CI 0.34-0.84) but poor using CBF (kappa 0.24, 95% CI 0.01-0.48). Mismatch by either definition was not associated with functional outcome, even when the analysis was restricted to just those with mismatch. Visual estimation is a reasonable proxy for mismatch volume on MTT but not CBF. Perfusion is more difficult for acute stroke patients than diffusion imaging. Mismatch is present in many patients beyond 12 h after stroke. Mismatch alone does not distinguish patients with good and poor prognosis; both can do well or poorly. Other factors, e.g. reperfusion, may influence outcome more strongly, even in patients without mismatch.

The efficacy of interactive, motion capture-based rehabilitation on functional outcomes in an inpatient stroke population: a randomized controlled trial.

PubMed

Cannell, John; Jovic, Emelyn; Rathjen, Amy; Lane, Kylie; Tyson, Anna M; Callisaya, Michele L; Smith, Stuart T; Ahuja, Kiran Dk; Bird, Marie-Louise

2018-02-01

To compare the efficacy of novel interactive, motion capture-rehabilitation software to usual care stroke rehabilitation on physical function. Randomized controlled clinical trial. Two subacute hospital rehabilitation units in Australia. In all, 73 people less than six months after stroke with reduced mobility and clinician determined capacity to improve. Both groups received functional retraining and individualized programs for up to an hour, on weekdays for 8-40 sessions (dose matched). For the intervention group, this individualized program used motivating virtual reality rehabilitation and novel gesture controlled interactive motion capture software. For usual care, the individualized program was delivered in a group class on one unit and by rehabilitation assistant 1:1 on the other. Primary outcome was standing balance (functional reach). Secondary outcomes were lateral reach, step test, sitting balance, arm function, and walking. Participants (mean 22 days post-stroke) attended mean 14 sessions. Both groups improved (mean (95% confidence interval)) on primary outcome functional reach (usual care 3.3 (0.6 to 5.9), intervention 4.1 (-3.0 to 5.0) cm) with no difference between groups ( P = 0.69) on this or any secondary measures. No differences between the rehabilitation units were seen except in lateral reach (less affected side) ( P = 0.04). No adverse events were recorded during therapy. Interactive, motion capture rehabilitation for inpatients post stroke produced functional improvements that were similar to those achieved by usual care stroke rehabilitation, safely delivered by either a physical therapist or a rehabilitation assistant.

Nursing application of Bobath principles in stroke care.

PubMed

Passarella, P M; Lewis, N

1987-04-01

The nursing approach in the care of stroke patients has a direct impact on functional outcome. Nursing application of Bobath principles in stroke care offers a nursing focus on involvement of the affected side; facilitation of normal tone, posture, and movement; and development of more normal function. A research study evaluating the functional gains of stroke patients demonstrated a significant level of functional improvement in those treated with Bobath principles over stroke patients treated with the traditional nursing approach. Practical methods for applying Bobath principles in patient care activities are described. These therapeutic methods provide nurses with the means to maximize stroke patients' potential and further influence their functional recovery.

Subclinical hyperthyroidism is a risk factor for poor functional outcome after ischemic stroke.

PubMed

Wollenweber, Frank Arne; Zietemann, Vera; Gschwendtner, Andreas; Opherk, Christian; Dichgans, Martin

2013-05-01

Subclinical hyperthyroidism is associated with adverse cardiovascular events, including stroke and atrial fibrillation. However, its impact on functional outcome after stroke remains unexplored. A total of 165 consecutively recruited patients admitted for ischemic stroke were included in this observational prospective study. Blood samples were taken in the morning within 3 days after symptom onset, and patients were divided into the following 3 groups: subclinical hyperthyroidism (0.1< thyroid-stimulating hormone ≤ 0.44 μU/mL), subclinical hypothyroidism (2.5 ≤ thyroid-stimulating hormone <20 μU/mL), and euthyroid state (0.44< thyroid-stimulating hormone <2.5 μU/mL). Patients with overt thyroid dysfunction were excluded. Follow-up took place 3 months after stroke. Primary outcome was functional disability (modified Rankin Scale), and secondary outcome was level of dependency (Barthel Index). Ordinal logistic regression analysis was used to adjust for possible confounders. Variables previously reported to be affected by thyroid function, such as atrial fibrillation, total cholesterol, or body mass index, were included in an additional model. Nineteen patients (11.5%) had subclinical hyperthyroidism, and 23 patients (13.9%) had subclinical hypothyroidism. Patients with subclinical hyperthyroidism had a substantially increased risk of functional disability 3 months after stroke compared with subjects with euthyroid state (odds ratio, 2.63; 95% confidence interval, 1.02-6.82, adjusted for age, sex, smoking status, and time of blood sampling). The association remained significant, when including the baseline NIHSS, TIA, serum CRP, atrial fibrillation, body mass index, and total cholesterol as additional variables (odds ratio, 3.95; 95% confidence interval, 1.25-12.47), and was confirmed by the secondary outcome (Barthel Index: odds ratio, 9.12; 95% confidence interval, 2.08-39.89). Subclinical hyperthyroidism is a risk factor for poor outcome 3 months after ischemic stroke.

Stroke rehabilitation. 4. Stroke outcome and psychosocial consequences.

PubMed

Flick, C L

1999-05-01

This self-directed learning module highlights recent research in assessment of stroke outcomes and management of the psychosocial consequences of stroke. It is a part of the chapter on stroke rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article discusses predictive factors for mortality and functional recovery; proposed case mix adjustment and prospective payment systems for stroke rehabilitation; continuum of care and utilization of acute, nursing home, outpatient and home health rehabilitation programs; reintegration and socialization after stroke; vocational rehabilitation of stroke patients; and management of the psychosocial effects of stroke on patients and families.

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.

Compensatory Limb Use and Behavioral Assessment of Motor Skill Learning Following Sensorimotor Cortex Injury in a Mouse Model of Ischemic Stroke

PubMed Central

Kerr, Abigail L.; Tennant, Kelly A.

2014-01-01

Mouse models have become increasingly popular in the field of behavioral neuroscience, and specifically in studies of experimental stroke. As models advance, it is important to develop sensitive behavioral measures specific to the mouse. The present protocol describes a skilled motor task for use in mouse models of stroke. The Pasta Matrix Reaching Task functions as a versatile and sensitive behavioral assay that permits experimenters to collect accurate outcome data and manipulate limb use to mimic human clinical phenomena including compensatory strategies (i.e., learned non-use) and focused rehabilitative training. When combined with neuroanatomical tools, this task also permits researchers to explore the mechanisms that support behavioral recovery of function (or lack thereof) following stroke. The task is both simple and affordable to set up and conduct, offering a variety of training and testing options for numerous research questions concerning functional outcome following injury. Though the task has been applied to mouse models of stroke, it may also be beneficial in studies of functional outcome in other upper extremity injury models. PMID:25045916

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.

Plasma endotoxin activity rises during ischemic stroke and is associated with worse short-term outcome.

PubMed

Klimiec, Elzbieta; Pera, Joanna; Chrzanowska-Wasko, Joanna; Golenia, Aleksandra; Slowik, Agnieszka; Dziedzic, Tomasz

2016-08-15

Activation of Toll-like receptor 4 (TLR4) contributes to brain injury and poor outcome after cerebral ischemia. The expression of this receptor on monocytes is increased in patients with acute ischemic stroke. Endotoxin is an endogenous ligand for TLR4. The aim of our study was to determine if plasma endotoxin activity is increased in stroke patients and correlates with functional outcome. We included 88 patients with ischemic stroke (median age: 71, 56.8% men) and 59 age-matched controls. Plasma endotoxin activity and level of proteins regulating endotoxin interaction with TLR4 (LPS binding protein - LBP and sCD14) were measured in blood samples taken at day 1 (within 24h after stroke symptoms onset), 3 and 6. Short-term functional outcome was assessed at day 14 using modified Rankin Scale. Unfavourable outcome was defined as modified Rankin Scale score>2. Compared to controls, stroke patients had higher plasma endotoxin activity on day 1 (median: 0.39 vs 0.32EU/mL, P=0.03) as well as higher LBP (median: 18.7 vs 11.5μg/mL, P<0.01) and sCD14 level (median: 1330 vs 1070ng/mL, P<0.01). Plasma LPS activity and levels of LBP and sCD14 significantly rose during stroke. Higher LPS activity measured on day 6 was associated with unfavourable outcome (OR: 3.94, 95%CI: 1.03-15.02, P=0.04, adjusted for age and stroke severity). Plasma endotoxin activity rises during ischemic stroke and is associated with worse short-term outcome. Copyright © 2016 Elsevier B.V. All rights reserved.

Reported Prestroke Physical Activity Is Associated with Vascular Endothelial Growth Factor Expression and Good Outcomes after Stroke.

PubMed

López-Cancio, Elena; Ricciardi, Ana Clara; Sobrino, Tomás; Cortés, Jordi; de la Ossa, Natalia Pérez; Millán, Mónica; Hernández-Pérez, María; Gomis, Meritxell; Dorado, Laura; Muñoz-Narbona, Lucía; Campos, Francisco; Arenillas, Juan F; Dávalos, Antoni

2017-02-01

Physical activity (PhA) prior to stroke has been associated with good outcomes after the ischemic insult, but there is scarce data on the involved molecular mechanisms. We studied consecutive acute ischemic stroke patients admitted to a single tertiary stroke center. Prestroke PhA was evaluated with the International Physical Activity Questionnaire (metabolic equivalent of minutes/week). We studied several circulating angiogenic and neurogenic factors at different time points: vascular endothelial growth factor (VEGF), granulocyte colony-stimulating factor (G-CSF), and brain-derived neurotrophic factor (BDNF) at admission, day 7, and at 3 months. We considered good functional outcome at 3 months (modified Rankin scale  ≤ 2) as primary end point, and final infarct volume as secondary outcome. We studied 83 patients with at least 2 time point serum determinations (mean age 69.6 years, median National Institutes of Health Stroke Scale 17 at admission). Patients more physically active before stroke had a significantly higher increment of serum VEGF on the seventh day when compared to less active patients. This increment was an independent predictor of good functional outcome at 3 months and was associated with smaller infarct volume in multivariate analyses adjusted for relevant covariates. We did not find independent associations of G-CSF or BDNF levels neither with level of prestroke PhA nor with stroke outcomes. Although there are probably more molecular mechanisms by which PhA exerts its beneficial effects in stroke outcomes, our observation regarding the potential role of VEGF is plausible and in line with previous experimental studies. Further research in this field is needed. Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Neurologic, Functional and Cognitive Stroke Outcomes in Mexican Americans

PubMed Central

Lisabeth, Lynda D; Sánchez, Brisa N; Baek, Jonggyu; Skolarus, Lesli E; Smith, Melinda A; Garcia, Nelda; Brown, Devin L; Morgenstern, Lewis B

2014-01-01

Background and Purpose: Our objective was to compare neurologic, functional, and cognitive stroke outcomes in Mexican Americans (MAs) and non-Hispanic whites (NHWs) using data from a population-based study. Methods: Ischemic strokes (2008-2012) were identified from the Brain Attack Surveillance in Corpus Christi (BASIC) Project. Data were collected from patient or proxy interviews (conducted at baseline and 90 days post-stroke) and medical records. Ethnic differences in neurologic (National Institutes of Health Stroke Scale (NIHSS), range 0-44, higher scores worse), functional (activities of daily living (ADL)/instrumental activities of daily living (IADL) score, range 1-4, higher scores worse), and cognitive (Modified Mini-Mental State Examination (3MSE), range 0-100, lower scores worse) outcomes were assessed with Tobit or linear regression adjusted for demographics and clinical factors. Results: 513, 510, and 415 subjects had complete data for neurologic, functional and cognitive outcomes and covariates, respectively. Median age was 66 (IQR: 57-78); 64% were MA. In MAs, median NIHSS, ADL/IADL and 3MSE score were 3 (IQR: 1-6), 2.5 (IQR: 1.6-3.5) and 88 (IQR: 76-94), respectively. MAs scored 48% worse (95% CI: 23%-78%) on NIHSS, 0.36 points worse (95% CI: 0.16-0.57) on ADL/IADL score, and 3.39 points worse (95% CI: 0.35-6.43) on 3MSE than NHWs after multivariable adjustment. Conclusions: MAs scored worse than NHWs on all outcomes after adjustment for confounding factors; differences were only partially explained by ethnic differences in survival. These findings in combination with the increased stroke risk in MAs suggest that the public health burden of stroke in this growing population is substantial. PMID:24627112

The Association Between Kidney Disease and Cardiovascular Risk in a Multiethnic Cohort

PubMed Central

Nickolas, Thomas L.; Khatri, Minesh; Boden-Albala, Bernadette; Kiryluk, Krzysztof; Luo, Xiaodong; Gervasi-Franklin, Palma; Paik, Myunghee; Sacco, Ralph L.

2011-01-01

Background and Purpose The objective of this study was to determine the relationship between chronic kidney disease (CKD), race–ethnicity, and vascular outcomes. Methods A prospective, multiracial cohort of 3298 stroke-free subjects with 6.5 years of mean follow-up time for vascular outcomes (stroke, myocardial infarction, vascular death) was used. Kidney function was estimated using serum creatinine and Cockcroft-Gault formula. Cox proportional hazards models were fitted to evaluate the relationship between kidney function and vascular outcomes. Results In multivariate analysis, Cockcroft-Gault formula between 15 and 59 mL/min was associated with a significant 43% increased stroke risk in the overall cohort. Blacks with Cockcroft-Gault formula between 15 and 59 mL/min had significantly increased risk of both stroke (hazard ratio, 2.65; 95% CI, 1.47 to 4.77) and combined vascular outcomes (hazard ratio, 1.59; 95% CI, 1.10–2.92). Conclusion Chronic kidney disease is a significant risk factor for stroke and combined vascular events, especially in blacks. PMID:18617655

CE Neuropsychological and neurobehavioral outcome following childhood arterial ischemic stroke: Attention deficits, emotional dysregulation, and executive dysfunction

PubMed Central

Liégeois, Frédérique; Eve, Megan; Ganesan, Vijeya; King, John; Murphy, Tara

2013-01-01

Objectives To investigate neuropsychological and neurobehavioral outcome in children with arterial ischemic stroke (AIS). Background Childhood stroke can have consequences on motor, cognitive, and behavioral development. We present a cross-sectional study of neuropsychological and neurobehavioral outcome at least one year poststroke in a uniquely homogeneous sample of children who had experienced AIS. Method Forty-nine children with AIS aged 6 to 18 years were recruited from a specialist clinic. Neuropsychological measures of intelligence, reading comprehension, attention, and executive function were administered. A triangulation of data collection included questionnaires completed by the children, their parents, and teachers, rating behavior, executive functions, and emotions. Key Findings Focal neuropsychological vulnerabilities in attention (response inhibition and dual attention) and executive function were found, beyond general intellectual functioning, irrespective of hemispheric side of stroke. Difficulties with emotional and behavioral regulation were also found. Consistent with an “early plasticity” hypothesis, earlier age of stroke was associated with better performance on measures of executive function. Conclusions A significant proportion of children poststroke are at long-term risk of difficulties with emotional regulation, executive function, and attention. Data also suggest that executive functions are represented in widespread networks in the developing brain and are vulnerable to unilateral injury. PMID:24028185

The influence of attention deficits on functional recovery post stroke during the first 12 months after discharge from hospital.

PubMed

Hyndman, D; Pickering, R M; Ashburn, A

2008-06-01

Attention deficits have been linked to poor recovery after stroke and may predict outcome. We explored the influence of attention on functional recovery post stroke in the first 12 months after discharge from hospital. People with stroke completed measures of attention, balance, mobility and activities of daily living (ADL) ability at the point of discharge from hospital, and 6 and 12 months later. We used correlational analysis and stepwise linear regression to explore potential predictors of outcome. We recruited 122 men and women, mean age 70 years. At discharge, 56 (51%) had deficits of divided attention, 45 (37%) of sustained attention, 43 (36%) of auditory selective attention and 41 (37%) had visual selective attention deficits. Attention at discharge correlated with mobility, balance and ADL outcomes 12 months later. After controlling for the level of the outcome at discharge, correlations remained significant in only five of the 12 relationships. Stepwise linear regression revealed that the outcome measured at discharge, days until discharge and number of medications were better predictors of outcome: in no case was an attention variable at discharge selected as a predictor of outcome at 12 months. Although attention and function correlated significantly, this correlation was reduced after controlling for functional ability at discharge. Furthermore, side of lesion and the attention variables were not demonstrated as important predictors of outcome 12 months later.

Randomized controlled trial of a comprehensive stroke education program for patients and caregivers.

PubMed

Rodgers, H; Atkinson, C; Bond, S; Suddes, M; Dobson, R; Curless, R

1999-12-01

We report the findings of a randomized controlled trial to determine the effectiveness of a multidisciplinary Stroke Education Program (SEP) for patients and their informal carers. Two hundred four patients admitted with acute stroke and their 176 informal carers were randomized to receive an invitation to the SEP or to receive conventional stroke unit care. The SEP consisted of one 1-hour small group educational session for inpatients followed by six 1-hour sessions after discharge. The primary outcome measure was patient- and carer-perceived health status (SF-36) at 6 months after stroke. Knowledge of stroke, satisfaction with services, emotional outcome, disability, and handicap and were secondary outcome measures. Only 51 of 108 (47%) surviving patients randomized to the SEP completed the program, as did 20 of 93 (22%) informal carers of surviving patients. Perceived health status (Short Form 36 [SF-36] health survey) scores were similar for SEP patients and controls. Informal carers in the control group scored better on the social functioning component of the SF-36 than the SEP group (P=0.04). Patients and informal carers in the SEP group scored higher on the stroke knowledge scale than controls (patients, P=0.02; carers, P=0. 01). Patients in the SEP group were more satisfied with the information that they had received about stroke (P=0.004). There were no differences in emotional or functional outcomes between groups. Although the SEP improved patient and informal carer knowledge about stroke and patient satisfaction with some components of stroke services, this was not associated with an improvement in their perceived health status. Indeed, the social functioning of informal carers randomized to the SEP was less than in the control group.

Circulating FABP4 (Fatty Acid-Binding Protein 4) Is a Novel Prognostic Biomarker in Patients With Acute Ischemic Stroke.

PubMed

Tu, Wen-Jun; Zeng, Xian-Wei; Deng, Aijun; Zhao, Sheng-Jie; Luo, Ding-Zhen; Ma, Guo-Zhao; Wang, Hong; Liu, Qiang

2017-06-01

FABP4 (fatty acid-binding protein 4) is an intracellular lipid chaperone involved in coordination of lipid transportation and atherogenesis. This study aimed at observing the effect of FABP4 on the 3-month outcomes in Chinese patients with acute ischemic stroke. In a prospective multicenter observational study, serum concentrations of FABP4 were on admission measured in plasma of 737 consecutive patients with acute ischemic stroke. Serum concentrations of FABP4, National Institutes of Health Stroke Scale score, and conventional risk factors were evaluated to determine their value to predict functional outcome and mortality within 3 months. During follow-up, an unfavorable functional outcome was found in 260 patients (35.3%), and 94 patients (12.8%) died. In multivariate models comparing the third and fourth quartiles to the first quartile of FABP4, the concentrations of FABP4 were associated with poor functional outcome and mortality. Compared with the reference category (Q1-Q3), the concentrations of FABP4 in Q4 had a relative risk of 4.77 (95% confidence interval [CI], 2.02-8.15; P <0.001) for poor functional outcome and mortality (odds ratio, 6.15; 95% CI, 3.43-12.68) after adjusting for other significant outcome predictors in univariate logistic regression analysis. Receiver-operating characteristic curves to predict poor functional outcome and mortality demonstrated areas under the curve of FABP4 of 0.78 (95% CI, 0.75-0.82) and 0.83 (95% CI, 0.79-0.88), which improved the prognostic accuracy of National Institutes of Health Stroke Scale score with combined areas under the curve of 0.83 (95% CI, 0.76-0.89; P <0.01) and 0.86 (95% CI, 0.81-0.92), respectively. Data show that FABP4 is a novel independent prognostic marker improving the currently used risk stratification of stroke patients. © 2017 American Heart Association, Inc.

The Reliability and Predictive Ability of a Biomarker of Oxidative DNA Damage on Functional Outcomes after Stroke Rehabilitation

PubMed Central

Hsieh, Yu-Wei; Lin, Keh-Chung; Korivi, Mallikarjuna; Lee, Tsong-Hai; Wu, Ching-Yi; Wu, Kuen-Yuh

2014-01-01

We evaluated the reliability of 8-hydroxy-2′-deoxyguanosine (8-OHdG), and determined its ability to predict functional outcomes in stroke survivors. The rehabilitation effect on 8-OHdG and functional outcomes were also assessed. Sixty-one stroke patients received a 4-week rehabilitation. Urinary 8-OHdG levels were determined by liquid chromatography–tandem mass spectrometry. The test-retest reliability of 8-OHdG was good (interclass correlation coefficient = 0.76). Upper-limb motor function and muscle power determined by the Fugl-Meyer Assessment (FMA) and Medical Research Council (MRC) scales before rehabilitation showed significant negative correlation with 8-OHdG (r = −0.38, r = −0.30; p < 0.05). After rehabilitation, we found a fair and significant correlation between 8-OHdG and FMA (r = −0.34) and 8-OHdG and pain (r = 0.26, p < 0.05). Baseline 8-OHdG was significantly correlated with post-treatment FMA, MRC, and pain scores (r = −0.34, −0.31, and 0.25; p < 0.05), indicating its ability to predict functional outcomes. 8-OHdG levels were significantly decreased, and functional outcomes were improved after rehabilitation. The exploratory study findings conclude that 8-OHdG is a reliable and promising biomarker of oxidative stress and could be a valid predictor of functional outcomes in patients. Monitoring of behavioral indicators along with biomarkers may have crucial benefits in translational stroke research. PMID:24743892

The efficacy of interactive, motion capture-based rehabilitation on functional outcomes in an inpatient stroke population: a randomized controlled trial

PubMed Central

Cannell, John; Jovic, Emelyn; Rathjen, Amy; Lane, Kylie; Tyson, Anna M; Callisaya, Michele L; Smith, Stuart T; Ahuja, Kiran DK; Bird, Marie-Louise

2017-01-01

Objective: To compare the efficacy of novel interactive, motion capture-rehabilitation software to usual care stroke rehabilitation on physical function. Design: Randomized controlled clinical trial. Setting: Two subacute hospital rehabilitation units in Australia. Participants: In all, 73 people less than six months after stroke with reduced mobility and clinician determined capacity to improve. Interventions: Both groups received functional retraining and individualized programs for up to an hour, on weekdays for 8–40 sessions (dose matched). For the intervention group, this individualized program used motivating virtual reality rehabilitation and novel gesture controlled interactive motion capture software. For usual care, the individualized program was delivered in a group class on one unit and by rehabilitation assistant 1:1 on the other. Main measures: Primary outcome was standing balance (functional reach). Secondary outcomes were lateral reach, step test, sitting balance, arm function, and walking. Results: Participants (mean 22 days post-stroke) attended mean 14 sessions. Both groups improved (mean (95% confidence interval)) on primary outcome functional reach (usual care 3.3 (0.6 to 5.9), intervention 4.1 (−3.0 to 5.0) cm) with no difference between groups (P = 0.69) on this or any secondary measures. No differences between the rehabilitation units were seen except in lateral reach (less affected side) (P = 0.04). No adverse events were recorded during therapy. Conclusion: Interactive, motion capture rehabilitation for inpatients post stroke produced functional improvements that were similar to those achieved by usual care stroke rehabilitation, safely delivered by either a physical therapist or a rehabilitation assistant. PMID:28719977

Time to inpatient rehabilitation hospital admission and functional outcomes of stroke patients.

PubMed

Wang, Hua; Camicia, Michelle; Terdiman, Joe; Hung, Yun-Yi; Sandel, M Elizabeth

2011-04-01

To study the association of time to inpatient rehabilitation hospital (IRH) admission and functional outcomes of patients who have had a stroke. A retrospective cohort study. A regional IRH. Moderately (n = 614) and severely (n = 1294) impaired patients who had a stroke who were admitted to the facility between 2002 and 2006. Not applicable. Change in total, motor, and cognitive Functional Independence Measure (FIM) scores between IRH admission and discharge. After controlling for patient demographics and initial medical conditions and functional status, shorter periods from stroke onset to IRH admission were significantly associated with greater functional gains for these patients during IRH hospitalization. Moderately impaired patients achieved a greater total FIM gain when admitted to an IRH within 21 days of stroke. Severely impaired patients showed a gradient relationship between time to IRH admission and total FIM gain, with significantly different functional gain if admitted to an IRH within 30 and 60 days after stroke diagnosis. Results of multiple regression analysis also showed that age, race/ethnicity, side of stroke, history of a previous stroke, functional measures at IRH admission, IRH length of stay, and selected medications were associated with total, motor, and cognitive FIM score changes. In addition, certain factors such as older age, diagnosis of a hemorrhagic stroke or a previous history of stroke, and initial functional status were associated with longer periods between diagnosis and admission to an IRH after the stroke occurred. Our findings are consistent with the hypothesis that earlier transfer to an IRH may lead to better functional improvement after stroke. However, certain factors such as age, race/ethnicity, initial medical conditions and functional status, and length of stay at an IRH contributed to functional gain. Factors affecting the time to IRH admission also were addressed. Copyright © 2011 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.

The home stroke rehabilitation and monitoring system trial: a randomized controlled trial.

PubMed

Linder, Susan M; Rosenfeldt, Anson B; Reiss, Aimee; Buchanan, Sharon; Sahu, Komal; Bay, Curtis R; Wolf, Steven L; Alberts, Jay L

2013-01-01

Because many individuals poststroke lack access to the quality and intensity of rehabilitation to improve upper extremity motor function, a home-based robotic-assisted upper extremity rehabilitation device is being paired with an individualized home exercise program. The primary aim of this project is to determine the effectiveness of robotic-assisted home therapy compared with a home exercise program on upper extremity motor recovery and health-related quality of life for stroke survivors in rural and underserved locations. The secondary aim is to explore whether initial degree of motor function of the upper limb may be a factor in predicting the extent to which patients with stroke may be responsive to a home therapy approach. We hypothesize that the home exercise program intervention, when enhanced with robotic-assisted therapy, will result in significantly better outcomes in motor function and quality of life. A total of 96 participants within six-months of a single, unilateral ischemic, or hemorrhagic stroke will be recruited in this prospective, single-blind, multisite randomized clinical trial. The primary outcome is the change in upper extremity function using the Action Research Arm Test. Secondary outcomes include changes in: upper extremity function (Wolf Motor Function Test), upper extremity impairment (upper extremity portion of the Fugl-Meyer Test), self-reported quality of life (Stroke Impact Scale), and affect (Centers for Epidemiologic Studies Depression Scale). Similar or greater improvements in upper extremity function using the combined robotic home exercise program intervention compared with home exercise program alone will be interpreted as evidence that supports the introduction of in-home technology to augment the recovery of function poststroke. © 2012 The Authors. International Journal of Stroke © 2012 World Stroke Organization.

Impact of stroke-associated pneumonia on mortality, length of hospitalization, and functional outcome.

PubMed

Teh, W H; Smith, C J; Barlas, R S; Wood, A D; Bettencourt-Silva, J H; Clark, A B; Metcalf, A K; Bowles, K M; Potter, J F; Myint, P K

2018-05-10

Stroke-associated pneumonia (SAP) is common and associated with adverse outcomes. Data on its impact beyond 1 year are scarce. This observational study was conducted in a cohort of stroke patients admitted consecutively to a tertiary referral center in the east of England, UK (January 2003-April 2015). Logistic regression models examined inpatient mortality and length of stay (LOS). Cox regression models examined longer-term mortality at predefined time periods (0-90 days, 90 days-1 year, 1-3 years, and 3-10 years) for SAP. Effect of SAP on functional outcome at discharge was assessed using logistic regression. A total of 9238 patients (mean age [±SD] 77.61 ± 11.88 years) were included. SAP was diagnosed in 1083 (11.7%) patients. The majority of these cases (n = 658; 60.8%) were aspiration pneumonia. After controlling for age, sex, stroke type, Oxfordshire Community Stroke Project (OCSP) classification, prestroke modified Rankin scale, comorbidities, and acute illness markers, mortality estimates remained significant at 3 time periods: inpatient (OR 5.87, 95%CI [4.97-6.93]), 0-90 days (2.17 [1.97-2.40]), and 91-365 days (HR 1.31 [1.03-1.67]). SAP was also associated with higher odds of long LOS (OR 1.93 [1.67-2.22]) and worse functional outcome (OR 7.17 [5.44-9.45]). In this cohort, SAP did not increase mortality risk beyond 1 year post-stroke, but it was associated with reduced mortality beyond 3 years. Stroke-associated pneumonia is not associated with increased long-term mortality, but it is linked with increased mortality up to 1 year, prolonged LOS, and poor functional outcome on discharge. Targeted intervention strategies are required to improve outcomes of SAP patients who survive to hospital discharge. © 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

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

PubMed

Geurts, Marjolein; Scheijmans, Féline E V; van Seeters, Tom; Biessels, Geert J; Kappelle, L Jaap; Velthuis, Birgitta K; van der Worp, H Bart

2016-11-21

High body temperatures after ischemic stroke have been associated with larger infarct size, but the temporal profile of this relation is unknown. We assess the relation between temporal profile of body temperature and infarct size and functional outcome in patients with acute ischemic stroke. In 419 patients with acute ischemic stroke we assessed the relation between body temperature on admission and during the first 3 days with both infarct size and functional outcome. Infarct size was measured in milliliters on CT or MRI after 3 days. Poor functional outcome was defined as a modified Rankin Scale score ≥3 at 3 months. Body temperature on admission was not associated with infarct size or poor outcome in adjusted analyses. By contrast, each additional 1.0 °C in body temperature on day 1 was associated with 0.31 ml larger infarct size (95% confidence interval (CI) 0.04-0.59), on day 2 with 1.13 ml larger infarct size(95% CI, 0.83-1.43), and on day 3 with 0.80 ml larger infarct size (95% CI, 0.48-1.12), in adjusted linear regression analyses. Higher peak body temperatures on days two and three were also associated with poor outcome (adjusted relative risks per additional 1.0 °C in body temperature, 1.52 (95% CI, 1.17-1.99) and 1.47 (95% CI, 1.22-1.77), respectively). Higher peak body temperatures during the first days after ischemic stroke, rather than on admission, are associated with larger infarct size and poor functional outcome. This suggests that prevention of high temperatures may improve outcome if continued for at least 3 days.

Quantitative EEG and functional outcome following acute ischemic stroke.

PubMed

Bentes, Carla; Peralta, Ana Rita; Viana, Pedro; Martins, Hugo; Morgado, Carlos; Casimiro, Carlos; Franco, Ana Catarina; Fonseca, Ana Catarina; Geraldes, Ruth; Canhão, Patrícia; Pinho E Melo, Teresa; Paiva, Teresa; Ferro, José M

2018-06-18

To identify the most accurate quantitative electroencephalographic (qEEG) predictor(s) of unfavorable post-ischemic stroke outcome, and its discriminative capacity compared to already known demographic, clinical and imaging prognostic markers. Prospective cohort of 151 consecutive anterior circulation ischemic stroke patients followed for 12 months. EEG was recorded within 72 h and at discharge or 7 days post-stroke. QEEG (global band power, symmetry, affected/unaffected hemisphere and time changes) indices were calculated from mean Fast Fourier Transform and analyzed as predictors of unfavorable outcome (mRS ≥ 3), at discharge and 12 months poststroke, before and after adjustment for age, admission NIHSS and ASPECTS. Higher delta, lower alpha and beta relative powers (RP) predicted outcome. Indices with higher discriminative capacity were delta-theta to alpha-beta ratio (DTABR) and alpha RP. Outcome models including either of these and other clinical/imaging stroke outcome predictors were superior to models without qEEG data. In models with qEEG indices, infarct size was not a significant outcome predictor. DTAABR and alpha RP are the best qEEG indices and superior to ASPECTS in post-stroke outcome prediction. They improve the discriminative capacity of already known clinical and imaging stroke outcome predictors, both at discharge and 12 months after stroke. qEEG indices are independent predictors of stroke outcome. Copyright © 2018 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.

Hemoglobin concentration does not impact 3-month outcome following acute ischemic stroke.

PubMed

Sharma, Kartavya; Johnson, Daniel J; Johnson, Brenda; Frank, Steven M; Stevens, Robert D

2018-06-02

There is uncertainty regarding the effect of anemia and red blood cell transfusion on functional outcome following acute ischemic stroke. We studied the relationship of hemoglobin parameters and red cell transfusion with post stroke functional outcome after adjustment for neurological severity and medical comorbidities. Retrospective cohort study of 536 patients discharged with a diagnosis of ischemic stroke from a tertiary care hospital between January 2012 and April 2015. Hemoglobin level at hospital admission, lowest recorded value during hospitalization (nadir), delta hemoglobin (admission minus nadir), red cell transfusion during hospitalization were noted. Charlson Comorbidity Index (CCI) was computed as a summary measure of medical comorbidities. A multivariable logistic regression model was used to determine risk-adjusted odds of unfavorable outcome, defined as a modified Rankin Score of > 2. Anemia was present on hospital admission in 31% of patients. Forty five percent of patients had unfavorable outcome. In the univariable analysis increasing age, admission National Institutes of Health Stroke Scale (NIHSS), CCI, nadir hemoglobin, delta hemoglobin and blood transfusion were associated with unfavorable outcome. In the multivariable model, only increasing age, CCI and NIHSS remained associated with unfavorable outcome. No quadratic association was found on repeating the model to identify a possible U-shaped relationship of hemoglobin with outcome. Our findings contradict prior observational studies and highlight an area of clinical equipoise regarding the optimal management of anemia in patients hospitalized for ischemic stroke. This uncertainty could be addressed with appropriately designed clinical trials.

Brisk walking can promote functional recovery in chronic stroke patients.

PubMed

Batcho, Charles Sèbiyo; Stoquart, Gaëtan; Thonnard, Jean-Louis

2013-09-01

To determine whether regular brisk walking can promote functional recovery in community-dwelling stroke patients. A total of 44 chronic stroke patients, recruited in Belgium and Benin, respectively European high-income and African low-income countries. This longitudinal, single-cohort, observational study with 1 intervention period and 4 time-points of assessments (2 baseline, 1 post-intervention and 1 follow-up) was structured in 3 periods: pre-intervention period (1 month), intervention period (3 months) and follow-up period (3 month). Intervention consisted of a 3 times/week group-based brisk walking programme. Primary outcome measures were ACTIVLIM-Stroke questionnaire and the 6-minute walk test (6MWT). Secondary outcome measures were the Stroke Impairment Assessment Set (SIAS), the Hospital Anxiety and Depression Scale (HADS), and the Berg Balance Scale (BBS). All outcome measures were stable during the pre-intervention period (p ≥ 0.16). They all improved significantly after intervention (p ≤ 0.01), except the HADS (p = 0.058). However, during the follow-up period, SIAS (p = 0.002) and BBS (p = 0.001) decreased, while ACTIVLIM-Stroke, 6MWT and HADS showed no significant change (p ≥ 0.13). This study suggests regular brisk walking as an effective approach to promote functional recovery in chronic stroke survivors. However, further studies are required before generalizing these results to the whole stroke population.

Structural Integrity of Normal Appearing White Matter and Sex-Specific Outcomes After Acute Ischemic Stroke.

PubMed

Etherton, Mark R; Wu, Ona; Cougo, Pedro; Giese, Anne-Katrin; Cloonan, Lisa; Fitzpatrick, Kaitlin M; Kanakis, Allison S; Boulouis, Gregoire; Karadeli, Hasan H; Lauer, Arne; Rosand, Jonathan; Furie, Karen L; Rost, Natalia S

2017-12-01

Women have worse poststroke outcomes than men. We evaluated sex-specific clinical and neuroimaging characteristics of white matter in association with functional recovery after acute ischemic stroke. We performed a retrospective analysis of acute ischemic stroke patients with admission brain MRI and 3- to 6-month modified Rankin Scale score. White matter hyperintensity and acute infarct volume were quantified on fluid-attenuated inversion recovery and diffusion tensor imaging MRI, respectively. Diffusivity anisotropy metrics were calculated in normal appearing white matter contralateral to the acute ischemia. Among 319 patients with acute ischemic stroke, women were older (68.0 versus 62.7 years; P =0.004), had increased incidence of atrial fibrillation (21.4% versus 12.2%; P =0.04), and lower rate of tobacco use (21.1% versus 35.9%; P =0.03). There was no sex-specific difference in white matter hyperintensity volume, acute infarct volume, National Institutes of Health Stroke Scale, prestroke modified Rankin Scale score, or normal appearing white matter diffusivity anisotropy metrics. However, women were less likely to have an excellent outcome (modified Rankin Scale score <2: 49.6% versus 67.0%; P =0.005). In logistic regression analysis, female sex and the interaction of sex with fractional anisotropy, radial diffusivity, and axial diffusivity were independent predictors of functional outcome. Female sex is associated with decreased likelihood of excellent outcome after acute ischemic stroke. The correlation between markers of white matter integrity and functional outcomes in women, but not men, suggests a potential sex-specific mechanism. © 2017 American Heart Association, Inc.

Influence of prior transient ischaemic attack on stroke prognosis.

PubMed

Aboa-Eboulé, Corine; Béjot, Yannick; Osseby, Guy-Victor; Rouaud, Olivier; Binquet, Christine; Marie, Christine; Cottin, Yves; Giroud, Maurice; Bonithon-Kopp, Claire

2011-09-01

To evaluate potential neuroprotection afforded by prior transient ischaemic attack (TIA) on functional and survival outcomes after ischaemic stroke. All cases of first-ever ischaemic strokes, diagnosed between 1985 and 2008, were identified from the Dijon Stroke Registry. Patients were analysed in three groups according to the time interval between prior TIA and stroke (<4 weeks, ≥ 4 weeks, no TIA) or the duration of TIA (≤ 30 min, >30 min, no TIA). Outcomes were severe functional handicap (unable to walk, bedridden or death) at hospital discharge or at outpatient consultation, and 1-month and 1-year any-cause mortality. Stratified analyses were performed by stroke subtypes (non-lacunar, lacunar). Generalised linear mixed models and Cox proportional hazard models with a sandwich covariance matrix accounting for the treatment centre as a random effect were used for multivariate analyses. Among the 3015 patients with first-ever ischaemic stroke, 389 had had a prestroke TIA <4 weeks and 97 a prestroke TIA ≥ 4 weeks. Patients with TIAs had better ambulatory status (adjusted OR 0.61, 95% CI 0.45 to 0.81; p = 0.008) and better survival at 1 month (adjusted HR 0.76, 95% CI 0.65 to 0.89; p = 0.0006) and at 1 year (adjusted HR 0.72, 95% CI 0.67 to 0.76; p<0.0001) than those with no TIAs. Prestroke TIA <4 weeks and TIA duration ≤ 30 min also significantly improved the outcomes in overall, non-lacunar and lacunar strokes. Recent prestroke TIA was associated with better functional outcome and lower 1-month and 1-year mortality after stroke, suggesting a neuroprotective effect.

Sex-dependent effects of G protein-coupled estrogen receptor activity on outcome after ischemic stroke.

PubMed

Broughton, Brad R S; Brait, Vanessa H; Kim, Hyun Ah; Lee, Seyoung; Chu, Hannah X; Gardiner-Mann, Chantelle V; Guida, Elizabeth; Evans, Megan A; Miller, Alyson A; Arumugam, Thiruma V; Drummond, Grant R; Sobey, Christopher G

2014-03-01

Experimental studies indicate that estrogen typically, but not universally, has a neuroprotective effect in stroke. Ischemic stroke increases membrane-bound G protein-coupled estrogen receptor (GPER) distribution and expression in the brain of male but not female mice. We hypothesized that GPER activation may have a greater neuroprotective effect in males than in females after stroke. Vehicle (dimethyl sulfoxide), a GPER agonist (G-1, 30 μg/kg), or a GPER antagonist (G-15, 300 μg/kg) were administered alone or in combination to young or aged male mice, or young intact or ovariectomized female mice, 1 hour before or 3 hours after cerebral ischemia-reperfusion. Some mice were treated with a combination of G-1 and the pan-caspase inhibitor, quinoline-Val-Asp(Ome)-CH2-O-phenoxy (Q-VD-OPh), 1 hour before stroke. We evaluated functional and histological end points of stroke outcome up to 72 hours after ischemia-reperfusion. In addition, apoptosis was examined using cleaved caspase-3 immunohistochemistry. Surprisingly, G-1 worsened functional outcomes and increased infarct volume in males poststroke, in association with an increased expression of cleaved caspase-3 in peri-infarct neurons. These effects were blocked by G-15 or Q-VD-OPh. Conversely, G-15 improved functional outcomes and reduced infarct volume after stroke in males, whether given before or after stroke. In contrast to findings in males, G-1 reduced neurological deficit, apoptosis, and infarct volume in ovariectomized females, but had no significant effect in intact females. Future therapies for acute stroke could exploit the modulation of GPER activity in a sex-specific manner.

High blood glutamate oxaloacetate transaminase levels are associated with good functional outcome in acute ischemic stroke

PubMed Central

Campos, Francisco; Sobrino, Tomás; Ramos-Cabrer, Pedro; Castellanos, Mar; Blanco, Miguel; Rodríguez-Yáñez, Manuel; Serena, Joaquín; Leira, Rogelio; Castillo, José

2011-01-01

The capacity of the blood enzyme glutamate oxaloacetate transaminase (GOT) to remove glutamate from the brain by means of blood glutamate degradation has been shown in experimental models to be an efficient and novel neuroprotective tool against ischemic stroke; however, the beneficial effects of this enzyme should be tested in patients with stroke to validate these results. This study aims to investigate the association of GOT levels in blood with clinical outcome in patients with acute ischemic stroke. In two clinical independent studies, we found that patients with poor outcome show higher glutamate and lower GOT levels in blood at the time of admission. Lower GOT levels and higher glutamate levels were independently associated with poorer functional outcome at 3 months and higher infarct volume. These findings show a clear association between high blood glutamate levels and worse outcome and vice versa for GOT, presumably explained by the capacity of this enzyme to metabolize blood glutamate. PMID:21266984

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

Comprehensive stroke units: a review of comparative evidence and experience.

PubMed

Chan, Daniel K Y; Cordato, Dennis; O'Rourke, Fintan; Chan, Daniel L; Pollack, Michael; Middleton, Sandy; Levi, Chris

2013-06-01

Stroke unit care offers significant benefits in survival and dependency when compared to general medical ward. Most stroke units are either acute or rehabilitation, but comprehensive (combined acute and rehabilitation) model (comprehensive stroke unit) is less common. To examine different levels of evidence of comprehensive stroke unit compared to other organized inpatient stroke care and share local experience of comprehensive stroke units. Cochrane Library and Medline (1980 to December 2010) review of English language articles comparing stroke units to alternative forms of stroke care delivery, different types of stroke unit models, and differences in processes of care within different stroke unit models. Different levels of comparative evidence of comprehensive stroke units to other models of stroke units are collected. There are no randomized controlled trials directly comparing comprehensive stroke units to other stroke unit models (either acute or rehabilitation). Comprehensive stroke units are associated with reduced length of stay and greatest reduction in combined death and dependency in a meta-analysis study when compared to other stroke unit models. Comprehensive stroke units also have better length of stay and functional outcome when compared to acute or rehabilitation stroke unit models in a cross-sectional study, and better length of stay in a 'before-and-after' comparative study. Components of stroke unit care that improve outcome are multifactorial and most probably include early mobilization. A comprehensive stroke unit model has been successfully implemented in metropolitan and rural hospital settings. Comprehensive stroke units are associated with reductions in length of stay and combined death and dependency and improved functional outcomes compared to other stroke unit models. A comprehensive stroke unit model is worth considering as the preferred model of stroke unit care in the planning and delivery of metropolitan and rural stroke services. © 2012 The Authors. International Journal of Stroke © 2012 World Stroke Organization.

PAIS 2 (Paracetamol [Acetaminophen] in Stroke 2): Results of a Randomized, Double-Blind Placebo-Controlled Clinical Trial.

PubMed

de Ridder, Inger R; den Hertog, Heleen M; van Gemert, H Maarten A; Schreuder, A H C M L Tobien; Ruitenberg, Annemieke; Maasland, E Lisette; Saxena, Ritu; van Tuijl, Jordie H; Jansen, Ben P W; Van den Berg-Vos, Renske M; Vermeij, Frederique; Koudstaal, Peter J; Kappelle, L Jaap; Algra, Ale; van der Worp, H Bart; Dippel, Diederik W J

2017-04-01

Subfebrile body temperature and fever in the first days after stroke are strongly associated with unfavorable outcome. A subgroup analysis of a previous trial suggested that early treatment with paracetamol may improve functional outcome in patients with acute stroke and a body temperature of ≥36.5°C. In the present trial, we aimed to confirm this finding. PAIS 2 (Paracetamol [Acetaminophen] in Stroke 2) was a multicenter, randomized, double-blind, placebo-controlled clinical trial. We aimed to include 1500 patients with acute ischemic stroke or intracerebral hemorrhage within 12 hours of symptom onset. Patients were treated with paracetamol in a daily dose of 6 g or matching placebo for 3 consecutive days. The primary outcome was functional outcome at 3 months, assessed with the modified Rankin Scale and analyzed with multivariable ordinal logistic regression. Because of slow recruitment and lack of funding, the study was stopped prematurely. Between December 2011 and October 2015, we included 256 patients, of whom 136 (53%) were allocated to paracetamol. In this small sample, paracetamol had no effect on functional outcome (adjusted common odds ratio, 1.15; 95% confidence interval, 0.74-1.79). There was no difference in the number of serious adverse events (paracetamol n=35 [26%] versus placebo n=28 [24%]). Treatment with high-dose paracetamol seemed to be safe. The effect of high-dose paracetamol on functional outcome remains uncertain. Therefore, a large trial of early treatment with high-dose paracetamol is still needed. URL: http://www.trialregister.nl. Unique identifier: NTR2365. © 2017 American Heart Association, Inc.

XBP1 (X-Box-Binding Protein-1)-Dependent O-GlcNAcylation Is Neuroprotective in Ischemic Stroke in Young Mice and Its Impairment in Aged Mice Is Rescued by Thiamet-G.

PubMed

Jiang, Meng; Yu, Shu; Yu, Zhui; Sheng, Huaxin; Li, Ying; Liu, Shuai; Warner, David S; Paschen, Wulf; Yang, Wei

2017-06-01

Impaired protein homeostasis induced by endoplasmic reticulum dysfunction is a key feature of a variety of age-related brain diseases including stroke. To restore endoplasmic reticulum function impaired by stress, the unfolded protein response is activated. A key unfolded protein response prosurvival pathway is controlled by the endoplasmic reticulum stress sensor (inositol-requiring enzyme-1), XBP1 (downstream X-box-binding protein-1), and O-GlcNAc (O-linked β-N-acetylglucosamine) modification of proteins (O-GlcNAcylation). Stroke impairs endoplasmic reticulum function, which activates unfolded protein response. The rationale of this study was to explore the potentials of the IRE1/XBP1/O-GlcNAc axis as a target for neuroprotection in ischemic stroke. Mice with Xbp1 loss and gain of function in neurons were generated. Stroke was induced by transient or permanent occlusion of the middle cerebral artery in young and aged mice. Thiamet-G was used to increase O-GlcNAcylation. Deletion of Xbp1 worsened outcome after transient and permanent middle cerebral artery occlusion. After stroke, O-GlcNAcylation was activated in neurons of the stroke penumbra in young mice, which was largely Xbp1 dependent. This activation of O-GlcNAcylation was impaired in aged mice. Pharmacological increase of O-GlcNAcylation before or after stroke improved outcome in both young and aged mice. Our study indicates a critical role for the IRE1/XBP1 unfolded protein response branch in stroke outcome. O-GlcNAcylation is a prosurvival pathway that is activated in the stroke penumbra in young mice but impaired in aged mice. Boosting prosurvival pathways to counterbalance the age-related decline in the brain's self-healing capacity could be a promising strategy to improve ischemic stroke outcome in aged brains. © 2017 American Heart Association, Inc.

Ability of three motor measures to predict functional outcomes reported by stroke patients after rehabilitation.

PubMed

Li, Kuan-Yi; Lin, Keh-Chung; Wang, Tien-Ni; Wu, Ching-Yi; Huang, Yan-Hua; Ouyang, Pei

2012-01-01

This investigation examined the demographic characteristics along with 3 measures of motor function in determining outcomes in activities of daily living (ADL) after distributed constraint-induced therapy (dCIT). The study recruited 69 stroke patients who received 3 weeks of dCIT for 2 hours daily, 5 days a week. The self-reported outcome measures for daily function were the Motor Activity Log (MAL) including the amount of use (AOU) and quality of movement (QOM), Nottingham Extended Activities of Daily Living Questionnaire (NEADL), and the Stroke Impact Scale (SIS). Age, sex, onset, side of stroke, Fugl-Meyer assessment (FMA), Wolf Motor Function Test (WMFT), and Action Research Arm Test (ARAT) were the potential predictors. The ARAT grasp-grip-pinch score was the most dominant predictor for MAL-AOU and NEADL (P< 0.05), and the ARAT total score for the subscore of the ADL/instrumental ADL section of the SIS (P< 0.05). The FMA wrist-hand score was a significant predictor for MAL-QOM (P< 0.05). Age was the only demographic factor that significantly predicted NEADL performance (P< 0.05). Among the 3 commonly used measures of motor function after stroke, ARAT was the strongest determinant in predicting MAL-AOU, MAL-QOM, and SIS-ADL/instrumental ADL after dCIT.

Effectiveness of temporary deafferentation of the arm on somatosensory and motor functions following stroke: a systematic review.

PubMed

Opsommer, Emmanuelle; Zwissig, Camille; Korogod, Natalya; Weiss, Thomas

2016-12-01

After stroke, regaining functional use of the upper limb can be challenging. Temporary deafferentation (TD) is a novel approach used in neurorehabilitation to voluntarily reduce the somatosensory input in a body part by temporary anesthesia; which has been shown to improve sensorimotor functions in the affected limb. The primary objective of this systematic review was to present the best available evidence related to the effects of TD of the affected arm on the recovery of motor function and activity of the upper limb (arm and hand) following stroke. Further, this review aimed to assess the effects of TD on sensory function, activities of daily living (ADL) and quality of life following stroke, the acceptability and safety of the intervention as well as adverse events. Adult patients (18 years and older) with a clinical diagnosis of stroke, either hemorrhagic or ischemic. Reports of rehabilitation that included the use of a pneumatic tourniquet, regional anesthesia or nerve block to achieve TD of an arm, or the use of TD as a stand-alone intervention. Primary outcomes were motor function and activity of the upper limb using assessment scales, motor tests and global motor functions.Secondary outcomes included measures of sensory function, ADL, impact of stroke and quality of life and pain.Additional outcomes were neurophysiological changes as studied with functional magnetic resonance imaging, magnetoencephalography and/or transcranial magnetic stimulation.Acceptability and safety of the intervention as well as adverse events were also included. We included any experimental and epidemiological studies. There were no randomized controlled trials. We included non-randomized controlled trials, quasi-experimental, before and after studies and case-control studies. We searched for both published and unpublished studies in major databases and all reference lists of relevant articles in English, German or French languages. We included studies published from January 1980 to October 2015. Data were extracted from included studies using a standardized data extraction tool from the Joanna Briggs Institute. There was heterogeneity in the types of intervention and outcome measures, therefore statistical pooling of the findings was not appropriate. As such, the studies were grouped according to type of outcome where possible. Findings are presented in a narrative form. Eight studies met the eligibility criteria. All outcome parameters related to the primary outcome (motor function and activity of the more affected upper extremity) showed an improvement during or after TD. The sensory functions significantly improved during or after TD when measured either by the grating orienting task or the grating orientation accuracy, and slightly improved when measured using the von Frey hair testing during TD. There is evidence supporting the use of TD of the upper extremity in adults after stroke. Temporary deafferentation can be recommended (Grade B).

Predictors of Functional Dependence Despite Successful Revascularization in Large-Vessel Occlusion Strokes

PubMed Central

Shi, Zhong-Song; Liebeskind, David S.; Xiang, Bin; Ge, Sijian Grace; Feng, Lei; Albers, Gregory W.; Budzik, Ronald; Devlin, Thomas; Gupta, Rishi; Jansen, Olav; Jovin, Tudor G.; Killer-Oberpfalzer, Monika; Lutsep, Helmi L.; Macho, Juan; Nogueira, Raul G.; Rymer, Marilyn; Smith, Wade S.; Wahlgren, Nils; Duckwiler, Gary R.

2014-01-01

Background and Purpose High revascularization rates in large-vessel occlusion strokes treated by mechanical thrombectomy are not always associated with good clinical outcomes. We evaluated predictors of functional dependence despite successful revascularization among patients with acute ischemic stroke treated with thrombectomy. Methods We analyzed the pooled data from the Multi Mechanical Embolus Removal in Cerebral Ischemia (MERCI), Thrombectomy Revascularization of Large Vessel Occlusions in Acute Ischemic Stroke (TREVO), and TREVO 2 trials. Successful revascularization was defined as thrombolysis in cerebral infarction score 2b or 3. Functional dependence was defined as a score of 3 to 6 on the modified Rankin Scale at 3 months. We assessed relationship of demographic, clinical, angiographic characteristics, and hemorrhage with functional dependence despite successful revascularization. Results Two hundred and twenty-eight patients with successful revascularization had clinical outcome follow-up. The rates of functional dependence with endovascular success were 48.6% for Trevo thrombectomy and 58.0% for Merci thrombectomy. Age (odds ratio, 1.04; 95% confidence interval, 1.02–1.06 per 1-year increase), National Institutes of Health Stroke Scale score (odds ratio, 1.08; 95% confidence interval, 1.02–1.15 per 1-point increase), and symptom onset to endovascular treatment time (odds ratio, 1.11; 95% confidence interval, 1.01–1.22 per 30-minute delay) were predictors of functional dependence despite successful revascularization. Symptom onset to reperfusion time beyond 5 hours was associated with functional dependence. All subjects with symptomatic intracranial hemorrhage had functional dependence. Conclusions One half of patients with successful mechanical thrombectomy do not have good outcomes. Age, severe neurological deficits, and delayed endovascular treatment were associated with functional dependence despite successful revascularization. Our data support efforts to minimize delays to endovascular therapy in patients with acute ischemic stroke to improve outcomes. PMID:24876082

Rehabilitation of Motor Function after Stroke: A Multiple Systematic Review Focused on Techniques to Stimulate Upper Extremity Recovery

PubMed Central

Hatem, Samar M.; Saussez, Geoffroy; della Faille, Margaux; Prist, Vincent; Zhang, Xue; Dispa, Delphine; Bleyenheuft, Yannick

2016-01-01

Stroke is one of the leading causes for disability worldwide. Motor function deficits due to stroke affect the patients' mobility, their limitation in daily life activities, their participation in society and their odds of returning to professional activities. All of these factors contribute to a low overall quality of life. Rehabilitation training is the most effective way to reduce motor impairments in stroke patients. This multiple systematic review focuses both on standard treatment methods and on innovating rehabilitation techniques used to promote upper extremity motor function in stroke patients. A total number of 5712 publications on stroke rehabilitation was systematically reviewed for relevance and quality with regards to upper extremity motor outcome. This procedure yielded 270 publications corresponding to the inclusion criteria of the systematic review. Recent technology-based interventions in stroke rehabilitation including non-invasive brain stimulation, robot-assisted training, and virtual reality immersion are addressed. Finally, a decisional tree based on evidence from the literature and characteristics of stroke patients is proposed. At present, the stroke rehabilitation field faces the challenge to tailor evidence-based treatment strategies to the needs of the individual stroke patient. Interventions can be combined in order to achieve the maximal motor function recovery for each patient. Though the efficacy of some interventions may be under debate, motor skill learning, and some new technological approaches give promising outcome prognosis in stroke motor rehabilitation. PMID:27679565

Homeostasis model assessment of insulin resistance in relation to the poor functional outcomes in nondiabetic patients with ischemic stroke

PubMed Central

Li, Siou; Yin, Changhao; Zhao, Weina; Zhu, Haifu; Xu, Dan; Xu, Qing; Jiao, Yang; Wang, Xue; Qiao, Hong

2018-01-01

Whether insulin resistance (IR) predicts worse functional outcome in ischemic stroke is still a matter of debate. The aim of the present study is to determine the association between IR and risk of poor outcome in 173 Chinese nondiabetic patients with acute ischemic stroke. This is a prospective, population-based cohort study. Insulin sensitivity, expressed by the homeostasis model assessment (HOMA) of insulin sensitivity (HOMA index = (fasting insulin × fasting glucose)/22.5). IR was defined by HOMA-IR index in the top quartile (Q4). Functional impairment was evaluated at discharge using the modified Rankin scale (mRS). The median (interquartile range) HOMA-IR was 2.14 (1.17–2.83), and Q4 was at least 2.83. There was a significantly positive correlation between HOMA-IR and National Institutes of Health Stroke Scale (r = 0.408; P<0.001). In multivariate analyses, patients in IR group were associated with a higher risk of poor functional outcome (odds ratio (OR) = 3.23; 95% confidence interval (CI) = 1.75–5.08; P=0.001). In multivariate models comparing the third and fourth quartiles against the first quartile of the HOMA-IR, levels of HOMA-IR were associated with poor outcome, and the adjusted risk of poor outcome increased by 207% (OR = 3.05 (95% CI 1.70–4.89), P=0.006) and 429% (5.29 (3.05–9.80), P<0.001). In a receiver operating characteristic curve (ROC) analysis of poor outcome, the area under the curve (AUC) increased from 0.80 to 0.84 (95% CI: 0.79–0.88) by adding HOMA-IR to clinical examination variables (P=0.02). High HOMA-IR index is associated with a poor functional outcome in nondiabetic patients with acute ischemic stroke. PMID:29588341

Effects of Alteplase for Acute Stroke on the Distribution of Functional Outcomes: A Pooled Analysis of 9 Trials.

PubMed

Lees, Kennedy R; Emberson, Jonathan; Blackwell, Lisa; Bluhmki, Erich; Davis, Stephen M; Donnan, Geoffrey A; Grotta, James C; Kaste, Markku; von Kummer, Rüdiger; Lansberg, Maarten G; Lindley, Richard I; Lyden, Patrick; Murray, Gordon D; Sandercock, Peter A G; Toni, Danilo; Toyoda, Kazunori; Wardlaw, Joanna M; Whiteley, William N; Baigent, Colin; Hacke, Werner; Howard, George

2016-09-01

Thrombolytic therapy with intravenous alteplase within 4.5 hours of ischemic stroke onset increases the overall likelihood of an excellent outcome (no, or nondisabling, symptoms). Any improvement in functional outcome distribution has value, and herein we provide an assessment of the effect of alteplase on the distribution of the functional level by treatment delay, age, and stroke severity. Prespecified pooled analysis of 6756 patients from 9 randomized trials comparing alteplase versus placebo/open control. Ordinal logistic regression models assessed treatment differences after adjustment for treatment delay, age, stroke severity, and relevant interaction term(s). Treatment with alteplase was beneficial for a delay in treatment extending to 4.5 hours after stroke onset, with a greater benefit with earlier treatment. Neither age nor stroke severity significantly influenced the slope of the relationship between benefit and time to treatment initiation. For the observed case mix of patients treated within 4.5 hours of stroke onset (mean 3 hours and 20 minutes), the net absolute benefit from alteplase (ie, the difference between those who would do better if given alteplase and those who would do worse) was 55 patients per 1000 treated (95% confidence interval, 13-91; P=0.004). Treatment with intravenous alteplase initiated within 4.5 hours of stroke onset increases the chance of achieving an improved level of function for all patients across the age spectrum, including the over 80s and across all severities of stroke studied (top versus bottom fifth means: 22 versus 4); the earlier that treatment is initiated, the greater the benefit. © 2016 American Heart Association, Inc.

Interprofessional stroke rehabilitation for stroke survivors using home care.

PubMed

Markle-Reid, Maureen; Orridge, Camille; Weir, Robin; Browne, Gina; Gafni, Amiram; Lewis, Mary; Walsh, Marian; Levy, Charissa; Daub, Stacey; Brien, Heather; Roberts, Jacqueline; Thabane, Lehana

2011-03-01

To compare a specialized interprofessional team approach to community-based stroke rehabilitation with usual home care for stroke survivors using home care services. Randomized controlled trial of 101 community-living stroke survivors (<18 months post-stroke) using home care services. Subjects were randomized to intervention (n=52) or control (n=49) groups. The intervention was a 12-month specialized, evidence-based rehabilitation strategy involving an interprofessional team. The primary outcome was change in health-related quality of life and functioning (SF-36) from baseline to 12 months. Secondary outcomes were number of strokes during the 12-month follow-up, and changes in community reintegration (RNLI), perceived social support (PRQ85-Part 2), anxiety and depressive symptoms (Kessler-10), cognitive function (SPMSQ), and costs of use of health services from baseline to 12 months. A total of 82 subjects completed the 12-month follow-up. Compared with the usual care group, stroke survivors in the intervention group showed clinically important (although not statistically significant) greater improvements from baseline in mean SF-36 physical functioning score (5.87, 95% CI -3.98 to 15.7; p=0.24) and social functioning score (9.03, CI-7.50 to 25.6; p=0.28). The groups did not differ for any of the secondary effectiveness outcomes. There was a higher total per-person costs of use of health services in the intervention group compared to usual home care although the difference was not statistically significant (p=0.76). A 12-month specialized, interprofessional team is a feasible and acceptable approach to community-based stroke rehabilitation that produced greater improvements in quality of life compared to usual home care. Clinicaltrials.gov identifier: NCT00463229.

Are virtual reality technologies effective in improving lower limb outcomes for patients following stroke - a systematic review with meta-analysis.

PubMed

Gibbons, Emma Maureen; Thomson, Alecia Nicole; de Noronha, Marcos; Joseph, Samer

2016-12-01

Stroke is one of the leading causes of disability worldwide with many survivors restricted to their immediate environment secondary to various impairments. To review existing studies assessing effects of virtual reality (VR) on lower limb outcomes in stroke patients. We searched MEDLINE, CINAHL, EMBASE, PEDro, and Cochrane Library from their beginning to August 2015. Eighteen meta-analyses were performed using weighted mean differences (WMD) and standardized mean differences (SMD) and 95% confidence intervals (CI) to summarize results. Randomized control trials using VR interventions within adult stroke populations for lower limb outcomes. Trials were screened by two independent authors for eligibility and bias. Trials were grouped according to acute-subacute and chronic stroke populations and outcomes were classified as functional balance, static balance, functional gait/mobility, spatiotemporal gait parameters, or motor function. 22 studies with 552 participants were included. Significant differences in favor of VR group were found for functional balance (SMD 0.42, 95% CI 0.11-0.73), gait velocity (WMD 0.12, 95% CI 0.03-0.22), cadence (WMD 11.91, 95% CI 2.05-21.78), and stride length (WMD 9.79, 95% CI 0.74-18.84) within the chronic population. VR improves functional balance and various aspects of gait in chronic populations. Evidence also suggests that VR is just as effective as conventional therapy, hence its' use in practice is determined by affordability, and patient/practitioner preferences.

Processes of care associated with acute stroke outcomes.

PubMed

Bravata, Dawn M; Wells, Carolyn K; Lo, Albert C; Nadeau, Steven E; Melillo, Jean; Chodkowski, Diane; Struve, Frederick; Williams, Linda S; Peixoto, Aldo J; Gorman, Mark; Goel, Punit; Acompora, Gregory; McClain, Vincent; Ranjbar, Noshene; Tabereaux, Paul B; Boice, John L; Jacewicz, Michael; Concato, John

2010-05-10

Many processes of care have been proposed as metrics to evaluate stroke care. We sought to identify processes of stroke care that are associated with improved patient outcomes after adjustment for both patient characteristics and other process measures. This retrospective cohort study included patients 18 years or older with an ischemic stroke or transient ischemic attack (TIA) onset no more than 2 days before admission and a neurologic deficit on admission. Patients were excluded if they resided in a skilled nursing facility, were already admitted to the hospital at stroke onset, or were transferred from another acute-care facility. The combined outcome included in-hospital mortality, discharge to hospice, or discharge to a skilled nursing facility. Seven processes of stroke care were evaluated: fever management, hypoxia management, blood pressure management, neurologic evaluation, swallowing evaluation, deep vein thrombosis (DVT) prophylaxis, and early mobilization. Risk adjustment included age, comorbidity (medical history), concomitant medical illness present at admission, preadmission symptom course, prestroke functional status, code status, stroke severity, nonneurologic status, modified APACHE (Acute Physiology and Chronic Health Evaluation) III score, and admission brain imaging findings. Among 1487 patients, the outcome was observed in 239 (16%). Three processes of care were independently associated with an improvement in the outcome after adjustment: swallowing evaluation (adjusted odds ratio [OR], 0.64; 95% confidence interval [CI], 0.43-0.94); DVT prophylaxis (adjusted OR, 0.60; 95% CI, 0.37-0.96); and treating all episodes of hypoxia with supplemental oxygen (adjusted OR, 0.26; 95% CI, 0.09-0.73). Outcomes among patients with ischemic stroke or TIA can be improved by attention to swallowing function, DVT prophylaxis, and treatment of hypoxia.

Searching for the Smoker's Paradox in Acute Stroke Patients Treated With Intravenous Thrombolysis.

PubMed

Hussein, Haitham M; Niemann, Nicki; Parker, Emily D; Qureshi, Adnan I

2017-07-01

Inconsistent evidence supports better outcome in smokers after stroke. Our study examines this association in a large sample of ischemic stroke treated with intravenous thrombolysis. Virtual International Stroke Trials Archive (VISTA) database, composed of individual patient data of multiple clinical trials, was queried. The primary outcome was functional independence at 3 months noted by modified Rankin Scale (mRS; a 7-point scale ranging from 0 [no deficit] to 6 [death]) score≤ 2. The secondary outcomes were National Institutes of Health Stroke Scale (NIHSS; stroke severity measure, ranging from 0 [no deficit] to 42 [most severe]) score at 24 hours and the occurrence of symptomatic intractracranial hemorrhage. A total of 5383 patients were included: 1501 current smokers and 3882 nonsmokers. Smokers were younger (60 ± 13 vs. 71 ± 12 years, p < .0001) and had lower median NIHSS score at baseline (12 [8-17] vs. 13 [9-18], p < .0001). The rate of favorable functional outcome (mRS ≤ 2) at 3 months was significantly higher among current smokers (49.7% vs. 39.5%, p < .0001) and with crude ORs of 1.52, 95% CI 1.33-1.72. The association became non-significant after adjusting for age (OR 1.11, 95% CI 0.97-1.27). Subgroup analysis by age/gender strata showed that current smoking was associated with favorable outcome only in women ≥ 65 years. Current smoking was also associated with lower rates of symptomatic intracranial hemorrhage (adjusted OR 0.55, 95% CI 0.39-0.79). Smokers experience their first ever stroke 11 years younger than nonsmokers. This age difference explains the association between current smoking and favorable functional outcome. Smoking is associated with occurrence of first ever stroke at a younger age, therefore, focus should be on smoking prevention and treatment. The decision to treat ischemic stroke patients with intravenous thrombolysis should not be influenced by the patients' smoking status. © The Author 2017. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Outcomes of a contemporary cohort of 536 consecutive patients with acute ischemic stroke treated with endovascular therapy.

PubMed

Abilleira, Sònia; Cardona, Pere; Ribó, Marc; Millán, Mònica; Obach, Víctor; Roquer, Jaume; Cánovas, David; Martí-Fàbregas, Joan; Rubio, Francisco; Alvarez-Sabín, José; Dávalos, Antoni; Chamorro, Angel; de Miquel, Maria Angeles; Tomasello, Alejandro; Castaño, Carlos; Macho, Juan M; Ribera, Aida; Gallofré, Miquel

2014-04-01

We sought to assess outcomes after endovascular treatment/therapy of acute ischemic stroke, overall and by subgroups, and looked for predictors of outcome. We used data from a mandatory, population-based registry that includes external monitoring of completeness, which assesses reperfusion therapies for consecutive patients with acute ischemic stroke since 2011. We described outcomes overall and by subgroups (age ≤ or >80 years; onset-to-groin puncture ≤ or >6 hours; anterior or posterior strokes; previous IV recombinant tissue-type plasminogen activator or isolated endovascular treatment/therapy; revascularization or no revascularization), and determined independent predictors of good outcome (modified Rankin Scale score ≤2) and mortality at 3 months by multivariate modeling. We analyzed 536 patients, of whom 285 received previous IV recombinant tissue-type plasminogen activator. Overall, revascularization (modified Thrombolysis In Cerebral Infarction scores, 2b and 3) occurred in 73.9%, 5.6% developed symptomatic intracerebral hemorrhages, 43.3% achieved good functional outcome, and 22.2% were dead at 90 days. Adjusted comparisons by subgroups systematically favored revascularization (lower proportion of symptomatic intracerebral hemorrhages and death rates and higher proportion of good outcome). Multivariate analyses confirmed the independent protective effect of revascularization. Additionally, age >80 years, stroke severity, hypertension (deleterious), atrial fibrillation, and onset-to-groin puncture ≤6 hours (protective) also predicted good outcome, whereas lack of previous disability and anterior circulation strokes (protective) as well as and hypertension (deleterious) independently predicted mortality. This study reinforces the role of revascularization and time to treatment to achieve enhanced functional outcomes and identifies other clinical features that independently predict good/fatal outcome after endovascular treatment/therapy.

Prediction of motor recovery after stroke: advances in biomarkers.

PubMed

Stinear, Cathy M

2017-10-01

Stroke remains a leading cause of adult disability, and the recovery of motor function after stroke is crucial for the patient to regain independence. However, making accurate predictions of a patient's motor recovery and outcome is difficult when based on clinical assessment alone. Clinical assessment of motor impairment within a few days of stroke can help to predict subsequent recovery, while neurophysiological and neuroimaging biomarkers of corticomotor structure and function can help to predict both motor recovery and motor outcome after stroke. The combination of biomarkers can provide clinically useful information when planning the personalised rehabilitation of a patient. These biomarkers can also be used for patient selection and stratification in trials investigating rehabilitation interventions that are initiated early after stroke. Ongoing multicentre trials that incorporate motor biomarkers could help to bring their use into routine clinical practice. Copyright © 2017 Elsevier Ltd. All rights reserved.

Synergistic effects of aerobic exercise and cognitive training on cognition, physiological markers, daily function, and quality of life in stroke survivors with cognitive decline: study protocol for a randomized controlled trial.

PubMed

Yeh, Ting-Ting; Wu, Ching-Yi; Hsieh, Yu-Wei; Chang, Ku-Chou; Lee, Lin-Chien; Hung, Jen-Wen; Lin, Keh-Chung; Teng, Ching-Hung; Liao, Yi-Han

2017-08-31

Aerobic exercise and cognitive training have been effective in improving cognitive functions; however, whether the combination of these two can further enhance cognition and clinical outcomes in stroke survivors with cognitive decline remains unknown. This study aimed to determine the treatment effects of a sequential combination of aerobic exercise and cognitive training on cognitive function and clinical outcomes. Stroke survivors (n = 75) with cognitive decline will be recruited and randomly assigned to cognitive training, aerobic exercise, and sequential combination of aerobic exercise and cognitive training groups. All participants will receive training for 60 minutes per day, 3 days per week for 12 weeks. The aerobic exercise group will receive stationary bicycle training, the cognitive training group will receive cognitive-based training, and the sequential group will first receive 30 minutes of aerobic exercise, followed by 30 minutes of cognitive training. The outcome measures involve cognitive functions, physiological biomarkers, daily function and quality of life, physical functions, and social participation. Participants will be assessed before and immediately after the interventions, and 6 months after the interventions. Repeated measures of analysis of variance will be used to evaluate the changes in outcome measures at the three assessments. This trial aims to explore the benefits of innovative intervention approaches to improve the cognitive function, physiological markers, daily function, and quality of life in stroke survivors with cognitive decline. The findings will provide evidence to advance post-stroke cognitive rehabilitation. ClinicalTrials.gov, NCT02550990 . Registered on 6 September 2015.

Racial and ethnic disparities in stroke outcomes: a scoping review of post-stroke disability assessment tools.

PubMed

Burns, Suzanne Perea; White, Brandi M; Magwood, Gayenell; Ellis, Charles; Logan, Ayaba; Jones Buie, Joy N; Adams, Robert J

2018-03-23

To identify how post-stroke disability outcomes are assessed in studies that examine racial/ethnic disparities and to map the identified assessment content to the International Classification of Functioning, Disability, and Health (ICF) across the time course of stroke recovery. We conducted a scoping review of the literature. Articles published between January 2001 and July 2017 were identified through Scopus, PubMed, CINAHL, and PsycINFO according to predefined inclusion and exclusion criteria. We identified 1791 articles through database and hand-searching strategies. Of the articles, 194 met inclusion criteria for full-text review, and 41 met inclusion criteria for study inclusion. The included studies used a variety of outcome measures encompassing domains within the ICF: body functions, activities, participation, and contextual factors across the time course of stroke recovery. We discovered disproportionate representation among racial/ethnic groups in the post-stroke disability disparities literature. A wide variety of assessments are used to examine disparities in post-stroke disability across the time course of stroke recovery. Several studies have identified disparities through a variety of assessments; however, substantial problems abound from the assessments used including inconsistent use of assessments, lacking evidence on the validity of assessments among racial/ethnic groups, and inadequate representation among all racial/ethnic populations comprising the US. Implications for Rehabilitation An enhanced understanding of racial/ethnic disparities in post-stroke disability outcomes is inherently important among rehabilitation practitioners who frequently engage with racial/ethnic minority populations across the time course of stroke recovery. Clinicians should carefully consider the psychometric properties of assessment tools to counter potential racial bias. Clinicians should be aware that many assessments used in stroke rehabilitation lack cultural sensitivity and could result in inaccurate assessment findings.

Obstructive sleep apnea and stroke: links to health disparities☆, ☆☆

PubMed Central

Ramos, Alberto R.; Seixas, Azizi; Dib, Salim I.

2018-01-01

Obstructive sleep apnea (OSA) is a novel cardiovascular and cerebrovascular risk factor that presents unique opportunities to understand and reduce seemingly intractable stroke disparity among non-Hispanic blacks and Hispanic/Latinos. Individuals from these 2 groups have up to a 2-fold risk of stroke and greater burden of OSA. Obstructive sleep apnea directly and indirectly increases risk of stroke through a variety of autonomic, chemical, and inflammatory mechanisms and vascular risk factors such as hypertension, obesity, and diabetes mellitus. Untreated OSA exacerbates poststroke prognosis, as it may also influence rehabilitation efforts and functional outcomes such as cognitive function after a stroke. Conversely, treatment of OSA may reduce the risk of stroke and may yield better poststroke prognosis. Unfortunately, in racial/ethnic minority groups, there are limited awareness, knowledge, and screening opportunities for OSA. Increasing awareness and improving screening strategies for OSA in minorities may alleviate stroke risk burden and improve stroke outcomes in these populations. This review article is intended to highlight the epidemiology, clinical characteristics, pathophysiology, diagnosis, and treatment of OSA in relation to stroke risk, with an emphasis on race-ethnic disparities. PMID:29073399

Acupuncture for acute stroke: study protocol for a multicenter, randomized, controlled trial.

PubMed

Chen, Lifang; Fang, Jianqiao; Ma, Ruijie; Froym, Ronen; Gu, Xudong; Li, Jianhua; Chen, Lina; Xu, Shouyu; Ji, Conghua

2014-06-08

Acupuncture has been widely used as a treatment for stroke in China for more than 3,000 years. However, previous research has not yet shown that acupuncture is effective as a stroke treatment. We report a protocol for a multicenter, randomized, controlled, and outcome assessor-blind trial to evaluate the efficacy and safety of acupuncture on acute ischemic stroke. In a prospective trial involving three hospitals in the Zhejiang Province (China) 250 patients with a recent (less than 1 week previous) episode of ischemic stroke will be included. Patients will be randomized into two groups: an acupuncture group given scalp acupuncture and electroacupuncture, and a control group given no acupuncture. Eighteen treatment sessions will be performed over a three-week period. The primary outcome will be measured by changes in the National Institutes of Health Stroke Scale score at the one, three, and four-week follow-up. Secondary outcome measures will be: 1) the Fugl-Meyer assessment scale for motor function; 2) the mini-mental state examination and Montreal cognitive assessment for cognitive function; 3) the video-fluoroscopic swallowing study for swallowing ability; and 4) the incidence of adverse events. This trial is expected to clarify whether or not acupuncture is effective for acute stroke. It will also show if acupuncture can improve motor, cognitive, or swallowing function. Chinese Clinical Trial Registry ChiCTR-TRC-12001971.

Does the use of Nintendo Wii SportsTM improve arm function? Trial of WiiTM in Stroke: a randomized controlled trial and economics analysis.

PubMed

Adie, Katja; Schofield, Christine; Berrow, Margie; Wingham, Jennifer; Humfryes, John; Pritchard, Colin; James, Martin; Allison, Rhoda

2017-02-01

The Trial of Wii™ in Stroke investigated the efficacy of using the Nintendo Wii Sports™ (Wii TM ) to improve affected arm function after stroke. Multicentre, pragmatic, parallel group, randomized controlled trial. Home-based rehabilitation. A total of 240 participants aged 24-90 years with arm weakness following a stroke within the previous six months. Participants were randomly assigned to exercise daily for six weeks using the Wii TM or arm exercises at home. Primary outcome was change in the affected arm function at six weeks follow-up using the Action Research Arm Test. Secondary outcomes included occupational performance, quality of life, arm function at six months and a cost effectiveness analysis. The study was completed by 209 participants (87.1%). There was no significant difference in the primary outcome of affected arm function at six weeks follow-up (mean difference -1.7, 95% CI -3.9 to 0.5, p = 0.12) and no significant difference in secondary outcomes, including occupational performance, quality of life or arm function at six months, between the two groups. No serious adverse events related to the study treatment were reported. The cost effectiveness analysis showed that the Wii TM was more expensive than arm exercises £1106 (SD 1656) vs. £730 (SD 829) (probability 0.866). The trial showed that the Wii TM was not superior to arm exercises in home-based rehabilitation for stroke survivors with arm weakness. The Wii TM was well tolerated but more expensive than arm exercises.

Uric acid therapy improves the outcomes of stroke patients treated with intravenous tissue plasminogen activator and mechanical thrombectomy.

PubMed

Chamorro, Ángel; Amaro, Sergio; Castellanos, Mar; Gomis, Meritxell; Urra, Xabier; Blasco, Jordi; Arenillas, Juan F; Román, Luis S; Muñoz, Roberto; Macho, Juan; Cánovas, David; Marti-Fabregas, Joan; Leira, Enrique C; Planas, Anna M

2017-06-01

Background Numerous neuroprotective drugs have failed to show benefit in the treatment of acute ischemic stroke, making the search for new treatments imperative. Uric acid is an endogenous antioxidant making it a drug candidate to improve stroke outcomes. Aim To report the effects of uric acid therapy in stroke patients receiving intravenous thrombolysis and mechanical thrombectomy. Methods Forty-five patients with proximal vessel occlusions enrolled in the URICO-ICTUS trial received intravenous recombinant tissue plasminogen activator within 4.5 h after stroke onset and randomized to intravenous 1000 mg uric acid or placebo (NCT00860366). These patients also received mechanical thrombectomy because a brain computed tomogaphy angiography confirmed the lack of proximal recanalization at the end of systemic thrombolysis. The primary outcome was good functional outcome at 90 days (modified Rankin Score 0-2). Safety outcomes included mortality, symptomatic intracerebral bleeding, and gout attacks. Results The rate of successful revascularization was >80% in the uric acid and the placebo groups but good functional outcome was observed in 16 out of 24 (67%) patients treated with uric acid and 10 out of 21 (48%) treated with placebo (adjusted Odds Ratio, 6.12 (95% CI 1.08-34.56)). Mortality was observed in two out of 24 (8.3%) patients treated with uric acid and one out of 21 (4.8%) treated with placebo (adjusted Odds Ratio, 3.74 (95% CI 0.06-226.29)). Symptomatic cerebral bleeding and gout attacks were similar in both groups. Conclusions Uric acid therapy was safe and improved stroke outcomes in stroke patients receiving intravenous thrombolysis followed by thrombectomy. Validation of this simple strategy in a larger trial is urgent.

Using robot fully assisted functional movements in upper-limb rehabilitation of chronic stroke patients: preliminary results.

PubMed

Caimmi, Marco; Chiavenna, Andrea; Scano, Alessandro; Gasperini, Giulio; Giovanzana, Chiara; Molinari Tosatti, Lorenzo; Molteni, Franco

2017-06-01

Robotic rehabilitation is promising to promote function in stroke patients. The assist as needed training paradigm has shown to stimulate neuroplasticity but often cannot be used because stroke patients are too impaired to actively control the robot against gravity. To verify whether a rehabilitation intervention based on robot fully assisted reaching against gravity (RCH) and hand-to-mouth (HTM) can promote upper-limb function in chronic stroke. Cohort study. Chronic stroke outpatients referring to the robotic rehabilitation lab of a rehabilitation centre. Ten chronic stroke patients with mild to moderate upper-limb hemiparesis. Patients underwent 12 sessions (3 per week) of robotic treatment using an end-effector robot Every session consisted of 20 minutes each of RCH and HtM; movements were fully assisted, but patients were asked to try to actively participate. The Fugl-Meyer Assessment (FMA) was the primary outcome measure; Medical Research Council and Modified Ashworth Scale were the secondary outcome measures. All patients, but one, show functional improvements (FMA section A-D, mean increment 7.2±3.9 points, P<0.008). This preliminary study shows that a robotic intervention based on functional movements, fully assisted, can be effective in promoting function in chronic stroke patients. These results are promising considering the short time of the intervention (1 month) and the time from the stroke event, which was large (27±20 months). A larger study, comprehensive of objective instrumental measures, is necessary to confirm the results. This intervention could be extended even to subacute stroke and other neurological disorders.

Combination of 24-Hour and 7-Day Relative Neurological Improvement Strongly Predicts 90-Day Functional Outcome of Endovascular Stroke Therapy.

PubMed

Pu, Jie; Wang, Huaiming; Tu, Mingyi; Zi, Wenjie; Hao, Yonggang; Yang, Dong; Liu, Wenhua; Wan, Yue; Geng, Yu; Lin, Min; Jin, Ping; Xiong, Yunyun; Xu, Gelin; Yin, Qin; Liu, Xinfeng

2018-05-01

Early judgment of long-term prognosis is the key to making medical decisions in acute anterior circulation large-vessel occlusion stroke (LVOS) after endovascular treatment (EVT). We aimed to investigate the relationship between the combination of 24-hour and 7-day relative neurological improvement (RNI) and 90-day functional outcome. We selected the target population from a multicenter ischemic stroke registry. The National Institutes of Health Stroke Scale (NIHSS) scores at baseline, 24 hours, and 7 days were collected. RNI was calculated by the following equation: (baseline NIHSS - 24-hour/7-day NIHSS)/baseline NIHSS × 100%. A modified Rankin Scale score of 0-2 at 90 days was defined as a favorable outcome. Multivariable logistic regression analysis was used to evaluate the relationship between RNI and 90-day outcome. Receiver operator characteristic curve analysis was performed to identify the predictive power and cutoff point of RNI for functional outcome. A total of 568 patients were enrolled. Both 24-hour and 7-day RNI were independent predictors of 90-day outcome. The best cutoff points of 24-hour and 7-day RNI were 28% and 42%, respectively. Compared with those with 24-hour RNI of less than 28% and 7-day RNI of less than 42%, patients with 24-hour RNI of 28% or greater and 7-day RNI of 42% or greater had a 39.595-fold (95% confidence interval 22.388-70.026) increased probability of achieving 90-day favorable outcome. The combination of 24-hour and 7-day RNI very strongly predicts 90-day functional outcome in patients with acute anterior circulation LVOS who received EVT, and it can be used as an early accurate surrogate of long-term outcome. Copyright © 2018 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Do Commonly Used Functional Outcome Measures Capture Activities that Are Relevant for People with Stroke in India?

PubMed

Prakash, V; Ganesan, Mohan; Vasanthan, R; Hariohm, K

2017-04-01

In India, post-stroke outcomes are determined using functional outcome measures (FOMs), the contents of which have not been validated for their relevance to the Indian population. In this study, we aimed to evaluate the cultural validity of five frequently used stroke-specific FOMs by comparing their contents with the problems reported by patients with stroke in India. Face-to-face structured interviews were conducted with 152 patients diagnosed with stroke in India. Problems and goals identified by the patients were compared to each item included in the FOMs used in stroke rehabilitation. The Stroke Impact Scale (SIS) and the Frenchay Activities Index (FAI) include items related to the most frequently identified problems. However, neither covers problems related to the need for squatting and sitting on the floor. Use of public transport and community walking are not included in the SIS. Leisure and recreational activities (e.g. gardening, reading books), cognitive and speech functions (e.g. memory, thinking) and bowel and bladder dysfunctions were the common items identified as "not a problem" or "not relevant" by the patients. Our findings suggest that the SIS and FAI are the most appropriate FOMs for patients with stroke in India as they include items related to the majority of problems identified by study participants. Many items on both measures, however, were identified as not a problem or not relevant. There is a need for developing culture-specific FOMs that incorporate all major concerns expressed by patients with stroke in India.

Length of stay, discharge destination, and functional improvement: utility of the Australian National Subacute and Nonacute Patient Casemix Classification.

PubMed

Tooth, Leigh; McKenna, Kryss; Goh, Kong; Varghese, Paul

2005-07-01

Although implemented in 1998, no research has examined how well the Australian National Subacute and Nonacute Patient (AN-SNAP) Casemix Classification predicts length of stay (LOS), discharge destination, and functional improvement in public hospital stroke rehabilitation units in Australia. 406 consecutive admissions to 3 stroke rehabilitation units in Queensland, Australia were studied. Sociodemographic, clinical, and functional data were collected. General linear modeling and logistic regression were used to assess the ability of AN-SNAP to predict outcomes. AN-SNAP significantly predicted each outcome. There were clear relationships between the outcomes of longer LOS, poorer functional improvement and discharge into care, and the AN-SNAP classes that reflected poorer functional ability and older age. Other predictors included living situation, acute LOS, comorbidity, and stroke type. AN-SNAP is a consistent predictor of LOS, functional change and discharge destination, and has utility in assisting clinicians to set rehabilitation goals and plan discharge.

Paracetamol (Acetaminophen) in stroke 2 (PAIS 2): protocol for a randomized, placebo-controlled, double-blind clinical trial to assess the effect of high-dose paracetamol on functional outcome in patients with acute stroke and a body temperature of 36.5 °C or above.

PubMed

de Ridder, Inger R; de Jong, Frank Jan; den Hertog, Heleen M; Lingsma, Hester F; van Gemert, H Maarten A; Schreuder, A H C M L Tobien; Ruitenberg, Annemieke; Maasland, E Lisette; Saxena, Ritu; Oomes, Peter; van Tuijl, Jordie; Koudstaal, Peter J; Kappelle, L Jaap; Algra, Ale; van der Worp, H Bart; Dippel, Diederik W J

2015-04-01

In the first hours after stroke onset, subfebrile temperatures and fever have been associated with poor functional outcome. In the first Paracetamol (Acetaminophen) in Stroke trial, a randomized clinical trial of 1400 patients with acute stroke, patients who were treated with high-dose paracetamol showed more improvement on the modified Rankin Scale at three-months than patients treated with placebo, but this difference was not statistically significant. In the 661 patients with a baseline body temperature of 37.0 °C or above, treatment with paracetamol increased the odds of functional improvement (odds ratio 1.43; 95% confidence interval: 1.02-1.97). This relation was also found in the patients with a body temperature of 36.5 °C or higher (odds ratio 1.31; 95% confidence interval 1.01-1.68). These findings need confirmation. The study aims to assess the effect of high-dose paracetamol in patients with acute stroke and a body temperature of 36.5 °C or above on functional outcome. The Paracetamol (Acetaminophen) In Stroke 2 trial is a multicenter, randomized, double-blind, placebo-controlled clinical trial. We use a power of 85% to detect a significant difference in the scores on the modified Rankin Scale of the paracetamol group compared with the placebo group at a level of significance of 0.05 and assume a treatment effect of 7%. Fifteen-hundred patients with acute ischemic stroke or intracerebral hemorrhage and a body temperature of 36.5 °C or above will be included within 12 h of symptom onset. Patients will be treated with paracetamol in a daily dose of six-grams or matching placebo for three consecutive days. The Paracetamol (Acetaminophen) In Stroke 2 trial has been registered as NTR2365 in The Netherlands Trial Register. The primary outcome will be improvement on the modified Rankin Scale at three-months as analyzed by ordinal logistic regression. If high-dose paracetamol will be proven effective, a simple, safe, and extremely cheap therapy will be available for many patients with acute stroke worldwide. © 2013 The Authors. International Journal of Stroke © 2013 World Stroke Organization.

Randomized controlled trial of early rehabilitation after intracerebral hemorrhage stroke: difference in outcomes within 6 months of stroke.

PubMed

Liu, Ning; Cadilhac, Dominique A; Andrew, Nadine E; Zeng, Lingxia; Li, Zongfang; Li, Jin; Li, Yan; Yu, Xuewen; Mi, Baibing; Li, Zhe; Xu, Honghai; Chen, Yangjing; Wang, Juan; Yao, Wanxia; Li, Kuo; Yan, Feng; Wang, Jue

2014-12-01

Mechanisms, acute management, and outcomes for patients who experience intracerebral hemorrhage may differ from patients with ischemic stroke. Studies of very early rehabilitation have been mainly undertaken in patients with ischemic stroke, and it is unknown if benefits apply to those with intracerebral hemorrhage. We hypothesized that early rehabilitation, within 48 hours of stroke, would improve survival and functional outcomes in patients with intracerebral hemorrhage. This was a multicenter, randomized controlled study, with blinded assessment of outcome at 3 and 6 months. Eligible patients were randomized to receive standard care or standard care plus early rehabilitation. Primary outcome includes survival. Secondary outcomes includes health-related quality of life using the 36-item Short Form Questionnaire, function measured with the modified Barthel Index, and anxiety measured with the Zung Self-Rated Anxiety Scale. Two hundred forty-three of 326 patients were randomized (mean age, 59 years; 56% men). At 6 months, patients receiving standard care were more likely to have died (adjusted hazard ratio, 4.44; 95% confidence interval [CI], 1.24-15.87); for morbidity outcomes, a 6-point difference in the Physical Component Summary score of the 36-item Short Form Questionnaire (95% CI, 4.2-8.7), a 7-point difference for the Mental Component Summary score (95% CI, 4.5-9.5), a 13-point difference in Modified Barthel Index scores (95% CI, 6.8-18.3), and a 6-point difference in Self-Rating Anxiety Scale scores (95% CI, 4.4-8.3) was reported in favor of the intervention groups. For the first time, we have shown that commencing rehabilitation within 48 hours of intracerebral hemorrhage improves survival and functional outcomes at 6 months after stroke in hospitalized patients in China. http://www.chictr.org/en. Unique identifier: ChiCTR-TRC-13004039. © 2014 American Heart Association, Inc.

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

Nursing interventions for improving nutritional status and outcomes of stroke patients: descriptive reviews of processes and outcomes.

PubMed

Perry, Lin; Hamilton, Sharon; Williams, Jane; Jones, Susan

2013-02-01

Stroke produces many effects that impact eating. Nutrition is fundamental for recovery and rehabilitation, but the nursing nutritional role and associated outcomes have not been delineated. (1) To identify nursing interventions intended to improve nutritional status and related outcomes of stroke survivors, and (2) To examine the outcomes of identified nursing interventions on nutrition-related outcomes, including dietary intake, functional status, complications, activities of daily living, mortality, and quality of life for stroke survivors. A modified version of Cochrane literature searching and review methods was used to identify studies that described and evaluated nursing nutritional interventions for adult stroke patients in hospital and community settings. A minimum of 10 years content of seven databases and nine journals was searched to March 2011. Findings were presented descriptively. In total 27 papers from 26 studies were included: 5 randomized controlled trials, 5 clinical trials, 6 quasi-experiments, 4 case studies, and 6 qualitative/observational studies. Stroke nursing nutritional care encompassed screening of nutritional status and swallowing function; assessment of nutritional characteristics and preferences; referral; mealtime organization, supervision and monitoring; mealtime assistance and feeding skills. Nurses individualized care, coordinated or managed meal delivery and enteral feeding systems, were responsible for the dining environment and conduct of mealtimes; they taught staff, patients, and carers. There was little indication of integrated or psychosocial nursing nutritional care, or concepts, theories or models of nursing nutritional care. Many interventions were described but not evaluated. Little high quality evidence was of available. This review indicated the parameters of nursing nutritional care, and provided a framework for future research. A functional, supportive, and educational nursing nutritional role was described but little evidence was of sufficient quality to support policy and practice development or inform education. Nutritional care was revealed as an essential but under-recognized element of stroke nursing. © 2012 The authors. World Views on Evidence-Based Nursing © Sigma Theta Tau International.

Blood/Brain Biomarkers of Inflammation After Stroke and Their Association With Outcome: From C-Reactive Protein to Damage-Associated Molecular Patterns.

PubMed

Bustamante, Alejandro; Simats, Alba; Vilar-Bergua, Andrea; García-Berrocoso, Teresa; Montaner, Joan

2016-10-01

Stroke represents one of the most important causes of disability and death in developed countries. However, there is a lack of prognostic tools in clinical practice to monitor the neurological condition and predict the final outcome. Blood biomarkers have been proposed and studied in this indication; however, no biomarker is currently used in clinical practice. The stroke-related neuroinflammatory processes have been associated with a poor outcome in stroke, as well as with poststroke complications. In this review, we focus on the most studied blood biomarkers of this inflammatory processes, cytokines, and C-reactive protein, evaluating its association with outcome and complications in stroke through the literature, and performing a systematic review on the association of C-reactive protein and functional outcome after stroke. Globally, we identified uncertainty with regard to the association of the evaluated biomarkers with stroke outcome, with little added value on top of clinical predictors such as age or stroke severity, which makes its implementation unlikely in clinical practice for global outcome prediction. Regarding poststroke complications, despite being more practical scenarios in which to make medical decisions following a biomarker prediction, not many studies have been performed, although there are now some candidates for prediction of poststroke infections. Finally, as potential new candidates, we reviewed the pathophysiological actions of damage-associated molecular patterns as triggers of the neuroinflammatory cascade of stroke, and their possible use as biomarkers.

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.

Methodological Issues in Monitoring Health Services and Outcomes for Stroke Survivors: A Case Study

PubMed Central

Stuart, Mary; Papini, Donato; Benvenuti, Francesco; Nerattini, Marco; Roccato, Enrico; Macellari, Velio; Stanhope, Steven; Macko, Richard; Weinrich, Michael

2010-01-01

Background Obtaining comprehensive health outcomes and health services utilization data on stroke patients has been difficult. This research grew out of a memorandum of understanding between the NIH and the ISS (its Italian equivalent) to foster collaborative research on rehabilitation. Objective The purpose of this study was to pilot a methodology using administrative data to monitor and improve health outcomes for stroke survivors in Tuscany. Methods This study used qualitative and quantitative methods to study health resources available to and utilized by stroke survivors during the first 12 months post-stroke in two Italian health authorities (AUSL10 and 11). Mortality rates were used as an outcome measure. Results Number of inpatient days, number of prescriptions, and prescription costs were significantly higher for patients in AUSL 10 compared to AUSL 11. There was no significant difference between mortality rates. Conclusion Using administrative data to monitor process and outcomes for chronic stroke has the potential to save money and improve outcomes. However, measures of functional impairment and more sensitive outcome measures than mortality are important. Additional recommendations for enhanced data collection and reporting are discussed. PMID:21057665

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.

Effectiveness of virtual reality using Wii gaming technology in stroke rehabilitation: a pilot randomized clinical trial and proof of principle.

PubMed

Saposnik, Gustavo; Teasell, Robert; Mamdani, Muhammad; Hall, Judith; McIlroy, William; Cheung, Donna; Thorpe, Kevin E; Cohen, Leonardo G; Bayley, Mark

2010-07-01

Hemiparesis resulting in functional limitation of an upper extremity is common among stroke survivors. Although existing evidence suggests that increasing intensity of stroke rehabilitation therapy results in better motor recovery, limited evidence is available on the efficacy of virtual reality for stroke rehabilitation. In this pilot, randomized, single-blinded clinical trial with 2 parallel groups involving stroke patients within 2 months, we compared the feasibility, safety, and efficacy of virtual reality using the Nintendo Wii gaming system (VRWii) versus recreational therapy (playing cards, bingo, or "Jenga") among those receiving standard rehabilitation to evaluate arm motor improvement. The primary feasibility outcome was the total time receiving the intervention. The primary safety outcome was the proportion of patients experiencing intervention-related adverse events during the study period. Efficacy, a secondary outcome measure, was evaluated with the Wolf Motor Function Test, Box and Block Test, and Stroke Impact Scale at 4 weeks after intervention. Overall, 22 of 110 (20%) of screened patients were randomized. The mean age (range) was 61.3 (41 to 83) years. Two participants dropped out after a training session. The interventions were successfully delivered in 9 of 10 participants in the VRWii and 8 of 10 in the recreational therapy arm. The mean total session time was 388 minutes in the recreational therapy group compared with 364 minutes in the VRWii group (P=0.75). There were no serious adverse events in any group. Relative to the recreational therapy group, participants in the VRWii arm had a significant improvement in mean motor function of 7 seconds (Wolf Motor Function Test, 7.4 seconds; 95% CI, -14.5, -0.2) after adjustment for age, baseline functional status (Wolf Motor Function Test), and stroke severity. VRWii gaming technology represents a safe, feasible, and potentially effective alternative to facilitate rehabilitation therapy and promote motor recovery after stroke.

Effectiveness of Virtual Reality Using Wii Gaming Technology in Stroke Rehabilitation

PubMed Central

Saposnik, Gustavo; Teasell, Robert; Mamdani, Muhammad; Hall, Judith; McIlroy, William; Cheung, Donna; Thorpe, Kevin E.; Cohen, Leonardo G.; Bayley, Mark

2016-01-01

Background and Purpose Hemiparesis resulting in functional limitation of an upper extremity is common among stroke survivors. Although existing evidence suggests that increasing intensity of stroke rehabilitation therapy results in better motor recovery, limited evidence is available on the efficacy of virtual reality for stroke rehabilitation. Methods In this pilot, randomized, single-blinded clinical trial with 2 parallel groups involving stroke patients within 2 months, we compared the feasibility, safety, and efficacy of virtual reality using the Nintendo Wii gaming system (VRWii) versus recreational therapy (playing cards, bingo, or “Jenga”) among those receiving standard rehabilitation to evaluate arm motor improvement. The primary feasibility outcome was the total time receiving the intervention. The primary safety outcome was the proportion of patients experiencing intervention-related adverse events during the study period. Efficacy, a secondary outcome measure, was evaluated with the Wolf Motor Function Test, Box and Block Test, and Stroke Impact Scale at 4 weeks after intervention. Results Overall, 22 of 110 (20%) of screened patients were randomized. The mean age (range) was 61.3 (41 to 83) years. Two participants dropped out after a training session. The interventions were successfully delivered in 9 of 10 participants in the VRWii and 8 of 10 in the recreational therapy arm. The mean total session time was 388 minutes in the recreational therapy group compared with 364 minutes in the VRWii group (P=0.75). There were no serious adverse events in any group. Relative to the recreational therapy group, participants in the VRWii arm had a significant improvement in mean motor function of 7 seconds (Wolf Motor Function Test, 7.4 seconds; 95% CI, −14.5, −0.2) after adjustment for age, baseline functional status (Wolf Motor Function Test), and stroke severity. Conclusions VRWii gaming technology represents a safe, feasible, and potentially effective alternative to facilitate rehabilitation therapy and promote motor recovery after stroke. PMID:20508185

A study on the natural history of scanning behaviour in patients with visual field defects after stroke.

PubMed

Loetscher, Tobias; Chen, Celia; Wignall, Sophie; Bulling, Andreas; Hoppe, Sabrina; Churches, Owen; Thomas, Nicole A; Nicholls, Michael E R; Lee, Andrew

2015-04-24

A visual field defect (VFD) is a common consequence of stroke with a detrimental effect upon the survivors' functional ability and quality of life. The identification of effective treatments for VFD is a key priority relating to life post-stroke. Understanding the natural evolution of scanning compensation over time may have important ramifications for the development of efficacious therapies. The study aims to unravel the natural history of visual scanning behaviour in patients with VFD. The assessment of scanning patterns in the acute to chronic stages of stroke will reveal who does and does not learn to compensate for vision loss. Eye-tracking glasses are used to delineate eye movements in a cohort of 100 stroke patients immediately after stroke, and additionally at 6 and 12 months post-stroke. The longitudinal study will assess eye movements in static (sitting) and dynamic (walking) conditions. The primary outcome constitutes the change of lateral eye movements from the acute to chronic stages of stroke. Secondary outcomes include changes of lateral eye movements over time as a function of subgroup characteristics, such as side of VFD, stroke location, stroke severity and cognitive functioning. The longitudinal comparison of patients who do and do not learn compensatory scanning techniques may reveal important prognostic markers of natural recovery. Importantly, it may also help to determine the most effective treatment window for visual rehabilitation.

Rehabilitation Outcomes: Ischemic versus Hemorrhagic Strokes.

PubMed

Perna, Robert; Temple, Jessica

2015-01-01

Background. Ischemic and hemorrhagic strokes have different pathophysiologies and possibly different long-term cerebral and functional implications. Hemorrhagic strokes expose the brain to irritating effects of blood and ischemic strokes reflect localized or diffuse cerebral vascular pathology. Methods. Participants were individuals who suffered either an ischemic (n = 172) or hemorrhagic stroke (n = 112) within the past six months and were involved in a postacute neurorehabilitation program. Participants completed three months of postacute neurorehabilitation and the Mayo Portland Adaptability Inventory-4 (MPAI-4) at admission and discharge. Admission MPAI-4 scores and level of functioning were comparable. Results. Group ANOVA comparisons show no significant group differences at admission or discharge or difference in change scores. Both groups showed considerably reduced levels of productivity/employment after discharge as compared to preinjury levels. Conclusions. Though the pathophysiology of these types of strokes is different, both ultimately result in ischemic injuries, possibly accounting for lack of findings of differences between groups. In the present study, participants in both groups experienced similar functional levels across all three MPAI-4 domains both at admission and discharge. Limitations of this study include a highly educated sample and few outcome measures.

Prognostic value of serum thioredoxin levels in ischemic stroke.

PubMed

Yu, Tieer; Zhang, Wanli; Lin, Yuanshao; Li, Qian; Xue, Jie; Cai, Zhengyi; Cheng, Yifan; Shao, Bei

2017-11-01

Thioredoxin (Trx) is one of significant antioxidative molecules to diminish oxidative stress. Current evidence suggests that Trx is a potent antioxidant with cytoprotective functions. The aim of our study was to investigate specifically the association between serum Trx levels and acute ischemic stroke (AIS) patients. 198 AIS patients and 75 controls were enrolled to the study. Serum Trx levels were measured using an enzyme-linked immunosorbent assay (ELISA). Stroke severity was assessed with the National Institutes of Health Stroke Scale (NIHSS) score on admission. Clinical endpoint was functional outcome measured by Barthel Index (BI) 3 months after admission. Multivariate binary logistic regression analyses were performed to identify predictors. We found that serum Trx levels were significantly increased in patients as compared to controls. Serum Trx was an independent biomarker to predict ischemic stroke (OR, 1.264; 95% CI, 1.04-1.537; P = 0.019). In addition, there was a negative correlation between NIHSS score at admission and serum Trx levels in cardioembolic stroke patients (r = -0.422; P = 0.013). Furthermore, higher serum Trx levels in AIS patients were associated with favorable functional outcome. Serum Trx was an independent predictor for the functional outcome (OR, 0.862; 95% CI, 0.75-0.991; P = 0.037). Serum Trx might be as a biomarker of cardioembolic stroke severity. Increased serum Trx levels could be a useful tool to predict good prognosis in patients with AIS.

Animal models of post-ischemic forced use rehabilitation: methods, considerations, and limitations

PubMed Central

2013-01-01

Many survivors of stroke experience arm impairments, which can severely impact their quality of life. Forcing use of the impaired arm appears to improve functional recovery in post-stroke hemiplegic patients, however the mechanisms underlying improved recovery remain unclear. Animal models of post-stroke rehabilitation could prove critical to investigating such mechanisms, however modeling forced use in animals has proven challenging. Potential problems associated with reported experimental models include variability between stroke methods, rehabilitation paradigms, and reported outcome measures. Herein, we provide an overview of commonly used stroke models, including advantages and disadvantages of each with respect to studying rehabilitation. We then review various forced use rehabilitation paradigms, and highlight potential difficulties and translational problems. Lastly, we discuss the variety of functional outcome measures described by experimental researchers. To conclude, we outline ongoing challenges faced by researchers, and the importance of translational communication. Many stroke patients rely critically on rehabilitation of post-stroke impairments, and continued effort toward progression of rehabilitative techniques is warranted to ensure best possible treatment of the devastating effects of stroke. PMID:23343500

Upper Limb Outcome Measures Used in Stroke Rehabilitation Studies: A Systematic Literature Review

PubMed Central

Santisteban, Leire; Térémetz, Maxime; Bleton, Jean-Pierre; Baron, Jean-Claude; Maier, Marc A.; Lindberg, Påvel G.

2016-01-01

Background Establishing which upper limb outcome measures are most commonly used in stroke studies may help in improving consensus among scientists and clinicians. Objective In this study we aimed to identify the most commonly used upper limb outcome measures in intervention studies after stroke and to describe domains covered according to ICF, how measures are combined, and how their use varies geographically and over time. Methods Pubmed, CinHAL, and PeDRO databases were searched for upper limb intervention studies in stroke according to PRISMA guidelines and477 studies were included. Results In studies 48different outcome measures were found. Only 15 of these outcome measures were used in more than 5% of the studies. The Fugl-Meyer Test (FMT)was the most commonly used measure (in 36% of studies). Commonly used measures covered ICF domains of body function and activity to varying extents. Most studies (72%) combined multiple outcome measures: the FMT was often combined with the Motor Activity Log (MAL), the Wolf Motor Function Test and the Action Research Arm Test, but infrequently combined with the Motor Assessment Scale or the Nine Hole Peg Test. Key components of manual dexterity such as selective finger movements were rarely measured. Frequency of use increased over a twelve-year period for the FMT and for assessments of kinematics, whereas other measures, such as the MAL and the Jebsen Taylor Hand Test showed decreased use over time. Use varied largely between countries showing low international consensus. Conclusions The results showed a large diversity of outcome measures used across studies. However, a growing number of studies used the FMT, a neurological test with good psychometric properties. For thorough assessment the FMT needs to be combined with functional measures. These findings illustrate the need for strategies to build international consensus on appropriate outcome measures for upper limb function after stroke. PMID:27152853

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.

Speech-language pathologist-led fiberoptic endoscopic evaluation of swallowing: functional outcomes for patients after stroke.

PubMed

Bax, Louise; McFarlane, Mary; Green, Emma; Miles, Anna

2014-03-01

Dysphagia is a common complication after stroke and is associated with the development of pneumonia. Early detection of dysphagia and specifically aspiration is, therefore, critical in the prevention of pneumonia. Fiberoptic endoscopic evaluation of swallowing (FEES) is a safe bedside instrumental tool for detecting dysphagia and aspiration and, therefore, has the potential to inform dysphagia management. This study investigated the clinical utility of a speech-language pathologist-led FEES service on functional outcomes for patients after acute stroke. A retrospective file audit was carried out on 220 patients before FEES was introduced and on 220 patients after the implementation of a speech-language pathologist-led FEES service. The primary outcome measure was incidence of pneumonia, and secondary outcome measures included mortality, diet on discharge, discharge destination, duration nil-by-mouth, incidence of nonoral feeding, and length of stay. There was a significant increase in instrumental assessment use in the group that had access to FEES (P < .001). There was a significant reduction of pneumonia rates in the group that had access to FEES (P = .037). Patients were also significantly more likely to leave hospital on standard diets (P = .004) but had longer periods of nonoral feeding (P = .013) and increased length of hospitalization (P < .001). When used selectively, FEES services have potential for improving functional outcomes for patients after stroke. Copyright © 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.

External Validation of the ASTRAL and DRAGON Scores for Prediction of Functional Outcome in Stroke.

PubMed

Cooray, Charith; Mazya, Michael; Bottai, Matteo; Dorado, Laura; Skoda, Ondrej; Toni, Danilo; Ford, Gary A; Wahlgren, Nils; Ahmed, Niaz

2016-06-01

ASTRAL (Acute Stroke Registry and Analysis of Lausanne) and DRAGON (includes dense middle cerebral artery sign, prestroke modified Rankin Scale score, age, glucose, onset to treatment, National Institutes of Health Stroke Scale score) are 2 recently developed scores for predicting functional outcome after acute stroke in unselected acute ischemic stroke patients and in patients treated with intravenous thrombolysis, respectively. We aimed to perform external validation of these scores to assess their predictive performance in the large multicentre Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register. We calculated the ASTRAL and DRAGON scores in 36 131 and 33 716 patients, respectively, registered in Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register between 2003 and 2013. The proportion of patients with 3-month modified Rankin Scale scores of 3 to 6 was observed for each score point and compared with the predicted proportion according to the risk scores. Calibration was assessed using calibration plots, and predictive performance was assessed using area under the curve of the receiver operating characteristic. Multivariate logistic regression coefficients for the variables in the 2 scores were compared with the original derivation cohorts. The ASTRAL showed an area under the curve of 0.790 (95% confidence interval, 0.786-0.795) and the DRAGON an area under the curve of 0.774 (95% confidence interval, 0.769-0.779). All ASTRAL parameters except range of visual fields and all DRAGON parameters were significantly associated with functional outcome in multivariate analysis. The ASTRAL and DRAGON scores show an acceptable predictive performance. ASTRAL does not require imaging-data and therefore may have an advantage for the use in prehospital patient assessment. Prospective studies of both scores evaluating the impact of their use on patient outcomes after intravenous thrombolysis and endovascular therapy are needed. © 2016 American Heart Association, Inc.

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.

The effects of a rhythm and music-based therapy program and therapeutic riding in late recovery phase following stroke: a study protocol for a three-armed randomized controlled trial

PubMed Central

2012-01-01

Background Stroke represents one of the most costly and long-term disabling conditions in adulthood worldwide and there is a need to determine the effectiveness of rehabilitation programs in the late phase after stroke. Limited scientific support exists for training incorporating rhythm and music as well as therapeutic riding and well-designed trials to determine the effectiveness of these treatment modalities are warranted. Methods/Design A single blinded three-armed randomized controlled trial is described with the aim to evaluate whether it is possible to improve the overall health status and functioning of individuals in the late phase of stroke (1-5 years after stroke) through a rhythm and music-based therapy program or therapeutic riding. About 120 individuals will be consecutively and randomly allocated to one of three groups: (T1) rhythm and music-based therapy program; (T2) therapeutic riding; or (T3) control group receiving the T1 training program a year later. Evaluation is conducted prior to and after the 12-week long intervention as well as three and six months later. The evaluation comprises a comprehensive functional and cognitive assessment (both qualitative and quantitative), and questionnaires. Based on the International classification of functioning, disability, and health (ICF), the outcome measures are classified into six comprehensive domains, with participation as the primary outcome measure assessed by the Stroke Impact Scale (SIS, version 2.0.). The secondary outcome measures are grouped within the following domains: body function, activity, environmental factors and personal factors. Life satisfaction and health related quality of life constitute an additional domain. Current status A total of 84 participants were randomised and have completed the intervention. Recruitment proceeds and follow-up is on-going, trial results are expected in early 2014. Discussion This study will ascertain whether any of the two intervention programs can improve overall health status and functioning in the late phase of stroke. A positive outcome would increase the scientific basis for the use of such interventions in the late phase after stroke. Trial registration Clinical Trials.gov Identifier: NCT01372059 PMID:23171380

The effects of a rhythm and music-based therapy program and therapeutic riding in late recovery phase following stroke: a study protocol for a three-armed randomized controlled trial.

PubMed

Bunketorp Käll, Lina; Lundgren-Nilsson, Åsa; Blomstrand, Christian; Pekna, Marcela; Pekny, Milos; Nilsson, Michael

2012-11-21

Stroke represents one of the most costly and long-term disabling conditions in adulthood worldwide and there is a need to determine the effectiveness of rehabilitation programs in the late phase after stroke. Limited scientific support exists for training incorporating rhythm and music as well as therapeutic riding and well-designed trials to determine the effectiveness of these treatment modalities are warranted. A single blinded three-armed randomized controlled trial is described with the aim to evaluate whether it is possible to improve the overall health status and functioning of individuals in the late phase of stroke (1-5 years after stroke) through a rhythm and music-based therapy program or therapeutic riding. About 120 individuals will be consecutively and randomly allocated to one of three groups: (T1) rhythm and music-based therapy program; (T2) therapeutic riding; or (T3) control group receiving the T1 training program a year later. Evaluation is conducted prior to and after the 12-week long intervention as well as three and six months later. The evaluation comprises a comprehensive functional and cognitive assessment (both qualitative and quantitative), and questionnaires. Based on the International classification of functioning, disability, and health (ICF), the outcome measures are classified into six comprehensive domains, with participation as the primary outcome measure assessed by the Stroke Impact Scale (SIS, version 2.0.). The secondary outcome measures are grouped within the following domains: body function, activity, environmental factors and personal factors. Life satisfaction and health related quality of life constitute an additional domain. A total of 84 participants were randomised and have completed the intervention. Recruitment proceeds and follow-up is on-going, trial results are expected in early 2014. This study will ascertain whether any of the two intervention programs can improve overall health status and functioning in the late phase of stroke. A positive outcome would increase the scientific basis for the use of such interventions in the late phase after stroke. Clinical Trials.gov Identifier: NCT01372059.

The effect of music-movement therapy on physical and psychological states of stroke patients.

PubMed

Jun, Eun-Mi; Roh, Young Hwa; Kim, Mi Ja

2013-01-01

This study evaluated the effects of combined music-movement therapy on physical and psychological functioning of hospitalised stroke patients. Few studies have focused on music-movement therapy's effects on physical and psychological functioning of stroke patients. A quasi-experimental design with pre- and post-tests was used. A convenience sample was used: patients hospitalised for stroke and within two weeks of the onset of stroke were randomised to either an experimental group (received music-movement therapy in their wheelchairs for 60 minutes three times per week for 8 weeks) or control group (received only routine treatment). The effect of music-movement therapy was assessed in terms of physical outcomes (range of motion, muscle strength and activities of daily living) and psychological outcomes (mood states, depression), measured in both groups pre- and post-test. The experimental group had significantly increased shoulder flexion and elbow joint flexion in physical function and improved mood state in psychological function, compared with the control group. Early rehabilitation of hospitalised stroke patients within two weeks of the onset of stroke was effective by using music-movement therapy. It improved their mood state and increased shoulder flexion and elbow joint flexion. The findings of this study suggest that rehabilitation for stroke patients should begin as early as possible, even during their hospitalisation. Nursing practice should incorporate the concept of combining music and movements to improve stroke patients' physical and psychological states starting from the acute phase. © 2012 Blackwell Publishing Ltd.

Role of ankle foot orthoses in functional stability of individuals with stroke.

PubMed

Rao, N; Aruin, A S

2016-10-01

Ankle foot orthoses (AFOs) are frequently prescribed to improve ambulation in individuals with stroke. However, the role of AFOs in balance control is not completely understood. The aim of the study was to evaluate the contribution of the AFOs in functional stability of individuals with stroke. Twenty three individuals with unilateral hemiparesis due to stroke were assessed using the Functional Reach Test. The subjects performed reaches forward, left and right while standing with or without an AFO. When provided with AFO, individuals with stroke improved the maximal reaching distance in all the directions (p < 0.05). The study found that individuals with unilateral stroke clearly demonstrated improvements in functional stability when they were provided with AFOs. This outcome could be used in the optimization of balance rehabilitation of individuals with stroke. Implications for Rehabilitation Functional stability is impaired in individuals with stroke. Functional Reach Test (FRT) was used to assess the role of ankle foot orthoses (AFOs) in balance control. Individuals with stroke improved their functional stability while they were provided with AFOs. Functional Reach Test could assist clinicians in the evaluation of postural stability associated with the use of AFOs.

Comprehensive Outpatient Rehabilitation Program: Hospital-Based Stroke Outpatient Rehabilitation.

PubMed

Rice, Danielle; Janzen, Shannon; McIntyre, Amanda; Vermeer, Julianne; Britt, Eileen; Teasell, Robert

2016-05-01

Few studies have considered the effectiveness of outpatient rehabilitation programs for stroke patients. The objective of this study was to assess the effectiveness of a hospital-based interdisciplinary outpatient stroke rehabilitation program with respect to physical functioning, mobility, and balance. The Comprehensive Outpatient Rehabilitation Program provides a hospital-based interdisciplinary approach to stroke rehabilitation in Southwestern Ontario. Outcome measures from physiotherapy and occupational therapy sessions were available at intake and discharge from the program. A series of paired sample t-tests were performed to assess patient changes between time points for each outcome measure. A total of 271 patients met the inclusion criteria for analysis (56.1% male; mean age = 62.9 ± 13.9 years). Significant improvements were found between admission and discharge for the Functional Independence Measure, grip strength, Chedoke-McMaster Stroke Assessment, two-minute walk test, maximum walk test, Timed Up and Go, Berg Balance Scale, and one-legged stance (P < .003 for all). The findings indicate that an interdisciplinary rehabilitation program was effective at improving the physical functioning, mobility, and balance of individuals after a stroke. A hospital-based, stroke-specific rehabilitation program should be considered when patients continue to experience deficits after inpatient rehabilitation. Copyright © 2016 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Predictors of Good Outcome After Endovascular Therapy for Vertebrobasilar Occlusion Stroke.

PubMed

Bouslama, Mehdi; Haussen, Diogo C; Aghaebrahim, Amin; Grossberg, Jonathan A; Walker, Gregory; Rangaraju, Srikant; Horev, Anat; Frankel, Michael R; Nogueira, Raul G; Jovin, Tudor G; Jadhav, Ashutosh P

2017-12-01

Endovascular therapy is increasingly used in acute ischemic stroke treatment and is now considered the gold standard approach for selected patient populations. Prior studies have demonstrated that eventual patient outcomes depend on both patient-specific factors and procedural considerations. However, these factors remain unclear for acute basilar artery occlusion stroke. We sought to determine prognostic factors of good outcome in acute posterior circulation large vessel occlusion strokes treated with endovascular therapy. We reviewed our prospectively collected endovascular databases at 2 US tertiary care academic institutions for patients with acute posterior circulation strokes from September 2005 to September 2015 who had 3-month modified Rankin Scale documented. Baseline characteristics, procedural data, and outcomes were evaluated. A good outcome was defined as a 90-day modified Rankin Scale score of 0 to 2. The association between clinical and procedural parameters and functional outcome was assessed. A total of 214 patients qualified for the study. Smoking status, creatinine levels, baseline National Institutes of Health Stroke Scale score, anesthesia modality (conscious sedation versus general anesthesia), procedural length, and reperfusion status were significantly associated with good outcomes in the univariate analysis. Multivariate logistic regression indicated that only smoking (odds ratio=2.61; 95% confidence interval, 1.23-5.56; P =0.013), low baseline National Institutes of Health Stroke Scale score (odds ratio=1.09; 95% confidence interval, 1.04-1.13; P <0.0001), and successful reperfusion status (odds ratio=10.80; 95% confidence interval, 1.36-85.96; P =0.025) were associated with good outcome. In our retrospective case series, only smoking, low baseline National Institutes of Health Stroke Scale score, and successful reperfusion status were associated with good outcome in patients with posterior circulation stroke treated with endovascular therapy. © 2017 American Heart Association, Inc.

[Acute surgical treatment of malignant stroke].

PubMed

Lilja-Cyron, Alexander; Eskesen, Vagn; Hansen, Klaus; Kondziella, Daniel; Kelsen, Jesper

2016-10-24

Malignant stroke is an intracranial herniation syndrome caused by cerebral oedema after a large hemispheric or cerebellar stroke. Malignant middle cerebral artery infarction is a devastating disease with a mortality around 80% despite intensive medical treatment. Decompressive craniectomy reduces mortality and improves functional outcome - especially in younger patients (age ≤ 60 years). Decompression of the posterior fossa is a life-saving procedure in patients with malignant cerebellar infarctions and often leads to good neurological outcome.

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.

Intrinsic or Extrinsic? Using Videogames to Motivate Stroke Survivors: A Systematic Review.

PubMed

Swanson, LaTasha R; Whittinghill, David M

2015-06-01

The main objective of this study was to explore, via a systematic review of available literature, the effectiveness of videogame-based rehabilitation interventions on the motivation and health outcomes of stroke patients. Using a systematic literature review of 18 articles, we sought to address three key research questions: (1) Do videogames improve function or health outcomes among stroke survivors? (2) Do videogames increase stroke patients' motivation to engage in rehabilitation exercise and activities? (3) Which motivational techniques, principles, and theoretical frameworks have been applied in the reviewed studies? A key word search was conducted, and articles were coded for inclusion of motivational theories or principles, intervention effectiveness, and participants' motivation to perform tasks. Three motivational frameworks and principles were used (self-determination theory [SDT], flow theory, and operant conditioning) to investigate intrinsic and extrinsic approaches. Past research suggests videogame-based interventions are effective at improving and increasing a variety of health-related outcomes, including motor functioning, energy expenditure, muscle strength, and recovery times in stroke patients. Past evidence shows videogame-based interventions are a promising tool to motivate stroke patients' engagement in effective rehabilitation activities. This study also identifies an opportunity for future research to apply motivational theories from SDT to studies on stroke rehabilitation and videogames.

The Efficacy of Prophylactic Antibiotics on Post-Stroke Infections: An Updated Systematic Review and Meta-Analysis

PubMed Central

Liu, Liang; Xiong, Xiao-Yi; Zhang, Qin; Fan, Xiao-Tang; Yang, Qing-Wu

2016-01-01

Post-stroke infections are common complications in acute stroke patients and are associated with an unfavorable functional outcome. However, reports on the effects of prophylactic antibiotics treatment on post-stroke infections are conflicting, especially those on post-stroke pneumonia and outcomes. We searched the PubMed, Embase, and Web of Knowledge databases up through March 11th, 2016. Seven randomized controlled trials including 4261 patients were analyzed among this systematic review and meta-analysis. We found preventive antibiotics treatment at the time of stroke onset did reduce the incidence of infections in adults with acute stroke (OR = 0.57, 95% CI: 0.38–0.85, P = 0.005), including reducing the number of urinary tract infections (OR = 0.34, 95% CI: 0.26–0.46, P < 0.001), but did not significantly decrease the rate of post-stroke pneumonia (OR = 0.91, 95% CI: 0.73–1.13, P = 0.385). Importantly, antibiotics treatment also showed no significant effect on the number of fatalities among stroke patients (OR = 1.07, 95% CI: 0.90–1.26, P = 0.743) and functional outcome scores on the modified Rankin Scale (OR = 1.76, 95% CI: 0.86–3.63, p = 0.124). Our study indicated that preventive antibiotics treatment not reduced the rate of post-stroke pneumonia or mortality, even though decreased the risk of infections, especially urinary tract infections. Thus, preventive antibiotics treatment may not be recommended for acute stroke patients. PMID:27841284

Association Between Onset-to-Door Time and Clinical Outcomes After Ischemic Stroke.

PubMed

Matsuo, Ryu; Yamaguchi, Yuko; Matsushita, Tomonaga; Hata, Jun; Kiyuna, Fumi; Fukuda, Kenji; Wakisaka, Yoshinobu; Kuroda, Junya; Ago, Tetsuro; Kitazono, Takanari; Kamouchi, Masahiro

2017-11-01

The role of early hospital arrival in improving poststroke clinical outcomes in patients without reperfusion treatment remains unclear. This study aimed to determine whether early hospital arrival was associated with favorable outcomes in patients without reperfusion treatment or with minor stroke. This multicenter, hospital-based study included 6780 consecutive patients (aged, 69.9±12.2 years; 63.9% men) with ischemic stroke who were prospectively registered in Fukuoka, Japan, between July 2007 and December 2014. Onset-to-door time was categorized as T 0-1 , ≤1 hour; T 1-2 , >1 and ≤2 hours; T 2-3 , >2 and ≤3 hours; T 3-6 , >3 and ≤6 hours; T 6-12 , >6 and ≤12 hours; T 12-24 , >12 and ≤24 hours; and T 24- , >24 hours. The main outcomes were neurological improvement (decrease in National Institutes of Health Stroke Scale score of ≥4 during hospitalization or 0 at discharge) and good functional outcome (3-month modified Rankin Scale score of 0-1). Associations between onset-to-door time and main outcomes were evaluated after adjusting for potential confounders using logistic regression analysis. Odds ratios (95% confidence intervals) increased significantly with shorter onset-to-door times within 6 hours, for both neurological improvement ( T 0- 1 , 2.79 [2.28-3.42]; T 1-2 , 2.49 [2.02-3.07]; T 2-3 , 1.52 [1.21-1.92]; T 3-6 , 1.72 [1.44-2.05], with reference to T 24- ) and good functional outcome ( T 0-1 , 2.68 [2.05-3.49], T 1-2 2.10 [1.60-2.77], T 2-3 1.53 [1.15-2.03], T 3-6 1.31 [1.05-1.64], with reference to T 24- ), even after adjusting for potential confounding factors including reperfusion treatment and basal National Institutes of Health Stroke Scale. These associations were maintained in 6216 patients without reperfusion treatment and in 4793 patients with minor stroke (National Institutes of Health Stroke Scale ≤4 on hospital arrival). Early hospital arrival within 6 hours after stroke onset is associated with favorable outcomes after ischemic stroke, regardless of reperfusion treatment or stroke severity. © 2017 American Heart Association, Inc.

Serum Uric Acid Is Associated with Poor Outcome in Black Africans in the Acute Phase of Stroke

PubMed Central

Ayeah, Chia Mark; Ba, H.; Mbahe, Salomon

2017-01-01

Background Prognostic significance of serum uric acid (SUA) in acute stroke still remains controversial. Objectives To determine the prevalence of hyperuricemia and its association with outcome of stroke patients in the Douala General Hospital (DGH). Methods This was a hospital based prospective cohort study which included acute stroke patients with baseline SUA levels and 3-month poststroke follow-up data. Associations between high SUA levels and stroke outcomes were analyzed using multiple logistic regression and survival analysis (Cox regression and Kaplan-Meier). Results A total of 701 acute stroke patients were included and the prevalence of hyperuricemia was 46.6% with a mean SUA level of 68.625 ± 24 mg/l. Elevated SUA after stroke was associated with death (OR = 2.067; 95% CI: 1.449–2.950; p < 0.001) but did not predict this issue. However, an independent association between increasing SUA concentration and mortality was noted in a Cox proportional hazards regression model (adjusted HR = 1.740; 95% CI: 1.305–2.320; p < 0.001). Furthermore, hyperuricemia was an independent predictor of poor functional outcome within 3 months after stroke (OR = 2.482; 95% CI: 1.399–4.404; p = 0.002). Conclusion The prevalence of hyperuricemia in black African stroke patients is quite high and still remains a predictor of poor outcome. PMID:29082062

Obese Japanese Patients with Stroke Have Higher Functional Recovery in Convalescent Rehabilitation Wards: A Retrospective Cohort Study.

PubMed

Nishioka, Shinta; Wakabayashi, Hidetaka; Yoshida, Tomomi; Mori, Natsumi; Watanabe, Riko; Nishioka, Emi

2016-01-01

A protective effect of excessive body mass index (BMI) on mortality or functional outcome in patients with stroke is not well established in the Asian population. This study aimed to explore whether obese patients with stroke have advantages for functional improvement in Japanese rehabilitation wards. This retrospective cohort study included consecutive patients with stroke admitted and discharged from convalescent rehabilitation wards between 2011 and 2015. Demographic data, BMI, Functional Independence Measure (FIM) score, and nutritional status were analyzed. Participants were classified into 4 groups according to BMI (underweight <18.5 kg/m(2), standard 18.5-<23 kg/m(2), overweight 23-<27.5 kg/m(2), obese ≥27.5 kg/m(2)). The primary outcome was the FIM gain, and the secondary outcome was the FIM score at discharge. Multiple regression analysis was performed to analyze the relationship between BMI and functional recovery. In total, 897 participants (males 484, females 413; mean age 71.6 years) were analyzed and classified as underweight (134), standard (432), overweight (277), and obese (54). The median FIM gain and the FIM score at discharge were 30 and 114, respectively. The FIM gain in the obese group was significantly higher than those in the other groups. Multiple regression analysis revealed that obesity was independently correlated with the FIM gain, and those at discharge after adjusting for confounders such as age, gender, and FIM score on admission. Obese Japanese convalescent patients with stroke may have some advantages for functional recovery in rehabilitation wards. Copyright © 2015 National Stroke Association. Published by Elsevier Inc. All rights reserved.

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.

Effect of Increased Intensity of Physiotherapy on Patient Outcomes After Stroke: An Evidence-Based Analysis

PubMed Central

Sehatzadeh, S

2015-01-01

Background After stroke, impairment of the upper and lower limb can limit patients’ motor function and ability to perform activities of daily living (ADL). Physiotherapy (PT) is an established clinical practice for stroke patients, playing an important role in improving limb function. Recently, several randomized trials have evaluated the effect of higher-intensity physiotherapy (increased duration and/or frequency) on patients’ functional ability. Objectives Our objective is to investigate whether an increased intensity of PT after stroke results in better outcomes for patients. Data Sources A literature search was performed on June 7, 2013, for English-language randomized controlled trials published from January 1, 2003, to June 7, 2013. Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid Embase, EBSCO Cumulative Index to Nursing & Allied Health Literature (CINAHL), and EBM Reviews were searched. Review Methods We reviewed the full text of articles that compared 2 or more levels of PT intensity. Outcomes of interest included motor function, ADL, and quality of life (QOL). Results High-quality evidence showed that higher-intensity upper-limb PT and higher-intensity lower-limb PT both resulted in significantly greater improvements in motor function. Moderate-quality evidence showed that higher-intensity general PT did not. Moderate-quality evidence showed a significant improvement in ADL performance with higher-intensity upper-limb PT, but no improvement with higher-intensity general PT; no studies reported on ADL outcomes on lower-limb PT specifically. According to moderate-quality evidence, patient QOL did not change significantly after increased intensity of upper-limb, lower-limb, or general PT. When considering the results, one difference should be noted: Compared with the studies examining upper- and lower-limb PT, the studies examining general PT looked at a smaller increase—2 hours or less of additional therapy per week. Limitations This analysis is limited to the earlier post-stroke phase and is not equipped to comment on expected outcomes of later-stage PT. Conclusions Overall, this analysis found support for the use of more intensive PT to improve motor function and ability to perform ADL after stroke. PMID:26356355

Volume of Plasma Expansion and Functional Outcomes in Stroke.

PubMed

Miller, Joseph B; Lewandowski, Christopher; Wira, Charles R; Taylor, Andrew; Burmeister, Charlotte; Welch, Robert

2017-04-01

Plasma expansion in acute ischemic stroke has potential to improve cerebral perfusion, but the long-term effects on functional outcome are mixed in prior trials. The goal of this study was to evaluate how the magnitude of plasma expansion affects neurological recovery in acute stroke. This was a secondary analysis of data from the Albumin in Acute Stroke Part 2 trial investigating the relationship between the magnitude of overall intravenous volume infusion (crystalloid and colloid) to clinical outcome. The data were inclusive of 841 patients with a mean age of 64 years and a median National Institutes of Health Stroke Scale (NIHSS) of 11. In a multivariable-adjusted logistic regression model, this analysis tested the volume of plasma expansion over the first 48 h of hospitalization as a predictor of favorable outcome, defined as either a modified Rankin Scale score of 0 or 1 or a NIHSS score of 0 or 1 at 90 days. This model included all study patients, irrespective of albumin or isotonic saline treatment. Patients that received higher volumes of plasma expansion more frequently had large vessel ischemic stroke and higher NIHSS scores. The multivariable-adjusted model revealed that there was decreased odds of a favorable outcome for every 250 ml additional volume plasma expansion over the first 48 h (OR 0.91, 95 % CI, 0.88-0.94). The present study demonstrates an association between greater volume of plasma expansion and worse neurological recovery.

Cognitive-communication disorder following right hemisphere stroke: exploring rehabilitation access and outcomes.

PubMed

Hewetson, Ronelle; Cornwell, Petrea; Shum, David

2017-07-01

Rehabilitation positively influences return to activities and social roles in people with aphasia. The cognitive-communication disorder (CCD) found following a right hemisphere stroke has been less extensively researched with rehabilitation access and outcomes yet to be determined. To document rehabilitation access and outcomes for people with CCD post-stroke; and compare outcomes based on presence (viz CCD; aphasia) or absence of communication impairment. A retrospective chart audit was completed for patients with first onset unilateral stroke, with a hospital length of stay (LOS) of at least two days and a communication assessment by a speech pathologist. Data extracted included presence and severity of communication impairment, access to and LOS in a rehabilitation unit, and functional outcome measures recorded at rehabilitation discharge. The majority of the 115 patients who met inclusion criteria were living independently (n = 112, 97.4%) at the time of stroke. CCD (66%) was diagnosed with similar frequency to aphasia (68%). The presence of communication impairment did not result in significant differences in rehabilitation LOS and discharge destination when compared to hemispheric strokes without communication impairment. Severity of CCD was an independent predictor of functional gain by rehabilitation discharge. People with CCD require comparable access to rehabilitation as people with aphasia, and severity of CCD should be considered in determining rehabilitation LOS. A large number of people are discharged with ongoing CCD which warrants exploration of potential participation restrictions created by the communication impairment.

Baseline Blood Pressure Effect on the Benefit and Safety of Intra-Arterial Treatment in MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands).

PubMed

Mulder, Maxim J H L; Ergezen, Saliha; Lingsma, Hester F; Berkhemer, Olvert A; Fransen, Puck S S; Beumer, Debbie; van den Berg, Lucie A; Lycklama À Nijeholt, Geert; Emmer, Bart J; van der Worp, H Bart; Nederkoorn, Paul J; Roos, Yvo B W E M; van Oostenbrugge, Robert J; van Zwam, Wim H; Majoie, Charles B L M; van der Lugt, Aad; Dippel, Diederik W J

2017-07-01

High blood pressure (BP) is associated with poor outcome and the occurrence of symptomatic intracranial hemorrhage in acute ischemic stroke. Whether BP influences the benefit or safety of intra-arterial treatment (IAT) is not known. We aimed to assess the relation of BP with functional outcome, occurrence of symptomatic intracranial hemorrhage and effect of IAT. This is a post hoc analysis of the MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands). BP was measured at baseline, before IAT or stroke unit admission. We estimated the association of baseline BP with the score on the modified Rankin Scale at 90 days and safety parameters with ordinal and logistic regression analysis. Effect of BP on the effect of IAT was tested with multiplicative interaction terms. Systolic BP (SBP) had the best correlation with functional outcome. This correlation was U-shaped; both low and high baseline SBP were associated with poor functional outcome. Higher SBP was associated with symptomatic intracranial hemorrhage (adjusted odds ratio, 1.25 for every 10 mm Hg higher SBP [95% confidence interval, 1.09-1.44]). Between SBP and IAT, there was no interaction for functional outcome, symptomatic intracranial hemorrhage, or other safety parameters; the absolute benefit of IAT was evident for the whole SBP range. The same was found for diastolic BP. BP does not affect the benefit or safety of IAT in patients with acute ischemic stroke caused by proximal intracranial vessel occlusion. Our data provide no arguments to withhold or delay IAT based on BP. URL: http://www.isrctn.com. Unique identifier: ISRCTN10888758. © 2017 American Heart Association, Inc.

Chronic kidney disease and poor outcomes in ischemic stroke: is impaired cerebral autoregulation the missing link?

PubMed

Castro, Pedro; Azevedo, Elsa; Rocha, Isabel; Sorond, Farzaneh; Serrador, Jorge M

2018-03-02

Chronic kidney disease increases stroke incidence and severity but the mechanisms behind this cerebro-renal interaction are mostly unexplored. Since both vascular beds share similar features, microvascular dysfunction could be the possible missing link. Therefore, we examined the relationship between renal function and cerebral autoregulation in the early hours post ischemia and its impact on outcome. We enrolled 46 ischemic strokes (middle cerebral artery). Dynamic cerebral autoregulation was assessed by transfer function (coherence, phase and gain) of spontaneous blood pressure oscillations to blood flow velocity within 6 h from symptom-onset. Estimated glomerular filtration rate (eGFR) was calculated. Hemorrhagic transformation (HT) and white matter lesions (WML) were collected from computed tomography performed at presentation and 24 h. Outcome was evaluated with modified Rankin Scale at 3 months. High gain (less effective autoregulation) was correlated with lower eGFR irrespective of infarct side (p < 0.05). Both lower eGFR and higher gain correlated with WML grade (p < 0.05). Lower eGFR and increased gain, alone and in combination, progressively reduced the odds of a good functional outcome [ipsilateral OR = 4.39 (CI95% 3.15-25.6), p = 0.019; contralateral OR = 8.15 (CI95% 4.15-15.6), p = 0.002] and increased risk of HT [ipsilateral OR = 3.48 (CI95% 0.60-24.0), p = 0.132; contralateral OR = 6.43 (CI95% 1.40-32.1), p = 0.034]. Lower renal function correlates with less effective dynamic cerebral autoregulation in acute ischemic stroke, both predicting a bad outcome. The evaluation of serum biomarkers of renal dysfunction could have interest in the future for assessing cerebral microvascular risk and relationship with stroke complications.

Robot Assisted Training for the Upper Limb after Stroke (RATULS): study protocol for a randomised controlled trial.

PubMed

Rodgers, Helen; Shaw, Lisa; Bosomworth, Helen; Aird, Lydia; Alvarado, Natasha; Andole, Sreeman; Cohen, David L; Dawson, Jesse; Eyre, Janet; Finch, Tracy; Ford, Gary A; Hislop, Jennifer; Hogg, Steven; Howel, Denise; Hughes, Niall; Krebs, Hermano Igo; Price, Christopher; Rochester, Lynn; Stamp, Elaine; Ternent, Laura; Turner, Duncan; Vale, Luke; Warburton, Elizabeth; van Wijck, Frederike; Wilkes, Scott

2017-07-20

Loss of arm function is a common and distressing consequence of stroke. We describe the protocol for a pragmatic, multicentre randomised controlled trial to determine whether robot-assisted training improves upper limb function following stroke. Study design: a pragmatic, three-arm, multicentre randomised controlled trial, economic analysis and process evaluation. NHS stroke services. adults with acute or chronic first-ever stroke (1 week to 5 years post stroke) causing moderate to severe upper limb functional limitation. Randomisation groups: 1. Robot-assisted training using the InMotion robotic gym system for 45 min, three times/week for 12 weeks 2. Enhanced upper limb therapy for 45 min, three times/week for 12 weeks 3. Usual NHS care in accordance with local clinical practice Randomisation: individual participant randomisation stratified by centre, time since stroke, and severity of upper limb impairment. upper limb function measured by the Action Research Arm Test (ARAT) at 3 months post randomisation. upper limb impairment (Fugl-Meyer Test), activities of daily living (Barthel ADL Index), quality of life (Stroke Impact Scale, EQ-5D-5L), resource use, cost per quality-adjusted life year and adverse events, at 3 and 6 months. Blinding: outcomes are undertaken by blinded assessors. Economic analysis: micro-costing and economic evaluation of interventions compared to usual NHS care. A within-trial analysis, with an economic model will be used to extrapolate longer-term costs and outcomes. Process evaluation: semi-structured interviews with participants and professionals to seek their views and experiences of the rehabilitation that they have received or provided, and factors affecting the implementation of the trial. allowing for 10% attrition, 720 participants provide 80% power to detect a 15% difference in successful outcome between each of the treatment pairs. Successful outcome definition: baseline ARAT 0-7 must improve by 3 or more points; baseline ARAT 8-13 improve by 4 or more points; baseline ARAT 14-19 improve by 5 or more points; baseline ARAT 20-39 improve by 6 or more points. The results from this trial will determine whether robot-assisted training improves upper limb function post stroke. ISRCTN, identifier: ISRCTN69371850 . Registered 4 October 2013.

Inhibition of mitogen-activated protein kinase 1/2 in the acute phase of stroke improves long-term neurological outcome and promotes recovery processes in rats.

PubMed

Mostajeran, M; Edvinsson, L; Warfvinge, K; Singh, R; Ansar, S

2017-04-01

Extracellular signal-regulated kinase (ERK) 1/2 is activated during acute phase of stroke and contributes to stroke pathology. We have found that acute treatment with MEK1/2 inhibitors decreases infarct size and neurological deficits 2 days after experimental stroke. However, it is not known whether benefits of this inhibition persist long-term. Therefore, the aim of this study was to assess neurological function, infarct size and recovery processes 14 days after stroke in male rats to determine long-term outcome following acute treatment with the MEK1/2 inhibitor U0126. Transient middle cerebral artery occlusion was induced in male rats. U0126 or vehicle was given at 0 and 24 h of reperfusion. Neurological function was assessed by staircase, 6-point and 28-point neuroscore tests up to 14 days after induction of stroke. At day 14, infarct volumes were determined and recovery processes were evaluated by measuring protein expression of the tyrosine kinase receptor Tie-2 and nestin. Levels of p-ERK1/2 protein were determined. Acute treatment with U0126 significantly improved long-term functional recovery, reduced infarct size, and enhanced Tie-2 and nestin protein expression at 14 days post-stroke. There was no residual blockade of p-ERK1/2 at this time point. It is demonstrated that benefits of early treatment with U0126 persist beyond subacute phase of ischaemic stroke in male rats. Prevention of ERK1/2 activation in the acute phase results in improved long-term functional outcome and enhances later-stage recovery processes. These results expand our understanding of the benefits and promise of using MEK1/2 inhibitors in stroke recovery. © 2015 Scandinavian Physiological Society. Published by John Wiley & Sons Ltd.

Effects of action observation therapy and mirror therapy after stroke on rehabilitation outcomes and neural mechanisms by MEG: study protocol for a randomized controlled trial.

PubMed

Shih, Tsai-Yu; Wu, Ching-Yi; Lin, Keh-Chung; Cheng, Chia-Hsiung; Hsieh, Yu-Wei; Chen, Chia-Ling; Lai, Chih-Jou; Chen, Chih-Chi

2017-10-04

Loss of upper-extremity motor function is one of the most debilitating deficits following stroke. Two promising treatment approaches, action observation therapy (AOT) and mirror therapy (MT), aim to enhance motor learning and promote neural reorganization in patients through different afferent inputs and patterns of visual feedback. Both approaches involve different patterns of motor observation, imitation, and execution but share some similar neural bases of the mirror neuron system. AOT and MT used in stroke rehabilitation may confer differential benefits and neural activities that remain to be determined. This clinical trial aims to investigate and compare treatment effects and neural activity changes of AOT and MT with those of the control intervention in patients with subacute stroke. An estimated total of 90 patients with subacute stroke will be recruited for this study. All participants will be randomly assigned to receive AOT, MT, or control intervention for a 3-week training period (15 sessions). Outcome measurements will be taken at baseline, immediately after treatment, and at the 3-month follow-up. For the magnetoencephalography (MEG) study, we anticipate that we will recruit 12 to 15 patients per group. The primary outcome will be the Fugl-Meyer Assessment score. Secondary outcomes will include the modified Rankin Scale, the Box and Block Test, the ABILHAND questionnaire, the Questionnaire Upon Mental Imagery, the Functional Independence Measure, activity monitors, the Stroke Impact Scale version 3.0, and MEG signals. This clinical trial will provide scientific evidence of treatment effects on motor, functional outcomes, and neural activity mechanisms after AOT and MT in patients with subacute stroke. Further application and use of AOT and MT may include telerehabilitation or home-based rehabilitation through web-based or video teaching. ClinicalTrials.gov, ID: NCT02871700 . Registered on 1 August 2016.

Long-term outcome after arterial ischemic stroke in children and young adults.

PubMed

Goeggel Simonetti, Barbara; Cavelti, Ariane; Arnold, Marcel; Bigi, Sandra; Regényi, Mária; Mattle, Heinrich P; Gralla, Jan; Fluss, Joel; Weber, Peter; Hackenberg, Annette; Steinlin, Maja; Fischer, Urs

2015-05-12

To compare long-term outcome of children and young adults with arterial ischemic stroke (AIS) from 2 large registries. Prospective cohort study comparing functional and psychosocial long-term outcome (≥2 years after AIS) in patients who had AIS during childhood (1 month-16 years) or young adulthood (16.1-45 years) between January 2000 and December 2008, who consented to follow-up. Data of children were collected prospectively in the Swiss Neuropediatric Stroke Registry, young adults in the Bernese stroke database. Follow-up information was available in 95/116 children and 154/187 young adults. Median follow-up of survivors was 6.9 years (interquartile range 4.7-9.4) and did not differ between the groups (p = 0.122). Long-term functional outcome was similar (p = 0.896): 53 (56%) children and 84 (55%) young adults had a favorable outcome (modified Rankin Scale 0-1). Mortality in children was 14% (13/95) and in young adults 7% (11/154) (p = 0.121) and recurrence rate did not differ (p = 0.759). Overall psychosocial impairment and quality of life did not differ, except for more behavioral problems among children (13% vs 5%, p = 0.040) and more frequent reports of an impact of AIS on everyday life among adults (27% vs 64%, p < 0.001). In a multivariate regression analysis, low Pediatric NIH Stroke Scale/NIH Stroke Scale score was the most important predictor of favorable outcome (p < 0.001). There were no major differences in long-term outcome after AIS in children and young adults for mortality, disability, quality of life, psychological, or social variables. © 2015 American Academy of Neurology.

Efficacy and Safety of Apixaban Compared With Warfarin in Patients With Atrial Fibrillation in Relation to Renal Function Over Time: Insights From the ARISTOTLE Randomized Clinical Trial.

PubMed

Hijazi, Ziad; Hohnloser, Stefan H; Andersson, Ulrika; Alexander, John H; Hanna, Michael; Keltai, Matyas; Parkhomenko, Alexander; López-Sendón, José L; Lopes, Renato D; Siegbahn, Agneta; Granger, Christopher B; Wallentin, Lars

2016-07-01

Renal impairment confers an increased risk of stroke, bleeding, and death in patients with atrial fibrillation. Little is known about the efficacy and safety of apixaban in relation to renal function changes over time. To evaluate changes of renal function over time and their interactions with outcomes during a median of 1.8 years of follow-up in patients with atrial fibrillation randomized to apixaban vs warfarin treatment. The prospective, randomized, double-blind Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) clinical trial randomized 18 201 patients with atrial fibrillation to apixaban or warfarin. Serial creatinine measurements were available in 16 869 patients. Worsening of renal function was defined as an annual decrease in estimated glomerular filtration more than 20%. The relations between treatment, outcomes, and renal function were investigated using Cox regression models, with renal function as a time-dependent covariate. Stroke or systemic embolism (primary outcome), major bleeding (safety outcome), and mortality were examined in relation to renal function over time estimated with both the Cockcroft-Gault and Chronic Kidney Disease Epidemiology Collaboration equations. Among 16 869 patients, the median age was 70 years and 65.2% of patients were men. Worsening in estimated glomerular filtration more than 20% was observed in 2294 patients (13.6%) and was associated with older age and more cardiovascular comorbidities. The risks of stroke or systemic embolism, major bleeding, and mortality were higher in patients with worsening renal function (HR, 1.53; 95% CI, 1.17-2.01 for stroke or systemic embolism; HR, 1.56; 95% CI, 1.27-1.93 for major bleeding; and HR, 2.31; 95% CI, 1.98-2.68 for mortality). The beneficial effects of apixaban vs warfarin on rates of stroke or systemic embolism and major bleeding were consistent in patients with normal or poor renal function over time and also in those with worsening renal function. In patients with atrial fibrillation, declining renal function was more common in elderly patients and those with cardiovascular comorbidities. Worsening renal function was associated with a higher risk of subsequent cardiovascular events and bleeding. The superior efficacy and safety of apixaban as compared with warfarin were similar in patients with normal, poor, and worsening renal function. clinicaltrials.gov Identifier: NCT00412984.

Atorvastatin treatment is associated with increased BDNF level and improved functional recovery after atherothrombotic stroke.

PubMed

Zhang, Jingmiao; Mu, Xiali; Breker, Dane A; Li, Ying; Gao, Zongliang; Huang, Yonglu

2017-01-01

Statins have a positive impact on ischemic stroke outcome. It has been reported that statin have neuroprotective function after ischemic stroke in addition to lipid-lowering effect in animal model. However, the neuroprotective function of statin after stroke has not been confirmed in clinical studies. The aim of this study was to evaluate in a clinical model if statins induce neuroprotection after stroke. We, therefore, assessed serum brain-derived neurotrophic factor (BDNF) levels and functional recovery in atherothrombotic stroke patients and investigated their relationship with atorvastatin treatment. Seventy-eight patients with atherothrombotic stroke were enrolled and randomly assigned to atorvastatin treatment group or placebo control group. Neurological function after stroke was assessed with the National Institutes of Health Stroke Scale, modified Rankin Scale (mRS) and Barthel Index (BI). The serum BDNF levels were both measured at 1 day and 6 weeks after stroke. Linear regression was used to assess the association between BDNF levels and neurological function scores. The mRS and BI were markedly improved in the atorvastatin group when compared to placebo at 6 weeks after stroke. The serum BDNF levels in atorvastatin group were significantly elevated by 6 weeks after stroke and higher than the BDNF levels in controls. In addition, the serum BDNF levels significantly correlated with mRS and BI after stroke. Our results demonstrated that atorvastatin treatment was associated with the increased BDNF level and improved functional recovery after atherothrombotic stroke. This study indicates that atorvastatin-related elevation in the BDNF level may promote functional recovery in stroke patients.

Ten problems and solutions when predicting individual outcome from lesion site after stroke.

PubMed

Price, Cathy J; Hope, Thomas M; Seghier, Mohamed L

2017-01-15

In this paper, we consider solutions to ten of the challenges faced when trying to predict an individual's functional outcome after stroke on the basis of lesion site. A primary goal is to find lesion-outcome associations that are consistently observed in large populations of stroke patients because consistent associations maximise confidence in future individualised predictions. To understand and control multiple sources of inter-patient variability, we need to systematically investigate each contributing factor and how each factor depends on other factors. This requires very large cohorts of patients, who differ from one another in typical and measurable ways, including lesion site, lesion size, functional outcome and time post stroke (weeks to decades). These multivariate investigations are complex, particularly when the contributions of different variables interact with one another. Machine learning algorithms can help to identify the most influential variables and indicate dependencies between different factors. Multivariate lesion analyses are needed to understand how the effect of damage to one brain region depends on damage or preservation in other brain regions. Such data-led investigations can reveal predictive relationships between lesion site and outcome. However, to understand and improve the predictions we need explanatory models of the neural networks and degenerate pathways that support functions of interest. This will entail integrating the results of lesion analyses with those from functional imaging (fMRI, MEG), transcranial magnetic stimulation (TMS) and diffusor tensor imaging (DTI) studies of healthy participants and patients. Copyright © 2016 Elsevier Inc. All rights reserved.

Ten problems and solutions when predicting individual outcome from lesion site after stroke

PubMed Central

Price, Cathy J.; Hope, Thomas M.; Seghier, Mohamed L.

2016-01-01

In this paper, we consider solutions to ten of the challenges faced when trying to predict an individual’s functional outcome after stroke on the basis of lesion site. A primary goal is to find lesion-outcome associations that are consistently observed in large populations of stroke patients because consistent associations maximise confidence in future individualised predictions. To understand and control multiple sources of inter-patient variability, we need to systematically investigate each contributing factor and how each factor depends on other factors. This requires very large cohorts of patients, who differ from one another in typical and measurable ways, including lesion site, lesion size, functional outcome and time post stroke (weeks to decades). These multivariate investigations are complex, particularly when the contributions of different variables interact with one another. Machine learning algorithms can help to identify the most influential variables and indicate dependencies between different factors. Multivariate lesion analyses are needed to understand how the effect of damage to one brain region depends on damage or preservation in other brain regions. Such data-led investigations can reveal predictive relationships between lesion site and outcome. However, to understand and improve predictions we need explanatory models of the neural networks and degenerate pathways that support functions of interest. This will entail integrating the results of lesion analyses with those from functional imaging (fMRI, MEG), transcranial magnetic stimulation (TMS) and diffusor tensor imaging (DTI) studies of healthy participants and patients. PMID:27502048

Does the use of Nintendo Wii Sports™ improve arm function and is it acceptable to patients after stroke? Publication of the Protocol of the Trial of Wii™ in Stroke - TWIST.

PubMed

Adie, Katja; Schofield, Christine; Berrow, Margie; Wingham, Jennifer; Freeman, Janet; Humfryes, John; Pritchard, Colin

2014-01-01

Many stroke patients experience loss of arm function requiring rehabilitation, which is expensive, repetitive, and does not always translate into "real life." Nintendo Wii Sports™ (Wii™) may offer task-specific training that is repetitive and motivating. The Trial of Wii™ in Stroke (TWIST) is designed to investigate feasibility, efficacy, and acceptability using Wii™ to improve affected arm function for patients after stroke. This is a randomized controlled trial (RCT), incorporating a qualitative study and health economics analysis that compares playing Wii™ versus arm exercises in patients receiving standard rehabilitation in a home setting within 6 months of stroke with a motor deficit of less than 5 on the MRC (Medical Research Council) scale (arm). In this study, we expect to randomize 240 participants. Primary outcome is change in affected arm function at 6 weeks follow-up in intervention and control group using the Action Research Arm Test. Secondary outcomes include occupational performance using the Canadian Occupational Performance Measure, quality of life using the Stroke Impact Scale, cost effectiveness analysis, and a qualitative study investigating factors that influence use of Wii™ for patients and carers. TWIST is the first UK RCT assessing the feasibility, cost effectiveness, and acceptability of Wii™ in stroke rehabilitation. The trial has been registered with ISRCTN 06807619 and UK CRN 11030. Results of the study will be published after completion of study in August 2014.

Factors Associated With Ischemic Stroke Survival and Recovery in Older Adults.

PubMed

Winovich, Divya Thekkethala; Longstreth, William T; Arnold, Alice M; Varadhan, Ravi; Zeki Al Hazzouri, Adina; Cushman, Mary; Newman, Anne B; Odden, Michelle C

2017-07-01

Little is known about factors that predispose older adults to poor recovery after a stroke. In this study, we sought to evaluate prestroke measures of frailty and related factors as markers of vulnerability to poor outcomes after ischemic stroke. In participants aged 65 to 99 years with incident ischemic strokes from the Cardiovascular Health Study, we evaluated the association of several risk factors (frailty, frailty components, C-reactive protein, interleukin-6, and cystatin C) assessed before stroke with stroke outcomes of survival, cognitive decline (≥5 points on Modified Mini-Mental State Examination), and activities of daily living decline (increase in limitations). Among 717 participants with incident ischemic stroke with survival data, slow walking speed, low grip strength, and cystatin C were independently associated with shorter survival. Among participants <80 years of age, frailty and interleukin-6 were also associated with shorter survival. Among 509 participants with recovery data, slow walking speed, and low grip strength were associated with both cognitive and activities of daily living decline poststroke. C-reactive protein and interleukin-6 were associated with poststroke cognitive decline among men only. Frailty status was associated with activities of daily living decline among women only. Markers of physical function-walking speed and grip strength-were consistently associated with survival and recovery after ischemic stroke. Inflammation, kidney function, and frailty also seemed to be determinants of survival and recovery after an ischemic stroke. These markers of vulnerability may identify targets for differing pre and poststroke medical management and rehabilitation among older adults at risk of poor stroke outcomes. © 2017 American Heart Association, Inc.

Kinesthetic taping improves walking function in patients with stroke: a pilot cohort study.

PubMed

Boeskov, Birgitte; Carver, Line Tornehøj; von Essen-Leise, Anders; Henriksen, Marius

2014-01-01

Stroke is an important cause of severe disability and impaired motor function. Treatment modalities that improve motor function in patients with stroke are needed. The objective of this study was to investigate the effect of kinesthetic taping of the anterior thigh and knee on maximal walking speed and clinical indices of spasticity in patients with stroke. Thirty-two patients (9 women) receiving rehabilitation after stroke (average, 50 days since stroke) who had impaired walking ability were recruited. Primary outcome was maximal walking speed measured by the 10-meter walk test. Secondary outcomes were number of steps taken during the test and clinical signs of spasticity measured by the Tardieu Scale. Tests were conducted before and immediately after application of kinesthetic tape to the anterior thigh and knee of the paretic lower limb. After application of the tape, the maximal walking speed increased, on average, by 0.08 m/s (95% CI, 0.04 to 0.12; P < .0001). The number of steps taken during the test was significantly decreased by 1.4 steps (95% CI, -2.3 to -0.5; P < .0031). The Tardieu scores were not significantly changed by the tape intervention, although a trend was observed indicating a lesser degree of spasticity. The results of this study indicate that kinesthetic taping of the anterior thigh and knee provides an immediate improvement in walking function in patients with stroke. Such a positive effect on motor function could be a valuable adjunct in physical therapy and rehabilitation of patients with 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.

Association Between CYP2C19 Loss-of-Function Allele Status and Efficacy of Clopidogrel for Risk Reduction Among Patients With Minor Stroke or Transient Ischemic Attack.

PubMed

Wang, Yilong; Zhao, Xingquan; Lin, Jinxi; Li, Hao; Johnston, S Claiborne; Lin, Yi; Pan, Yuesong; Liu, Liping; Wang, David; Wang, Chunxue; Meng, Xia; Xu, Jianfeng; Wang, Yongjun

2016-07-05

Data are limited regarding the association between CYP2C19 genetic variants and clinical outcomes of patients with minor stroke or transient ischemic attack treated with clopidogrel. To estimate the association between CYP2C19 genetic variants and clinical outcomes of clopidogrel-treated patients with minor stroke or transient ischemic attack. Three CYP2C19 major alleles (*2, *3, *17) were genotyped among 2933 Chinese patients from 73 sites who were enrolled in the Clopidogrel in High-Risk Patients with Acute Nondisabling Cerebrovascular Events (CHANCE) randomized trial conducted from January 2, 2010, to March 20, 2012. Patients with acute minor ischemic stroke or transient ischemic attack in the trial were randomized to treatment with clopidogrel combined with aspirin or to aspirin alone. The primary efficacy outcome was new stroke. The secondary efficacy outcome was a composite of new composite vascular events (ischemic stroke, hemorrhagic stroke, myocardial infarction, or vascular death). Bleeding was the safety outcome. Among 2933 patients, 1948 (66.4%) were men, with a mean age of 62.4 years. Overall, 1207 patients (41.2%) were noncarriers and 1726 patients (58.8%) were carriers of loss-of-function alleles (*2, *3). After day 90 follow-up, clopidogrel-aspirin reduced the rate of new stroke in the noncarriers but not in the carriers of the loss-of-function alleles (P = .02 for interaction; events among noncarriers, 41 [6.7%] with clopidogrel-aspirin vs 74 [12.4%] with aspirin; hazard ratio [HR], 0.51 [95% CI, 0.35-0.75]; events among carriers, 80 [9.4%] with clopidogrel-aspirin vs 94 [10.8%] with aspirin; HR, 0.93 [95% CI, 0.69 to 1.26]). Similar results were observed for the secondary composite efficacy outcome (noncarriers: 41 [6.7%] with clopidogrel-aspirin vs 75 [12.5%] with aspirin; HR, 0.50 [95% CI, 0.34-0.74]; carriers: 80 [9.4%] with clopidogrel-aspirin vs 95 [10.9%] with aspirin; HR, 0.92 [95% CI, 0.68-1.24]; P = .02 for interaction). The effect of treatment assignment on bleeding did not vary significantly between the carriers and the noncarriers of the loss-of-function alleles (2.3% for carriers and 2.5% for noncarriers in the clopidogrel-aspirin group vs 1.4% for carriers and 1.7% for noncarriers in the aspirin only group; P = .78 for interaction). Among patients with minor ischemic stroke or transient ischemic attack, the use of clopidogrel plus aspirin compared with aspirin alone reduced the risk of a new stroke only in the subgroup of patients who were not carriers of the CYP2C19 loss-of-function alleles. These findings support a role of CYP2C19 genotype in the efficacy of this treatment. clinicaltrials.gov Identifier: NCT00979589.

The effects of very early mirror therapy on functional improvement of the upper extremity in acute stroke patients.

PubMed

Yeldan, Ipek; Huseyınsınoglu, Burcu Ersoz; Akıncı, Buket; Tarakcı, Ela; Baybas, Sevim; Ozdıncler, Arzu Razak

2015-11-01

[Purpose] The aim of the study was to evaluate the effects of a very early mirror therapy program on functional improvement of the upper extremity in acute stroke patients. [Subjects] Eight stroke patients who were treated in an acute neurology unit were included in the study. [Methods] The patients were assigned alternatively to either the mirror therapy group receiving mirror therapy and neurodevelopmental treatment or the neurodevelopmental treatment only group. The primary outcome measures were the upper extremity motor subscale of the Fugl-Meyer Assessment, Motricity Index upper extremity score, and the Stroke Upper Limb Capacity Scale. Somatosensory assessment with the Ayres Southern California Sensory Integration Test, and the Barthel Index were used as secondary outcome measures. [Results] No statistically significant improvements were found for any measures in either group after the treatment. In terms of minimally clinically important differences, there were improvements in Fugl-Meyer Assessment and Barthel Index in both mirror therapy and neurodevelopmental treatment groups. [Conclusion] The results of this pilot study revealed that very early mirror therapy has no additional effect on functional improvement of upper extremity function in acute stroke patients. Multicenter trials are needed to determine the results of early application of mirror therapy in stroke rehabilitation.

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

Social isolation after stroke leads to depressive-like behavior and decreased BDNF levels in mice.

PubMed

O'Keefe, Lena M; Doran, Sarah J; Mwilambwe-Tshilobo, Laetitia; Conti, Lisa H; Venna, Venugopal R; McCullough, Louise D

2014-03-01

Social isolation prior to stroke leads to poorer outcomes after an ischemic injury in both animal and human studies. However, the impact of social isolation following stroke, which may be more clinically relevant as a target for therapeutic intervention, has yet to be examined. In this study, we investigated both the sub-acute (2 weeks) and chronic (7 weeks) effects of social isolation on post-stroke functional and histological outcome. Worsened histological damage from ischemic injury and an increase in depressive-like behavior was observed in isolated mice as compared to pair-housed mice. Mice isolated immediately after stroke showed a decrease in the levels of brain-derived neurotrophic factor (BDNF). These changes, both histological and behavioral, suggest an overall negative effect of social isolation on stroke outcome, potentially contributing to post-stroke depression and anxiety. Therefore, it is important to identify patients who have perceived isolation post-stroke to hopefully prevent this exacerbation of histological damage and subsequent depression. Copyright © 2013 Elsevier B.V. All rights reserved.

Endovascular Therapy is Effective and Safe for Patients with Severe Ischemic Stroke: Pooled Analysis of IMS III and MR CLEAN Data

PubMed Central

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

2015-01-01

Background and Purpose We assessed the effect of endovascular treatment in acute ischemic stroke patients with severe neurological deficit (NIHSS ≥20) following a pre-specified analysis plan. Methods The pooled analysis of the IMS III and MR CLEAN trial included participants with an NIHSS ≥20 prior to intravenous (IV) t-PA treatment (IMS III) or randomization (MR CLEAN) who were treated with IV t-PA ≤ 3 hours of stroke onset. Our hypothesis was that participants with severe stroke randomized to endovascular therapy following IV t-PA would have improved 90-day outcome (distribution of modified Rankin scale [mRS] scores), as compared to those who received IV t-PA alone. Results Among 342 participants in the pooled analysis (194 from IMS III, 148 from MR CLEAN), an ordinal logistic regression model showed that the endovascular group had superior 90-day outcome compared to the IV t-PA group (adjusted odds ratio [aOR] 1.78; 95% confidence interval [CI] 1.20-2.66). In the logistic regression model of the dichotomous outcome (mRS 0-2, or ‘functional independence’), the endovascular group had superior outcomes (aOR 1.97; 95% CI 1.09-3.56). Functional independence (mRS ≤2) at 90 days was 25% in the endovascular group as compared to 14% in the IV t-PA group. Conclusions Endovascular therapy following IV t-PA within 3 hours of symptom onset improves functional outcome at 90 days after severe ischemic stroke. PMID:26486865

Rehabilitation Outcomes: Ischemic versus Hemorrhagic Strokes

PubMed Central

Perna, Robert; Temple, Jessica

2015-01-01

Background. Ischemic and hemorrhagic strokes have different pathophysiologies and possibly different long-term cerebral and functional implications. Hemorrhagic strokes expose the brain to irritating effects of blood and ischemic strokes reflect localized or diffuse cerebral vascular pathology. Methods. Participants were individuals who suffered either an ischemic (n = 172) or hemorrhagic stroke (n = 112) within the past six months and were involved in a postacute neurorehabilitation program. Participants completed three months of postacute neurorehabilitation and the Mayo Portland Adaptability Inventory-4 (MPAI-4) at admission and discharge. Admission MPAI-4 scores and level of functioning were comparable. Results. Group ANOVA comparisons show no significant group differences at admission or discharge or difference in change scores. Both groups showed considerably reduced levels of productivity/employment after discharge as compared to preinjury levels. Conclusions. Though the pathophysiology of these types of strokes is different, both ultimately result in ischemic injuries, possibly accounting for lack of findings of differences between groups. In the present study, participants in both groups experienced similar functional levels across all three MPAI-4 domains both at admission and discharge. Limitations of this study include a highly educated sample and few outcome measures. PMID:26246694

Microbiota Dysbiosis Controls the Neuroinflammatory Response after Stroke.

PubMed

Singh, Vikramjeet; Roth, Stefan; Llovera, Gemma; Sadler, Rebecca; Garzetti, Debora; Stecher, Bärbel; Dichgans, Martin; Liesz, Arthur

2016-07-13

Acute brain ischemia induces a local neuroinflammatory reaction and alters peripheral immune homeostasis at the same time. Recent evidence has suggested a key role of the gut microbiota in autoimmune diseases by modulating immune homeostasis. Therefore, we investigated the mechanistic link among acute brain ischemia, microbiota alterations, and the immune response after brain injury. Using two distinct models of acute middle cerebral artery occlusion, we show by next-generation sequencing that large stroke lesions cause gut microbiota dysbiosis, which in turn affects stroke outcome via immune-mediated mechanisms. Reduced species diversity and bacterial overgrowth of bacteroidetes were identified as hallmarks of poststroke dysbiosis, which was associated with intestinal barrier dysfunction and reduced intestinal motility as determined by in vivo intestinal bolus tracking. Recolonizing germ-free mice with dysbiotic poststroke microbiota exacerbates lesion volume and functional deficits after experimental stroke compared with the recolonization with a normal control microbiota. In addition, recolonization of mice with a dysbiotic microbiome induces a proinflammatory T-cell polarization in the intestinal immune compartment and in the ischemic brain. Using in vivo cell-tracking studies, we demonstrate the migration of intestinal lymphocytes to the ischemic brain. Therapeutic transplantation of fecal microbiota normalizes brain lesion-induced dysbiosis and improves stroke outcome. These results support a novel mechanism in which the gut microbiome is a target of stroke-induced systemic alterations and an effector with substantial impact on stroke outcome. We have identified a bidirectional communication along the brain-gut microbiota-immune axis and show that the gut microbiota is a central regulator of immune homeostasis. Acute brain lesions induced dysbiosis of the microbiome and, in turn, changes in the gut microbiota affected neuroinflammatory and functional outcome after brain injury. The microbiota impact on immunity and stroke outcome was transmissible by microbiota transplantation. Our findings support an emerging concept in which the gut microbiota is a key regulator in priming the neuroinflammatory response to brain injury. These findings highlight the key role of microbiota as a potential therapeutic target to protect brain function after injury. Copyright © 2016 the authors 0270-6474/16/367428-13$15.00/0.

What is the best imaging strategy for acute stroke?

PubMed

Wardlaw, J M; Keir, S L; Seymour, J; Lewis, S; Sandercock, P A G; Dennis, M S; Cairns, J

2004-01-01

To determine the cost-effectiveness of computed tomographic (CT) scanning after acute stroke. To assess the contribution of brain imaging to the diagnosis and management of stroke, and to estimate the costs, benefits and risks of different imaging strategies in order to provide data to inform national and local policy on the use of brain imaging in stroke. A decision-analysis model was developed to represent the pathway of care in acute stroke using 'scan all patients within 48 hours' as the comparator against which to cost 12 alternative scan strategies. Hospitals in Scotland. Subjects were patients admitted to hospital with a first stroke and those managed as outpatients. The effect on functional outcome after ischaemic or haemorrhagic stroke, tumours or infections, of correctly administered antithrombotic or other treatment; of time to scan and stroke severity on diagnosis by CT or MRI; on management, including length of stay, functional outcome, and quality-adjusted life years (QALYs), of the diagnostic information provided by CT scanning; the cost-effectiveness (cost versus QALYs) of different strategies for use of CT after acute stroke. Death and functional outcome at long-term follow-up; accuracy of CT and MRI; cost of CT scanning by time of day and week; effect of CT diagnosis on change in health outcome, length of stay in hospital and QALYs; cost-effectiveness of various scanning strategies. CT is very sensitive and specific for haemorrhage within the first 8 days of stroke only. Suboptimal scanning used in epidemiology studies suggests that the frequency of primary intracerebral haemorrhage (PICH) has been underestimated. Aspirin increases the risk of PICH. There were no reliable data on functional outcome or on the effect of antithrombotic treatment given long term after PICH. In 60% of patients with recurrent stroke after PICH, the cause is another PICH and mortality is high among PICH patients. A specific MR sequence (gradient echo) is required to identify prior PICH reliably. CT scanners were distributed unevenly in Scotland, 65% provided CT scanning within 48 hours of stroke, and 100% within 7 days for hospital-admitted patients, but access out of hours was very variable, and for outpatients was poor. The average cost of a CT brain scan for stroke was pounds 30.23 to pounds 89.56 in normal working hours and pounds 55.05 to pounds 173.46 out of hours. Average length of stay was greatest for severe strokes and those who survived in a dependent state. For a cohort of 1000 patients aged 70-74 years, the policy 'scan all strokes within 48 hours', cost pounds 10,279,728 and achieved 1982.3 QALYS. The most cost-effective strategy was 'scan all immediately' (pounds 9,993,676 and 1982.4 QALYS). The least cost-effective was to 'scan patients on anticoagulants, in a life-threatening condition immediately and the rest within 14 days'. In general, strategies in which most patients were scanned immediately cost least and achieved the most QALYs, as the cost of providing CT (even out of hours) was less than the cost of inpatient care. Increasing independent survival by even a small proportion through early use of aspirin in the majority with ischaemic stroke, avoiding aspirin in those with haemorrhagic stroke, and appropriate early management of those who have not had a stroke, reduced costs and increased QALYs.

Effect of Treatment Delay, Stroke Type, and Thrombolysis on the Effect of Glyceryl Trinitrate, a Nitric Oxide Donor, on Outcome after Acute Stroke: A Systematic Review and Meta-Analysis of Individual Patient from Randomised Trials.

PubMed

Bath, Philip M; Woodhouse, Lisa; Krishnan, Kailash; Anderson, Craig; Berge, Eivind; Ford, Gary A; Robinson, Thompson G; Saver, Jeffrey L; Sprigg, Nikola; Wardlaw, Joanna M; In Acute Stroke Collaboration Basc, Blood Pressure

2016-01-01

Background. Nitric oxide (NO) donors are a candidate treatment for acute stroke and two trials have suggested that they might improve outcome if administered within 4-6 hours of stroke onset. We assessed the safety and efficacy of NO donors using individual patient data (IPD) from completed trials. Methods. Randomised controlled trials of NO donors in patients with acute or subacute stroke were identified and IPD sought from the trialists. The effect of NO donor versus control on functional outcome was assessed using the modified Rankin scale (mRS) and death, by time to randomisation. Secondary outcomes included measures of disability, mood, and quality of life. Results. Five trials (4,197 participants) were identified, all involving glyceryl trinitrate (GTN). Compared with control, GTN lowered blood pressure by 7.4/3.3 mmHg. At day 90, GTN did not alter any clinical measures. However, in 312 patients randomised within 6 hours of stroke onset, GTN was associated with beneficial shifts in the mRS (odds ratio (OR) 0.52, 95% confidence interval (CI) 0.34-0.78) and reduced death (OR 0.32, 95% CI 0.14-0.78). Conclusions. NO donors do not alter outcome in patients with recent stroke. However, when administered within 6 hours, NO donors might improve outcomes in both ischaemic and haemorrhagic stroke.

Development and validation of clinical prediction models for mortality, functional outcome and cognitive impairment after stroke: a study protocol

PubMed Central

Fahey, Marion; Rudd, Anthony; Béjot, Yannick; Wolfe, Charles; Douiri, Abdel

2017-01-01

Introduction Stroke is a leading cause of adult disability and death worldwide. The neurological impairments associated with stroke prevent patients from performing basic daily activities and have enormous impact on families and caregivers. Practical and accurate tools to assist in predicting outcome after stroke at patient level can provide significant aid for patient management. Furthermore, prediction models of this kind can be useful for clinical research, health economics, policymaking and clinical decision support. Methods 2869 patients with first-ever stroke from South London Stroke Register (SLSR) (1995–2004) will be included in the development cohort. We will use information captured after baseline to construct multilevel models and a Cox proportional hazard model to predict cognitive impairment, functional outcome and mortality up to 5 years after stroke. Repeated random subsampling validation (Monte Carlo cross-validation) will be evaluated in model development. Data from participants recruited to the stroke register (2005–2014) will be used for temporal validation of the models. Data from participants recruited to the Dijon Stroke Register (1985–2015) will be used for external validation. Discrimination, calibration and clinical utility of the models will be presented. Ethics Patients, or for patients who cannot consent their relatives, gave written informed consent to participate in stroke-related studies within the SLSR. The SLSR design was approved by the ethics committees of Guy’s and St Thomas’ NHS Foundation Trust, Kings College Hospital, Queens Square and Westminster Hospitals (London). The Dijon Stroke Registry was approved by the Comité National des Registres and the InVS and has authorisation of the Commission Nationale de l’Informatique et des Libertés. PMID:28821511

Reciprocal Interaction of 24-Hour Blood Pressure Variability and Systolic Blood Pressure on Outcome in Stroke Thrombolysis.

PubMed

Kellert, Lars; Hametner, Christian; Ahmed, Niaz; Rauch, Geraldine; MacLeod, Mary J; Perini, Francesco; Lees, Kennedy R; Ringleb, Peter A

2017-07-01

Significance and management of blood pressure (BP) changes in acute stroke care are unclear. Here, we aimed to investigate the impact of 24-hour BP variability (BPV) on outcome in patients with acute ischemic stroke treated with intravenous thrombolysis. From the Safe Implementation of Treatment in Stroke International Stroke Thrombolysis registry, 28 976 patients with documented pre-treatment systolic BP at 2 and 24 hours were analyzed. The primary measure of BP variability was successive variability. Data were preprocessed using coarsened exact matching. We assessed early neurological improvement, symptomatic intracerebral hemorrhage (SICH), and long-term functional outcome (modified Rankin Scale [mRS] at 90 days) by binary and ordinal regression analyses. Attempts to explain successive variation for analysis of BPV with patients characteristics at admission found systolic BP (5.5% variance) to be most influential, yet 92% of BPV variance remained unexplained. Independently from systolic BP, successive variation for analysis of BPV was associated with poor functional outcome mRS score of 0 to 2 (odds ratio [OR], 0.94; 95% confidence interval [CI], 0.90-0.98), disadvantage across the shift of mRS (OR, 1.04; 95% CI, 1.01-1.08), mortality (OR, 1.10; 95% CI, 1.01-1.08), SICH SITS (OR, 1.14; 95% CI, 1.06-1.23), and SICH ECASS (OR, 1.24; 95% CI, 1.10-1.40; ECASS [European Cooperative Acute Stroke Study 2]). Analyzing successive variation for analysis of BPV as a function of pre-treatment, systolic BP significantly improved the prediction of functional outcome (mRS score of 0-1, mRS score of 0-2, neurological improvement, mRS-shift: all P interaction <0.01). Excluding patients with atrial fibrillation in a sensitivity analysis gave consistent results overall. This study suggests the need for a more individual BP management accounting for pre-treatment BP and the acute BP course (ie, BPV) to achieve best possible outcome for the patient. © 2017 American Heart Association, Inc.

Incidence and outcome of subtypes of ischaemic stroke: initial results from the north East melbourne stroke incidence study (NEMESIS).

PubMed

Dewey, Helen M; Sturm, Jonathan; Donnan, Geoffrey A; Macdonell, Richard A L; McNeil, John J; Thrift, Amanda G

2003-01-01

Information about the incidence and outcome of stroke subtypes is necessary to understand the likely impact of stroke prevention and treatment strategies. The purpose of this study was to determine the incidence and outcome of subtypes of cerebral infarction (CI). All strokes occurring in a population of 133816 in Melbourne, Australia, during a 12-month period of 1996 and 1997 were identified and cases of CI subtyped according to the Oxfordshire Community Stroke Project classification. 276 'first-ever-in-a-lifetime' stroke cases were registered. CI accounted for 72% of cases. Annual incidence rates per 100000 persons adjusted to the 'world' population were 11 (95% CI, 4-18) for TACI, 25 (95% CI, 15-35) for PACI, 17 (95% CI, 9-25) for POCI and 18 (95% CI, 10-26) for LACI. 28-day case fatality was highest for TACI (35%; 95% CI, 19-51%) and first year recurrence rate highest for PACI (17%; 95% CI, 8-26%). TACI had the poorest functional outcome at 3 and 12 months. These findings are similar to those of two previous studies conducted in the northern hemisphere. Copyright 2003 S. Karger AG, Basel

Development, reliability, and validity of the Alberta Perinatal Stroke Project Parental Outcome Measure.

PubMed

Bemister, Taryn B; Brooks, Brian L; Kirton, Adam

2014-07-01

Perinatal stroke is a leading cause of cerebral palsy and lifelong disability, although parent and family outcomes have not yet been studied in this specific population. The Alberta Perinatal Stroke Project Parental Outcome Measure was developed as a 26-item questionnaire on the impact of perinatal stroke on parents and families. The items were derived from expert opinion and scientific literature on issues salient to parents of children with perinatal stroke, including guilt and blame, which are not well captured in existing measures of family impact. Data were collected from 82 mothers and 28 fathers who completed the Parental Outcome Measure and related questionnaires (mean age, 39.5 years; mean child age, 7.4 years). Analyses examined the Parental Outcome Measure's internal consistency, test-retest reliability, validity, and factor structure. The Parental Outcome Measure demonstrated three unique theoretical constructs: Psychosocial Impact, Guilt, and Blame. The Parental Outcome Measure has excellent internal consistency (Cronbach α = 0.91) and very good test-retest reliability more than 2-5 weeks (r = 0.87). Regarding validity, the Parental Outcome Measure is sensitive to condition severity, accounts for additional variance in parent outcomes, and strongly correlates with measures of anxiety, depression, stress, quality of life, family functioning, and parent adjustment. The Parental Outcome Measure contributes to the literature as the first brief measure of family impact designed for parents of children with perinatal stroke. Copyright © 2014 Elsevier Inc. All rights reserved.

The sensory side of post-stroke motor rehabilitation.

PubMed

Bolognini, Nadia; Russo, Cristina; Edwards, Dylan J

2016-04-11

Contemporary strategies to promote motor recovery following stroke focus on repetitive voluntary movements. Although successful movement relies on efficient sensorimotor integration, functional outcomes often bias motor therapy toward motor-related impairments such as weakness, spasticity and synergies; sensory therapy and reintegration is implied, but seldom targeted. However, the planning and execution of voluntary movement requires that the brain extracts sensory information regarding body position and predicts future positions, by integrating a variety of sensory inputs with ongoing and planned motor activity. Neurological patients who have lost one or more of their senses may show profoundly affected motor functions, even if muscle strength remains unaffected. Following stroke, motor recovery can be dictated by the degree of sensory disruption. Consequently, a thorough account of sensory function might be both prognostic and prescriptive in neurorehabilitation. This review outlines the key sensory components of human voluntary movement, describes how sensory disruption can influence prognosis and expected outcomes in stroke patients, reports on current sensory-based approaches in post-stroke motor rehabilitation, and makes recommendations for optimizing rehabilitation programs based on sensory stimulation.

The sensory side of post-stroke motor rehabilitation

PubMed Central

Bolognini, Nadia; Russo, Cristina; Edwards, Dylan J.

2017-01-01

Contemporary strategies to promote motor recovery following stroke focus on repetitive voluntary movements. Although successful movement relies on efficient sensorimotor integration, functional outcomes often bias motor therapy toward motor-related impairments such as weakness, spasticity and synergies; sensory therapy and reintegration is implied, but seldom targeted. However, the planning and execution of voluntary movement requires that the brain extracts sensory information regarding body position and predicts future positions, by integrating a variety of sensory inputs with ongoing and planned motor activity. Neurological patients who have lost one or more of their senses may show profoundly affected motor functions, even if muscle strength remains unaffected. Following stroke, motor recovery can be dictated by the degree of sensory disruption. Consequently, a thorough account of sensory function might be both prognostic and prescriptive in neurorehabilitation. This review outlines the key sensory components of human voluntary movement, describes how sensory disruption can influence prognosis and expected outcomes in stroke patients, reports on current sensory-based approaches in post-stroke motor rehabilitation, and makes recommendations for optimizing rehabilitation programs based on sensory stimulation. PMID:27080070

Falls and Fear of Falling After Stroke: A Case-Control Study.

PubMed

Goh, Hui-Ting; Nadarajah, Mohanasuntharaam; Hamzah, Norhamizan Binti; Varadan, Parimalaganthi; Tan, Maw Pin

2016-12-01

Falls are common after stroke, with potentially serious consequences. Few investigations have included age-matched control participants to directly compare fall characteristics between older adults with and without stroke. Further, fear of falling, a significant psychological consequence of falls, has only been examined to a limited degree as a risk factor for future falls in a stroke population. To compare the fall history between older adults with and without a previous stroke and to identify the determinants of falls and fear of falling in older stroke survivors. Case-control observational study. Primary teaching hospital. Seventy-five patients with stroke (mean age ± standard deviation, 66 ± 7 years) and 50 age-matched control participants with no previous stroke were tested. Fall history, fear of falling, and physical, cognitive, and psychological function were assessed. A χ 2 test was performed to compare characteristics between groups, and logistic regression was performed to determine the risk factors for falls and fear of falling. Fall events in the past 12 months, Fall Efficacy Scale-International, Berg Balance Scale, Functional Ambulation Category, Fatigue Severity Scale, Montreal Cognitive Assessment, and Patient Healthy Questionnaire-9 were measured for all participants. Fugl-Meyer Motor Assessment was used to quantify severity of stroke motor impairments. Twenty-three patients and 13 control participants reported at least one fall in the past 12 months (P = .58). Nine participants with stroke had recurrent falls (≥2 falls) compared with none of the control participants (P < .01). Participants with stroke reported greater concern for falling than did nonstroke control participants (P < .01). Female gender was associated with falls in the nonstroke group, whereas falls in the stroke group were not significantly associated with any measured outcomes. Fear of falling in the stroke group was associated with functional ambulation level and balance. Functional ambulation level alone explained 22% of variance in fear of falling in the stroke group. Compared with persons without a stroke, patients with stroke were significantly more likely to experience recurrent falls and fear of falling. Falls in patients with stroke were not explained by any of the outcome measures used, whereas fear of falling was predicted by functional ambulation level. This study has identified potentially modifiable risk factors with which to devise future prevention strategies for falls in patients with stroke. III. Copyright © 2016. Published by Elsevier Inc.

Influence of direct admission to Comprehensive Stroke Centers on the outcome of acute stroke patients treated with intravenous thrombolysis.

PubMed

Pérez de la Ossa, Natalia; Millán, Mónica; Arenillas, Juan F; Sánchez-Ojanguren, Josep; Palomeras, Ernest; Dorado, Laura; Guerrero, Cristina; Dávalos, Antoni

2009-08-01

Acute stroke patients can be transferred directly to a Comprehensive Stroke Center (CSC), where acute stroke expertise is provided 24 h a day, seven days a week, and thrombolytic treatment is administered; or they may initially receive attention at an unspecialized community hospital with secondary transfer to the CSC. Our aim is to analyze the influence of previous attention at unspecialized community hospitals on the outcome of ischemic stroke patients treated with thrombolysis. We studied 153 consecutive ischemic stroke patients treated with t-PA over a 30-month period. The primary outcome variable was functional independence at 90 days (Rankin scale, mRS

Safety and functional outcome of thrombolysis in dissection-related ischemic stroke: a meta-analysis of individual patient data.

PubMed

Zinkstok, Sanne M; Vergouwen, Mervyn D I; Engelter, Stefan T; Lyrer, Philippe A; Bonati, Leo H; Arnold, Marcel; Mattle, Heinrich P; Fischer, Urs; Sarikaya, Hakan; Baumgartner, Ralf W; Georgiadis, Dimitrios; Odier, Céline; Michel, Patrik; Putaala, Jukka; Griebe, Martin; Wahlgren, Nils; Ahmed, Niaz; van Geloven, Nan; de Haan, Rob J; Nederkoorn, Paul J

2011-09-01

The safety and efficacy of thrombolysis in cervical artery dissection (CAD) are controversial. The aim of this meta-analysis was to pool all individual patient data and provide a valid estimate of safety and outcome of thrombolysis in CAD. We performed a systematic literature search on intravenous and intra-arterial thrombolysis in CAD. We calculated the rates of pooled symptomatic intracranial hemorrhage and mortality and indirectly compared them with matched controls from the Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register. We applied multivariate regression models to identify predictors of excellent (modified Rankin Scale=0 to 1) and favorable (modified Rankin Scale=0 to 2) outcome. We obtained individual patient data of 180 patients from 14 retrospective series and 22 case reports. Patients were predominantly female (68%), with a mean±SD age of 46±11 years. Most patients presented with severe stroke (median National Institutes of Health Stroke Scale score=16). Treatment was intravenous thrombolysis in 67% and intra-arterial thrombolysis in 33%. Median follow-up was 3 months. The pooled symptomatic intracranial hemorrhage rate was 3.1% (95% CI, 1.3 to 7.2). Overall mortality was 8.1% (95% CI, 4.9 to 13.2), and 41.0% (95% CI, 31.4 to 51.4) had an excellent outcome. Stroke severity was a strong predictor of outcome. Overlapping confidence intervals of end points indicated no relevant differences with matched controls from the Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register. Safety and outcome of thrombolysis in patients with CAD-related stroke appear similar to those for stroke from all causes. Based on our findings, thrombolysis should not be withheld in patients with CAD.

Associations of Ischemic Lesion Volume With Functional Outcome in Patients With Acute Ischemic Stroke: 24-Hour Versus 1-Week Imaging.

PubMed

Bucker, Amber; Boers, Anna M; Bot, Joseph C J; Berkhemer, Olvert A; Lingsma, Hester F; Yoo, Albert J; van Zwam, Wim H; van Oostenbrugge, Robert J; van der Lugt, Aad; Dippel, Diederik W J; Roos, Yvo B W E M; Majoie, Charles B L M; Marquering, Henk A

2017-05-01

Ischemic lesion volume (ILV) on noncontrast computed tomography at 1 week can be used as a secondary outcome measure in patients with acute ischemic stroke. Twenty-four-hour ILV on noncontrast computed tomography has greater availability and potentially allows earlier estimation of functional outcome. We aimed to assess lesion growth 24 hours after stroke onset and compare the associations of 24-hour and 1-week ILV with functional outcome. We included 228 patients from MR CLEAN trial (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands), who received noncontrast computed tomography at 24-hour and 1-week follow-up on which ILV was measured. Relative and absolute lesion growth was determined. Logistic regression models were constructed either including the 24-hour or including the 1-week ILV. Ordinal and dichotomous (0-2 and 3-6) modified Rankin scale scores were, respectively, used as primary and secondary outcome measures. Median ILV was 42 mL (interquartile range, 21-95 mL) and 64 mL (interquartile range: 30-120 mL) at 24 hours and 1 week, respectively. Relative lesion growth exceeding 30% occurred in 121 patients (53%) and absolute lesion growth exceeding 20 mL occurred in 83 patients (36%). Both the 24-hour and 1-week ILVs were similarly significantly associated with functional outcome (both P <0.001). In the logistic analyses, the areas under the curve of the receiver-operator characteristic curves were similar: 0.85 (95% confidence interval, 0.80-0.90) and 0.87 (95% confidence interval, 0.82-0.91) for including the 24-hour and 1-week ILV, respectively. Growth of ILV is common 24-hour poststroke onset. Nevertheless, the 24-hour ILV proved to be a valuable secondary outcome measure as it is equally strongly associated with functional outcome as the 1-week ILV. URL: http://www.isrctn.com. Unique identifier: ISRCTN10888758. © 2017 American Heart Association, Inc.

Pomegranate supplementation improves cognitive and functional recovery following ischemic stroke: A randomized trial.

PubMed

Bellone, John A; Murray, Jeffrey R; Jorge, Paolo; Fogel, Travis G; Kim, Mary; Wallace, Desiree R; Hartman, Richard E

2018-02-13

We tested whether supplementing with pomegranate polyphenols can enhance cognitive/functional recovery after stroke. In this parallel, block-randomized clinical trial, we administered commercially-available pomegranate polyphenol or placebo pills twice per day for one week to adult inpatients in a comprehensive rehabilitation setting starting approximately 2 weeks after stroke. Pills contained 1 g of polyphenols derived from whole pomegranate, equivalent to levels in approximately 8 oz of juice. Placebo pills were similar to the pomegranate pills except that they contained only lactose. Of the 163 patients that were screened, 22 were eligible and 16 were randomized (8 per group). We excluded one subject per group from the neuropsychological analyses since they were lost to follow-up, but we included all subjects in the analysis of functional data since outcome data were available. Clinicians and subjects were blinded to group assignment. Neuropsychological testing (primary outcome: Repeatable Battery for the Assessment of Neuropsychological Status) and functional independence scores were used to determine changes in cognitive and functional ability. Pomegranate-treated subjects demonstrated more neuropsychological and functional improvement and spent less time in the hospital than placebo controls. Pomegranate polyphenols enhanced cognitive and functional recovery after stroke, justifying pursuing larger clinical trials.

Prevalence and Predictors of Long-Term Functional Impairment, Epilepsy, Mortality, and Stroke Recurrence after Childhood Stroke: A Prospective Study of a Chilean Cohort.

PubMed

López-Espejo, Mauricio; Hernández-Chávez, Marta

2017-07-01

To evaluate the prevalence and predictors of long-term impairment, epilepsy, mortality, and recurrences after the first stroke in a cohort of Chilean children. A prospective study involving 98 children who suffered a first stroke and underwent follow-up for at least 3 years in a single center. Functional outcome was measured using the modified Rankin Scale for children. We utilized multivariate logistic regression models to estimate the odds ratios (ORs) for outcomes while adjusting for age, sex, and underlying conditions (significance <.05). Stroke recurrences were present in 18 children and were strongly associated with arteriopathies (OR 8.11; CI 1.5-43). Of 26 children who died during the follow-up period, a significant proportion had a cardiopathy (OR 6.57; CI 1.3-32) or a chronic head and neck disease (OR 41.3; CI 3.5-490). Among 72 survivors (median age 1.49 years; 38 girls; mean follow-up time 4.85 years), 28 presented marked impairment; these children were younger (P = .019) and had more commonly arteriopathies (OR 9.33; CI 1.7-51) and epilepsy (OR 10.5; CI 3.1-36) as compared to survivors without disabilities. Cumulative epilepsy prevalence was 55.6%; children with epilepsy were younger (P = .037) and had more commonly acute symptomatic seizures (OR 12.16; CI 2.93-50.4) as compared to survivors without epilepsy. The prevalence of long-term adverse outcomes after childhood stroke is high and does not differ from other geographical and racial groups. Younger age, acute seizures, and arteriopathies but not sex and other underlying conditions predict adverse outcome following childhood stroke. Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Enhanced clarity and holism: the outcome of implementing the ICF with an acute stroke multidisciplinary team in England

PubMed Central

Harries, Priscilla; Kilbride, Cherry; De Souza, Lorraine

2013-01-01

Purpose: Although it is recommended that the ICF (International Classification of Functioning, Disability and Health) should be implemented to aid communication within multidisciplinary stroke services, there is no empirical evidence to demonstrate the outcomes of such implementation. Working with one stroke service, this project aimed to address this gap and sought to evaluate the outcomes of implementing an ICF-based clinical tool into practice. Method: Using an action research framework with mixed methods, data were collected from individual interviews, a focus group, questionnaires, email communications, minutes from relevant meetings and field notes. Thematic analysis was undertaken, using immersion and crystallisation, to define overall themes. Descriptive statistics were used to analyse quantitative data. Data from both sources were combined to create key findings. Results: Three findings were determined from the data analysis. The ICF (1) fosters communication within and beyond the multidisciplinary stroke team; (2) promotes holistic thinking; and (3) helps to clarify team roles. Conclusions: The ICF enhanced clarity of communication and team roles within the acute stroke multidisciplinary team as well as with other clinicians, patients and their relatives. In addition, the ICF challenged stroke clinicians to think holistically, thereby appropriately extending their domain of concern beyond their traditional remit. Implications for Rehabilitation The ICF is a globally accepted framework to describe functioning and is in use in a variety of clinical settings. Yet, the outcomes of using it in clinical practice have yet to be fully explored. This study found that the ICF enhanced clarity of communication and team roles within an acute stroke multidisciplinary team and to others beyond the team, including clinicians, patients and their relatives. Using the ICF also challenged clinicians to think holistically about patient needs following a stroke. PMID:23530624

Enhanced clarity and holism: the outcome of implementing the ICF with an acute stroke multidisciplinary team in England.

PubMed

Tempest, Stephanie; Harries, Priscilla; Kilbride, Cherry; De Souza, Lorraine

2013-01-01

Although it is recommended that the ICF (International Classification of Functioning, Disability and Health) should be implemented to aid communication within multidisciplinary stroke services, there is no empirical evidence to demonstrate the outcomes of such implementation. Working with one stroke service, this project aimed to address this gap and sought to evaluate the outcomes of implementing an ICF-based clinical tool into practice. Using an action research framework with mixed methods, data were collected from individual interviews, a focus group, questionnaires, email communications, minutes from relevant meetings and field notes. Thematic analysis was undertaken, using immersion and crystallisation, to define overall themes. Descriptive statistics were used to analyse quantitative data. Data from both sources were combined to create key findings. Three findings were determined from the data analysis. The ICF (1) fosters communication within and beyond the multidisciplinary stroke team; (2) promotes holistic thinking; and (3) helps to clarify team roles. The ICF enhanced clarity of communication and team roles within the acute stroke multidisciplinary team as well as with other clinicians, patients and their relatives. In addition, the ICF challenged stroke clinicians to think holistically, thereby appropriately extending their domain of concern beyond their traditional remit. The ICF is a globally accepted framework to describe functioning and is in use in a variety of clinical settings. Yet, the outcomes of using it in clinical practice have yet to be fully explored. This study found that the ICF enhanced clarity of communication and team roles within an acute stroke multidisciplinary team and to others beyond the team, including clinicians, patients and their relatives. Using the ICF also challenged clinicians to think holistically about patient needs following a stroke.

Effect of Increased Intensity of Physiotherapy on Patient Outcomes After Stroke: An Economic Literature Review and Cost-Effectiveness Analysis

PubMed Central

Chan, B

2015-01-01

Background Functional improvements have been seen in stroke patients who have received an increased intensity of physiotherapy. This requires additional costs in the form of increased physiotherapist time. Objectives The objective of this economic analysis is to determine the cost-effectiveness of increasing the intensity of physiotherapy (duration and/or frequency) during inpatient rehabilitation after stroke, from the perspective of the Ontario Ministry of Health and Long-term Care. Data Sources The inputs for our economic evaluation were extracted from articles published in peer-reviewed journals and from reports from government sources or the Canadian Stroke Network. Where published data were not available, we sought expert opinion and used inputs based on the experts' estimates. Review Methods The primary outcome we considered was cost per quality-adjusted life-year (QALY). We also evaluated functional strength training because of its similarities to physiotherapy. We used a 2-state Markov model to evaluate the cost-effectiveness of functional strength training and increased physiotherapy intensity for stroke inpatient rehabilitation. The model had a lifetime timeframe with a 5% annual discount rate. We then used sensitivity analyses to evaluate uncertainty in the model inputs. Results We found that functional strength training and higher-intensity physiotherapy resulted in lower costs and improved outcomes over a lifetime. However, our sensitivity analyses revealed high levels of uncertainty in the model inputs, and therefore in the results. Limitations There is a high level of uncertainty in this analysis due to the uncertainty in model inputs, with some of the major inputs based on expert panel consensus or expert opinion. In addition, the utility outcomes were based on a clinical study conducted in the United Kingdom (i.e., 1 study only, and not in an Ontario or Canadian setting). Conclusions Functional strength training and higher-intensity physiotherapy may result in lower costs and improved health outcomes. However, these results should be interpreted with caution. PMID:26366241

Anesthesia in Experimental Stroke Research

PubMed Central

Hoffmann, Ulrike; Sheng, Huaxin; Ayata, Cenk; Warner, David S.

2016-01-01

Anesthetics have enabled major advances in development of experimental models of human stroke. Yet their profound pharmacologic effects on neural function can confound the interpretation of experimental stroke research. Anesthetics have drug and dose-specific effects on cerebral blood flow and metabolism, neurovascular coupling, autoregulation, ischemic depolarizations, excitotoxicity, inflammation, neural networks, and numerous molecular pathways relevant for stroke outcome. Both pre- and post-conditioning properties have been described. Anesthetics also modulate systemic arterial blood pressure, lung ventilation, and thermoregulation, all of which may interact with the ischemic insult as well as the therapeutic interventions. These confounds present a dilemma. Here, we provide an overview of the anesthetic mechanisms of action and molecular and physiologic effects on factors relevant to stroke outcomes that can guide the choice and optimization of the anesthetic regimen in experimental stroke. PMID:27534542

Self-Perceived Participation and Autonomy at 1-Year Post Stroke: A Part of the Stroke Arm Longitudinal Study at the University of Gothenburg (SALGOT Study).

PubMed

Törnbom, Karin; Hadartz, Kristin; Sunnerhagen, Katharina S

2018-04-01

Identifying factors predicting the long-term outcome of participation and autonomy after stroke is essential for developing individualized rehabilitation interventions. The aim was to describe self-assessed participation and autonomy and to explore factors associated with the same at 1 year post stroke. Participants consisted of 79 persons (mean age = 67) with a first-time stroke at the 1-year follow-up. To investigate perceived participation and autonomy at 1 year, a self-assessment questionnaire, the Impact on Participation and Autonomy-English version (IPA-E) was used. Multivariate logistic regression models were performed using age, gender, stroke severity, and functional dependency at discharge as potential contributors to the perceived level of participation and autonomy. A high percentage (70%-88%) evaluated their functions as fair to very good within all domains of the IPA-E at 1 year post stroke. However, around a fifth experienced their Family role as poor to very poor. Participants' functional dependency at discharge significantly influenced the outcome for the domains of Family role (odds ratio [OR] = 5.66, P < .01), Social relations (OR = 3.23, P < .03), and Autonomy indoors (OR = 3.44, P < .04) at 1 year post stroke. Aspects of the Family role domain deserve further attention in interventions aimed at improving participation and autonomy at 1 year post stroke. The results also indicate that supporting indoor autonomy and social relations of persons with stroke during the acute rehabilitation is important to enhance participation and autonomy at 1 year post stroke. Copyright © 2018 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Is aura around citicoline fading? A systemic review

PubMed Central

Agarwal, Saurabh; Patel, Bhoomika M.

2017-01-01

Stroke and traumatic brain injury (TBI) are the critical public health and socioeconomic problems throughout the world. At present, citicoline is used as a coadjuvant for the management of acute ischemic stroke (AIS) and TBI in various countries. This systemic review analyzes the beneficial role of citicoline in AIS and TBI. This systemic review is based on “PubMed” and “Science Direct” search results for citicoline role in stroke and TBI. In this systemic review, we included 12 human trials. A meta-analysis was performed on the basis of neurological evaluation, functional evaluation and Glasgow outcome scale, domestic adaptation evaluation outcomes, and cognitive outcome individually. In neurological evaluation, domestic adaptation evaluation, and cognitive outcomes, there was no significant difference in both the citicoline and placebo groups (odds ratio [OR] = 1.04 [0.9–1.2, P = 0.583]; OR = 1.1 [0.94–1.27, P = 0.209]; OR = 0.953 [0.75–1.2, P = 0.691]). In evaluation of functional outcomes, there was significant difference in both groups and OR was 1.18 (1.04–1.34, P = 0.01). Functional outcomes were significantly improved by citicoline, but the positive role of this drug in neurological recovery, domestic adaptation, and cognitive outcomes is still a topic of discussion for future. PMID:28458415

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

The influence of computer-based cognitive flexibility training on subjective cognitive well-being after stroke: A multi-center randomized controlled trial

PubMed Central

Murre, Jaap M. J.; Buitenweg, Jessika I. V.; Veltman, Dick J.; Aaronson, Justine A.; Nijboer, Tanja C. W.; Kruiper-Doesborgh, Suzanne J. C.; van Bennekom, Coen A. M.; Ridderinkhof, K. Richard; Schmand, Ben

2017-01-01

Background Stroke can result in cognitive complaints that can have a large impact on quality of life long after its occurrence. A number of computer-based training programs have been developed with the aim to improve cognitive functioning. Most studies investigating their efficacy used only objective outcome measures, whereas a reduction of subjective cognitive complaints may be equally important for improving quality of life. A few studies used subjective outcome measures but were inconclusive, partly due to methodological shortcomings such as lack of proper active and passive control groups. Objective The aim of the current study was to investigate whether computer-based cognitive flexibility training can improve subjective cognitive functioning and quality of life after stroke. Methods We performed a randomized controlled double blind trial (RCT). Adults (30–80 years old) who had a stroke 3 months to 5 years ago, were randomly assigned to either an intervention group (n = 38), an active control group (i.e., mock training; n = 35), or a waiting list control group (n = 24). The intervention and mock training consisted of 58 half-hour sessions within 12 weeks. The primary subjective outcome measures were cognitive functioning (Cognitive Failure Questionnaire), executive functioning (Dysexecutive Functioning Questionnaire), quality of life (Short Form Health Survey), instrumental activities of daily living (IADL; Lawton & Brody IADL scale), and participation in society (Utrecht Scale for Evaluation of Rehabilitation-Participation). Secondary subjective outcome measures were recovery after stroke, depressive symptoms (Hospital Anxiety Depression Scale—depression subscale), fatigue (Checklist Individual Strength—Fatigue subscale), and subjective cognitive improvement (exit list). Finally, a proxy of the participant rated the training effects in subjective cognitive functioning, subjective executive functioning, and IADL. Results and conclusions All groups improved on the two measures of subjective cognitive functioning and subjective executive functioning, but not on the other measures. These cognitive and executive improvements remained stable 4 weeks after training completion. However, the intervention group did not improve more than the two control groups. This suggests that improvement was due to training-unspecific effects. The proxies did not report any improvements. We, therefore, conclude that the computer-based cognitive flexibility training did not improve subjective cognitive functioning or quality of life after stroke. PMID:29145410

The influence of computer-based cognitive flexibility training on subjective cognitive well-being after stroke: A multi-center randomized controlled trial.

PubMed

van de Ven, Renate M; Murre, Jaap M J; Buitenweg, Jessika I V; Veltman, Dick J; Aaronson, Justine A; Nijboer, Tanja C W; Kruiper-Doesborgh, Suzanne J C; van Bennekom, Coen A M; Ridderinkhof, K Richard; Schmand, Ben

2017-01-01

Stroke can result in cognitive complaints that can have a large impact on quality of life long after its occurrence. A number of computer-based training programs have been developed with the aim to improve cognitive functioning. Most studies investigating their efficacy used only objective outcome measures, whereas a reduction of subjective cognitive complaints may be equally important for improving quality of life. A few studies used subjective outcome measures but were inconclusive, partly due to methodological shortcomings such as lack of proper active and passive control groups. The aim of the current study was to investigate whether computer-based cognitive flexibility training can improve subjective cognitive functioning and quality of life after stroke. We performed a randomized controlled double blind trial (RCT). Adults (30-80 years old) who had a stroke 3 months to 5 years ago, were randomly assigned to either an intervention group (n = 38), an active control group (i.e., mock training; n = 35), or a waiting list control group (n = 24). The intervention and mock training consisted of 58 half-hour sessions within 12 weeks. The primary subjective outcome measures were cognitive functioning (Cognitive Failure Questionnaire), executive functioning (Dysexecutive Functioning Questionnaire), quality of life (Short Form Health Survey), instrumental activities of daily living (IADL; Lawton & Brody IADL scale), and participation in society (Utrecht Scale for Evaluation of Rehabilitation-Participation). Secondary subjective outcome measures were recovery after stroke, depressive symptoms (Hospital Anxiety Depression Scale-depression subscale), fatigue (Checklist Individual Strength-Fatigue subscale), and subjective cognitive improvement (exit list). Finally, a proxy of the participant rated the training effects in subjective cognitive functioning, subjective executive functioning, and IADL. All groups improved on the two measures of subjective cognitive functioning and subjective executive functioning, but not on the other measures. These cognitive and executive improvements remained stable 4 weeks after training completion. However, the intervention group did not improve more than the two control groups. This suggests that improvement was due to training-unspecific effects. The proxies did not report any improvements. We, therefore, conclude that the computer-based cognitive flexibility training did not improve subjective cognitive functioning or quality of life after stroke.

Serum tenascin-C predicts severity and outcome of acute intracerebral hemorrhage.

PubMed

Wang, Lin-Guo; Huangfu, Xue-Qin; Tao, Bo; Zhong, Guan-Jin; Le, Zhou-Di

2018-06-01

Tenascin-C is a matricellular protein related to brain injury. We studied serum tenascin-C in acute intracerebral hemorrhage (ICH) and examined the associations with severity and outcome following the acute event. Tenascin-C samples were obtained from 162 patients with acute hemorrhagic stroke and 162 healthy controls. Poor 90-day functional outcome was defined as modified Rankin Scale score > 2. Early neurological deterioration (END) and hematoma growth (HG) were recorded at 24 h. Patients had higher tenascin-C levels than controls. Tenascin-C levels were positively correlated with hematoma volume or National Institutes of Health Stroke Scale score at baseline. Elevated tenascin-C levels were independently associated with END, HG, 90-day mortality and poor functional outcome. Moreover, tenascin-C levels significantly predicted END, HG and 90-day outcomes under receiver operating characteristic curves. An increase in serum tenascin-C level is associated with an adverse outcome in ICH patients, supporting the potential role of serum tenascin-C as a prognostic biomarker for hemorrhagic stroke. Copyright © 2018 Elsevier B.V. All rights reserved.

Highly Prevalent Hyperuricaemia is Associated with Adverse Clinical Outcomes Among Ghanaian Stroke Patients: An Observational Prospective Study.

PubMed

Sarfo, F S; Akassi, J; Antwi, N K B; Obese, V; Adamu, S; Akpalu, A; Bedu-Addo, G

2015-09-01

Although a direct causal relationship between hyperuricaemia and stroke continues to be debated, strong associations between serum uric acid (SUA) and cerebrovascular disease exist. Very few studies have been conducted to evaluate the frequency and association between this potentially modifiable biomarker of vascular risk and stroke in sub-Saharan Africa. Therefore the aim of this study was to examine the association between hyperuricaemia and the traditional risk factors and the outcomes of stroke in Ghanaian patients. In this prospective observational study, 147 patients presenting with stroke at a tertiary referral centre in Ghana were consecutively recruited. Patients were screened for vascular risk factors and SUA concentrations measured after an overnight fast. Associations between hyperuricaemia and stroke outcomes were analysed using Kaplan-Meier and Cox proportional hazards regression analysis. The frequency of hyperuricaemia among Ghanaian stroke patients was 46.3%. Non-significant associations were observed between hyperuricaemia and the traditional risk factors of stroke. SUA concentration was positively correlated with stroke severity and associated with early mortality after an acute stroke with unadjusted hazards ratio of 2.3 (1.4 - 4.2, p=0.001). A potent and independent dose-response association between increasing SUA concentration and hazard of mortality was found on Cox proportional hazards regression, aHR (95% CI) of 1.65 (1.14-2.39), p=0.009 for each 100µmol/l increase in SUA. Hyperuricaemia is highly frequent and associated with adverse functional outcomes among Ghanaian stroke patients. Further studies are warranted to determine whether reducing SUA levels after a stroke would be beneficial within our setting.

Glucose in prediabetic and diabetic range and outcome after stroke.

PubMed

Osei, E; Fonville, S; Zandbergen, A A M; Koudstaal, P J; Dippel, D W J; den Hertog, H M

2017-02-01

Newly diagnosed disturbed glucose metabolism is highly prevalent in patients with stroke. Limited data are available on their prognostic value on outcome after stroke. We aimed to assess the association of glucose in the prediabetic and diabetic range with unfavourable short-term outcome after stroke. We included 839 consecutive patients with ischemic stroke and 168 patients with intracerebral haemorrhage. In all nondiabetic patients, fasting glucose levels were determined on day 2-4. Prediabetic range was defined as fasting glucose of 5.6-6.9 mmol/L, diabetic range as ≥7.0 mmol/L, pre-existent diabetes as the use of anti-diabetic medication prior to admission. Outcome measures were poor functional outcome or death defined as modified Rankin Scale (mRS) score >2 and discharge not to home. The association of prediabetic range, diabetic range and pre-existent diabetes (versus normal glucose) with unfavourable outcome was expressed as odds ratios, estimated with multiple logistic regression, with adjustment for prognostic factors. Compared with normal glucose, prediabetic range (aOR 1.8; 95%CI 1.1-2.8), diabetic range (aOR 2.5; 95%CI 1.3-4.9) and pre-existent diabetes (aOR 2.6; 95%CI 1.6-4.0) were associated with poor functional outcome or death. Patients in the prediabetic range (aOR 0.6; 95%CI 0.4-0.9), diabetic range (aOR 0.4; 95%CI 0.2-0.9) and pre-existent diabetes (aOR 0.6; 95%CI 0.4-0.9) were more likely not to be discharged to home. Patients with glucose in the prediabetic and diabetic range have an increased risk of unfavourable short-term outcome after stroke. These findings illustrate the potential impact of early detection and treatment of these patients. © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Constraint-Induced Movement Therapy for Rehabilitation of Arm Dysfunction After Stroke in Adults

PubMed Central

2011-01-01

Executive Summary Objective The purpose of this evidence-based analysis is to determine the effectiveness and cost of CIMT for persons with arm dysfunction after a stroke. Clinical Need: Condition and Target Population A stroke is a sudden loss of brain function caused by the interruption of blood flow to the brain (ischemic stroke) or the rupture of blood vessels in the brain (hemorrhagic stroke). A stroke can affect any number of areas including the ability to move, see, remember, speak, reason, and read and write. Stroke is the leading cause of adult neurological disability in Canada; 300,000 people or 1% of the population live with its effects. Up to 85% of persons experiencing a complete stroke have residual arm dysfunction which will interfere with their ability to live independently. Rehabilitation interventions are the cornerstone of care and recovery after a stroke. Constraint-Induced Movement Therapy Constraint-Induced Movement (CIMT) is a behavioural approach to neurorehabilitation based on the principle of ‘learned non-use’. The term is derived from studies in nonhuman primates in which somatosensory deafferentation of a single forelimb was performed and after which the animal then failed to use that limb. This failure to use the limb was deemed ‘learned non-use’. The major components of CIMT include: i) intense repetitive task-oriented training of the impaired limb ii) immobilization of the unimpaired arm, and iii) shaping. With regard to the first component, persons may train the affected arm for several hours a day for up to 10-15 consecutive days. With immobilization, the unaffected arm may be restrained for up to 90% of waking hours. And finally, with shaping, the difficulty of the training tasks is progressively increased as performance improves and encouraging feedback is provided immediately when small gains are achieved. Research Question What is the effectiveness and cost of CIMT compared with physiotherapy and/or occupational therapy rehabilitative care for the treatment of arm dysfunction after stroke in persons 18 years of age and older? Research Methods Literature Search Search Strategy A literature search was performed on January 21, 2011 using OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, OVID EMBASE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane Library, Centre for Reviews and Dissemination. (Appendix 1) A preliminary search completed in August 2010 found a Cochrane Systematic review published in 2009. As a result, the literature search for this evidence-based analysis was designed to include studies published from January 1, 2008 to January 21, 2011. Inclusion Criteria Systematic reviews of randomized controlled trials with or without meta-analysis. Study participants 18 years of age and older with arm dysfunction after stroke. Studies comparing the use of CIMT with occupational therapy and/or physiotherapy rehabilitative care (usual care) to improve arm function. Studies which described CIMT as having the following three components: i) restraining unimpaired arm and/or wrist with a sling, hand splint or cast; ii) intensive training with functional task practice of the affected arm; iii) application of shaping methodology during training. No restriction was placed on intensity or duration of treatment otherwise. Duration and intensity of therapy is equal in treatment and control groups. Therapy beginning a minimum of one month after stroke. Published between 2008 and 2011. Exclusion Criteria Narrative reviews, case series, case reports, controlled clinical trials. Letters to the editor Grey literature. Non-English language publications. Outcomes of Interest Primary Outcome Arm motor function: Action Research Arm Test (ARAT) Secondary Outcome Arm motor impairment: Fugl-Meyer Motor Assessment (FMA) Activities of daily living (ADL): Functional Independence Measure (FIM), Chedoke Arm and Hand Inventory Perceived motor function: Motor Activity Log (MAL) Amount of Use (AOU) and Quality of Movement (QOM) scales Quality of Life: Stroke Impact Scale (SIS) Summary of Findings A significant difference was found in our primary outcome of arm motor function measured with the Action Research Arm Test in favour of CIMT compared with usual care delivered with the same intensity and duration. Significant differences were also found in three of the five secondary outcome measures including Arm Motor Impairment and Perceived Motor Function Amount of Use and Quality of Use. There was a nonsignificant effect found with the FIM score and the quality of life Stroke Impact Scale outcome measure. The nonsignificant effect found with the scale score and the quality of life score may be a factor of a nonresponsive outcome measure (FIM scale) and/or a type II statistical error from an inadequate sample size. The quality of evidence was moderate for arm motor function and low for all other outcome measures except quality of life, which was very low. Table 1: Summary of Results* Outcome Outcome Measure Number of Studies (n) Mean Difference in Change scores CIMT vs. Usual Care [95% C.I.] Results GRADE Quality of Evidence Arm motor function Action Research Arm Test 4(43) 13.6[8.7, 18.6] Significant Moderate Arm motor impairment Fugl-Meyer Motor Assessment 8(169) 6.5[2.3, 10.7] Significant Low Activities of daily living Functional Independence Measure 4(128) 3.6[−0.22, 7.4] Nonsignificant Low Self-reported amount of arm use Perceived Arm Motor Function (Amount of Use) Scale 8(241) 1.1[0.60, 1.7] Significant Low Self-reported quality of arm use Perceived Arm Motor Function (Quality of Use) Scale 8(241) 0.97[0.7, 1.3] Significant Low Quality of life Stroke Impact Scale 2(66) 3.9[−5.6, 13.5] Nonsignificant Very Low * CI, Confidence Intervals; n, Sample Size PMID:23074418

Ischemic Stroke: Advances in Diagnosis and Management.

PubMed

Cassella, Courtney R; Jagoda, Andy

2017-11-01

Acute ischemic stroke carries the risk of morbidity and mortality. Since the advent of intravenous thrombolysis, there have been improvements in stroke care and functional outcomes. Studies of populations once excluded from thrombolysis have begun to elucidate candidates who might benefit and thus should be engaged in the process of shared decision-making. Imaging is evolving to better target the ischemic penumbra salvageable with prompt reperfusion. Availability and use of computed tomography angiography identifies large-vessel occlusions, and new-generation endovascular therapy devices are improving outcomes in these patients. With this progress in stroke treatment, risk stratification tools and shared decision-making are fundamental. Copyright © 2017 Elsevier Inc. All rights reserved.

Effects of activity repetition training with Salat (prayer) versus task oriented training on functional outcomes of stroke.

PubMed

Ghous, Misbah; Malik, Arshad Nawaz; Amjad, Mian Imran; Kanwal, Maria

2017-07-01

Stroke is one of most disabling condition which directly affects quality of life. The objective of this study was to compare the effect of activity repetition training with salat (prayer) versus task oriented training on functional outcomes of stroke. The study design was randomized control trial and 32 patients were randomly assigned into two groups'. The stroke including infarction or haemorrhagic, age bracket 30-70 years was included. The demographics were recorded and standardized assessment tool included Berg Balance Scale (BBS), Motor assessment scale (MAS) and Time Up and Go Test (TUG). The measurements were obtained at baseline, after four and six weeks. The mean age of the patients was 54.44±10.59 years with 16 (59%) male and 11(41%) female patients. Activity Repetition Training group showed significant improvement (p<0.05) and is effective in enhancing the functional status as compare to task oriented training group. The repetition with motivation and concentration is the key in re-learning process of neural plasticity.

Obstructive Sleep Apnea is Related to Impaired Cognitive and Functional Status after Stroke.

PubMed

Aaronson, Justine A; van Bennekom, Coen A M; Hofman, Winni F; van Bezeij, Tijs; van den Aardweg, Joost G; Groet, Erny; Kylstra, Wytske A; Schmand, Ben

2015-09-01

Obstructive sleep apnea (OSA) is a common sleep disorder in stroke patients and is associated with prolonged hospitalization, decreased functional outcome, and recurrent stroke. Research on the effect of OSA on cognitive functioning following stroke is scarce. The primary objective of this study was to compare stroke patients with and without OSA on cognitive and functional status upon admission to inpatient rehabilitation. Case-control study. 147 stroke patients admitted to a neurorehabilitation unit. N/A. All patients underwent sleep examination for diagnosis of OSA. We assessed cognitive status by neuropsychological examination and functional status by two neurological scales and a measure of functional independence. We included 80 stroke patients with OSA and 67 stroke patients without OSA. OSA patients were older and had a higher body mass index than patients without OSA. OSA patients performed worse on tests of attention, executive functioning, visuoperception, psychomotor ability, and intelligence than those without OSA. No differences were found for vigilance, memory, and language. OSA patients had a worse neurological status, lower functional independence scores, and a longer period of hospitalization in the neurorehabilitation unit than the patients without OSA. OSA status was not associated with stroke type or classification. Obstructive sleep apnea (OSA) is associated with a lower cognitive and functional status in patients admitted for stroke rehabilitation. This underlines the importance of OSA as a probable prognostic factor, and calls for well-designed randomized controlled trials to study its treatability. © 2015 Associated Professional Sleep Societies, LLC.

Daidzein Augments Cholesterol Homeostasis via ApoE to Promote Functional Recovery in Chronic Stroke

PubMed Central

Kim, Eunhee; Woo, Moon-Sook; Qin, Luye; Ma, Thong; Beltran, Cesar D.; Bao, Yi; Bailey, Jason A.; Corbett, Dale; Ratan, Rajiv R.; Lahiri, Debomoy K.

2015-01-01

Stroke is the world's leading cause of physiological disability, but there are currently no available agents that can be delivered early after stroke to enhance recovery. Daidzein, a soy isoflavone, is a clinically approved agent that has a neuroprotective effect in vitro, and it promotes axon growth in an animal model of optic nerve crush. The current study investigates the efficacy of daidzein on neuroprotection and functional recovery in a clinically relevant mouse model of stroke recovery. In light of the fact that cholesterols are essential lipid substrates in injury-induced synaptic remodeling, we found that daidzein enhanced the cholesterol homeostasis genetic program, including Lxr and downstream transporters, Apoe, Abca1, and Abcg1 genes in vitro. Daidzein also elevated the cholesterol homeostasis genes in the poststroke brain with Apoe, the highest expressing transporter, but did not affect infarct volume or hemispheric swelling. Despite the absence of neuroprotection, daidzein improved motor/gait function in chronic stroke and elevated synaptophysin expression. However, the daidzein-enhanced functional benefits and synaptophysin expression were abolished in Apoe-knock-out mice, suggesting the importance of daidzein-induced ApoE upregulation in fostering stroke recovery. Dissociation between daidzein-induced functional benefits and the absence of neuroprotection further suggest the presence of nonoverlapping mechanisms underlying recovery processes versus acute pathology. With its known safety in humans, early and chronic use of daidzein aimed at augmenting ApoE may serve as a novel, translatable strategy to promote functional recovery in stroke patients without adverse acute effect. SIGNIFICANCE STATEMENT There have been recurring translational failures in treatment strategies for stroke. One underlying issue is the disparity in outcome analysis between animal and clinical studies. The former mainly depends on acute infarct size, whereas long-term functional recovery is an important outcome in patients. In an attempt to identify agents that promote functional recovery, we discovered that an FDA-approved soy isoflavone, daidzein, improved stroke-induced behavioral deficits via enhancing cholesterol homeostasis in chronic stroke, and this occurs without causing adverse effects in the acute phase. With its known safety in humans, the study suggests that the early and chronic use of daidzein serves as a potential strategy to promote functional recovery in stroke patients. PMID:26558782

Daidzein Augments Cholesterol Homeostasis via ApoE to Promote Functional Recovery in Chronic Stroke.

PubMed

Kim, Eunhee; Woo, Moon-Sook; Qin, Luye; Ma, Thong; Beltran, Cesar D; Bao, Yi; Bailey, Jason A; Corbett, Dale; Ratan, Rajiv R; Lahiri, Debomoy K; Cho, Sunghee

2015-11-11

Stroke is the world's leading cause of physiological disability, but there are currently no available agents that can be delivered early after stroke to enhance recovery. Daidzein, a soy isoflavone, is a clinically approved agent that has a neuroprotective effect in vitro, and it promotes axon growth in an animal model of optic nerve crush. The current study investigates the efficacy of daidzein on neuroprotection and functional recovery in a clinically relevant mouse model of stroke recovery. In light of the fact that cholesterols are essential lipid substrates in injury-induced synaptic remodeling, we found that daidzein enhanced the cholesterol homeostasis genetic program, including Lxr and downstream transporters, Apoe, Abca1, and Abcg1 genes in vitro. Daidzein also elevated the cholesterol homeostasis genes in the poststroke brain with Apoe, the highest expressing transporter, but did not affect infarct volume or hemispheric swelling. Despite the absence of neuroprotection, daidzein improved motor/gait function in chronic stroke and elevated synaptophysin expression. However, the daidzein-enhanced functional benefits and synaptophysin expression were abolished in Apoe-knock-out mice, suggesting the importance of daidzein-induced ApoE upregulation in fostering stroke recovery. Dissociation between daidzein-induced functional benefits and the absence of neuroprotection further suggest the presence of nonoverlapping mechanisms underlying recovery processes versus acute pathology. With its known safety in humans, early and chronic use of daidzein aimed at augmenting ApoE may serve as a novel, translatable strategy to promote functional recovery in stroke patients without adverse acute effect. There have been recurring translational failures in treatment strategies for stroke. One underlying issue is the disparity in outcome analysis between animal and clinical studies. The former mainly depends on acute infarct size, whereas long-term functional recovery is an important outcome in patients. In an attempt to identify agents that promote functional recovery, we discovered that an FDA-approved soy isoflavone, daidzein, improved stroke-induced behavioral deficits via enhancing cholesterol homeostasis in chronic stroke, and this occurs without causing adverse effects in the acute phase. With its known safety in humans, the study suggests that the early and chronic use of daidzein serves as a potential strategy to promote functional recovery in stroke patients. Copyright © 2015 the authors 0270-6474/15/3515113-14$15.00/0.

DRAGON score predicts functional outcomes in acute ischemic stroke patients receiving both intravenous tissue plasminogen activator and endovascular therapy.

PubMed

Wang, Arthur; Pednekar, Noorie; Lehrer, Rachel; Todo, Akira; Sahni, Ramandeep; Marks, Stephen; Stiefel, Michael F

2017-01-01

The DRAGON score, which includes clinical and computed tomographic (CT) scan parameters, predicts functional outcomes in ischemic stroke patients treated with intravenous tissue plasminogen activator (IV tPA). We assessed the utility of the DRAGON score in predicting functional outcome in stroke patients receiving both IV tPA and endovascular therapy. A retrospective chart review of patients treated at our institution from February 2009 to October 2015 was conducted. All patients with computed tomography angiography (CTA) proven large vessel occlusions (LVO) who underwent intravenous thrombolysis and endovascular therapy were included. Baseline DRAGON scores and modified Rankin Score (mRS) at the time of hospital discharge was calculated. Good outcome was defined as mRS ≤3. Fifty-eight patients with LVO of the anterior circulation were studied. The mean DRAGON score of patients on admission was 5.3 (range, 3-8). All patients received IV tPA and endovascular therapy. Multivariate analysis demonstrated that DRAGON scores ≥7 was associated with higher mRS ( P < 0.006) and higher mortality ( P < 0.0001) compared with DRAGON scores ≤6. Patients with DRAGON scores of 7 and 8 on admission had a mortality rate of 3.8% and 40%, respectively. The DRAGON score can help predict better functional outcomes in ischemic stroke patients receiving both IV tPA and endovascular therapy. This data supports the use of the DRAGON score in selecting patients who could potentially benefit from more invasive therapies such as endovascular treatment. Larger prospective studies are warranted to further validate these results.

Lower uric acid is associated with poor short-term outcome and a higher frequency of posterior arterial involvement in ischemic stroke.

PubMed

Liu, Hanxiang; Reynolds, Gavin P; Wang, Wenmin; Wei, Xianwen

2018-06-01

Uric acid has neuroprotective properties in experimental and clinical studies of neurodegenerative disease. It is, however, associated with increased risk of stroke, yet, despite some inconsistent findings, increasing evidence suggests it may also be related to improved stroke outcomes. We have determined whether there is an effect of plasma uric acid on the short-term outcome of stroke patients in a general hospital setting using the modified Rankin Scale (mRS). We also investigated the relationship of uric acid with other clinical correlates. Plasma uric acid was determined in 108 acute ischemic stroke patients and their mRS scores measured. Patients with a poor outcome (mRS > 2) had significantly lower uric acid than those with a better outcome; this remained after correcting for the effect of sex on uric acid concentrations. There was no significant association with other epidemiological factors or with cognitive function determined by Mini-Mental State Examination. An association between uric acid and the cerebral circulation was also found in which lower uric acid occurs with posterior artery involvement. These findings demonstrate in a naturalistic cohort of patients the association of uric acid with short-term disability following ischemic stroke. They also raise the question of whether uric acid may influence the regional brain involvement in stroke.

Dexamphetamine improves upper extremity outcome during rehabilitation after stroke: a pilot randomized controlled trial.

PubMed

Schuster, Corina; Maunz, Gerd; Lutz, Karin; Kischka, Udo; Sturzenegger, Rolf; Ettlin, Thierry

2011-10-01

For early inpatient stroke rehabilitation, the effectiveness of amphetamine combined with physiotherapy varies across studies. To investigate whether the recovery of activities of daily living (ADL, primary outcome) and motor function (secondary outcome) can be improved by dexamphetamine added to physiotherapy. In a double-blind, placebo-controlled trial, 16 patients, from 918 who were screened, were randomized to the experimental group (EG, dexamphetamine + physiotherapy) or control group (CG, placebo + physiotherapy). Both groups received multidisciplinary inpatient rehabilitation. Dexamphetamine (10 mg oral) or placebo was administered 2 days per week before physiotherapy. ADL and motor function were measured using the Chedoke-McMaster Stroke Assessment (CMSA) twice during baseline, every week during the 5-week treatment period, and at follow-up 1 week, 6 months, and 12 months after intervention. The majority of ineligible patients had too little paresis, were on anticoagulants, or had a stroke >60 days prior to entry. Participants (EG, n = 7, age 70.3 ± 10 years, 5 women, 37.9 ± 9 days after stroke; CG, n = 9, age 65.2 ± 17 years, 3 women, 40.3 ± 9 days after stroke) did not differ at baseline except for the leg subscale. Analysis of variance from baseline to 1 week follow-up revealed significant improvements in favor of EG for subscales ADL (P = .023) and arm function (P = .020) at end of treatment. No adverse events were detected. In this small trial that was based on prior positive trials, significant gains in ADL and arm function suggest that the dose and timing of dexamphetamine can augment physiotherapy. Effect size calculation suggests inclusion of at least 25 patients per group in future studies.

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.

Intravenous thrombolysis and endovascular therapy for acute ischemic stroke with internal carotid artery occlusion: a systematic review of clinical outcomes.

PubMed

Mokin, Maxim; Kass-Hout, Tareq; Kass-Hout, Omar; Dumont, Travis M; Kan, Peter; Snyder, Kenneth V; Hopkins, L Nelson; Siddiqui, Adnan H; Levy, Elad I

2012-09-01

Strokes secondary to acute internal carotid artery (ICA) occlusion are associated with extremely poor prognosis. The best treatment approach to acute stroke in this setting is unknown. We sought to determine clinical outcomes in patients with acute ischemic stroke attributable to ICA occlusion treated with intravenous (IV) systemic thrombolysis or intra-arterial endovascular therapy. Using the PubMed database, we searched for studies that included patients with acute ischemic stroke attributable to ICA occlusion who received treatment with IV thrombolysis or intra-arterial endovascular interventions. Studies providing data on functional outcomes beyond 30 days and mortality and symptomatic intracerebral hemorrhage (sICH) rates were included in our analysis. We compared the proportions of patients with favorable functional outcomes, sICH, and mortality rates in the 2 treatment groups by calculating χ(2) and confidence intervals for odds ratios. We identified 28 studies with 385 patients in the IV thrombolysis group and 584 in the endovascular group. Rates of favorable outcomes and sICH were significantly higher in the endovascular group than the IV thrombolysis-only group (33.6% vs 24.9%, P=0.004 and 11.1% vs 4.9%, P=0.001, respectively). No significant difference in mortality rate was found between the groups (27.3% in the IV thrombolysis group vs 32.0% in the endovascular group; P=0.12). According to our systematic review, endovascular treatment of acute ICA occlusion results in improved clinical outcomes. A higher rate of sICH after endovascular treatment does not result in increased overall mortality rate.

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

Hemorrhagic versus ischemic stroke: Who can best benefit from blended conventional physiotherapy with robotic-assisted gait therapy?

PubMed

Dierick, Frédéric; Dehas, Mélanie; Isambert, Jean-Luc; Injeyan, Soizic; Bouché, Anne-France; Bleyenheuft, Yannick; Portnoy, Sigal

2017-01-01

Contrary to common belief of clinicians that hemorrhagic stroke survivors have better functional prognoses than ischemic, recent studies show that ischemic survivors could experience similar or even better functional improvements. However, the influence of stroke subtype on gait and posture outcomes following an intervention blending conventional physiotherapy with robotic-assisted gait therapy is missing. This study compared gait and posture outcome measures between ambulatory hemorrhagic patients and ischemic patients, who received a similar 4 weeks' intervention blending a conventional bottom-up physiotherapy approach and an exoskeleton top-down robotic-assisted gait training (RAGT) approach with Lokomat. Forty adult hemiparetic stroke inpatient subjects were recruited: 20 hemorrhagic and 20 ischemic, matched by age, gender, side of hemisphere lesion, stroke severity, and locomotor impairments. Functional Ambulation Category, Postural Assessment Scale for Stroke, Tinetti Performance Oriented Mobility Assessment, 6 Minutes Walk Test, Timed Up and Go and 10-Meter Walk Test were performed before and after a 4-week long intervention. Functional gains were calculated for all tests. Hemorrhagic and ischemic subjects showed significant improvements in Functional Ambulation Category (P<0.001 and P = 0.008, respectively), Postural Assessment Scale for Stroke (P<0.001 and P = 0.003), 6 Minutes Walk Test (P = 0.003 and P = 0.015) and 10-Meter Walk Test (P = 0.001 and P = 0.024). Ischemic patients also showed significant improvements in Timed Up and Go. Significantly greater mean Functional Ambulation Category and Tinetti Performance Oriented Mobility Assessment gains were observed for hemorrhagic compared to ischemic, with large (dz = 0.81) and medium (dz = 0.66) effect sizes, respectively. Overall, both groups exhibited quasi similar functional improvements and benefits from the same type, length and frequency of blended conventional physiotherapy and RAGT protocol. The use of intensive treatment plans blending top-down physiotherapy and bottom-up robotic approaches is promising for post-stroke rehabilitation.

Hemorrhagic versus ischemic stroke: Who can best benefit from blended conventional physiotherapy with robotic-assisted gait therapy?

PubMed Central

Dehas, Mélanie; Isambert, Jean-Luc; Injeyan, Soizic; Bouché, Anne-France; Bleyenheuft, Yannick; Portnoy, Sigal

2017-01-01

Background Contrary to common belief of clinicians that hemorrhagic stroke survivors have better functional prognoses than ischemic, recent studies show that ischemic survivors could experience similar or even better functional improvements. However, the influence of stroke subtype on gait and posture outcomes following an intervention blending conventional physiotherapy with robotic-assisted gait therapy is missing. Objective This study compared gait and posture outcome measures between ambulatory hemorrhagic patients and ischemic patients, who received a similar 4 weeks’ intervention blending a conventional bottom-up physiotherapy approach and an exoskeleton top-down robotic-assisted gait training (RAGT) approach with Lokomat. Methods Forty adult hemiparetic stroke inpatient subjects were recruited: 20 hemorrhagic and 20 ischemic, matched by age, gender, side of hemisphere lesion, stroke severity, and locomotor impairments. Functional Ambulation Category, Postural Assessment Scale for Stroke, Tinetti Performance Oriented Mobility Assessment, 6 Minutes Walk Test, Timed Up and Go and 10-Meter Walk Test were performed before and after a 4-week long intervention. Functional gains were calculated for all tests. Results Hemorrhagic and ischemic subjects showed significant improvements in Functional Ambulation Category (P<0.001 and P = 0.008, respectively), Postural Assessment Scale for Stroke (P<0.001 and P = 0.003), 6 Minutes Walk Test (P = 0.003 and P = 0.015) and 10-Meter Walk Test (P = 0.001 and P = 0.024). Ischemic patients also showed significant improvements in Timed Up and Go. Significantly greater mean Functional Ambulation Category and Tinetti Performance Oriented Mobility Assessment gains were observed for hemorrhagic compared to ischemic, with large (dz = 0.81) and medium (dz = 0.66) effect sizes, respectively. Conclusion Overall, both groups exhibited quasi similar functional improvements and benefits from the same type, length and frequency of blended conventional physiotherapy and RAGT protocol. The use of intensive treatment plans blending top-down physiotherapy and bottom-up robotic approaches is promising for post-stroke rehabilitation. PMID:28575054

Telerehabilitation to improve outcomes for people with stroke: study protocol for a randomised controlled trial

PubMed Central

2012-01-01

Background In New Zealand, around 45,000 people live with stroke and many studies have reported that benefits gained during initial rehabilitation are not sustained. Evidence indicates that participation in physical interventions can prevent the functional decline that frequently occurs after discharge from acute care facilities. However, on-going stroke services provision following discharge from acute care is often related to non-medical factors such as availability of resources and geographical location. Currently most people receive no treatment beyond three months post stroke. The study aims to determine if the Augmented Community Telerehabilitation Intervention (ACTIV) results in better physical function for people with stroke than usual care, as measured by the Stroke Impact Scale, physical subcomponent. Methods/design This study will use a multi-site, two-arm, assessor blinded, parallel randomised controlled trial design. People will be eligible if they have had their first ever stroke, are over 20 and have some physical impairment in either arm or leg, or both. Following discharge from formal physiotherapy services (inpatient, outpatient or community), participants will be randomised into ACTIV or usual care. ACTIV uses readily available technology, telephone and mobile phones, combined with face-to-face visits from a physiotherapist over a six-month period, to help people with stroke resume activities they enjoyed before the stroke. The impact of stroke on physical function and quality of life will be assessed, measures of cost will be collected and a discrete choice survey will be used to measure preferences for rehabilitation options. These outcomes will be collected at baseline, six months and 12 months. In-depth interviews will be used to explore the experiences of people participating in the intervention arm of the study. Discussion The lack of on-going rehabilitation for people with stroke diminishes the chance of their best possible outcome and may contribute to a functional decline following discharge from formal rehabilitation. Best practice guidelines recommend a prolonged period of rehabilitation, however this is expensive and therefore not undertaken in most publicly funded centres. An effective, cost-effective, and preference-sensitive therapy using basic technology to assist programme delivery may improve patient autonomy as they leave formal rehabilitation and return home. Trial registration ACTRN12612000464864 PMID:23216861

Efficacy of robot-assisted rehabilitation for the functional recovery of the upper limb in post-stroke patients: a randomized controlled study.

PubMed

Taveggia, Giovanni; Borboni, Alberto; Salvi, Lorena; Mulé, Chiara; Fogliaresi, Stefania; Villafañe, Jorge H; Casale, Roberto

2016-12-01

A prompt and effective physical and rehabilitation medicine approach is essential to obtain recovery of an impaired limb to prevent tendon shortening, spasticity and pain. Robot-assisted virtual reality intervention has been shown to be more effective than conventional interventions and achieved greater improvement in upper limb function. The aim of this study was to evaluate the effectiveness of robotic-assisted motion and activity in addition to PRM for the rehabilitation of the upper limb in post-stroke inpatients. Randomized controlled trial. Departments of Physical and Rehabilitation Medicine from three different hospitals (Sarnico, Brescia; Bergamo; Milan). A total of 54 patients and enrolled 23 men and 31 women with post-stroke hemiparesis, aged 18 to 80 years old, enrolled from July 2014 to February 2015. Of the 54 enrolled patients, 57% were female (mean age 71±12 years), and all had upper limb function deficit post-stroke. The experimental group received a passive mobilization of the upper limb through the robotic device ARMEO Spring and the control group received PRM for 6 consecutive weeks (5 days/week) in addition to traditional PRM. We assessed the impact on functional recovery (Functional Independence Measure [FIM] scale), strength (Motricity Index [MI]), spasticity (Modified Ashworth Scale [MAS]) and pain (Numeric Rating Pain Scale [NRPS]). All patients were evaluated by a blinded observer using the outcomes tests at enrollment (T0), after the treatment (T1) and at follow up 6 weeks later (T2). Both control and experimental groups evidenced an improvement of the outcomes after the treatment (MI, Ashworth and NRPS with P<0.05). The experimental group showed further improvements after the follow up (all outcomes with P<0.01). In the treatment of pain, disability and spasticity in upper limb after stroke, robot-assisted mobilization associated to PRM is as effective as traditional rehabilitation. Robot-assisted treatment has an impact on upper limb motor function in stroke patients.

Mirror therapy for improving lower limb motor function and mobility after stroke: A systematic review and meta-analysis.

PubMed

Broderick, P; Horgan, F; Blake, C; Ehrensberger, M; Simpson, D; Monaghan, K

2018-06-01

Mirror therapy has been proposed as an effective intervention for lower limb rehabilitation post stroke. This systematic review with meta-analysis examined if lower limb mirror therapy improved the primary outcome measures of muscle tone and motor function and the secondary outcome measures balance characteristics, functional ambulation, walking velocity, passive range of motion (PROM) for ankle dorsiflexion and gait characteristics in patients with stroke compared to other interventions. Standardised mean differences (SMD) and mean differences (MD) were used to assess the effect of mirror therapy on lower limb functioning. Nine studies were included in the review. Among the primary outcome measures there was evidence of a significant effect of mirror therapy on motor function compared with sham and non-sham interventions (SMD 0.54; 95% CI 0.24-0.93). Furthermore, among the secondary outcome measures there was evidence of a significant effect of mirror therapy for balance capacity (SMD -0.55; 95% CI -1.01 to -0.10), walking velocity (SMD 0.71; 95% CI 0.35-1.07), PROM for ankle dorsiflexion (SMD 1.20; 95% CI 0.71-1.69) and step length (SMD 0.56; 95% CI -0.00 to 1.12). The results indicate that using mirror therapy for the treatment of certain lower limb deficits in patients with stroke may have a positive effect. Although results are somewhat positive, overly favourable interpretation is cautioned due to methodological issues concerning included studies. Copyright © 2018 Elsevier B.V. All rights reserved.

Impact of spontaneous intracerebral hemorrhage on cognitive functioning: An update.

PubMed

Planton, M; Raposo, N; Danet, L; Albucher, J-F; Péran, P; Pariente, J

Intracerebral hemorrhage (ICH) accounts for 15% of all strokes and approximately 50% of stroke-related mortality and disability worldwide. Patients who have experienced ICH are at high risk of negative outcome, including stroke and cognitive disorders. Vascular cognitive impairment are frequently seen after brain hemorrhage, yet little is known about them, as most studies have focused on neuropsychological outcome in ischemic stroke survivors, using well-documented acute and chronic cognitive scores. However, recent evidence supports the notion that ICH and dementia are closely related and each increases the risk of the other. The location of the lesion also plays a significant role as regards the neuropsychological profile, while the pathophysiology of ICH can indicate a specific pattern of dysfunction. Several cognitive domains may be affected, such as language, memory, executive function, processing speed and gnosis. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

Patient dissatisfaction with acute stroke care.

PubMed

Asplund, Kjell; Jonsson, Fredrik; Eriksson, Marie; Stegmayr, Birgitta; Appelros, Peter; Norrving, Bo; Terént, Andreas; Asberg, Kerstin Hulter

2009-12-01

Riks-Stroke, the Swedish Stroke Register, was used to explore patient characteristics and stroke services as determinants of patient dissatisfaction with acute in-hospital care. All 79 hospitals in Sweden admitting acute stroke patients participate in Riks-Stroke. During 2001 to 2007, 104,876 patients (87% of survivors) responded to a follow-up questionnaire 3 months after acute stroke; this included questions on satisfaction with various aspects of stroke care. The majority (>90%) were satisfied with acute in-hospital stroke care. Dissatisfaction was closely associated with outcome at 3 months. Patient who were dependent regarding activities of daily living, felt depressed, or had poor self-perceived general health were more likely to be dissatisfied. Dissatisfaction with global acute stroke care was linked to dissatisfaction with other aspects of care, including rehabilitation and support by community services. Patients treated in stroke units were less often dissatisfied than patients in general wards, as were patients who had been treated in a small hospital (vs medium or large hospitals) and patient who had participated in discharge planning. In multivariate analyses, the strongest predictor of dissatisfaction with acute care was poor outcome (dependency regarding activities of daily living, depressed mood, poor self-perceived health). Dissatisfaction with in-hospital acute stroke care is part of a more extensive complex comprising poor functional outcome, depressive mood, poor self-perceived general health, and dissatisfaction not only with acute care but also with health care and social services at large. Several aspects of stroke care organization are associated with a lower risk of dissatisfaction.

Methodology of the Stroke Self-Management Rehabilitation Trial: an international, multisite pilot trial.

PubMed

Jones, Kelly M; Bhattacharjee, Rohit; Krishnamurthi, Rita; Blanton, Sarah; Theadom, Alice; Barker-Collo, Suzanne; Thrift, Amanda; Parmar, Priya; Maujean, Annick; Ranta, Annemarei; Sanya, Emmanuel; Feigin, Valery L

2015-02-01

Stroke is a major cause of long-term adult disability with many survivors living in the community relying on family members for on-going support. However, reports of inadequate understanding of rehabilitation techniques are common. A self-management DVD-based observational learning tool may help improve functional outcomes for survivors of stroke and reduce caregivers' burden. This article describes the methodology of the stroke self-management rehabilitation trial. The overall aim of this pilot trial is to assess the feasibility and preliminary efficacy of a DVD-based intervention for improving functional outcomes of survivors of stroke 2 months postrandomization to inform the design of a full-scale randomized clinical trial. Recruitment of a minimum of 20 survivors of stroke and their informal caregivers (where available) in each of the participating centers will occur across multiple international sites. After baseline assessments, participants will be randomly assigned to an intervention or standard care group. The intervention comprises a structured DVD observation and practice schedule over 8 weeks. All participants will complete follow-up assessments. The outcome measures will include a global shift in the Rankin Scale scores and dichotomized scores, changes in quality of life, general health, depression, and caregiver burden at 2 months postrandomization. A qualitative analysis of the effects of the intervention will also be undertaken. The results of the pilot study will provide knowledge of whether observational learning techniques delivered via DVD can effectively improve recovery after stroke and reduce caregiver burden. Copyright © 2015 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Characteristics and Outcomes of Very Elderly Enrolled in a Prehospital Stroke Research Study.

PubMed

Sanossian, Nerses; Apibunyopas, Kathleen C; Liebeskind, David S; Starkman, Sidney; Burgos, Adrian M; Conwit, Robin; Eckstein, Marc; Pratt, Frank; Stratton, Sam; Hamilton, Scott; Saver, Jeffrey L

2016-11-01

Greater numbers of individuals aged ≥80 years enjoy a high quality of life, yet historically stroke trials have excluded this population. We aimed to describe a population of very elderly successfully enrolled into an acute stroke trial and compare their characteristics and outcomes with the younger cohort. We analyzed consecutive patients enrolled <2 hours of symptom onset in a prehospital stroke treatment trial, the FAST-MAG clinical trial (Field Administration of Stroke Therapy-Magnesium). We gathered demographic, treatment, and outcome data for nonelderly (<80 years old), very elderly (≥80 years old), and extreme elderly (≥90 years old). We describe key differences in the population of elderly and the impact of their inclusion on the clinical trial. Of 1700 participants in FAST-MAG, there were 1210 nonelderly, 490 very elderly, and 60 extreme elderly subjects. Very elderly stroke patients successfully enrolled in a research study were more likely to be women, white, and have an ischemic mechanism rather than an intracerebral hemorrhage. Although the very elderly had generally poorer outcomes, 4 in 10 were functionally independent at 90 days. Inclusion of the very elderly population in acute stroke clinical trials would both significantly increase study participation and generalizability of future acute stroke clinical trials. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00059332. © 2016 American Heart Association, Inc.

Endovascular Mechanical Thrombectomy in Large-Vessel Occlusion Ischemic Stroke Presenting with Low National Institutes of Health Stroke Scale: Systematic Review and Meta-Analysis.

PubMed

Griessenauer, Christoph J; Medin, Caroline; Maingard, Julian; Chandra, Ronil V; Ng, Wyatt; Brooks, Duncan Mark; Asadi, Hamed; Killer-Oberpfalzer, Monika; Schirmer, Clemens M; Moore, Justin M; Ogilvy, Christopher S; Thomas, Ajith J; Phan, Kevin

2018-02-01

Mechanical thrombectomy has become the standard of care for management of most large vessel occlusion (LVO) strokes. When patients with LVO present with minor stroke symptomatology, no consensus on the role of mechanical thrombectomy exists. A systematic review and meta-analysis were performed to identify studies that focused on mechanical thrombectomy, either as a standalone treatment or with intravenous tissue plasminogen activator (IV tPA), in patients with mild strokes with LVO, defined as a baseline National Institutes of Health Stroke Scale score ≤5 at presentation. Data on methodology, quality criteria, and outcome measures were extracted, and outcomes were compared using odds ratio as a summary statistic. Five studies met the selection criteria and were included. When compared with medical therapy without IV tPA, mechanical thrombectomy and medical therapy with IV tPA were associated with improved 90-day modified Rankin Scale (mRS) score. Among medical patients who were not eligible for IV tPA, those who underwent mechanical thrombectomy were more likely to experience good 90-day mRS than those who were not. There was no significant difference in functional outcome between mechanical thrombectomy and medical therapy with IV tPA, and no treatment subgroup was associated with intracranial hemorrhage or death. In patients with mild strokes due to LVO, mechanical thrombectomy and medical therapy with IV tPA led to better 90-day functional outcome. Mechanical thrombectomy plays an important role in the management of these patients, particularly in those not eligible for IV tPA. Copyright © 2017 Elsevier Inc. All rights reserved.

Alterations of the Ceramide Metabolism in the Peri-Infarct Cortex Are Independent of the Sphingomyelinase Pathway and Not Influenced by the Acid Sphingomyelinase Inhibitor Fluoxetine.

PubMed

Brunkhorst, R; Friedlaender, F; Ferreirós, N; Schwalm, S; Koch, A; Grammatikos, G; Toennes, S; Foerch, C; Pfeilschifter, J; Pfeilschifter, W

2015-01-01

Ceramides induce important intracellular signaling pathways, modulating proliferation, migration, apoptosis, and inflammation. However, the relevance of the ceramide metabolism in the reconvalescence phase after stroke is unclear. Besides its well-known property as a selective serotonin reuptake inhibitor, fluoxetine has been reported to inhibit the acid sphingomyelinase (ASM), a key regulator of ceramide levels which derives ceramide from sphingomyelin. Furthermore, fluoxetine has shown therapeutic potential in a randomized controlled rehabilitation trial in stroke patients. Our aim was to investigate and modulate ceramide concentrations in the peri-infarct cortex, whose morphological and functional properties correlate with long-term functional outcome in stroke. We show that certain ceramide species are modulated after experimental stroke and that these changes do not result from alterations of ASM activity, but rather from nontranscriptional induction of the ceramide de novo pathway. Unexpectedly, although reducing lesion size, fluoxetine did not improve functional outcome in our model and had no significant influence on ASM activity or the concentration of ceramides. The ceramide metabolism could emerge as a potential therapeutic target in the reconvalescence phase after stroke, as its accumulation in the peri-infarct cortex potentially influences membrane functions as well as signaling events in the tissue essential for neurological recovery.

Translating knowledge for action against stroke--using 5-minute videos for stroke survivors and caregivers to improve post-stroke outcomes: study protocol for a randomized controlled trial (Movies4Stroke).

PubMed

Kamal, Ayeesha Kamran; Khoja, Adeel; Usmani, Bushra; Muqeet, Abdul; Zaidi, Fabiha; Ahmed, Masood; Shakeel, Saadia; Soomro, Nabila; Gowani, Ambreen; Asad, Nargis; Ahmed, Asma; Sayani, Saleem; Azam, Iqbal; Saleem, Sarah

2016-01-27

Two thirds of the global mortality of stroke is borne by low and middle income countries (LMICs). Pakistan is the world's sixth most populous country with a stroke-vulnerable population and is without a single dedicated chronic care center. In order to provide evidence for a viable solution responsive to this health care gap, and leveraging the existing >70% mobile phone density, we thought it rational to test the effectiveness of a mobile phone-based video intervention of short 5-minute movies to educate and support stroke survivors and their primary caregivers. Movies4Stroke will be a randomized control, outcome assessor blinded, parallel group, single center superiority trial. Participants with an acute stroke, medically stable, with mild to moderate disability and having a stable primary caregiver will be included. After obtaining informed consent the stroke survivor-caregiver dyad will be randomized. Intervention participants will have the movie program software installed in their phone, desktop, or Android device which will allow them to receive, view and repeat 5-minute videos on stroke-related topics at admission, discharge and first and third months after enrollment. The control arm will receive standard of care at an internationally accredited center with defined protocols. The primary outcome measure is medication adherence as ascertained by a locally validated Morisky Medication Adherence Scale and control of major risk factors such as blood pressure, blood sugar and blood cholesterol at 12 months post discharge. Secondary outcome measures are post-stroke complications and mortality, caregiver knowledge and change in functional outcomes after acute stroke at 1, 3, 6, 9 and 12 months. Movies4Stroke is designed to enroll 300 participant dyads after inflating 10% to incorporate attrition and non-compliance and has been powered at 95% to detect a 15% difference between intervention and usual care arm. Analysis will be done by the intention-to-treat principle. Movies4Stroke is a randomized trial testing an application aimed at supporting caregivers and stroke survivors in a LMIC with no rehabilitation or chronic support systems. NCT02202330 (28 January 2015).

Impaired Cerebral Autoregulation Is Associated with Brain Atrophy and Worse Functional Status in Chronic Ischemic Stroke

PubMed Central

Aoi, Mikio C.; Hu, Kun; Lo, Men-Tzung; Selim, Magdy; Olufsen, Mette S.; Novak, Vera

2012-01-01

Dynamic cerebral autoregulation (dCA) is impaired following stroke. However, the relationship between dCA, brain atrophy, and functional outcomes following stroke remains unclear. In this study, we aimed to determine whether impairment of dCA is associated with atrophy in specific regions or globally, thereby affecting daily functions in stroke patients. We performed a retrospective analysis of 33 subjects with chronic infarctions in the middle cerebral artery territory, and 109 age-matched non-stroke subjects. dCA was assessed via the phase relationship between arterial blood pressure and cerebral blood flow velocity. Brain tissue volumes were quantified from MRI. Functional status was assessed by gait speed, instrumental activities of daily living (IADL), modified Rankin Scale, and NIH Stroke Score. Compared to the non-stroke group, stroke subjects showed degraded dCA bilaterally, and showed gray matter atrophy in the frontal, parietal and temporal lobes ipsilateral to infarct. In stroke subjects, better dCA was associated with less temporal lobe gray matter atrophy on the infracted side ( = 0.029), faster gait speed ( = 0.018) and lower IADL score (0.002). Our results indicate that better dynamic cerebral perfusion regulation is associated with less atrophy and better long-term functional status in older adults with chronic ischemic infarctions. PMID:23071639

Effects of an aquatic therapy approach (Halliwick-Therapy) on functional mobility in subacute stroke patients: a randomized controlled trial.

PubMed

Tripp, Florian; Krakow, Karsten

2014-05-01

To evaluate the effects of an aquatic physiotherapy method (Halliwick-Therapy) upon mobility in the post-acute phase of stroke rehabilitation. Randomized controlled trial. Hospital for neurological rehabilitation. Adult patients after first-ever stroke in post-acute inpatient rehabilitation at least two weeks after the onset of stroke (n = 30). In the Halliwick-Therapy group (n = 14) the treatment over a period of two weeks included 45 minutes of aquatic therapy three times per week and a conventional physiotherapeutic treatment twice a week. Subjects in the control group (n = 16) received conventional physiotherapeutic treatment over a period of two weeks five times per week. The primary outcome variable was postural stability (Berg Balance Scale). Secondary outcome variables were functional reach, functional gait ability and basic functional mobility. Compared to the control group, significantly more subjects in the Halliwick-Therapy group (83.3% versus 46.7%) attained significant improvement of the Berg Balance Scale (P < 0.05). Improvement of the functional gait ability was significantly higher in the Halliwick-Therapy group (mean (SD) 1.25(0.86)) than in the control group (mean (SD) 0.73 (0.70)) (P < 0.1). The mean differences of improvements in functional reach and basic functional mobility were not statistically significant between groups. This study indicates that Halliwick-Therapy is safe and well tolerated in stroke patients in post-acute rehabilitation and has positive effects upon some aspects of mobility.

Body temperature and response to thrombolytic therapy in acute ischaemic stroke.

PubMed

Millán, M; Grau, L; Castellanos, M; Rodríguez-Yáñez, M; Arenillas, J F; Nombela, F; Pérez de la Ossa, N; López-Manzanares, L; Serena, J; Castillo, J; Dávalos, A

2008-12-01

To determine the relationship between body temperature (BT), arterial recanalization, functional outcome, and hemorrhagic transformation (HT) of cerebral infarction in patients treated with i.v. tissue plasminogen activator (tPA). We studied 254 patients treated with tPA within 3 h from stroke onset. National Institute of Health Stroke Scale score, BT, and transcranial Doppler ultrasound (n = 99) on admission and at 24 h were recorded. Hypodensity volume and HT were evaluated on CT at 24-36 h. Poor outcome (Rankin Scale > 2) was evaluated at 3 months. Arterial recanalization at 24 h was found in 70.7% of patients, HT in 24.8% (symptomatic in 4.7%) and poor outcome in 44.1%. Baseline BT was not associated with greater stroke severity at admission or at 24 h, HT or poor outcome. However, BT at 24 h correlated to stroke severity (P < 0.001) and hypodensity volume (P < 0.001) at 24 h, and was higher in patients who did not recanalize (P = 0.001), had symptomatic HT (P = 0.063) and poor outcome (P < 0.001). The adjusted odds ratio of poor outcome for patients with BT at 24 h > or = 37 degrees C was 2.56 (1.19-5.50, P = 0.016). Body temperature > or =37 degrees C at 24 h, but not at baseline, is associated with a lack of recanalization, greater hypodensity volume and worse outcome in stroke patients treated with tPA.

Translational MR Neuroimaging of Stroke and Recovery

PubMed Central

Mandeville, Emiri T.; Ayata, Cenk; Zheng, Yi; Mandeville, Joseph B.

2016-01-01

Multiparametric magnetic resonance imaging (MRI) has become a critical clinical tool for diagnosing focal ischemic stroke severity, staging treatment, and predicting outcome. Imaging during the acute phase focuses on tissue viability in the stroke vicinity, while imaging during recovery requires the evaluation of distributed structural and functional connectivity. Preclinical MRI of experimental stroke models provides validation of non-invasive biomarkers in terms of cellular and molecular mechanisms, while also providing a translational platform for evaluation of prospective therapies. This brief review of translational stroke imaging discusses the acute to chronic imaging transition, the principles underlying common MRI methods employed in stroke research, and experimental results obtained by clinical and preclinical imaging to determine tissue viability, vascular remodeling, structural connectivity of major white matter tracts, and functional connectivity using task-based and resting-state fMRI during the stroke recovery process. PMID:27578048

The influence of functional electrical stimulation on hand motor recovery in stroke patients: a review.

PubMed

Quandt, Fanny; Hummel, Friedhelm C

2014-01-01

Neuromuscular stimulation has been used as one potential rehabilitative treatment option to restore motor function and improve recovery in patients with paresis. Especially stroke patients who often regain only limited hand function would greatly benefit from a therapy that enhances recovery and restores movement. Multiple studies investigated the effect of functional electrical stimulation on hand paresis, the results however are inconsistent. Here we review the current literature on functional electrical stimulation on hand motor recovery in stroke patients. We discuss the impact of different parameters such as stage after stoke, degree of impairment, spasticity and treatment protocols on the functional outcome. Importantly, we outline the results from recent studies investigating the cortical effects elicited by functional electrical stimulation giving insights into the underlying mechanisms responsible for long-term treatment effects. Bringing together the findings from present research it becomes clear that both, treatment outcomes as well as the neurophysiologic mechanisms causing functional recovery, vary depending on patient characteristics. In order to develop unified treatment guidelines it is essential to conduct homogenous studies assessing the impact of different parameters on rehabilitative success.

The influence of functional electrical stimulation on hand motor recovery in stroke patients: a review

PubMed Central

2014-01-01

Neuromuscular stimulation has been used as one potential rehabilitative treatment option to restore motor function and improve recovery in patients with paresis. Especially stroke patients who often regain only limited hand function would greatly benefit from a therapy that enhances recovery and restores movement. Multiple studies investigated the effect of functional electrical stimulation on hand paresis, the results however are inconsistent. Here we review the current literature on functional electrical stimulation on hand motor recovery in stroke patients. We discuss the impact of different parameters such as stage after stoke, degree of impairment, spasticity and treatment protocols on the functional outcome. Importantly, we outline the results from recent studies investigating the cortical effects elicited by functional electrical stimulation giving insights into the underlying mechanisms responsible for long-term treatment effects. Bringing together the findings from present research it becomes clear that both, treatment outcomes as well as the neurophysiologic mechanisms causing functional recovery, vary depending on patient characteristics. In order to develop unified treatment guidelines it is essential to conduct homogenous studies assessing the impact of different parameters on rehabilitative success. PMID:25276333

Insulin Resistance and Prognosis of Nondiabetic Patients With Ischemic Stroke: The ACROSS-China Study (Abnormal Glucose Regulation in Patients With Acute Stroke Across China).

PubMed

Jing, Jing; Pan, Yuesong; Zhao, Xingquan; Zheng, Huaguang; Jia, Qian; Mi, Donghua; Chen, Weiqi; Li, Hao; Liu, Liping; Wang, Chunxue; He, Yan; Wang, David; Wang, Yilong; Wang, Yongjun

2017-04-01

Insulin resistance was common in patients with stroke. This study investigated the association between insulin resistance and outcomes in nondiabetic patients with first-ever acute ischemic stroke. Patients with ischemic stroke without history of diabetes mellitus in the ACROSS-China registry (Abnormal Glucose Regulation in Patients With Acute Stroke Across China) were included. Insulin resistance was defined as a homeostatis model assessment-insulin resistance (HOMA-IR) index in the top quartile (Q4). HOMA-IR was calculated as fasting insulin (μU/mL)×fasting glucose (mmol/L)/22.5. Multivariable logistic regression or Cox regression was performed to estimate the association between HOMA-IR and 1-year prognosis (mortality, stroke recurrence, poor functional outcome [modified Rankin scale score 3-6], and dependence [modified Rankin scale score 3-5]). Among the 1245 patients with acute ischemic stroke enrolled in this study, the median HOMA-IR was 1.9 (interquartile range, 1.1-3.1). Patients with insulin resistance were associated with a higher mortality risk than those without (adjusted hazard ratio, 1.68; 95% confidence interval, 1.12-2.53; P =0.01), stroke recurrence (adjusted hazard ratio, 1.57, 95% confidence interval, 1.12-2.19; P =0.008), and poor outcome (adjusted odds ratio, 1.42; 95% confidence interval, 1.03-1.95; P =0.03) but not dependence after adjustment for potential confounders. Higher HOMA-IR quartile categories were associated with a higher risk of 1-year death, stroke recurrence, and poor outcome ( P for trend =0.005, 0.005, and 0.001, respectively). Insulin resistance was associated with an increased risk of death, stroke recurrence, and poor outcome but not dependence in nondiabetic patients with acute ischemic stroke. © 2017 American Heart Association, Inc.

Assessing the impact of health literacy on education retention of stroke patients.

PubMed

Sanders, Kalina; Schnepel, Loretta; Smotherman, Carmen; Livingood, William; Dodani, Sunita; Antonios, Nader; Lukens-Bull, Katryne; Balls-Berry, Joyce; Johnson, Yvonne; Miller, Terri; Hodges, Wayne; Falk, Diane; Wood, David; Silliman, Scott

2014-04-10

Inadequate health literacy is a pervasive problem with major implications for reduced health status and health disparities. Despite the role of focused education in both primary and secondary prevention of stroke, the effect of health literacy on stroke education retention has not been reported. We examined the relationship of health literacy to the retention of knowledge after recommended stroke education. This prospective cross-sectional study was conducted at an urban safety-net hospital. Study subjects were patients older than 18 admitted to the hospital stroke unit with a diagnosis of acute ischemic stroke who were able to provide informed consent to participate (N = 100). Health literacy levels were measured by using the short form of Test of Functional Health Literacy in Adults. Patient education was provided to patients at an inpatient stroke unit by using standardized protocols, in compliance with Joint Commission specifications. The education outcomes for poststroke care education, knowledge retention, was assessed for each subject. The effect of health literacy on the Stroke Patient Education Retention scores was assessed by using univariate and multivariate analyses. Of the 100 participating patients, 59% had inadequate to marginal health literacy. Stroke patients who had marginal health literacy (mean score, 7.45; standard deviation [SD], 1.9) or adequate health literacy (mean score, 7.31; SD, 1.76) had statistically higher education outcome scores than those identified as having inadequate health literacy (mean score, 5.58; SD, 2.06). Results from multivariate analysis indicated that adequate health literacy was most predictive of education outcome retention. This study demonstrated a clear relationship between health literacy and stroke education outcomes. Studies are needed to better understand the relationship of health literacy to key educational outcomes for primary or secondary prevention of stroke and to refine stroke education for literacy levels of high-risk populations.

Transthyretin Concentrations in Acute Stroke Patients Predict Convalescent Rehabilitation.

PubMed

Isono, Naofumi; Imamura, Yuki; Ohmura, Keiko; Ueda, Norihide; Kawabata, Shinji; Furuse, Motomasa; Kuroiwa, Toshihiko

2017-06-01

For stroke patients, intensive nutritional management is an important and effective component of inpatient rehabilitation. Accordingly, acute care hospitals must detect and prevent malnutrition at an early stage. Blood transthyretin levels are widely used as a nutritional monitoring index in critically ill patients. Here, we had analyzed the relationship between the transthyretin levels during the acute phase and Functional Independence Measure in stroke patients undergoing convalescent rehabilitation. We investigated 117 patients who were admitted to our hospital with acute ischemic or hemorrhagic stroke from February 2013 to October 2015 and subsequently transferred to convalescent hospitals after receiving acute treatment. Transthyretin concentrations were evaluated at 3 time points as follows: at admission, and 5 and 10 days after admission. After categorizing patients into 3 groups according to the minimum transthyretin level, we analyzed the association between transthyretin and Functional Independence Measure. In our patients, transthyretin levels decreased during the first 5 days after admission and recovered slightly during the subsequent 5 days. Notably, Functional Independence Measure efficiency was significantly associated with the decrease in transthyretin levels during the 5 days after admission. Patients with lower transthyretin levels had poorer Functional Independence Measure outcomes and tended not to be discharged to their own homes. A minimal transthyretin concentration (<10 mg/dL) is predictive of a poor outcome in stroke patients undergoing convalescent rehabilitation. In particular, an early decrease in transthyretin levels suggests restricted rehabilitation efficiency. Accordingly, transthyretin levels should be monitored in acute stroke patients to indicate mid-term rehabilitation prospects. Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Exercise Training and Recreational Activities to Promote Executive Functions in Chronic Stroke: A Proof-of-Concept Study

PubMed Central

Liu-Ambrose, Teresa; Eng, Janice J

2015-01-01

Background Stroke survivors represent a target population in need of intervention strategies to promote cognitive function and prevent dementia. Both exercise and recreational activities are promising strategies. We assessed the effect of a six-month exercise and recreation program on executive functions in adults with chronic stroke. Methods A six-month ancillary study within a multi-centre randomized trial. Twenty-eight chronic stroke survivors (i.e., ≥ 12 months since an index stroke) were randomized to one of two experimental groups: intervention (INT; n=12) or delayed intervention (D-INT; n=16). Participants of the INT group received a six-month community-based structured program that included two sessions of exercise training and one session of recreation and leisure activities per week. Participants of the D-INT group received usual care. The primary outcome measure was the Stroop Test, a cognitive test of selective attention and conflict resolution. Secondary cognitive measures included set shifting and working memory. Mood, functional capacity, and general balance and mobility were additional secondary outcome measures. Results Compared with the D-INT group, the INT group significantly improved selective attention and conflict resolution (p=0.02), working memory (p=0.04), and functional capacity (p=0.02) at the end of the six-month intervention period. Improved selective attention and conflict resolution was significantly associated with functional capacity at six months (r=0.39; p=0.04). Conclusions This is the first randomized study to demonstrate that an exercise and recreation program can significantly benefit executive functions in community-dwelling chronic stroke survivors who are mildly cognitively impaired – a population at high-risk for dementia and functional decline. Thus, clinicians should consider prescribing exercise and recreational activities in the cognitive rehabilitation of chronic stroke survivors. Clinical Trial Registration http://clinicaltrials.gov. Unique identifier: NCT01085240. PMID:25440324

Thrombolysis ImPlementation in Stroke (TIPS): evaluating the effectiveness of a strategy to increase the adoption of best evidence practice – protocol for a cluster randomised controlled trial in acute stroke care

PubMed Central

2014-01-01

Background Stroke is a leading cause of death and disability internationally. One of the three effective interventions in the acute phase of stroke care is thrombolytic therapy with tissue plasminogen activator (tPA), if given within 4.5 hours of onset to appropriate cases of ischaemic stroke. Objectives To test the effectiveness of a multi-component multidisciplinary collaborative approach compared to usual care as a strategy for increasing thrombolysis rates for all stroke patients at intervention hospitals, while maintaining accepted benchmarks for low rates of intracranial haemorrhage and high rates of functional outcomes for both groups at three months. Methods and design A cluster randomised controlled trial of 20 hospitals across 3 Australian states with 2 groups: multi- component multidisciplinary collaborative intervention as the experimental group and usual care as the control group. The intervention is based on behavioural theory and analysis of the steps, roles and barriers relating to rapid assessment for thrombolysis eligibility; it involves a comprehensive range of strategies addressing individual-level and system-level change at each site. The primary outcome is the difference in tPA rates between the two groups post-intervention. The secondary outcome is the proportion of tPA treated patients in both groups with good functional outcomes (modified Rankin Score (mRS <2) and the proportion with intracranial haemorrhage (mRS ≥2), compared to international benchmarks. Discussion TIPS will trial a comprehensive, multi-component and multidisciplinary collaborative approach to improving thrombolysis rates at multiple sites. The trial has the potential to identify methods for optimal care which can be implemented for stroke patients during the acute phase. Study findings will include barriers and solutions to effective thrombolysis implementation and trial outcomes will be published whether significant or not. Trial registration Australian New Zealand Clinical Trials Registry: ACTRN12613000939796 PMID:24666591

Development and validation of clinical prediction models for mortality, functional outcome and cognitive impairment after stroke: a study protocol.

PubMed

Fahey, Marion; Rudd, Anthony; Béjot, Yannick; Wolfe, Charles; Douiri, Abdel

2017-08-18

Stroke is a leading cause of adult disability and death worldwide. The neurological impairments associated with stroke prevent patients from performing basic daily activities and have enormous impact on families and caregivers. Practical and accurate tools to assist in predicting outcome after stroke at patient level can provide significant aid for patient management. Furthermore, prediction models of this kind can be useful for clinical research, health economics, policymaking and clinical decision support. 2869 patients with first-ever stroke from South London Stroke Register (SLSR) (1995-2004) will be included in the development cohort. We will use information captured after baseline to construct multilevel models and a Cox proportional hazard model to predict cognitive impairment, functional outcome and mortality up to 5 years after stroke. Repeated random subsampling validation (Monte Carlo cross-validation) will be evaluated in model development. Data from participants recruited to the stroke register (2005-2014) will be used for temporal validation of the models. Data from participants recruited to the Dijon Stroke Register (1985-2015) will be used for external validation. Discrimination, calibration and clinical utility of the models will be presented. Patients, or for patients who cannot consent their relatives, gave written informed consent to participate in stroke-related studies within the SLSR. The SLSR design was approved by the ethics committees of Guy's and St Thomas' NHS Foundation Trust, Kings College Hospital, Queens Square and Westminster Hospitals (London). The Dijon Stroke Registry was approved by the Comité National des Registres and the InVS and has authorisation of the Commission Nationale de l'Informatique et des Libertés. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Community reintegration after stroke.

PubMed

Bhogal, Sanjit K; Teasell, Robert W; Foley, Norine C; Speechley, Mark R

2003-01-01

A systematic review of the literature from 1970-2002 was conducted to highlight the issues facing stroke survivors and their families upon integration into the community. Areas of interests were social support, caregiver burden and depression, family interactions, family education intervention, social and leisure activities post stroke, and leisure therapy. Four studies were selected for detailed reviews of the effectiveness of social support, 10 studies for family education intervention, and 3 studies for leisure therapy post stroke. There was evidence that improved social support as an intervention improves outcomes and that an active educational-counseling approach has a positive impact on family functioning post stroke. However, consensus regarding leisure therapy was not achieved. This article also stresses the impact of caring for a stroke survivor and the effect it has on family functioning and caregiver burden.

Comparison of Bobath based and movement science based treatment for stroke: a randomised controlled trial.

PubMed

van Vliet, P M; Lincoln, N B; Foxall, A

2005-04-01

Bobath based (BB) and movement science based (MSB) physiotherapy interventions are widely used for patients after stroke. There is little evidence to suggest which is most effective. This single-blind randomised controlled trial evaluated the effect of these treatments on movement abilities and functional independence. A total of 120 patients admitted to a stroke rehabilitation ward were randomised into two treatment groups to receive either BB or MSB treatment. Primary outcome measures were the Rivermead Motor Assessment and the Motor Assessment Scale. Secondary measures assessed functional independence, walking speed, arm function, muscle tone, and sensation. Measures were performed by a blinded assessor at baseline, and then at 1, 3, and 6 months after baseline. Analysis of serial measurements was performed to compare outcomes between the groups by calculating the area under the curve (AUC) and inserting AUC values into Mann-Whitney U tests. Comparison between groups showed no significant difference for any outcome measures. Significance values for the Rivermead Motor Assessment ranged from p = 0.23 to p = 0.97 and for the Motor Assessment Scale from p = 0.29 to p = 0.87. There were no significant differences in movement abilities or functional independence between patients receiving a BB or an MSB intervention. Therefore the study did not show that one approach was more effective than the other in the treatment of stroke patients.

Comparison of Bobath based and movement science based treatment for stroke: a randomised controlled trial

PubMed Central

van Vliet, P M; Lincoln, N; Foxall, A

2005-01-01

Objectives: Bobath based (BB) and movement science based (MSB) physiotherapy interventions are widely used for patients after stroke. There is little evidence to suggest which is most effective. This single-blind randomised controlled trial evaluated the effect of these treatments on movement abilities and functional independence. Methods: A total of 120 patients admitted to a stroke rehabilitation ward were randomised into two treatment groups to receive either BB or MSB treatment. Primary outcome measures were the Rivermead Motor Assessment and the Motor Assessment Scale. Secondary measures assessed functional independence, walking speed, arm function, muscle tone, and sensation. Measures were performed by a blinded assessor at baseline, and then at 1, 3, and 6 months after baseline. Analysis of serial measurements was performed to compare outcomes between the groups by calculating the area under the curve (AUC) and inserting AUC values into Mann-Whitney U tests. Results: Comparison between groups showed no significant difference for any outcome measures. Significance values for the Rivermead Motor Assessment ranged from p = 0.23 to p = 0.97 and for the Motor Assessment Scale from p = 0.29 to p = 0.87. Conclusions: There were no significant differences in movement abilities or functional independence between patients receiving a BB or an MSB intervention. Therefore the study did not show that one approach was more effective than the other in the treatment of stroke patients. PMID:15774435

Simple prediction scores predict good and devastating outcomes after stroke more accurately than physicians.

PubMed

Reid, John Michael; Dai, Dingwei; Delmonte, Susanna; Counsell, Carl; Phillips, Stephen J; MacLeod, Mary Joan

2017-05-01

physicians are often asked to prognosticate soon after a patient presents with stroke. This study aimed to compare two outcome prediction scores (Five Simple Variables [FSV] score and the PLAN [Preadmission comorbidities, Level of consciousness, Age, and focal Neurologic deficit]) with informal prediction by physicians. demographic and clinical variables were prospectively collected from consecutive patients hospitalised with acute ischaemic or haemorrhagic stroke (2012-13). In-person or telephone follow-up at 6 months established vital and functional status (modified Rankin score [mRS]). Area under the receiver operating curves (AUC) was used to establish prediction score performance. five hundred and seventy-five patients were included; 46% female, median age 76 years, 88% ischaemic stroke. Six months after stroke, 47% of patients had a good outcome (alive and independent, mRS 0-2) and 26% a devastating outcome (dead or severely dependent, mRS 5-6). The FSV and PLAN scores were superior to physician prediction (AUCs of 0.823-0.863 versus 0.773-0.805, P < 0.0001) for good and devastating outcomes. The FSV score was superior to the PLAN score for predicting good outcomes and vice versa for devastating outcomes (P < 0.001). Outcome prediction was more accurate for those with later presentations (>24 hours from onset). the FSV and PLAN scores are validated in this population for outcome prediction after both ischaemic and haemorrhagic stroke. The FSV score is the least complex of all developed scores and can assist outcome prediction by physicians. © The Author 2016. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com

Does the NRS Capture Changes in Communication during Inpatient Stroke Rehabilitation?

PubMed

Barr, Leigh G; Kubilius, Barbra; Ansley, Barb; Whiteman, Rhonda; Sahlas, Demetrios J

2017-10-01

In Ontario, the National Rehabilitation Reporting System (NRS) is mandated for use as a measurement of change for stroke patients after admission to and discharge from rehabilitation. The NRS includes the functional independence measure (FIM) and supplementary measurement items developed by the Canadian Institute for Health Information (CIHI). Uncertainty exists regarding the efficacy of the NRS as the sole measure of outcome for communication in stroke rehabilitation patients. The use of additional speech-language pathology outcome measurement tools for this population has therefore been suggested. This study sought to establish whether the FIM and CIHI communication items capture quantifiable gains during stroke rehabilitation and therefore whether additional measures are needed to assess outcomes. A retrospective analysis was completed of 1252 complete data records of stroke patients discharged from inpatient rehabilitation at Hamilton Health Sciences between 2006 and 2011. Statistically significant improvements were observed in all total matched FIM scores (M = 72.68 to M = 96.39, P < .001) and for each expression (M = 4.61 to M = 5.35, P < .001) and comprehension (M = 4.69 to M = 5.33, P < .001) subscale. The most severely affected group demonstrated the greatest gains. These findings were independent of stroke severity. Additional outcome measurement tools for communication are therefore not required to assess outcomes in rehabilitation of stroke patients, although additional research is necessary to evaluate the clinical significance of the improvements that are observed using existing measurements of change. Copyright © 2017 National Stroke Association. All rights reserved.

Cognitive functioning over 2 years after intracerebral hemorrhage in school-aged children.

PubMed

Murphy, Lexa K; Compas, Bruce E; Gindville, Melissa C; Reeslund, Kristen L; Jordan, Lori C

2017-11-01

Previous research investigating outcomes after pediatric intracerebral hemorrhage (ICH) has generally been limited to global and sensorimotor outcomes. This study examined cognitive outcomes after spontaneous ICH in school-aged children with serial assessments over 2 years after stroke. Seven children (age range 6-16y, median 13; six males, one female; 57% white, 43% black) presenting with spontaneous ICH (six arteriovenous malformations) were assessed at 3 months, 12 months, and 24 months after stroke. The Pediatric Stroke Outcome Measure (PSOM) quantified neurological outcome and Wechsler Intelligence Scales measured cognitive outcomes: verbal comprehension, perceptual reasoning, working memory, and processing speed. PSOM scales showed improved neurological function over the first 12 months, with mild to no sensorimotor deficits and moderate overall deficits at 1- and 2-year follow-ups (median 2-year sensorimotor PSOM=0.5, total PSOM=1.5). Changes in cognitive function indicated a different trajectory; verbal comprehension and perceptual reasoning improved over 24 months; low performance was sustained in processing speed and working memory. Age-normed centile scores decreased between 1- and 2-year follow-ups for working memory, suggesting emerging deficits compared with peers. Early and serial cognitive testing in children with ICH is needed to assess cognitive functioning and support children in school as they age and cognitive deficits become more apparent and important for function. In children with intracerebral hemorrhage (ICH), motor function improved between 3 months and 24 months. Improvements in cognitive function were variable between 3 months and 24 months. Working memory centiles declined, suggesting emerging deficits compared with peers. Processing speed improved but remained significantly below the 50th centile. Cognitive impact of ICH may increase with age in children. © 2017 Mac Keith Press.

Rehabilitation outcomes of stroke patients treated with multi-modal endovascular reperfusion therapy.

PubMed

Meiner, Z; Cohen, J E; Gomori, J M; Sajin, A; Schwartz, I; Tsenter, J; Yovchev, I; Eichel, R; Ben-Hur, T; Leker, R R

2012-03-01

The aim of this study was to investigate the influence of multi-modal endovascular reperfusion therapy (MMRT) on functional outcomes following rehabilitation. Data from 14 MMRT-treated patients were analyzed and compared to MMRT-ineligible, age and stroke severity-matched patients treated at the same Neurological and Rehabilitation departments. Neurological evaluation was assessed with the NIH stroke scale (NIHSS). Activity of daily living was measured using the FIMTM instrument. Functional outcome was measured using the modified Rankin scale (mRS). The baseline characteristics of both groups were similar. NIHSS scores were lower in the MMRT group and they had slightly better functional and rehabilitation scores on admission to rehabilitation. At the end of rehabilitation, more MMRT-treated patients reached functional independence (mRS≤2; 50% vs. 7% respectively P=0.03). FIM scores were also higher in the MMRT group (mean score 93.3 vs. 87.7, respectively) but the difference did not reach significance. The delta in FIM and NIHSS scores obtained during rehabilitation did not significantly differ between the groups. MMRT remained a significant modifier of good outcome after regression analysis (OR 21.5 95% CI 1.1-410). MMRT-treated patients have better chances of attaining independence after rehabilitation therapy. However, the additional improvements gained while in active rehabilitation were independent of reperfusion status.

Association between gastrointestinal bleeding and 3-year mortality in patients with acute, first-ever ischemic stroke.

PubMed

Chou, Yu-Fang; Weng, Wei-Chieh; Huang, Wen-Yi

2017-10-01

The influence of gastrointestinal bleeding on clinical presentation and outcomes of patients with acute ischemic stroke remains controversial. We investigate the effect of gastrointestinal bleeding on the outcomes of patients with acute, first-ever ischemic stroke. We enrolled 934 patients with acute, first-ever ischemic stroke and followed up them for 3years. Patients were divided into 2 groups according to the presence or absence of gastrointestinal bleeding during acute stroke stage. Clinical presentation, stroke risk factors, laboratory data, co-morbidities, and outcomes were recorded. Seventy-six (8.1%) patients had gastrointestinal bleeding at admission. The prevalence of old age, atrial fibrillation, and previous transient ischemic attack was higher in patients with gastrointestinal bleeding (P<0.001, P=0.038, and P=0.018, respectively). Total anterior circulation syndrome occurred more frequently among patients with gastrointestinal bleeding (P<0.001). The mean length of acute ward stay, initial impaired consciousness, and stroke in evolution were higher in patients with gastrointestinal bleeding (P<0.001, P<0.001, and P<0.001, respectively). The occurrence of pneumonia and dependent functional outcome were higher in patients with gastrointestinal bleeding (P<0.001 and P<0.001, respectively). A multivariate Cox regression analysis revealed that gastrointestinal bleeding is a significant risk factor for 3-year all-cause mortality (hazard ratio=2.76; 95% confidence interval=1.61-4.72; P<0.001). In conclusion, gastrointestinal bleeding is associated with increased risk of 3-year mortality in patients with acute, first-ever ischemic stroke. Prophylactic therapies for gastrointestinal bleeding might improve ischemic stroke outcome. Copyright © 2017 Elsevier Ltd. All rights reserved.

The prognostic value of midregional proatrial natriuretic peptide in patients with hemorrhagic stroke.

PubMed

Fischer, Marlene; Katan, Mira; Morgenthaler, Nils G; Seiler, Marleen; Müller, Beat; Lackner, Peter; Errath, Mario; Helbok, Raimund; Pfausler, Bettina; Beer, Ronny; Schmutzhard, Erich; Broessner, Gregor

2014-01-01

Atrial natriuretic peptide (ANP) is a well-known prognostic marker of outcome and mortality in patients with cardiovascular disease. Midregional proatrial natriuretic peptide (MR-proANP) is a stable fragment of the ANP precursor hormone. As a prognostic marker after ischemic stroke, it reliably predicts poststroke mortality and functional outcome. This study aimed to analyze the prognostic value of MR-proANP in patients with hemorrhagic stroke, i.e. subarachnoid (SAH) and intracerebral hemorrhage (ICH). MR-proANP was analyzed in patients with spontaneous SAH or spontaneous ICH. All patients were prospectively randomized into two treatment arms: (1) a prophylactic normothermia group with a target core temperature 36.5°C using endovascular cooling, and (2) a control group with conventional stepwise predefined fever management using antipyretic medication and surface cooling. Blood samples were obtained on admission and on days 4 and 7. Measurement of MR-proANP was performed in serum using sandwich immunoassay. The primary endpoint was functional outcome [assessed by the Glasgow Outcome Score (GOS)] and the secondary endpoints were mortality within 180 days after hemorrhagic stroke and influence of temperature on MR-proANP. A favorable outcome was defined as GOS 4-5, and the patients were considered to have a poor outcome with a 180-day GOS score between 1 and 3. Analysis of MR-proANP was performed in 24 patients with spontaneous SAH and 22 patients with spontaneous ICH. MR-proANP was elevated on days 4 and 7 as compared to baseline levels (p < 0.05 and p < 0.001, respectively). High MR-proANP levels (>120 pmol/l) were associated with increased mortality and poor outcome (after 180 days; p < 0.05, respectively). There was no significant difference regarding MR-proANP serum concentrations between the endovascular and the control groups. Increased levels of MR-proANP are independently associated with poor functional outcome and increased mortality after 180 days in patients with hemorrhagic stroke. Endovascular temperature control had no significant influence on MR-proANP levels.

Multidisciplinary transmural rehabilitation for older persons with a stroke: the design of a randomised controlled trial.

PubMed

Vluggen, Tom P M M; van Haastregt, Jolanda C M; Verbunt, Jeanine A; Keijsers, Elly J M; Schols, Jos M G A

2012-12-31

Stroke is one of the major causes of loss of independence, decreased quality of life and mortality among elderly people. About half of the elderly stroke patients discharged after rehabilitation in a nursing home still experience serious impairments in daily functioning one year post stroke, which can lead to difficulties in picking up and managing their social life. The aim of this study is to evaluate the effectiveness and feasibility of a new multidisciplinary transmural rehabilitation programme for older stroke patients. A two group multicentre randomised controlled trial is used to evaluate the effects of the rehabilitation programme. The programme consists of three care modules: 1) neurorehabilitation treatment for elderly stroke patients; 2) empowerment training for patient and informal caregiver; and 3) stroke education for patient and informal caregiver. The total programme has a duration of between two and six months, depending on the individual problems of the patient and informal caregiver. The control group receives usual care in the nursing home and after discharge. Patients aged 65 years and over are eligible for study participation when they are admitted to a geriatric rehabilitation unit in a nursing home due to a recent stroke and are expected to be able to return to their original home environment after discharge. Data are gathered by face-to-face interviews, self-administered questionnaires, focus groups and registration forms. Primary outcomes for patients are activity level after stroke, functional dependence, perceived quality of life and social participation. Outcomes for informal caregivers are perceived care burden, objective care burden, quality of life and perceived health. Outcome measures of the process evaluation are implementation fidelity, programme deliverance and the opinion of the stroke professionals, patients and informal caregivers about the programme. Outcome measures of the economic evaluation are the healthcare utilisation and associated costs. Data are collected at baseline, and after six and 12 months. The first results of the study will be expected in 2014. International Standard Randomised Controlled Trial Register Number ISRCTN62286281, The Dutch Trial Register NTR2412.

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.

Gait training assisted by multi-channel functional electrical stimulation early after stroke: study protocol for a randomized controlled trial.

PubMed

van Bloemendaal, Maijke; Bus, Sicco A; de Boer, Charlotte E; Nollet, Frans; Geurts, Alexander C H; Beelen, Anita

2016-10-01

Many stroke survivors suffer from paresis of lower limb muscles, resulting in compensatory gait patterns characterised by asymmetries in spatial and temporal parameters and reduced walking capacity. Functional electrical stimulation has been used to improve walking capacity, but evidence is mostly limited to the orthotic effects of peroneal functional electrical stimulation in the chronic phase after stroke. The aim of this study is to investigate the therapeutic effects of up to 10 weeks of multi-channel functional electrical stimulation (MFES)-assisted gait training on the restoration of spatiotemporal gait symmetry and walking capacity in subacute stroke patients. In a proof-of-principle study with a randomised controlled design, 40 adult patients with walking deficits who are admitted for inpatient rehabilitation within 31 days since the onset of stroke are randomised to either MFES-assisted gait training or conventional gait training. Gait training is delivered in 30-minute sessions each workday for up to 10 weeks. The step length symmetry ratio is the primary outcome. Blinded assessors conduct outcome assessments at baseline, every 2 weeks during the intervention period, immediately post intervention and at 3-month follow-up. This study aims to provide preliminary evidence for the feasibility and effectiveness of MFES-assisted gait rehabilitation early after stroke. Results will inform the design of a larger multi-centre trial. This trial is registered at the Netherlands Trial Register (number NTR4762 , registered 28 August 2014).

Functional effects of treadmill-based gait training at faster speeds in stroke survivors: a prospective, single-group study.

PubMed

Mohammadi, Roghayeh; Ershad, Navid; Rezayinejad, Marziyeh; Fatemi, Elham; Phadke, Chetan P

2017-09-01

To examine the functional effects of walking retraining at faster than self-selected speed (SSS). Ten individuals with chronic stroke participated in a 4-week training over a treadmill at walking speeds 40% faster than SSS, three times per week, 30 min/session. Outcome measures assessed before, after, and 2 months after the end of intervention were the Timed Up and Go, the 6-Minute Walk, the 10-Meter Walk test, the Modified Ashworth Scale, SSS, and fastest comfortable speed. After 4 weeks of training, all outcome measures showed clinically meaningful and statistically significant improvements (P<0.05) that were maintained at 2 months after the end of the training. The results showed that a strategy of training at a speed 40% faster than SSS can improve functional activity in individuals with chronic stroke, with effects lasting up to 2 months after the intervention.

Effects of robot-assisted upper limb rehabilitation on daily function and real-world arm activity in patients with chronic stroke: a randomized controlled trial.

PubMed

Liao, Wan-Wen; Wu, Ching-Yi; Hsieh, Yu-Wei; Lin, Keh-Chung; Chang, Wan-Ying

2012-02-01

To compare the outcome of robot-assisted therapy with dose-matched active control therapy by using accelerometers to study functional recovery in chronic stroke patients. Prospective, randomized, controlled trial. Stroke units in three medical centres. Twenty patients post stroke for a mean of 22 months. Robot-assisted therapy (n = 10) or dose-matched active control therapy (n = 10). All patients received either of these two therapies for 90-105 minutes each day, 5 days per week, for four weeks. Outcome measures included arm activity ratio (the ratio of mean activity between the impaired and unimpaired arm) and scores on the Fugl-Meyer Assessment Scale, Functional Independence Measure, Motor Activity Log and ABILHAND questionnaire. The robot-assisted therapy group significantly increased motor function, hemiplegic arm activity and bilateral arm coordination (Fugl-Meyer Assessment Scale: 51.20 ± 8.82, P = 0.002; mean arm activity ratio: 0.76 ± 0.10, P = 0.026; ABILHAND questionnaire: 1.24 ± 0.28, P = 0.043) compared with the dose-matched active control group (Fugl-Meyer Assessment Scale: 40.90 ± 13.14; mean arm movement ratio: 0.69 ± 0.11; ABILHAND questionnaire: 0.95 ± 0.43). Symmetrical and bilateral robotic practice, combined with functional task training, can significantly improve motor function, arm activity, and self-perceived bilateral arm ability in patients late after stroke.

Revisiting Hemicraniectomy: Late Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Stroke and the Role of Infarct Growth Rate

PubMed Central

Akhtar, Naveed; Salam, Abdul; Alboudi, Ayman; Kamran, Kainat; Ahmed, Arsalan; Khan, Rabia A.; Mirza, Mohsin K.; Inshasi, Jihad

2017-01-01

Objective and Methods. The outcome in late decompressive hemicraniectomy in malignant middle cerebral artery stroke and the optimal timings of surgery has not been addressed by the randomized trials and pooled analysis. Retrospective, multicenter, cross-sectional study to measure outcome following DHC under 48 or over 48 hours using the modified Rankin scale [mRS] and dichotomized as favorable ≤4 or unfavorable >4 at three months. Results. In total, 137 patients underwent DHC. Functional outcome analyzed as mRS 0–4 versus mRS 5-6 showed no difference in this split between early and late operated on patients [P = 0.140] and mortality [P = 0.975]. Multivariate analysis showed that age ≥ 55 years, MCA with additional infarction, septum pellucidum deviation ≥1 cm, and uncal herniation were independent predictors of poor functional outcome at three months. In the “best” multivariate model, second infarct growth rate [IGR2] >7.5 ml/hr, MCA with additional infarction, and patients with temporal lobe involvement were independently associated with surgery under 48 hours. Both first infarct growth rate [IGR1] and second infarct growth rate [IGR2] were nearly double [P < 0.001] in patients with early surgery [under 48 hours]. Conclusions. The outcome and mortality in malignant middle cerebral artery stroke patients operated on over 48 hours of stroke onset were comparable to those of patients operated on less than 48 hours after stroke onset. Our data identifies IGR, temporal lobe involvement, and middle cerebral artery with additional infarct as independent predictors for early surgery. PMID:28409051

Revisiting Hemicraniectomy: Late Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Stroke and the Role of Infarct Growth Rate.

PubMed

Kamran, Saadat; Akhtar, Naveed; Salam, Abdul; Alboudi, Ayman; Kamran, Kainat; Ahmed, Arsalan; Khan, Rabia A; Mirza, Mohsin K; Inshasi, Jihad; Shuaib, Ashfaq

2017-01-01

Objective and Methods. The outcome in late decompressive hemicraniectomy in malignant middle cerebral artery stroke and the optimal timings of surgery has not been addressed by the randomized trials and pooled analysis. Retrospective, multicenter, cross-sectional study to measure outcome following DHC under 48 or over 48 hours using the modified Rankin scale [mRS] and dichotomized as favorable ≤4 or unfavorable >4 at three months. Results. In total, 137 patients underwent DHC. Functional outcome analyzed as mRS 0-4 versus mRS 5-6 showed no difference in this split between early and late operated on patients [ P = 0.140] and mortality [ P = 0.975]. Multivariate analysis showed that age ≥ 55 years, MCA with additional infarction, septum pellucidum deviation ≥1 cm, and uncal herniation were independent predictors of poor functional outcome at three months. In the "best" multivariate model, second infarct growth rate [IGR2] >7.5 ml/hr, MCA with additional infarction, and patients with temporal lobe involvement were independently associated with surgery under 48 hours. Both first infarct growth rate [IGR1] and second infarct growth rate [IGR2] were nearly double [ P < 0.001] in patients with early surgery [under 48 hours]. Conclusions. The outcome and mortality in malignant middle cerebral artery stroke patients operated on over 48 hours of stroke onset were comparable to those of patients operated on less than 48 hours after stroke onset. Our data identifies IGR, temporal lobe involvement, and middle cerebral artery with additional infarct as independent predictors for early surgery.

Selection for inpatient rehabilitation after acute stroke: a systematic review of the literature.

PubMed

Hakkennes, Sharon J; Brock, Kim; Hill, Keith D

2011-12-01

To identify patient-related factors that have been found to correlate with functional outcomes post acute stroke to guide clinical decision making with regard to rehabilitation admission after acute stroke. We systematically searched the scientific literature between 1966 and January 2010. The primary source of studies was the electronic databases Medline, CINAHL, and Embase. The search was supplemented with citation tracking. Two reviewers independently applied the inclusion criteria to identify relevant articles from the citations obtained through the literature search. Eligible studies included systematic reviews of prognostic indicators, studies of prognostic indicators of acute discharge disposition, and studies of rehabilitation admission criteria after acute stroke. Of the 8895 studies identified, 83 articles, representing 79 studies, were included in the review. One reviewer extracted the data relating to the participants, prognostic indicators, and outcomes. A second reviewer independently checked data extracted with disagreement resolved by a third reviewer. Quality of included studies was assessed for internal and external validity. Of the 79 studies, 26 were systematic reviews of prognostic indicators of functional level and/or discharge disposition, 48 were studies of prognostic indicators of acute discharge disposition, and 6 were studies of rehabilitation selection criteria. The methodologic quality of the included studies was generally poor. Age, cognition, functional level after stroke, and, to a lesser extent, continence were found to have a consistent association with outcome across all 3 research areas. In addition, stroke severity was also associated with acute discharge disposition, final discharge disposition, and functional level. Sex and side of stroke appeared to have no association across all 3 of the research areas. This review highlights a number of important prognostic indicators and rehabilitation selection criteria that may assist clinicians in improving selection procedures and standardizing access to inpatient rehabilitation after stroke, although the quality of many studies is low. Further high quality studies and reviews of prognostic indicators and clinician decision making with regards to rehabilitation acceptance are required. Copyright © 2011 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.

Association of early National Institutes of Health Stroke Scale improvement with vessel recanalization and functional outcome after intravenous thrombolysis in ischemic stroke.

PubMed

Kharitonova, Tatiana; Mikulik, Robert; Roine, Risto O; Soinne, Lauri; Ahmed, Niaz; Wahlgren, Nils

2011-06-01

Early neurological improvement (ENI) after thrombolytic therapy of acute stroke has been linked with recanalization and favorable outcome, although its definition shows considerable variation. We tested the ability of ENI, as defined in previous publications, to predict vessel recanalization and 3-month functional outcome after intravenous thrombolysis recorded in an extensive patient cohort in the Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register (SITS-ISTR). Of 21,534 patients registered between December 2002 and December 2008, 798 patients (3.7%) had CT- or MR angiography-documented baseline vessel occlusion and also angiography data at 22 to 36 hours post-treatment. ENI definitions assessed at 2 hours and 24 hours post-treatment were (1) National Institutes of Health Stroke Scale (NIHSS) score improvement ≥4 points from baseline; (2) NIHSS 0, 1, or improvement ≥8; (3) NIHSS ≤3 or improvement ≥10; (4) improvement by 20%; (5) 40% from baseline; or (6) NIHSS score 0 to 1. Receiver operating curve analysis and multiple logistic regression were performed to evaluate the association of ENI with vessel recanalization and favorable functional outcome (modified Rankin Scale score 0 to 2 at 3 months). ENI at 2 hours had fair accuracy to diagnose recanalization as derived from receiver operating curve analysis. Definitions of improvement based on percent of NIHSS score change from baseline demonstrate better accuracy to diagnose recanalization at 2 hours and 24 hours than the definitions based on NIHSS cutoffs (the best performance at 2 hours was area under the curve 0.633, sensitivity 58%, specificity 69%, positive predictive value 68%, and negative predictive value 59% for 20% improvement; and area under the curve 0.692, sensitivity 69%, specificity 70%, positive predictive value 70%, and negative predictive value 62% for 40% improvement at 24 hours). ENI-predicted functional outcome with OR 2.8 to 6.0 independently from recanalization in the angiography cohort (n=695) and with OR of 6.9 to 9.7 in the whole cohort (n=18 181). Early 20% neurological improvement at 2 hours was the best predictor of 3-month functional outcome and recanalization after thrombolysis, although fairly accurate, and may serve as a surrogate marker of recanalization if only imaging evaluation of vessel status is not available. If recanalization status is required after intravenous thrombolysis, vascular imaging is recommended despite ENI.

Clinical utility of the AlphaFIM® instrument in stroke rehabilitation.

PubMed

Lo, Alexander; Tahair, Nicola; Sharp, Shelley; Bayley, Mark T

2012-02-01

The AlphaFIM instrument is an assessment tool designed to facilitate discharge planning of stroke patients from acute care, by extrapolating overall functional status from performance in six key Functional Independence Measure (FIM) instrument items. To determine whether acute care AlphaFIM rating is correlated to stroke rehabilitation outcomes. In this prospective observational study, data were analyzed from 891 patients referred for inpatient stroke rehabilitation through an Internet-based referral system. Simple linear and stepwise regression models determined correlations between rehabilitation-ready AlphaFIM rating and rehabilitation outcomes (admission and discharge FIM ratings, FIM gain, FIM efficiency, and length of stay). Covariates including demographic data, stroke characteristics, medical history, cognitive deficits, and activity tolerance were included in the stepwise regressions. The AlphaFIM instrument was significant in predicting admission and discharge FIM ratings at rehabilitation (adjusted R² 0.40 and 0.28, respectively; P < 0.0001) and was weakly correlated with FIM gain and length of stay (adjusted R² 0.04 and 0.09, respectively; P < 0.0001), but not FIM efficiency. AlphaFIM rating was inversely related to FIM gain. Age, bowel incontinence, left hemiparesis, and previous infarcts were negative predictors of discharge FIM rating on stepwise regression. Intact executive function and physical activity tolerance of 30 to 60 mins were predictors of FIM gain. The AlphaFIM instrument is a valuable tool for triaging stroke patients from acute care to rehabilitation and predicts functional status at discharge from rehabilitation. Patients with low AlphaFIM ratings have the potential to make significant functional gains and should not be denied admission to inpatient rehabilitation programs.

Predicting home and community walking activity in people with stroke.

PubMed

Fulk, George D; Reynolds, Chelsea; Mondal, Sumona; Deutsch, Judith E

2010-10-01

To determine the ability of the 6-minute walk test (6MWT) and other commonly used clinical outcome measures to predict home and community walking activity in high-functioning people with stroke. Cross-sectional. Outpatient physical therapy clinic. Participants (N=32) with chronic stroke (n=19; >6mo poststroke) with self-selected gait speed (GS) faster than .40m/s and age-matched healthy participants (n=13). Not applicable. 6MWT, self-selected GS, Berg Balance Scale (BBS), lower extremity motor section of the Fugl-Meyer Assessment, and Stroke Impact Scale. Dependent variable: average steps taken per day during a 7-day period, measured using an accelerometer. 6MWT, self-selected GS, and BBS were moderately related to home and community walking activity. The 6MWT was the only predictor of average steps taken per day; it explained 46% of the variance in steps per day. The 6MWT is a useful outcome measure in higher functioning people with stroke to guide intervention and assess community walking activity. Copyright © 2010 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.

Early High-dosage Atorvastatin Treatment Improved Serum Immune-inflammatory Markers and Functional Outcome in Acute Ischemic Strokes Classified as Large Artery Atherosclerotic Stroke

PubMed Central

Tuttolomondo, Antonino; Di Raimondo, Domenico; Pecoraro, Rosaria; Maida, Carlo; Arnao, Valentina; Corte, Vittoriano Della; Simonetta, Irene; Corpora, Francesca; Di Bona, Danilo; Maugeri, Rosario; Iacopino, Domenico Gerardo; Pinto, Antonio

2016-01-01

Abstract Statins have beneficial effects on cerebral circulation and brain parenchyma during ischemic stroke and reperfusion. The primary hypothesis of this randomized parallel trial was that treatment with 80 mg/day of atorvastatin administered early at admission after acute atherosclerotic ischemic stroke could reduce serum levels of markers of immune-inflammatory activation of the acute phase and that this immune-inflammatory modulation could have a possible effect on prognosis of ischemic stroke evaluated by some outcome indicators. We enrolled 42 patients with acute ischemic stroke classified as large arteries atherosclerosis stroke (LAAS) randomly assigned in a randomized parallel trial to the following groups: Group A, 22 patients treated with atorvastatin 80 mg (once-daily) from admission day until discharge; Group B, 20 patients not treated with atorvastatin 80 mg until discharge, and after discharge, treatment with atorvastatin has been started. At 72 hours and at 7 days after acute ischemic stroke, subjects of group A showed significantly lower plasma levels of tumor necrosis factor-α, interleukin (IL)-6, vascular cell adhesion molecule-1, whereas no significant difference with regard to plasma levels of IL-10, E-Selectin, and P-Selectin was observed between the 2 groups. At 72 hours and 7 days after admission, stroke patients treated with atorvastatin 80 mg in comparison with stroke subjects not treated with atorvastatin showed a significantly lower mean National Institutes of Health Stroke Scale and modified Rankin scores. Our findings provide the first evidence that atorvastatin acutely administered immediately after an atherosclerotic ischemic stroke exerts a lowering effect on immune-inflammatory activation of the acute phase of stroke and that its early use is associated to a better functional and prognostic profile. PMID:27043681

Early High-dosage Atorvastatin Treatment Improved Serum Immune-inflammatory Markers and Functional Outcome in Acute Ischemic Strokes Classified as Large Artery Atherosclerotic Stroke: A Randomized Trial.

PubMed

Tuttolomondo, Antonino; Di Raimondo, Domenico; Pecoraro, Rosaria; Maida, Carlo; Arnao, Valentina; Della Corte, Vittoriano; Simonetta, Irene; Corpora, Francesca; Di Bona, Danilo; Maugeri, Rosario; Iacopino, Domenico Gerardo; Pinto, Antonio

2016-03-01

Statins have beneficial effects on cerebral circulation and brain parenchyma during ischemic stroke and reperfusion. The primary hypothesis of this randomized parallel trial was that treatment with 80 mg/day of atorvastatin administered early at admission after acute atherosclerotic ischemic stroke could reduce serum levels of markers of immune-inflammatory activation of the acute phase and that this immune-inflammatory modulation could have a possible effect on prognosis of ischemic stroke evaluated by some outcome indicators. We enrolled 42 patients with acute ischemic stroke classified as large arteries atherosclerosis stroke (LAAS) randomly assigned in a randomized parallel trial to the following groups: Group A, 22 patients treated with atorvastatin 80 mg (once-daily) from admission day until discharge; Group B, 20 patients not treated with atorvastatin 80 mg until discharge, and after discharge, treatment with atorvastatin has been started. At 72 hours and at 7 days after acute ischemic stroke, subjects of group A showed significantly lower plasma levels of tumor necrosis factor-α, interleukin (IL)-6, vascular cell adhesion molecule-1, whereas no significant difference with regard to plasma levels of IL-10, E-Selectin, and P-Selectin was observed between the 2 groups. At 72 hours and 7 days after admission, stroke patients treated with atorvastatin 80 mg in comparison with stroke subjects not treated with atorvastatin showed a significantly lower mean National Institutes of Health Stroke Scale and modified Rankin scores. Our findings provide the first evidence that atorvastatin acutely administered immediately after an atherosclerotic ischemic stroke exerts a lowering effect on immune-inflammatory activation of the acute phase of stroke and that its early use is associated to a better functional and prognostic profile.

Right hemisphere grey matter structure and language outcomes in chronic left hemisphere stroke

PubMed Central

Xing, Shihui; Lacey, Elizabeth H.; Skipper-Kallal, Laura M.; Jiang, Xiong; Harris-Love, Michelle L.; Zeng, Jinsheng

2016-01-01

The neural mechanisms underlying recovery of language after left hemisphere stroke remain elusive. Although older evidence suggested that right hemisphere language homologues compensate for damage in left hemisphere language areas, the current prevailing theory suggests that right hemisphere engagement is ineffective or even maladaptive. Using a novel combination of support vector regression-based lesion-symptom mapping and voxel-based morphometry, we aimed to determine whether local grey matter volume in the right hemisphere independently contributes to aphasia outcomes after chronic left hemisphere stroke. Thirty-two left hemisphere stroke survivors with aphasia underwent language assessment with the Western Aphasia Battery-Revised and tests of other cognitive domains. High-resolution T1-weighted images were obtained in aphasia patients and 30 demographically matched healthy controls. Support vector regression-based multivariate lesion-symptom mapping was used to identify critical language areas in the left hemisphere and then to quantify each stroke survivor’s lesion burden in these areas. After controlling for these direct effects of the stroke on language, voxel-based morphometry was then used to determine whether local grey matter volumes in the right hemisphere explained additional variance in language outcomes. In brain areas in which grey matter volumes related to language outcomes, we then compared grey matter volumes in patients and healthy controls to assess post-stroke plasticity. Lesion–symptom mapping showed that specific left hemisphere regions related to different language abilities. After controlling for lesion burden in these areas, lesion size, and demographic factors, grey matter volumes in parts of the right temporoparietal cortex positively related to spontaneous speech, naming, and repetition scores. Examining whether domain general cognitive functions might explain these relationships, partial correlations demonstrated that grey matter volumes in these clusters related to verbal working memory capacity, but not other cognitive functions. Further, grey matter volumes in these areas were greater in stroke survivors than healthy control subjects. To confirm this result, 10 chronic left hemisphere stroke survivors with no history of aphasia were identified. Grey matter volumes in right temporoparietal clusters were greater in stroke survivors with aphasia compared to those without history of aphasia. These findings suggest that the grey matter structure of right hemisphere posterior dorsal stream language homologues independently contributes to language production abilities in chronic left hemisphere stroke, and that these areas may undergo hypertrophy after a stroke causing aphasia. PMID:26521078

[Atrial fibrillation in cerebrovascular disease: national neurological perspective].

PubMed

Sargento-Freitas, Joao; Silva, Fernando; Koehler, Sebastian; Isidoro, Luís; Mendonça, Nuno; Machado, Cristina; Cordeiro, Gustavo; Cunha, Luís

2013-01-01

Cardioembolism due to atrial fibrillation assumes a dominant etiologic role in cerebrovascular diseases due to its growing incidence, high embolic risk and particular aspects of clinical events caused. Our objectives are to analyze the frequency of atrial fibrillation in patients with ischemic stroke, study the vital and functional impact of stroke due to different etiologies and evaluate antithrombotic options before and after stroke. We conducted a retrospective study including patients admitted in a central hospital due to ischemic stroke in 2010 (at least one year of follow-up). Etiology of stroke was defined using the Trial of ORG 10172 in Acute Stroke (TOAST) classification, and functional outcome by modified Rankin scale. We performed a descriptive analysis of different stroke etiologies and antithrombotic medication in patients with atrial fibrillation. We then conducted a cohort study to evaluate the clinical impact of antithrombotic options in secondary prevention after cardioembolic stroke. In our population (n = 631) we found superior frequency of cardioembolism (34.5%) to that reported in the literature. Mortality, morbidity and antithrombotic options are similar to other previous series, confirming the severity of cardioembolic strokes and the underuse of vitamin K antagonists. Oral anticoagulation was effective in secondary prevention independently from post-stroke functional condition. Despite unequivocal recommendations, oral anticoagulation is still underused in stroke prevention. This study confirms the clinical efficacy of vitamin K antagonists in secondary prevention independently from residual functional impairment.

Combining Afferent Stimulation and Mirror Therapy for Improving Muscular, Sensorimotor, and Daily Functions After Chronic Stroke: A Randomized, Placebo-Controlled Study.

PubMed

Lee, Ya-yun; Lin, Keh-chung; Wu, Ching-yi; Liao, Ching-hua; Lin, Jui-chi; Chen, Chia-ling

2015-10-01

Mirror therapy (MT) combined with mesh glove (MG) afferent stimulation (MT + MG) has been suggested as an effective intervention for motor recovery in patients with stroke. This study aimed to further determine the treatment effects of the MT + MG approach on muscular properties, sensorimotor functions, and daily function. This was a single-blind, randomized, placebo-controlled study. Forty-eight participants with chronic stroke were recruited from medical centers and were randomly assigned to the MT, MT + MG, and MT with sham MG stimulation (MT + sham) groups. The intervention consisted of 1.5 hrs/day, 5 days/wk for 4 wks. Primary outcomes were the Fugl-Meyer Assessment and muscular properties (muscle tone and stiffness). Secondary outcomes included measures of sensorimotor and daily functions. Compared with the MT and MT + sham groups, the MT + MG group demonstrated improved muscular properties. The MT + MG and MT + sham groups showed greater improvement in manual dexterity and daily function than the MT group did. No beneficial effects on the Fugl-Meyer Assessment and other sensorimotor outcomes were found for the MT + MG group. Although no significant group differences were found in the Fugl-Meyer Assessment, MT + MG induced distinctive effects on muscular properties, manual dexterity, and daily function.

Long-Term Improvements After Multimodal Rehabilitation in Late Phase After Stroke: A Randomized Controlled Trial.

PubMed

Bunketorp-Käll, Lina; Lundgren-Nilsson, Åsa; Samuelsson, Hans; Pekny, Tulen; Blomvé, Karin; Pekna, Marcela; Pekny, Milos; Blomstrand, Christian; Nilsson, Michael

2017-07-01

Treatments that improve function in late phase after stroke are urgently needed. We assessed whether multimodal interventions based on rhythm-and-music therapy or horse-riding therapy could lead to increased perceived recovery and functional improvement in a mixed population of individuals in late phase after stroke. Participants were assigned to rhythm-and-music therapy, horse-riding therapy, or control using concealed randomization, stratified with respect to sex and stroke laterality. Therapy was given twice a week for 12 weeks. The primary outcome was change in participants' perception of stroke recovery as assessed by the Stroke Impact Scale with an intention-to-treat analysis. Secondary objective outcome measures were changes in balance, gait, grip strength, and cognition. Blinded assessments were performed at baseline, postintervention, and at 3- and 6-month follow-up. One hundred twenty-three participants were assigned to rhythm-and-music therapy (n=41), horse-riding therapy (n=41), or control (n=41). Post-intervention, the perception of stroke recovery (mean change from baseline on a scale ranging from 1 to 100) was higher among rhythm-and-music therapy (5.2 [95% confidence interval, 0.79-9.61]) and horse-riding therapy participants (9.8 [95% confidence interval, 6.00-13.66]), compared with controls (-0.5 [-3.20 to 2.28]); P =0.001 (1-way ANOVA). The improvements were sustained in both intervention groups 6 months later, and corresponding gains were observed for the secondary outcomes. Multimodal interventions can improve long-term perception of recovery, as well as balance, gait, grip strength, and working memory in a mixed population of individuals in late phase after stroke. URL: http//www.ClinicalTrials.gov. Unique identifier: NCT01372059. © 2017 American Heart Association, Inc.

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.

Positioning and early mobilisation in stroke.

PubMed

Keating, Moira; Penney, Maree; Russell, Petra; Bailey, Emma

Stroke unit care, providing early rehabilitation, improves long-term outcomes for patients following a stroke. Early mobilisation and good positioning are recognised as key aspects of care in stroke units. Nurses working on stroke units have an important role because they are able to implement positioning and early mobilisation strategies 24 hours a day, reducing the risk of complications and improving functional recovery. Patients benefit if nurses work effectively with the therapy team in positioning and early mobilisation. Nurses also need appropriate training and expertise to make best use of specialist equipment.

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

New modalities of brain stimulation for stroke rehabilitation

PubMed Central

Lucas, T. H.; Carey, J. R.; Fetz, E. E.

2014-01-01

Stroke is a leading cause of disability, and the number of stroke survivors continues to rise. Traditional neurorehabilitation strategies aimed at restoring function to weakened limbs provide only modest benefit. New brain stimulation techniques designed to augment traditional neurorehabilitation hold promise for reducing the burden of stroke-related disability. Investigators discovered that repetitive transcranial magnetic stimulation (rTMS), trans-cranial direct current stimulation (tDCS), and epidural cortical stimulation (ECS) can enhance neural plasticity in the motor cortex post-stroke. Improved outcomes may be obtained with activity-dependent stimulation, in which brain stimulation is contingent on neural or muscular activity during normal behavior. We review the evidence for improved motor function in stroke patients treated with rTMS, tDCS, and ECS and discuss the mediating physiological mechanisms. We compare these techniques to activity-dependent stimulation, discuss the advantages of this newer strategy for stroke rehabilitation, and suggest future applications for activity-dependent brain stimulation. PMID:23192336

Impact of Transcranial Doppler Ultrasound on Logistics and Outcomes in Stroke Thrombolysis: Results From the SITS-ISTR.

PubMed

Mazya, Michael V; Ahmed, Niaz; Azevedo, Elsa; Davalos, Antoni; Dorado, Laura; Karlinski, Michal; Lorenzano, Svetlana; Neumann, Jiří; Toni, Danilo; Moreira, Tiago P

2018-07-01

Diagnostic transcranial Doppler ultrasound (TCD) is commonly used in patients with acute stroke before or during treatment with intravenous thrombolysis (IVT). We aimed to assess how much TCD delays IVT initiation and whether TCD influences outcomes. We analyzed data from the SITS-ISTR (Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register) collected from December 2002 to December 2011. Outcomes were door-to-needle time, symptomatic intracerebral hemorrhage, functional outcome per the modified Rankin Scale, and mortality at 3 months. In hospitals performing any TCD pre-IVT, 1701 of 11 265 patients (15%) had TCD before IVT initiation. Door-to-needle time was higher in patients with pre-IVT TCD (74 versus 60 minutes; P <0.001). At hospitals performing any TCD during IVT infusion, of 9044 patients with IVT, 747 were examined with TCD during IVT. No treatment delay was seen with TCD during IVT. After multivariate adjustment, TCD during IVT was independently associated with modestly increased excellent functional outcome (modified Rankin Scale, 0-1; adjusted odds ratio, 1.28; 95% confidence interval, 1.06-1.55; P =0.012) and lower mortality (adjusted odds ratio, 0.73; 95% confidence interval, 0.55-0.95; P =0.022). We recommend that TCD, if performed, should be done during IVT infusion, to avoid treatment delay. The association of hyperacute TCD with beneficial outcomes suggests potential impact on patient management, which warrants further study. © 2018 American Heart Association, Inc.

Biomarkers and perfusion – training-induced changes after stroke (BAPTISe): protocol of an observational study accompanying a randomized controlled trial

PubMed Central

2013-01-01

Background Physical activity is believed to exert a beneficial effect on functional and cognitive rehabilitation of patients with stroke. Although studies have addressed the impact of physical exercise in cerebrovascular prevention and rehabilitation, the underlying mechanisms leading to improvement are poorly understood. Training-induced increase of cerebral perfusion is a possible mediating mechanism. Our exploratory study aims to investigate training-induced changes in blood biomarker levels and magnetic resonance imaging in patients with subacute ischemic stroke. Methods/design This biomarker-driven study uses an observational design to examine a subgroup of patients in the randomized, controlled PHYS-STROKE trial. In PHYS-STROKE, 215 patients with subacute stroke (hemorrhagic and ischemic) receive either 4 weeks of physical training (aerobic training, 5 times a week, for 50 minutes) or 4 weeks of relaxation sessions (5 times a week, for 50 minutes). A convenience sample of 100 of these patients with ischemic stroke will be included in BAPTISe and will receive magnetic resonance imaging (MRI) scans and an additional blood draw before and after the PHYS-STROKE intervention. Imaging scans will address parameters of cerebral perfusion, vessel size imaging, and microvessel density (the Q factor) to estimate the degree of neovascularization in the brain. Blood tests will determine several parameters of immunity, inflammation, endothelial function, and lipometabolism. Primary objective of this study is to evaluate differential changes in MRI and blood-derived biomarkers between groups. Other endpoints are next cerebrovascular events and functional status of the patient after the intervention and after 3 months assessed by functional scores, in particular walking speed and Barthel index (co-primary endpoints of PHYS-STROKE). Additionally, we will assess the association between functional outcomes and biomarkers including imaging results. For all endpoints we will compare changes between patients who received physical fitness training and patients who had relaxation sessions. Discussion This exploratory study will be the first to investigate the effects of physical fitness training in patients with ischemic stroke on MRI-based cerebral perfusion, pertinent blood biomarker levels, and functional outcome. The study may have an impact on current patient rehabilitation strategies and reveal important information about the roles of MRI and blood-derived biomarkers in ischemic stroke. Trial registration NCT01954797. PMID:24330706

Design and rationale of the Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy (MR RESCUE) Trial.

PubMed

Kidwell, Chelsea S; Jahan, Reza; Alger, Jeffry R; Schaewe, Timothy J; Guzy, Judy; Starkman, Sidney; Elashoff, Robert; Gornbein, Jeffrey; Nenov, Val; Saver, Jeffrey L

2014-01-01

Multimodal imaging has the potential to identify acute ischaemic stroke patients most likely to benefit from late recanalization therapies. The general aim of the Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy Trial is to investigate whether multimodal imaging can identify patients who will benefit substantially from mechanical embolectomy for the treatment of acute ischaemic stroke up to eight-hours from symptom onset. Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy is a randomized, controlled, blinded-outcome clinical trial. Acute ischaemic stroke patients with large vessel intracranial internal carotid artery or middle cerebral artery M1 or M2 occlusion enrolled within eight-hours of symptom onset are eligible. The study sample size is 120 patients. Patients are randomized to endovascular embolectomy employing the Merci Retriever (Concentric Medical, Mountain View, CA) or the Penumbra System (Penumbra, Alameda, CA) vs. standard medical care, with randomization stratified by penumbral pattern. The primary aim of the trial is to test the hypothesis that the presence of substantial ischaemic penumbral tissue visualized on multimodal imaging (magnetic resonance imaging or computed tomography) predicts patients most likely to respond to mechanical embolectomy for treatment of acute ischaemic stroke due to a large vessel, intracranial occlusion up to eight-hours from symptom onset. This hypothesis will be tested by analysing whether pretreatment imaging pattern has a significant interaction with treatment as a determinant of functional outcome based on the distribution of scores on the modified Rankin Scale measure of global disability assessed 90 days post-stroke. Nested hypotheses test for (1) treatment efficacy in patients with a penumbral pattern pretreatment, and (2) absence of treatment benefit (equivalency) in patients without a penumbral pattern pretreatment. An additional aim will only be tested if the primary hypothesis of an interaction is negative: that patients treated with mechanical embolectomy have improved functional outcome vs. standard medical management. © 2012 The Authors. International Journal of Stroke © 2012 World Stroke Organization.

[The alpha-fetoprotein in prognosis of survival of and functional rehabilitation of patients with ischemic stroke].

PubMed

Arkhipkin, A A; Liang, O V; Kochetov, A G

2014-10-01

The study was carried out to determine the prognostic value of alpha-fetoprotein in development of lethal outcome and degree of functional rehabilitation of patients with ischemic stroke. The sampling included 216 patients in acute period of ischemic stroke. At the first day of development of disease they were measured the level of human alpha-fetoprotein. At the second day of disease patients were evaluated the degree of functional rehabilitation and the rate of lethal outcomes was calculated. Previously, the reference interval for alpha-fetoprotein was calculated according the guidelines of the International federation of clinical chemistry and national standard. The reference interval amounted to 0.59-3.78 mE/l. The study results demonstrated that low level of alpha-fetoprotein is related to higher risk of lethal outcome (SE=1.7, p=0.012). The increasing of level of alpha-fetoprotein over mentioned threshold value statistically significant increases probability of survival of patients. The further increasing more than 2.28 mE/l is related to subsequent good functional rehabilitation according the modifies Rankine scale (SE=1.4, p=0.001) and Barthel index (SE=1.49, p<0.001).

Sex-related differences in the risk factors for in-hospital mortality and outcomes of ischemic stroke patients in rural areas of Taiwan.

PubMed

Ong, Cheung-Ter; Wong, Yi-Sin; Sung, Sheng-Feng; Wu, Chi-Shun; Hsu, Yung-Chu; Su, Yu-Hsiang; Hung, Ling-Chien

2017-01-01

Sex-related differences in the clinical presentation and outcomes of stroke patients are issues that have attracted increased interest from the scientific community. The present study aimed to investigate sex-related differences in the risk factors for in-hospital mortality and outcome in ischemic stroke patients. A total of 4278 acute ischemic stroke patients admitted to a stroke unit between January 1, 2007 and December 31, 2014 were included in the study. We considered demographic characteristics, clinical characteristics, co-morbidities, and complications, among others, as factors that may affect clinical presentation and in-hospital mortality. Good and poor outcomes were defined as modified Ranking Score (mRS)≦2 and mRS>2. Neurological deterioration (ND) was defined as an increase of National Institutes of Health Stroke Score (NIHSS) ≥ 4 points. Hemorrhagic transformation (HT) was defined as signs of hemorrhage in cranial CT or MRI scans. Transtentorial herniation was defined by brain edema, as seen in cranial CT or MRI scans, associated with the onset of acute unilateral or bilateral papillary dilation, loss of reactivity to light, and decline of ≥ 2 points in the Glasgow coma scale score. Of 4278 ischemic stroke patients (women 1757, 41.1%), 269 (6.3%) received thrombolytic therapy. The in hospital mortality rate was 3.35% (139/4278) [4.45% (80/1757) for women and 2.34% (59/2521) for men, p < 0.01]. At discharge, 41.2% (1761/4278) of the patients showed good outcomes [35.4% (622/1757) for women and 45.2% (1139/2521) for men]. Six months after stroke, 56.1% (1813/3231) showed good outcomes [47.4% (629/1328) for women and 62.2% (1184/1903) for men, p < 0.01]. Atrial fibrillation (AF), diabetes mellitus, stroke history, and old age were factors contributing to poor outcomes in men and women. Hypertension was associated with poor outcomes in women but not in men in comparison with patients without hypertension. Stroke severity and increased intracranial pressure were associated with increased in-hospital mortality in men and women. AF was associated with increased in-hospital mortality in women but not in men compared with patients without AF. The in-hospital mortality rate was not significantly different between women and men. Functional outcomes at discharge and six months after stroke were poorer in women than in men. Hypertension is an independent factor causing poorer outcomes in women than in men. AF is an independent factor affecting sex differences in hospital mortality in women.

Circuit class or seven-day therapy for increasing intensity of rehabilitation after stroke: protocol of the CIRCIT trial.

PubMed

Hillier, Susan; English, Coralie; Crotty, Maria; Segal, Leonie; Bernhardt, Julie; Esterman, Adrian

2011-12-01

There is strong evidence for a dose-response relationship between physical therapy early after stroke and recovery of function. The optimal method of maximizing physical therapy within finite health care resources is unknown. To determine the effectiveness and cost-effectiveness of two alternative models of physical therapy service delivery (seven-days per week therapy services or group circuit class therapy over five-days a week) to usual care for people receiving inpatient rehabilitation after stroke. Multicenter, three-armed randomized controlled trial with blinded assessment of outcomes. A total of 282 people admitted to inpatient rehabilitation facilities after stroke with an admission functional independence measure (FIM) score within the moderate range (total 40-80 points or motor 38-62 points) will be randomized to receive one of three interventions: • usual care therapy over five-days a week • standard care therapy over seven-days a week, or • group circuit class therapy over five-days a week. Participants will receive the allocated intervention for the length of their hospital stay. Analysis will be by intention-to-treat. The primary outcome measure is walking ability (six-minute walk test) at four-week postintervention with three- and six-month follow-up. Economic analysis will include a costing analysis based on length of hospital stay and staffing/resource costs and a cost-utility analysis (incremental quality of life per incremental cost, relative to usual care). Secondary outcomes include walking speed and independence, ability to perform activities of daily living, arm function, quality of life and participant satisfaction. © 2011 The Authors. International Journal of Stroke © 2011 World Stroke Organization.

Low free triiodothyronine levels are related to symptomatic intracranial hemorrhage and poor functional outcomes after intravenous thrombolysis in acute ischemic stroke patients.

PubMed

Liu, Junfeng; Wang, Deren; Xiong, Yao; Yuan, Ruozhen; Tao, Wendan; Liu, Ming

2016-05-01

Low free triiodothyronine (fT3) levels have been associated with increased mortality and poor functional outcomes in patients with stroke. However, the research of relationship between fT3 levels and acute ischemic stroke (AIS) patients with intravenous thrombolysis (IVT) is scarce. We aimed to investigate the association of fT3 levels with symptomatic intracranial hemorrhage (sICH) and functional outcomes at discharge in AIS patients with IVT. Patients with AIS admitted to West China hospital, Sichuan University, who had underwent IVT treatment, were consecutively and retrospectively included. Demographic and clinical information were collected and analyzed according to the levels of fT3. We used logistic regression analysis to estimate the multivariable adjusted association of fT3 levels and post-IVT sICH, and functional outcomes at discharge. Among the 46 patients (26 males; mean age, 63.6 years) in the final analysis, 17 patients (37.0%) had fT3 levels lower than the reference range. After adjustment for age, gender, and statistically important variables (NIHSS on admission, urea levels and creatinine levels), low fT3 levels were significantly associated with post-IVT sICH (p = 0.01, OR = 0.27, 95% CI 0.10-0.77) and poor functional outcomes at discharge (p = 0.04 OR = 2.58, 95% CI 1.05-6.35). We found that lower free T3 levels are independently related to post-IVT sICH and poor functional outcomes at discharge in AIS patients with IVT, which should be verified and extended in large cohorts in the future.

The effects of music-supported therapy on motor, cognitive, and psychosocial functions in chronic stroke.

PubMed

Fujioka, Takako; Dawson, Deirdre R; Wright, Rebecca; Honjo, Kie; Chen, Joyce L; Chen, J Jean; Black, Sandra E; Stuss, Donald T; Ross, Bernhard

2018-05-24

Neuroplasticity accompanying learning is a key mediator of stroke rehabilitation. Training in playing music in healthy populations and patients with movement disorders requires resources within motor, sensory, cognitive, and affective systems, and coordination among these systems. We investigated effects of music-supported therapy (MST) in chronic stroke on motor, cognitive, and psychosocial functions compared to conventional physical training (GRASP). Twenty-eight adults with unilateral arm and hand impairment were randomly assigned to MST (n = 14) and GRASP (n = 14) and received 30 h of training over a 10-week period. The assessment was conducted at four time points: before intervention, after 5 weeks, after 10 weeks, and 3 months after training completion. As for two of our three primary outcome measures concerning motor function, all patients slightly improved in Chedoke-McMaster Stroke Assessment hand score, while the time to complete Action Research Arm Test became shorter in the MST group. The third primary outcome measure for well-being, Stroke Impact Scale, was improved for emotion and social communication earlier in MST and coincided with the improved executive function for task switching and music rhythm perception. The results confirmed previous findings and expanded the potential usage of MST for enhancing quality of life in community-dwelling chronic-stage survivors. © 2018 New York Academy of Sciences.

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.

Predictors of Acute, Rehabilitation and Total Length of Stay in Acute Stroke: A Prospective Cohort Study.

PubMed

Ng, Yee Sien; Tan, Kristin Hx; Chen, Cynthia; Senolos, Gilmore C; Chew, Effie; Koh, Gerald Ch

2016-09-01

The poststroke acute and rehabilitation length of stay (LOS) are key markers of stroke care efficiency. This study aimed to describe the characteristics and identify the predictors of poststroke acute, rehabilitation and total LOS. This study also defined a subgroup of patients as "short" LOS and compared its complication rates and functional outcomes in rehabilitation with a "long" acute LOS group. A prospective cohort study (n = 1277) was conducted in a dedicated rehabilitation unit within a tertiary academic acute hospital over a 5-year period between 2004 and 2009. The functional independence measure (FIM) was the primary functional outcome measure in the rehabilitation phase. A group with an acute LOS of less than 7 days was defined as "short" acute LOS. Ischaemic strokes comprised 1019 (80%) of the cohort while the rest were haemorrhagic strokes. The mean acute and rehabilitation LOS were 9 ± 7 days and 18 ± 10 days, respectively. Haemorrhagic strokes and anterior circulation infarcts had significantly longer acute, rehabilitation and total LOS compared to posterior circulation and lacunar infarcts. The acute, rehabilitation and total LOS were significantly shorter for stroke admissions after 2007. There was poor correlation (r = 0.12) between the acute and rehabilitation LOS. In multivariate analyses, stroke type was strongly associated with acute LOS, while rehabilitation admission FIM scores were significantly associated with rehabilitation LOS. Patients in the short acute LOS group had fewer medical complications and similar FIM efficacies compared to the longer acute LOS group. Consideration for stroke type and initial functional status will facilitate programme planning that has a better estimation of the LOS duration, allowing for more equitable resource distribution across the inpatient stroke continuum. We advocate earlier transfers of appropriate patients to rehabilitation units as this ensures rehabilitation efficacy is maintained while the development of medical complications is potentially minimised.

Family functioning is associated with depressive symptoms in caregivers of acute stroke survivors.

PubMed

Epstein-Lubow, Gary P; Beevers, Christopher G; Bishop, Duane S; Miller, Ivan W

2009-06-01

To determine whether family functioning is uniquely associated with caregiver depressive symptoms in the immediate aftermath of stroke. Cross-sectional data from the baseline assessment of an intervention study for stroke survivors and their families. Neurology inpatient service of a large urban hospital. Stroke survivors (n=192), each with a primary caregiver. The mean age of stroke survivors was 66 years, and most, 57%, were men (n=110). The mean age of caregivers was 57 years, and 73% (n=140) of the caregivers were women. Eighty-five percent of caregivers were white. Not applicable. Measures were chosen to assess caregivers' depressive symptoms (Centers for Epidemiologic Studies Depression Scale), family functioning (Family Assessment Device), and additional factors such as health status (Medical Outcomes Study 36-Item Short-Form Health Survey) and stroke survivors' cognitive abilities (modified Mini-Mental State Examination) and functional impairments (FIM and Frenchay Activities Index). Depressive symptoms were mild to moderate in 14% and severe in 27% of caregivers. Family functioning was assessed as unhealthy in 34% of caregiver-patient dyads. In statistical regression models, caregiver depression was associated with patients' sex, caregivers' general health, and family functioning. Forty-one percent of caregivers experienced prominent depressive symptoms after their family member's stroke. Higher depression severity in caregivers was associated with caring for a man, and having worse health and poor family functioning. After stroke, the assessment of caregivers' health and family functioning may help determine which caregivers are most at risk for a depressive syndrome.

Pregnancy and puerperium-related strokes in Asian women.

PubMed

Khan, Maria; Wasay, Mohammad; Menon, Bindu; Saadatnia, Mohammad; Venketasubramanian, Narayanaswamy; Gunaratne, Padma; Mehndiratta, M M; Dai, Alper; Kaul, Subhash

2013-11-01

Despite an increased risk of stroke in pregnancy and puerperium, the overall incidence of the condition in this population is low. Therefore, there is limited data pertaining to these patients particularly from Asian countries. Our objective was to describe the risk factors and outcomes of 110 pregnancy-related ischemic strokes from 5 Asian countries. Data were collected by retrospective chart review in most cases and prospectively in the rest. Inclusion criteria for this subanalysis were women, pregnant or within 1-month postpartum, presenting to the study center with acute ischemic stroke (arterial or venous) confirmed by neuroimaging. Intracranial hemorrhages other than the ones associated with cerebral venous thrombosis or hemorrhagic infarct were excluded. Risk factors were diagnosed based on already published criteria. Outcomes were measured using modified Rankin score. Statistical analysis was done using Statistical Package for Social Sciences version 19.0. In all, 110 women with mean age of 27.94 years presented with pregnancy-related ischemic strokes; 58.2% of the strokes occurred postpartum and 49.1% were secondary to cerebral venous thrombosis. Venous strokes were significantly more likely to occur postpartum compared with arterial strokes (P=.01), to have abnormal "hypercoagulable panel result on admission" (P<.001), less likely to have traditional stroke risk factors (P<.001), to have hemorrhagic conversion of stroke (P<.001), and to have lesser stroke severity and better functional outcome at 3 months (P<.001 for each). Cerebral venous thrombosis is a significant contributor to pregnancy-related strokes in Asian women. Both traditional and pregnancy-specific risk factors should be addressed to control ischemic stroke risk in these women. Copyright © 2013 National Stroke Association. Published by Elsevier Inc. All rights reserved.

First-ever ischemic stroke in elderly patients: predictors of functional outcome following carotid artery stenting

PubMed Central

Lin, Chih-Ming; Chang, Yu-Jun; Liu, Chi-Kuang; Yu, Cheng-Sheng; Lu, Henry Horng-Shing

2016-01-01

Age is an important risk factor for stroke, and carotid artery stenosis is the primary cause of first-ever ischemic stroke. Timely intervention with stenting procedures can effectively prevent secondary stroke; however, the impact of stenting on various periprocedural physical functionalities has never been thoroughly investigated. The primary aim of this study was to investigate whether prestenting characteristics were associated with long-term functional outcomes in patients presenting with first-ever ischemic stroke. The secondary aim was to investigate whether patient age was an important factor in outcomes following stenting, measured by the modified Rankin scale (mRS). In total, 144 consecutive patients with first-ever ischemic stroke who underwent carotid artery stenting from January 2010 to November 2014 were included. Clinical data were obtained by review of medical records. The Barthel index (BI) and mRS were used to assess disability before stenting and at 12-month follow-up. In total, 72/144 patients showed improvement (mRS[+]), 71 showed stationary and one showed deterioration in condition (mRS[−]). The prestenting parameters, ratio of cerebral blood volume (1.41 vs 1.2 for mRS[−] vs mRS[+]), BI (75 vs 85), and high-sensitivity C-reactive protein (hsCRP 5.0 vs 3.99), differed significantly between the two outcome groups (P<0.05). The internal carotid artery/common carotid artery ratio (P=0.011), BI (P=0.019), ipsilateral internal carotid artery resistance index (P=0.003), and HbA1c (P=0.039) were all factors significantly associated with patient age group. There was no significant association between age and poststenting outcome measured by mRS with 57% of patients in the ≥75 years age group showing mRS(−) and 43% showing mRS(+) (P=0.371). Our findings indicate that in our elderly patient series, carotid artery stenting may benefit a significant proportion of carotid stenotic patients regardless of age. Ratio of cerebral blood volume, BI, and admission hsCRP could serve as important predictors of mRS improvement and may facilitate differentiation of patients at baseline. PMID:27555753

The early use of botulinum toxin in post-stroke spasticity: study protocol for a randomised controlled trial.

PubMed

Lindsay, Cameron; Simpson, Julie; Ispoglou, Sissi; Sturman, Steve G; Pandyan, Anand D

2014-01-08

Patients surviving stroke but who have significant impairment of function in the affected arm are at more risk of developing pain, stiffness and contractures. The abnormal muscle activity, associated with post-stroke spasticity, is thought to be causally associated with the development of these complications. Treatment of spasticity is currently delayed until a patient develops signs of these complications. This protocol is for a phase II study that aims to identify whether using OnabotulinumtoxinA (BoNT-A) in combination with physiotherapy early post stroke when initial abnormal muscle activity is neurophysiologically identified can prevent loss of range at joints and improve functional outcomes.The trial uses a screening phase to identify which people are appropriate to be included in a double blind randomised placebo-controlled trial. All patients admitted to Sandwell and West Birmingham NHS Trust Hospitals with a diagnosis of stroke will be screened to identify functional activity in the arm. Those who have no function will be appropriate for further screening. Patients who are screened and have abnormal muscle activity identified on EMG will be given electrical stimulation to forearm extensors for 3 months and randomised to have either injections of BoNT-A or normal saline. The primary outcome measure is the action research arm test - a measure of arm function. Further measures include spasticity, stiffness, muscle strength and fatigue as well as measures of quality of life, participation and caregiver strain. ISRCTN57435427, EudraCT2010-021257-39, NCT01882556.

An observational study of implicit motor imagery using laterality recognition of the hand after stroke.

PubMed

Amesz, Sarah; Tessari, Alessia; Ottoboni, Giovanni; Marsden, Jon

2016-01-01

To explore the relationship between laterality recognition after stroke and impairments in attention, 3D object rotation and functional ability. Observational cross-sectional study. Acute care teaching hospital. Thirty-two acute and sub-acute people with stroke and 36 healthy, age-matched controls. Laterality recognition, attention and mental rotation of objects. Within the stroke group, the relationship between laterality recognition and functional ability, neglect, hemianopia and dyspraxia were further explored. People with stroke were significantly less accurate (69% vs 80%) and showed delayed reaction times (3.0 vs 1.9 seconds) when determining the laterality of a pictured hand. Deficits either in accuracy or reaction times were seen in 53% of people with stroke. The accuracy of laterality recognition was associated with reduced functional ability (R(2) = 0.21), less accurate mental rotation of objects (R(2) = 0.20) and dyspraxia (p = 0.03). Implicit motor imagery is affected in a significant number of patients after stroke with these deficits related to lesions to the motor networks as well as other deficits seen after stroke. This research provides new insights into how laterality recognition is related to a number of other deficits after stroke, including the mental rotation of 3D objects, attention and dyspraxia. Further research is required to determine if treatment programmes can improve deficits in laterality recognition and impact functional outcomes after stroke.

Evaluation of Tai Chi Yunshou exercises on community-based stroke patients with balance dysfunction: a study protocol of a cluster randomized controlled trial.

PubMed

Tao, Jing; Rao, Ting; Lin, Lili; Liu, Wei; Wu, Zhenkai; Zheng, Guohua; Su, Yusheng; Huang, Jia; Lin, Zhengkun; Wu, Jinsong; Fang, Yunhua; Chen, Lidian

2015-02-25

Balance dysfunction after stroke limits patients' general function and participation in daily life. Previous researches have suggested that Tai Chi exercise could offer a positive improvement in older individuals' balance function and reduce the risk of falls. But convincing evidence for the effectiveness of enhancing balance function after stroke with Tai Chi exercise is still inadequate. Considering the difficulties for stroke patients to complete the whole exercise, the current trial evaluates the benefit of Tai Chi Yunshou exercise for patients with balance dysfunction after stroke through a cluster randomization, parallel-controlled design. A single-blind, cluster-randomized, parallel-controlled trial will be conducted. A total of 10 community health centers (5 per arm) will be selected and randomly allocated into Tai Chi Yunshou exercise group or balance rehabilitation training group. Each community health centers will be asked to enroll 25 eligible patients into the trial. 60 minutes per each session, 1 session per day, 5 times per week and the total training round is 12 weeks. Primary and secondary outcomes will be measured at baseline and 4-weeks, 8-weeks, 12-weeks, 6-week follow-up, 12-week follow-up after randomization. Safety and economic evaluation will also be assessed. This protocol aims to evaluate the effectiveness of Tai Chi Yunshou exercise for the balance function of patients after stroke. If the outcome is positive, this project will provide an appropriate and economic balance rehabilitation technology for community-based stroke patients. Chinese Clinical Trial Registry: ChiCTR-TRC-13003641. Registration date: 22 August, 2013 http://www.chictr.org/usercenter/project/listbycreater.aspx .

Multicenter Randomized Trial of Robot-Assisted Rehabilitation for Chronic Stroke: Methods and Entry Characteristics for VA ROBOTICS

PubMed Central

Lo, Albert C.; Guarino, Peter; Krebs, Hermano I.; Volpe, Bruce T.; Bever, Christopher T.; Duncan, Pamela W.; Ringer, Robert J.; Wagner, Todd H.; Richards, Lorie G.; Bravata, Dawn M.; Haselkorn, Jodie K.; Wittenberg, George F.; Federman, Daniel G.; Corn, Barbara H.; Maffucci, Alysia D.; Peduzzi, Peter

2017-01-01

Background Chronic upper extremity impairment due to stroke has significant medical, psychosocial, and financial consequences, but few studies have examined the effectiveness of rehabilitation therapy during the chronic stroke period. Objective To test the safety and efficacy of the MIT-Manus robotic device for chronic upper extremity impairment following stroke. Methods The VA Cooperative Studies Program initiated a multicenter, randomized, controlled trial in November 2006 (VA ROBOTICS). Participants with upper extremity impairment ≥6 months poststroke were randomized to robot-assisted therapy (RT), intensive comparison therapy (ICT), or usual care (UC). RT and ICT consisted of three 1-hour treatment sessions per week for 12 weeks. The primary outcome was change in the Fugl-Meyer Assessment upper extremity motor function score at 12 weeks relative to baseline. Secondary outcomes included the Wolf Motor Function Test and the Stroke Impact Scale. Results A total of 127 participants were randomized: 49 to RT, 50 to ICT, and 28 to UC. The majority of participants were male (96%), with a mean age of 65 years. The primary stroke type was ischemic (85%), and 58% of strokes occurred in the anterior circulation. Twenty percent of the participants reported a stroke in addition to their index stroke. The average time from the index stroke to enrollment was 56 months (range, 6 months to 24 years). The mean Fugl-Meyer score at entry was 18.9. Conclusions VA ROBOTICS demonstrates the feasibility of conducting multicenter clinical trials to rigorously test new rehabilitative devices before their introduction to clinical practice. The results are expected in early 2010. PMID:19541917

Robot-assisted gait training improves brachial–ankle pulse wave velocity and peak aerobic capacity in subacute stroke patients with totally dependent ambulation

PubMed Central

Han, Eun Young; Im, Sang Hee; Kim, Bo Ryun; Seo, Min Ji; Kim, Myeong Ok

2016-01-01

Abstract Objective: Brachial–ankle pulse wave velocity (baPWV) evaluates arterial stiffness and also predicts early outcome in stroke patients. The objectives of this study were to investigate arterial stiffness of subacute nonfunctional ambulatory stroke patients and to compare the effects of robot-assisted gait therapy (RAGT) combined with rehabilitation therapy (RT) on arterial stiffness and functional recovery with those of RT alone. Method: The RAGT group (N = 30) received 30 minutes of robot-assisted gait therapy and 30 minutes of conventional RT, and the control group (N = 26) received 60 minutes of RT, 5 times a week for 4 weeks. baPWV was measured and calculated using an automated device. The patients also performed a symptom-limited graded exercise stress test using a bicycle ergometer, and parameters of cardiopulmonary fitness were recorded. Clinical outcome measures were categorized into 4 categories: activities of daily living, balance, ambulatory function, and paretic leg motor function and were evaluated before and after the 4-week intervention. Results: Both groups exhibited significant functional recovery in all clinical outcome measures after the 4-week intervention. However, peak aerobic capacity, peak heart rate, exercise tolerance test duration, and baPWV improved only in the RAGT group, and the improvements in baPWV and peak aerobic capacity were more noticeable in the RAGT group than in the control group. Conclusion: Robot-assisted gait therapy combined with conventional rehabilitation therapy represents an effective method for reversing arterial stiffness and improving peak aerobic capacity in subacute stroke patients with totally dependent ambulation. However, further large-scale studies with longer term follow-up periods are warranted to measure the effects of RAGT on secondary prevention after stroke. PMID:27741123

Cluster Randomized Controlled Trial: Clinical and Cost-Effectiveness of a System of Longer-Term Stroke Care.

PubMed

Forster, Anne; Young, John; Chapman, Katie; Nixon, Jane; Patel, Anita; Holloway, Ivana; Mellish, Kirste; Anwar, Shamaila; Breen, Rachel; Knapp, Martin; Murray, Jenni; Farrin, Amanda

2015-08-01

We developed a new postdischarge system of care comprising a structured assessment covering longer-term problems experienced by patients with stroke and their carers, linked to evidence-based treatment algorithms and reference guides (the longer-term stroke care system of care) to address the poor longer-term recovery experienced by many patients with stroke. A pragmatic, multicentre, cluster randomized controlled trial of this system of care. Eligible patients referred to community-based Stroke Care Coordinators were randomized to receive the new system of care or usual practice. The primary outcome was improved patient psychological well-being (General Health Questionnaire-12) at 6 months; secondary outcomes included functional outcomes for patients, carer outcomes, and cost-effectiveness. Follow-up was through self-completed postal questionnaires at 6 and 12 months. Thirty-two stroke services were randomized (29 participated); 800 patients (399 control; 401 intervention) and 208 carers (100 control; 108 intervention) were recruited. In intention to treat analysis, the adjusted difference in patient General Health Questionnaire-12 mean scores at 6 months was -0.6 points (95% confidence interval, -1.8 to 0.7; P=0.394) indicating no evidence of statistically significant difference between the groups. Costs of Stroke Care Coordinator inputs, total health and social care costs, and quality-adjusted life year gains at 6 months, 12 months, and over the year were similar between the groups. This robust trial demonstrated no benefit in clinical or cost-effectiveness outcomes associated with the new system of care compared with usual Stroke Care Coordinator practice. URL: http://www.controlled-trials.com. Unique identifier: ISRCTN 67932305. © 2015 Bradford Teaching Hospitals NHS Foundation Trust.

Cough reflex attenuation and swallowing dysfunction in sub-acute post-stroke patients: prevalence, risk factors, and clinical outcome.

PubMed

Vilardell, N; Rofes, L; Nascimento, W V; Muriana, D; Palomeras, E; Clavé, P

2017-01-01

Cough and swallowing impairments in post-stroke patients (PSP) have been associated with increased risk for respiratory complications. To assess the prevalence of alterations in protective cough responses in subacute PSP and its association with oropharyngeal dysphagia (OD), clinical, and neurotopographic stroke factors and clinical outcomes. Three months after stroke, the cough reflex test (CRT) was performed by nebulizing incremental citric acid concentrations (7.8-1000 mmol L -1 ) to determine the concentration that elicited two and five coughs; OD was assessed by the volume-viscosity swallow test. Clinical and neurotopographic stroke risk factors and complications (readmissions, respiratory infections, institutionalization, and mortality) were recorded from 3 to 12 months post-stroke. We included 225 PSP. Prevalence of impaired CRT was 5.8%, that of OD was 40.4% (20.4% with impaired safety of swallow), and of both impairments was, 1.8%. No specific risk factors associated with impaired CRT were found; however, hemorrhagic, wide circulation infarction (TACI), and brainstem strokes delayed the cough response. OD was associated with age, TACI and poor functional and nutritional status. Outcome of PSPs was unaffected by impaired CRT but OD and impaired safety of swallow increased institutionalization, respiratory infections, and mortality with the poorest outcome for those with both impairments. Prevalence of subacute post-stroke OD and swallow safety impairments was much higher than CRT attenuation, and risk factors strongly differed suggesting that the swallow response receives a stronger cortical control than the cough reflex. OD has a greater impact on PSP clinical outcome than impaired cough, the poorest prognosis being for patients with both airway protective dysfunctions. © 2016 John Wiley & Sons Ltd.

Combining afferent stimulation and mirror therapy for rehabilitating motor function, motor control, ambulation, and daily functions after stroke.

PubMed

Lin, Keh-chung; Huang, Pai-chuan; Chen, Yu-ting; Wu, Ching-yi; Huang, Wen-ling

2014-02-01

Mirror therapy (MT) and mesh glove (MG) afferent stimulation may be effective in reducing motor impairment after stroke. A hybrid intervention of MT combined with MG (MT + MG) may broaden aspects of treatment benefits. To demonstrate the comparative effects of MG + MT, MT, and a control treatment (CT) on the outcomes of motor impairments, manual dexterity, ambulation function, motor control, and daily function. Forty-three chronic stroke patients with mild to moderate upper extremity impairment were randomly assigned to receive MT + MG, MT, or CT for 1.5 hours/day, 5 days/week for 4 weeks. Outcome measures were the Fugl-Meyer Assessment (FMA) and muscle tone measured by Myoton-3 for motor impairment and the Box and Block Test (BBT) and 10-Meter Walk Test (10 MWT) for motor function. Secondary outcomes included kinematic parameters for motor control and the Motor Activity Log and ABILHAND Questionnaire for daily function. FMA total scores were significantly higher and synergistic shoulder abduction during reach was less in the MT + MG and MT groups compared with the CT group. Performance on the BBT and the 10 MWT (velocity and stride length in self-paced task and velocity in as-quickly-as-possible task) were improved after MT + MG compared with MT. MT + MG improved manual dexterity and ambulation. MT + MG and MT reduced motor impairment and synergistic shoulder abduction more than CT. Future studies may integrate functional task practice into treatments to enhance functional outcomes in patients with various levels of motor severity. The long-term effects of MG + MT remain to be evaluated.

Effects of training with a passive hand orthosis and games at home in chronic stroke: a pilot randomised controlled trial.

PubMed

Nijenhuis, Sharon M; Prange-Lasonder, Gerdienke B; Stienen, Arno Ha; Rietman, Johan S; Buurke, Jaap H

2017-02-01

To compare user acceptance and arm and hand function changes after technology-supported training at home with conventional exercises in chronic stroke. Secondly, to investigate the relation between training duration and clinical changes. A randomised controlled trial. Training at home, evaluation at research institute. Twenty chronic stroke patients with severely to mildly impaired arm and hand function. Participants were randomly assigned to six weeks (30 minutes per day, six days a week) of self-administered home-based arm and hand training using either a passive dynamic wrist and hand orthosis combined with computerised gaming exercises (experimental group) or prescribed conventional exercises from an exercise book (control group). Main outcome measures are the training duration for user acceptance and the Action Research Arm Test for arm and hand function. Secondary outcomes are the Intrinsic Motivation Inventory, Fugl-Meyer assessment, Motor Activity Log, Stroke Impact Scale and grip strength. The control group reported a higher training duration (189 versus 118 minutes per week, P = 0.025). Perceived motivation was positive and equal between groups ( P = 0.935). No differences in clinical outcomes over training between groups were found (P ⩾ 0.165). Changes in Box and Block Test correlated positively with training duration ( P = 0.001). Both interventions were accepted. An additional benefit of technology-supported arm and hand training over conventional arm and hand exercises at home was not demonstrated. Training duration in itself is a major contributor to arm and hand function improvements.

Cell-Based and Exosome Therapy in Diabetic Stroke.

PubMed

Venkat, Poornima; Chopp, Michael; Chen, Jieli

2018-03-02

Stroke is a global health concern and it is imperative that therapeutic strategies with wide treatment time frames be developed to improve neurological outcome in patients. Patients with diabetes mellitus who suffer a stroke have worse neurological outcomes and long-term functional recovery than nondiabetic stroke patients. Diabetes induced vascular damage and enhanced inflammatory milieu likely contributes to worse post stroke outcomes. Diabetic stroke patients have an aggravated pathological cascade, and treatments that benefit nondiabetic stroke patients do not necessarily translate to diabetic stroke patients. Therefore, there is a critical need to develop therapeutics for stroke specifically in the diabetic population. Stem cell based therapy for stroke is an emerging treatment option with wide therapeutic time window. Cell-based therapies for stroke promote endogenous central nervous system repair and neurorestorative mechanisms such as angiogenesis, neurogenesis, vascular remodeling, white matter remodeling, and also modulate inflammatory and immune responses at the local and systemic level. Emerging evidence suggests that exosomes and their cargo microRNA mediate cell therapy derived neurorestorative effects. Exosomes are small vesicles containing protein and RNA characteristic of its parent cell. Exosomes are transported by biological fluids and facilitate communication between neighboring and remote cells. MicroRNAs, a class of naturally occurring, small noncoding RNA sequences, contained within exosomes can regulate recipient cell's signaling pathways and alter protein expression either acting alone or in concert with other microRNAs. In this perspective article, we summarize current knowledge and highlight the promising future of cell based and exosome therapy for stroke and specifically for diabetic stroke. Stem Cells Translational Medicine 2018. © 2018 The Authors Stem Cells Translational Medicine published by Wiley Periodicals, Inc. on behalf of AlphaMed Press.

Effectiveness of Mirror Therapy for Subacute Stroke in Relation to Chosen Factors.

PubMed

Radajewska, Alina; Opara, Józef; Biliński, Grzegorz; Kaczorowska, Antonina; Nawrat-Szołtysik, Agnieszka; Kucińska, Aleksandra; Lepsy, Ewelina

The aim of this study was to determine the effectiveness of mirror therapy (MT) combined with comprehensive treatment and to investigate the possible relationships of functional state. Prospective, controlled trial of 60 stroke inpatients. The Functional Index "Repty" (FIR) was an outcome measure to assess changes of independence in daily activities. The Frenchay Arm Test (FAT) and Motor Status Score were outcome measures to assess changes in hand function. The analysis of pre- and posttest data indicated a significant improvement in hand function ([INCREMENT]FAT in the Mirror group p = .035, N = 30). Age factor indicated a significant change in relation to FIR outcome ([INCREMENT]FIR in the Mirror group p = .005, N = 30 and [INCREMENT]FIR in the Mirror group [left hand paresis] p = .037, N = 15). Additional MT influenced improvement in hand function. The age is significant in terms of functional state. The older adults are likely to benefit from MT. A positive impact of combining MT with other treatment was indicated.

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.

Emerging Treatments for Motor Rehabilitation After Stroke

PubMed Central

Krishnan, Chandramouli; Khot, Sandeep P.

2015-01-01

Although numerous treatments are available to improve cerebral perfusion after acute stroke and prevent recurrent stroke, few rehabilitation treatments have been conclusively shown to improve neurologic recovery. The majority of stroke survivors with motor impairment do not recover to their functional baseline, and there remains a need for novel neurorehabilitation treatments to minimize long-term disability, maximize quality of life, and optimize psychosocial outcomes. In recent years, several novel therapies have emerged to restore motor function after stroke, and additional investigational treatments have also shown promise. Here, we familiarize the neurohospitalist with emerging treatments for poststroke motor rehabilitation. The rehabilitation treatments covered in this review will include selective serotonin reuptake inhibitor medications, constraint-induced movement therapy, noninvasive brain stimulation, mirror therapy, and motor imagery or mental practice. PMID:25829989

Thrombolysis in Acute Ischemic Stroke: A Simulation Study to Improve Pre- and in-Hospital Delays in Community Hospitals

PubMed Central

Lahr, Maarten M. H.; van der Zee, Durk-Jouke; Vroomen, Patrick C. A. J.; Luijckx, Gert-Jan; Buskens, Erik

2013-01-01

Background Various studies demonstrate better patient outcome and higher thrombolysis rates achieved by centralized stroke care compared to decentralized care, i.e. community hospitals. It remains largely unclear how to improve thrombolysis rate in decentralized care. The aim of this simulation study was to assess the impact of previously identified success factors in a central model on thrombolysis rates and patient outcome when implemented for a decentral model. Methods Based on a prospectively collected dataset of 1084 ischemic stroke patients, simulation was used to replicate current practice and estimate the effect of re-organizing decentralized stroke care to resemble a centralized model. Factors simulated included symptom onset call to help, emergency medical services transportation, and in-hospital diagnostic workup delays. Primary outcome was proportion of patients treated with thrombolysis; secondary endpoints were good functional outcome at 90 days, Onset-Treatment-Time (OTT), and OTT intervals, respectively. Results Combining all factors might increase thrombolysis rate by 7.9%, of which 6.6% ascribed to pre-hospital and 1.3% to in-hospital factors. Good functional outcome increased by 11.4%, 8.7% ascribed to pre-hospital and 2.7% to in-hospital factors. The OTT decreased 17 minutes, 7 minutes ascribed to pre-hospital and 10 minutes to in-hospital factors. An increase was observed in the proportion thrombolyzed within 1.5 hours; increasing by 14.1%, of which 5.6% ascribed to pre-hospital and 8.5% to in-hospital factors. Conclusions Simulation technique may target opportunities for improving thrombolysis rates in acute stroke. Pre-hospital factors proved to be the most promising for improving thrombolysis rates in an implementation study. PMID:24260151

Gender-Related Differences and Short-Term Outcome of Stroke: Results from a Hospital-Based Registry in Sub-Saharan Africa.

PubMed

Mapoure, Yacouba Njankouo; Eyambe, Ngowo Lydia; Dzudie, Anastase Tamdja; Ayeah, Chia Mark; Ba, Hamadou; Hentchoya, Romuald; Luma, Henry Namme

2017-01-01

Studies suggest that sex differences have an impact on patients with stroke, but existing data in Africa remain inconclusive about this inference. To study sex differences in terms of the clinical profile and short-term outcome of stroke in the Douala General Hospital, Cameroon. A hospital-based prospective cohort study was carried out in a tertiary care hospital over an 8-year period, which included all patients admitted for confirmed acute stroke. Information about the history of stroke with emphasis on clinical profile and outcome was collected. Descriptive statistics, t test, and chi square test were used for comparisons, while the Kaplan-Meier curve was used for survival rate analysis. Of the 818 patients included, 455 (55.6%) were male patients. When compared to males, female patients are more likely to experience a stroke at an older age (mean age 62.3 ± 14.1 vs. 58.4 ± 12.9 years, p < 0.001), to be unmarried, to remain unemployed, and to have higher rates of cardio-embolic stroke (p = 0.049), body mass index (p = 0.031), altered levels of consciousness at presentation (p = 0.005), higher mean HDL cholesterol levels (p = 0.001), and in-hospital complications (p = 0.011), especially urinary tract infections (p = 0.018). Males were more likely to have health insurance, to smoke, to consume alcohol (p < 0.001), and to have higher rates of dysarthria (p = 0.004), higher mean uric acid (p = 0.013), and creatinine (p < 0.001) concentrations. Ischemic and hemorrhagic strokes were more prevalent in men (p = 0.003). There are no sex differences in terms of stroke severity, length-of-hospital stay, case fatality, and functional outcome on admission. Sex differences exist in the clinical profile of stroke but not in the outcome. Knowledge of these differences could help influence stroke prevention, thereby improving stroke burden in Africa. © 2017 S. Karger AG, Basel.

[Effects of an intensive thalassotherapy and aquatic therapy program in stroke patients. A pilot study].

PubMed

Morer, C; Boestad, C; Zuluaga, P; Alvarez-Badillo, A; Maraver, F

2017-09-16

Stroke remains the leading cause of acquired disability. Health and social planning and management may vary and although prevention is crucial, having better treatments and strategies to reduce disability is needed. To determine the effect of an intensive program of thalassotherapy and aquatic therapy in stroke patients, valuing clinical parameters and functional validated scales. A quasi-experimental prospective study consisting of a specific program assessed pre- and post- 3 weeks treatment to 26 stroke patients with a mild-moderate disability. The outcomes measured were: Berg Balance scale, Timed Up and Go test, 10-meter walking test, 6-minute walking test and pain Visual Analogue Scale. After intervention, participants had a significant improvement in all outcomes measured. Our results suggest that an intensive program of thalassotherapy and aquatic therapy could be useful during stroke rehabilitation to improve balance, gait and pain.

Watsu approach for improving spasticity and ambulatory function in hemiparetic patients with stroke.

PubMed

Chon, Seung Chul; Oh, Duck Won; Shim, Jae Hun

2009-06-01

This study reports the effect of Watsu as rehabilitation method for hemiparetic patients with stroke. Watsu consisted of 40 treatment sessions for 8 weeks, delivered underwater or at water surface level, it applied in three patients. Outcome measures included tools for assessing spasticity and ambulatory function. All patients showed decreased scores in the TAS and RVGA after Watsu application. Watsu was helpful in controlling spasticity and improving ambulatory function of the patients with hemiparesis.

Current knowledge on the neuroprotective and neuroregenerative properties of citicoline in acute ischemic stroke

PubMed Central

Martynov, Mikhail Yu; Gusev, Eugeny I

2015-01-01

Ischemic stroke is one of the leading causes of long-lasting disability and death. Two main strategies have been proposed for the treatment of ischemic stroke: restoration of blood flow by thrombolysis or mechanical thrombus extraction during the first few hours of ischemic stroke, which is one of the most effective treatments and leads to a better functional and clinical outcome. The other direction of treatment, which is potentially applicable to most of the patients with ischemic stroke, is neuroprotection. Initially, neuroprotection was mainly targeted at protecting gray matter, but during the past few years there has been a transition from a neuron-oriented approach toward salvaging the whole neurovascular unit using multimodal drugs. Citicoline is a multimodal drug that exhibits neuroprotective and neuroregenerative effects in a variety of experimental and clinical disorders of the central nervous system, including acute and chronic cerebral ischemia, intracerebral hemorrhage, and global cerebral hypoxia. Citicoline has a prolonged therapeutic window and is active at various temporal and biochemical stages of the ischemic cascade. In acute ischemic stroke, citicoline provides neuroprotection by attenuating glutamate exitotoxicity, oxidative stress, apoptosis, and blood–brain barrier dysfunction. In the subacute and chronic phases of ischemic stroke, citicoline exhibits neuroregenerative effects and activates neurogenesis, synaptogenesis, and angiogenesis and enhances neurotransmitter metabolism. Acute and long-term treatment with citicoline is safe and in most clinical studies is effective and improves functional outcome. PMID:27186142

Unclear-onset intracerebral hemorrhage: Clinical characteristics, hematoma features, and outcomes.

PubMed

Inoue, Yasuteru; Miyashita, Fumio; Koga, Masatoshi; Minematsu, Kazuo; Toyoda, Kazunori

2017-12-01

Background and purpose Although unclear-onset ischemic stroke, including wake-up ischemic stroke, is drawing attention as a potential target for reperfusion therapy, acute unclear-onset intracerebral hemorrhage has been understudied. Clinical characteristics, hematoma features, and outcomes of patients who developed intracerebral hemorrhage during sleep or those with intracerebral hemorrhage who were unconscious when witnessed were determined. Methods Consecutive intracerebral hemorrhage patients admitted within 24 hours after onset or last-known normal time were classified into clear-onset intracerebral hemorrhage and unclear-onset intracerebral hemorrhage groups. Outcomes included initial hematoma volume, initial National Institutes of Health Stroke Scale score, hematoma growth on 24-hour follow-up computed tomography, and vital and functional prognoses at 30 days. Results Of 377 studied patients (122 women, 69 ± 11 years old), 147 (39.0%) had unclear-onset intracerebral hemorrhage. Patients with unclear-onset intracerebral hemorrhage had larger hematoma volumes (p = 0.044) and higher National Institutes of Health Stroke Scale scores (p < 0.001) than those with clear-onset intracerebral hemorrhage after multivariable adjustment for risk factors and comorbidities. Hematoma growth was similarly common between the two groups (p = 0.176). There were fewer patients with modified Rankin Scale (mRS) scores of 0-2 (p = 0.033) and more patients with mRS scores of 5-6 (p = 0.009) and with fatal outcomes (p = 0.049) in unclear-onset intracerebral hemorrhage group compared with clear-onset intracerebral hemorrhage as crude values, but not after adjustment. Conclusions Patients with unclear-onset intracerebral hemorrhage presented with larger hematomas and higher National Institutes of Health Stroke Scale scores at emergent visits than those with clear-onset intracerebral hemorrhage, independent of underlying characteristics. Unclear-onset intracerebral hemorrhage patients showed poorer 30-day vital and functional outcomes than clear-onset intracerebral hemorrhage patients; these differences seem to be mainly due to initial hematoma volumes and National Institutes of Health Stroke Scale scores.

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

Acute imaging does not improve ASTRAL score's accuracy despite having a prognostic value.

PubMed

Ntaios, George; Papavasileiou, Vasileios; Faouzi, Mohamed; Vanacker, Peter; Wintermark, Max; Michel, Patrik

2014-10-01

The ASTRAL score was recently shown to reliably predict three-month functional outcome in patients with acute ischemic stroke. The study aims to investigate whether information from multimodal imaging increases ASTRAL score's accuracy. All patients registered in the ASTRAL registry until March 2011 were included. In multivariate logistic-regression analyses, we added covariates derived from parenchymal, vascular, and perfusion imaging to the 6-parameter model of the ASTRAL score. If a specific imaging covariate remained an independent predictor of three-month modified Rankin score>2, the area-under-the-curve (AUC) of this new model was calculated and compared with ASTRAL score's AUC. We also performed similar logistic regression analyses in arbitrarily chosen patient subgroups. When added to the ASTRAL score, the following covariates on admission computed tomography/magnetic resonance imaging-based multimodal imaging were not significant predictors of outcome: any stroke-related acute lesion, any nonstroke-related lesions, chronic/subacute stroke, leukoaraiosis, significant arterial pathology in ischemic territory on computed tomography angiography/magnetic resonance angiography/Doppler, significant intracranial arterial pathology in ischemic territory, and focal hypoperfusion on perfusion-computed tomography. The Alberta Stroke Program Early CT score on plain imaging and any significant extracranial arterial pathology on computed tomography angiography/magnetic resonance angiography/Doppler were independent predictors of outcome (odds ratio: 0·93, 95% CI: 0·87-0·99 and odds ratio: 1·49, 95% CI: 1·08-2·05, respectively) but did not increase ASTRAL score's AUC (0·849 vs. 0·850, and 0·8563 vs. 0·8564, respectively). In exploratory analyses in subgroups of different prognosis, age or stroke severity, no covariate was found to increase ASTRAL score's AUC, either. The addition of information derived from multimodal imaging does not increase ASTRAL score's accuracy to predict functional outcome despite having an independent prognostic value. More selected radiological parameters applied in specific subgroups of stroke patients may add prognostic value of multimodal imaging. © 2014 World Stroke Organization.

Home blood pressure predicts stroke incidence among older adults with impaired physical function: the Ohasama study.

PubMed

Murakami, Keiko; Asayama, Kei; Satoh, Michihiro; Hosaka, Miki; Matsuda, Ayako; Inoue, Ryusuke; Tsubota-Utsugi, Megumi; Murakami, Takahisa; Nomura, Kyoko; Kikuya, Masahiro; Metoki, Hirohito; Imai, Yutaka; Ohkubo, Takayoshi

2017-12-01

Several observational studies have found modifying effects of functional status on the association between conventional office blood pressure (BP) and adverse outcomes. We aimed to examine whether the association between higher BP and stroke was attenuated or inverted among older adults with impaired function using self-measured home BP measurements. We followed 501 Japanese community-dwelling adults aged at least 60 years (mean age, 68.6 years) with no history of stroke. Multivariate-adjusted hazard ratios for 1-SD increase in home BP and office BP measurements were calculated by the Cox proportional hazards model. Functional status was assessed by self-reported physical function. During a median follow-up of 11.5 years, first strokes were observed in 47 participants. Higher home SBP, but not office SBP, was significantly associated with increased risk of stroke among both 349 participants with normal physical function and 152 participants with impaired physical function [hazard ratio (95% confidence interval) per 14.4-mmHg increase: 1.74 (1.12-2.69) and 1.77 (1.06-2.94), respectively], with no significant interaction for physical function (P = 0.56). Higher home DBP, but not office DBP, was also significantly associated with increased risk of stroke (P ≤ 0.029) irrespective of physical function (all P > 0.05 for interaction). Neither home BP nor office BP was significantly associated with all-cause mortality irrespective of physical function. Higher home BP was associated with increased risk of stroke even among those with impaired physical function. Measurements of home BP would be useful for stroke prevention, even after physical function decline.

Transcranial magnetic stimulation in mild to severe hemiparesis early after stroke: a proof of principle and novel approach to improve motor function

PubMed Central

Anjos, Sarah M.; Saposnik, Gustavo; Mello, Eduardo A.; Nagaya, Erina M.; Santos, Waldyr; Ferreiro, Karina N.; Melo, Eduardo S.; Reis, Felipe I.; Scaff, Milberto; Cohen, Leonardo G.

2016-01-01

Low-frequency repetitive transcranial magnetic stimulation (rTMS) of the unaffected hemisphere can enhance function of the paretic hand in patients with mild motor impairment. Effects of low-frequency rTMS to the contralesional motor cortex at an early stage of mild to severe hemiparesis after stroke are unknown. In this pilot, randomized, double-blind clinical trial we compared the effects of low-frequency rTMS or sham rTMS as add-on therapies to outpatient customary rehabilitation, in 30 patients within 5–45 days after ischemic stroke, and mild to severe hand paresis. The primary feasibility outcome was compliance with the interventions. The primary safety outcome was the proportion of intervention-related adverse events. Performance of the paretic hand in the Jebsen–Taylor test and pinch strength were secondary outcomes. Outcomes were assessed at baseline, after ten sessions of treatment administered over 2 weeks and at 1 month after end of treatment. Baseline clinical features were comparable across groups. For the primary feasibility outcome, compliance with treatment was 100% in the active group and 94% in the sham group. There were no serious intervention-related adverse events. There were significant improvements in performance in the Jebsen–Taylor test (mean, 12.3% 1 month after treatment) and pinch force (mean, 0.5 Newtons) in the active group, but not in the sham group. Low-frequency rTMS to the contralesional motor cortex early after stroke is feasible, safe and potentially effective to improve function of the paretic hand, in patients with mild to severe hemiparesis. These promising results will be valuable to design larger randomized clinical trials. PMID:22173953

Robot-assisted therapy for long-term upper-limb impairment after stroke.

PubMed

Lo, Albert C; Guarino, Peter D; Richards, Lorie G; Haselkorn, Jodie K; Wittenberg, George F; Federman, Daniel G; Ringer, Robert J; Wagner, Todd H; Krebs, Hermano I; Volpe, Bruce T; Bever, Christopher T; Bravata, Dawn M; Duncan, Pamela W; Corn, Barbara H; Maffucci, Alysia D; Nadeau, Stephen E; Conroy, Susan S; Powell, Janet M; Huang, Grant D; Peduzzi, Peter

2010-05-13

Effective rehabilitative therapies are needed for patients with long-term deficits after stroke. In this multicenter, randomized, controlled trial involving 127 patients with moderate-to-severe upper-limb impairment 6 months or more after a stroke, we randomly assigned 49 patients to receive intensive robot-assisted therapy, 50 to receive intensive comparison therapy, and 28 to receive usual care. Therapy consisted of 36 1-hour sessions over a period of 12 weeks. The primary outcome was a change in motor function, as measured on the Fugl-Meyer Assessment of Sensorimotor Recovery after Stroke, at 12 weeks. Secondary outcomes were scores on the Wolf Motor Function Test and the Stroke Impact Scale. Secondary analyses assessed the treatment effect at 36 weeks. At 12 weeks, the mean Fugl-Meyer score for patients receiving robot-assisted therapy was better than that for patients receiving usual care (difference, 2.17 points; 95% confidence interval [CI], -0.23 to 4.58) and worse than that for patients receiving intensive comparison therapy (difference, -0.14 points; 95% CI, -2.94 to 2.65), but the differences were not significant. The results on the Stroke Impact Scale were significantly better for patients receiving robot-assisted therapy than for those receiving usual care (difference, 7.64 points; 95% CI, 2.03 to 13.24). No other treatment comparisons were significant at 12 weeks. Secondary analyses showed that at 36 weeks, robot-assisted therapy significantly improved the Fugl-Meyer score (difference, 2.88 points; 95% CI, 0.57 to 5.18) and the time on the Wolf Motor Function Test (difference, -8.10 seconds; 95% CI, -13.61 to -2.60) as compared with usual care but not with intensive therapy. No serious adverse events were reported. In patients with long-term upper-limb deficits after stroke, robot-assisted therapy did not significantly improve motor function at 12 weeks, as compared with usual care or intensive therapy. In secondary analyses, robot-assisted therapy improved outcomes over 36 weeks as compared with usual care but not with intensive therapy. (ClinicalTrials.gov number, NCT00372411.) 2010 Massachusetts Medical Society

Pharyngeal Electrical Stimulation for Treatment of Dysphagia in Subacute Stroke

PubMed Central

Scutt, Polly; Love, Jo; Clavé, Pere; Cohen, David; Dziewas, Rainer; Iversen, Helle K.; Ledl, Christian; Ragab, Suzanne; Soda, Hassan; Warusevitane, Anushka; Woisard, Virginie; Hamdy, Shaheen

2016-01-01

Background and Purpose— Dysphagia is common after stroke, associated with increased death and dependency, and treatment options are limited. Pharyngeal electric stimulation (PES) is a novel treatment for poststroke dysphagia that has shown promise in 3 pilot randomized controlled trials. Methods— We randomly assigned 162 patients with a recent ischemic or hemorrhagic stroke and dysphagia, defined as a penetration aspiration score (PAS) of ≥3 on video fluoroscopy, to PES or sham treatment given on 3 consecutive days. The primary outcome was swallowing safety, assessed using the PAS, at 2 weeks. Secondary outcomes included dysphagia severity, function, quality of life, and serious adverse events at 6 and 12 weeks. Results— In randomized patients, the mean age was 74 years, male 58%, ischemic stroke 89%, and PAS 4.8. The mean treatment current was 14.8 (7.9) mA and duration 9.9 (1.2) minutes per session. On the basis of previous data, 45 patients (58.4%) randomized to PES seemed to receive suboptimal stimulation. The PAS at 2 weeks, adjusted for baseline, did not differ between the randomized groups: PES 3.7 (2.0) versus sham 3.6 (1.9), P=0.60. Similarly, the secondary outcomes did not differ, including clinical swallowing and functional outcome. No serious adverse device-related events occurred. Conclusions— In patients with subacute stroke and dysphagia, PES was safe but did not improve dysphagia. Undertreatment of patients receiving PES may have contributed to the neutral result. Clinical Trial Registration— URL: http://www.controlled-trials.com. Unique identifier: ISRCTN25681641. PMID:27165955

Efficacy of a Virtual Reality Commercial Gaming Device in Upper Limb Recovery after Stroke: A Randomized, Controlled Study.

PubMed

Kong, Keng-He; Loh, Yong-Joo; Thia, Ernest; Chai, Audrey; Ng, Chwee-Yin; Soh, Yan-Ming; Toh, Shirlene; Tjan, Soon-Yin

2016-10-01

To compare the efficacy of a virtual reality commercial gaming device, Nintendo wii (NW) with conventional therapy and customary care in facilitating upper limb recovery after stroke. Randomized, controlled, single-blinded study. Tertiary rehabilitation center. 105 subjects admitted to in inpatient rehabilitation program within 6 weeks of stroke onset. Subjects were randomly assigned to one of three groups of upper limb exercises: (1) NW gaming; (2) conventional therapy; (3) control. NW gaming and conventional therapy were provided fourtimes a week for 3 weeks. The main outcome measure was Fugl-Meyer assessment (FMA) of upper limb function. Secondary outcome measures included Action Research Arm Test, Functional Independence Measure, and Stroke Impact Scale. These measures were assessed at baseline, completion of intervention (week 3) and at 4 weeks and 8 weeks after completion of intervention. The primary outcome measure was the change in FMA scores at completion of intervention. The mean age was 57.5±9.8 years, and subjects were enrolled at a mean of 13.7±8.9 days after stroke. The mean baseline FMA score was 16.4±14.2. There was no difference in FMA scores between all 3 groups at the end of intervention, and at 4 and 8 weeks after completion of intervention. Similar findings were also noted for the secondary outcome measures. Twelve sessions of augmented upper limb exercises via NW gaming or conventional therapy over a 3-week period was not effective in enhancing upper limb motor recovery compared to control.

Pharyngeal Electrical Stimulation for Treatment of Dysphagia in Subacute Stroke: A Randomized Controlled Trial.

PubMed

Bath, Philip M; Scutt, Polly; Love, Jo; Clavé, Pere; Cohen, David; Dziewas, Rainer; Iversen, Helle K; Ledl, Christian; Ragab, Suzanne; Soda, Hassan; Warusevitane, Anushka; Woisard, Virginie; Hamdy, Shaheen

2016-06-01

Dysphagia is common after stroke, associated with increased death and dependency, and treatment options are limited. Pharyngeal electric stimulation (PES) is a novel treatment for poststroke dysphagia that has shown promise in 3 pilot randomized controlled trials. We randomly assigned 162 patients with a recent ischemic or hemorrhagic stroke and dysphagia, defined as a penetration aspiration score (PAS) of ≥3 on video fluoroscopy, to PES or sham treatment given on 3 consecutive days. The primary outcome was swallowing safety, assessed using the PAS, at 2 weeks. Secondary outcomes included dysphagia severity, function, quality of life, and serious adverse events at 6 and 12 weeks. In randomized patients, the mean age was 74 years, male 58%, ischemic stroke 89%, and PAS 4.8. The mean treatment current was 14.8 (7.9) mA and duration 9.9 (1.2) minutes per session. On the basis of previous data, 45 patients (58.4%) randomized to PES seemed to receive suboptimal stimulation. The PAS at 2 weeks, adjusted for baseline, did not differ between the randomized groups: PES 3.7 (2.0) versus sham 3.6 (1.9), P=0.60. Similarly, the secondary outcomes did not differ, including clinical swallowing and functional outcome. No serious adverse device-related events occurred. In patients with subacute stroke and dysphagia, PES was safe but did not improve dysphagia. Undertreatment of patients receiving PES may have contributed to the neutral result. URL: http://www.controlled-trials.com. Unique identifier: ISRCTN25681641. © 2016 The Authors.

Effects of Balance Control Training on Functional Outcomes in Subacute Hemiparetic Stroke Patients.

PubMed

Huh, Jin Seok; Lee, Yang-Soo; Kim, Chul-Hyun; Min, Yu-Sun; Kang, Min-Gu; Jung, Tae-Du

2015-12-01

To investigate the efficacy of balance control training using a newly developed balance control trainer (BalPro) on the balance and gait of patients with subacute hemiparetic stroke. Forty-three subacute stroke patients were assigned to either a balance control training (BCT) group or a control group. The BCT group (n=23) was trained with BalPro for 30 minutes a day, 5 days a week for 2 weeks, and received one daily session of conventional physical therapy. The control group (n=20) received two sessions of conventional physical therapy every day for 2 weeks. The primary outcome was assessment with the Berg Balance Scale (BBS). Secondary outcomes were Functional Ambulation Category (FAC), the 6-minute walking test (6mWT), Timed Up and Go (TUG), the Korean version of Modified Barthel Index (K-MBI), and the manual muscle test (MMT) of the knee extensor. All outcome measures were evaluated before and after 2 weeks of training in both groups. There were statistically significant improvements in all parameters except MMT and FAC after 2 weeks of treatment in both groups. After training, the BCT group showed greater improvements in the BBS and the 6mWT than did the control group. Balance control training using BalPro could be a useful treatment for improving balance and gait in subacute hemiparetic stroke patients.

Effects of Balance Control Training on Functional Outcomes in Subacute Hemiparetic Stroke Patients

PubMed Central

Huh, Jin Seok; Lee, Yang-Soo; Kim, Chul-Hyun; Min, Yu-Sun; Kang, Min-Gu

2015-01-01

Objective To investigate the efficacy of balance control training using a newly developed balance control trainer (BalPro) on the balance and gait of patients with subacute hemiparetic stroke. Methods Forty-three subacute stroke patients were assigned to either a balance control training (BCT) group or a control group. The BCT group (n=23) was trained with BalPro for 30 minutes a day, 5 days a week for 2 weeks, and received one daily session of conventional physical therapy. The control group (n=20) received two sessions of conventional physical therapy every day for 2 weeks. The primary outcome was assessment with the Berg Balance Scale (BBS). Secondary outcomes were Functional Ambulation Category (FAC), the 6-minute walking test (6mWT), Timed Up and Go (TUG), the Korean version of Modified Barthel Index (K-MBI), and the manual muscle test (MMT) of the knee extensor. All outcome measures were evaluated before and after 2 weeks of training in both groups. Results There were statistically significant improvements in all parameters except MMT and FAC after 2 weeks of treatment in both groups. After training, the BCT group showed greater improvements in the BBS and the 6mWT than did the control group. Conclusion Balance control training using BalPro could be a useful treatment for improving balance and gait in subacute hemiparetic stroke patients. PMID:26798615

High urinary albumin/creatinine ratio at admission predicts poor functional outcome in patients with acute ischaemic stroke.

PubMed

Watanabe, Yoko; Suda, Satoshi; Kanamaru, Takuya; Katsumata, Toshiya; Okubo, Seiji; Kaneko, Tomohiro; Mii, Akiko; Sakai, Yukinao; Katayama, Yasuo; Kimura, Kazumi; Tsuruoka, Shuichi

2017-03-01

Albuminuria and a low estimated glomerular filtration rate (eGFR) are widely recognized indices of kidney dysfunction and have been linked to cardiovascular events, including stroke. We evaluated albuminuria, measured using the urinary albumin/creatinine ratio (UACR), and the eGFR in the acute phase of ischaemic stroke, and investigated the clinical characteristics of ischaemic stroke patients with and those without kidney dysfunction. The study included 422 consecutive patients admitted between June 2010 and May 2012. General blood and urine examinations were performed at admission. Kidney dysfunction was defined as a low eGFR (<60 mL/min per 1.73 m 2 ), high albuminuria (≥30 mg/g creatinine), or both. Neurological severity was evaluated using the National Institutes of Health Stroke Scale (NIHSS) at admission and the modified Rankin scale (mRS) at discharge. A poor outcome was defined as a mRS score of 3-5 or death. The impacts of the eGFR and UACR on outcomes at discharge were evaluated using multiple logistic regression analysis. Kidney dysfunction was diagnosed in 278 of the 422 patients (65.9%). The eGFR was significantly lower and UACR was significantly higher in patients with a poor outcome than in those with a good outcome. In multivariate analyses performed after adjusting for confounding factors, UACR >31.2 mg/g creatinine (OR, 2.58; 95% CI, 1.52-4.43; P = 0.0005) was independently associated with a poor outcome, while a low eGFR was not associated. A high UACR at admission may predict a poor outcome at discharge in patients with acute ischaemic stroke. © 2016 Asian Pacific Society of Nephrology.

Anterior Temporal Lobe Connectivity Correlates with Functional Outcome after Aphasic Stroke

ERIC Educational Resources Information Center

Warren, Jane E.; Crinion, Jennifer T.; Ralph, Matthew A. Lambon; Wise, Richard J. S.

2009-01-01

Focal brain lesions are assumed to produce language deficits by two basic mechanisms: local cortical dysfunction at the lesion site, and remote cortical dysfunction due to disruption of the transfer and integration of information between connected brain regions. However, functional imaging studies investigating language outcome after aphasic…

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.

Value of Quantitative Collateral Scoring on CT Angiography in Patients with Acute Ischemic Stroke.

PubMed

Boers, A M M; Sales Barros, R; Jansen, I G H; Berkhemer, O A; Beenen, L F M; Menon, B K; Dippel, D W J; van der Lugt, A; van Zwam, W H; Roos, Y B W E M; van Oostenbrugge, R J; Slump, C H; Majoie, C B L M; Marquering, H A

2018-06-01

Many studies have emphasized the relevance of collateral flow in patients presenting with acute ischemic stroke. Our aim was to evaluate the relationship of the quantitative collateral score on baseline CTA with the outcome of patients with acute ischemic stroke and test whether the timing of the CTA acquisition influences this relationship. From the Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands (MR CLEAN) data base, all baseline thin-slice CTA images of patients with acute ischemic stroke with intracranial large-vessel occlusion were retrospectively collected. The quantitative collateral score was calculated as the ratio of the vascular appearance of both hemispheres and was compared with the visual collateral score. Primary outcomes were 90-day mRS score and follow-up infarct volume. The relation with outcome and the association with treatment effect were estimated. The influence of the CTA acquisition phase on the relation of collateral scores with outcome was determined. A total of 442 patients were included. The quantitative collateral score strongly correlated with the visual collateral score (ρ = 0.75) and was an independent predictor of mRS (adjusted odds ratio = 0.81; 95% CI, .77-.86) and follow-up infarct volume (exponent β = 0.88; P < .001) per 10% increase. The quantitative collateral score showed areas under the curve of 0.71 and 0.69 for predicting functional independence (mRS 0-2) and follow-up infarct volume of >90 mL, respectively. We found significant interaction of the quantitative collateral score with the endovascular therapy effect in unadjusted analysis on the full ordinal mRS scale ( P = .048) and on functional independence ( P = .049). Modification of the quantitative collateral score by acquisition phase on outcome was significant (mRS: P = .004; follow-up infarct volume: P < .001) in adjusted analysis. Automated quantitative collateral scoring in patients with acute ischemic stroke is a reliable and user-independent measure of the collateral capacity on baseline CTA and has the potential to augment the triage of patients with acute stroke for endovascular therapy. © 2018 by American Journal of Neuroradiology.

Sex Differences in Patient-Reported Poststroke Disability.

PubMed

White, Brandi M; Magwood, Gayenell S; Burns, Suzanne Perea; Ellis, Charles

2018-04-01

Recent studies have shown that stroke has a differential impact in women compared to men. Women are more likely to survive strokes than men, yet they experience more severe strokes resulting in greater poststroke disability. However, few studies have characterized sex differences in functional ability after stroke. This study examined sex differences in long-term disability among stroke survivors. This was a retrospective analysis of the 2015 National Health Interview Survey. Respondents were asked to rate their ability to perform 11 functional tasks. Univariate comparisons were completed to evaluate sex differences in performance, and multinomial logistic regression was used to determine the odds of reporting functional limitations. Five hundred fourteen men and 641 women stroke survivors completed the survey (mean age: 66.9 years). Approximately 75% of the sample reported having hypertension, 61% high cholesterol, 33% diabetes, 24% heart disease, 21% heart attack, and 16% chronic obstructive pulmonary disease. In the predictive models, men were less likely to report "very difficult/can't do at all" in walking ¼ mile (odds ratios [OR] = 0.68, 95% CI 0.51-0.90), climbing 10 steps (OR = 0.65, 95% CI 0.49-0.85), standing 2 hours (OR = 0.66, 95% CI 0.50-0.87), stooping (OR = 0.51, 95% CI 0.39-0.68), reaching overhead (OR = 0.69, 95% CI 0.49-0.97), carrying 10 pounds (OR = 0.45, 95% CI 0.34-0.59), and pushing large objects (OR = 0.37, 95% CI 0.28-0.5) compared to women. The functional outcomes of men stroke survivors were significantly greater than women. The specific factors that contribute to sex differences in stroke-related outcomes are not entirely clear. Future research is needed to better understand these differences to ensure that equity of care is received.

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.

Outcome in lacunar stroke: A cohort study.

PubMed

Mantero, V; Scaccabarozzi, C; Botto, E; Giussani, G; Aliprandi, A; Lunghi, A; Ciusani, E; Brenna, G; Salmaggi, A

2018-05-16

We evaluated a prospective cohort of 150 patients under observation in our centre for lacunar strokes. The purpose of this study was to evaluate the outcome at time of discharge and 6 months after lacunar stroke, as well as the correlation with cardiovascular risk factors and selected biochemical parameters already evaluated on admission. Focus was to identify possible prognostic factors, which might be targeted through appropriate intervention concentrating on reduction in the incidence and impact of early clinical deterioration. 150 patients with a lacunar stroke were included in the present study. A clinical 6-month follow-up was available for 98.7% of the patients. Infarcts were classified by size, shape and location. The most important predictors of high NIHSS score at time of discharge resulted NIHSS on admission (P < .001), leukocytosis (P = .013), in-hospital infections (P = .016) and size of lacunae (P = .005). Similarly, the most important predictors of poor outcome 6 months later were NIHSS on admission (P = .01), leukocytosis (P = .014), elevated CRP (P = .019), in addition to pre-admission Rankin (P < .001). Although infections are not causatively related to lacunar strokes, their prompt recognition and early treatment, control of inflammatory markers and fever are most important in influencing functional outcome in lacunar stroke. © 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Kinesthetic deficits after perinatal stroke: robotic measurement in hemiparetic children.

PubMed

Kuczynski, Andrea M; Semrau, Jennifer A; Kirton, Adam; Dukelow, Sean P

2017-02-15

While sensory dysfunction is common in children with hemiparetic cerebral palsy (CP) secondary to perinatal stroke, it is an understudied contributor to disability with limited objective measurement tools. Robotic technology offers the potential to objectively measure complex sensorimotor function but has been understudied in perinatal stroke. The present study aimed to quantify kinesthetic deficits in hemiparetic children with perinatal stroke and determine their association with clinical function. Case-control study. Participants were 6-19 years of age. Stroke participants had MRI confirmed unilateral perinatal arterial ischemic stroke or periventricular venous infarction, and symptomatic hemiparetic cerebral palsy. Participants completed a robotic assessment of upper extremity kinesthesia using a robotic exoskeleton (KINARM). Four kinesthetic parameters (response latency, initial direction error, peak speed ratio, and path length ratio) and their variabilities were measured with and without vision. Robotic outcomes were compared across stroke groups and controls and to clinical measures of sensorimotor function. Forty-three stroke participants (23 arterial, 20 venous, median age 12 years, 42% female) were compared to 106 healthy controls. Stroke cases displayed significantly impaired kinesthesia that remained when vision was restored. Kinesthesia was more impaired in arterial versus venous lesions and correlated with clinical measures. Robotic assessment of kinesthesia is feasible in children with perinatal stroke. Kinesthetic impairment is common and associated with stroke type. Failure to correct with vision suggests sensory network dysfunction.

Functional Gain After Inpatient Stroke Rehabilitation: Correlates and Impact on Long-Term Survival.

PubMed

Scrutinio, Domenico; Monitillo, Vincenzo; Guida, Pietro; Nardulli, Roberto; Multari, Vincenzo; Monitillo, Francesco; Calabrese, Gianluigi; Fiore, Pietro

2015-10-01

Prediction of functional outcome after stroke rehabilitation (SR) is a growing field of interest. The association between SR and survival still remains elusive. We sought to investigate the factors associated with functional outcome after SR and whether the magnitude of functional improvement achieved with rehabilitation is associated with long-term mortality risk. The study population consisted of 722 patients admitted for SR within 90 days of stroke onset, with an admission functional independence measure (FIM) score of <80 points. We used univariable and multivariable linear regression analyses to assess the association between baseline variables and FIM gain and univariable and multivariable Cox analyses to assess the association of FIM gain with long-term mortality. Age (P<0.001), marital status (P=0.003), time from stroke onset to rehabilitation admission (P<0.001), National Institutes of Health Stroke Scale score at rehabilitation admission (P<0.001), and aphasia (P=0.021) were independently associated with FIM gain. The R2 of the model was 0.275. During a median follow-up of 6.17 years, 36.9% of the patients died. At multivariable Cox analysis, age (P<0.0001), coronary heart disease (P=0.018), atrial fibrillation (P=0.042), total cholesterol (P=0.015), and total FIM gain (P<0.0001) were independently associated with mortality. The adjusted hazard ratio for death significantly decreased across tertiles of increasing FIM gain. Several factors are independently associated with functional gain after SR. Our findings strongly suggest that the magnitude of functional improvement is a powerful predictor of long-term mortality in patients admitted for SR. © 2015 American Heart Association, Inc.

Quality of life among older stroke patients in Taiwan during the first year after discharge.

PubMed

Shyu, Yea-Ing L; Maa, Suh-Hwa; Chen, Sien-Tsong; Chen, Min-Chi

2009-08-01

To explore the one-year poststroke trajectories in health-related quality of life and physical function in a sample of older stroke patients in Taiwan. Health-related quality of life has repeatedly been reported as decreased in poststroke patients. The vast majority of information on the health-related quality of life of older patients after stroke is based on data collected in Western developed countries. In contrast, little is known about older stroke patients in Asian countries. A descriptive, prospective and correlational design was used. Older stroke survivors (n = 98) were assessed at the end of one, three, six and 12 months after hospital discharge for health-related quality of life (measured by the Medical Outcomes Study Short Form 36) and physical functioning (measured by the Chinese Barthel Index and Instrumental Activities of Daily Living Scale). The subjects, who were 65-88 years old, performed considerably worse at 12 months after hospital discharge in social and physical functioning (means = 61.1, 54.8, respectively) than the age-matched community-dwelling norm (means = 78.7, 69.7, respectively). During the first year after discharge, subjects improved significantly on the Medical Outcomes Study Short Form 36 physical component summary scale and role limitations due to physical problems; during the first three months after discharge, they improved significantly on performance of activities of daily living and instrumental activities of daily living; and from the third to sixth month after discharge, they improved significantly in physical functioning. The first year, especially the first three months after hospital discharge, is critical for improvements in health-related quality of life and physical functioning for older stroke survivors in Taiwan. Older Taiwanese/Chinese people who suffer a stroke will likely benefit from interventions during the first 12 months after discharge and the most effective interventions may be earlier, during the first three months after discharge.

Development and Validation of a Predictive Model for Functional Outcome After Stroke Rehabilitation: The Maugeri Model.

PubMed

Scrutinio, Domenico; Lanzillo, Bernardo; Guida, Pietro; Mastropasqua, Filippo; Monitillo, Vincenzo; Pusineri, Monica; Formica, Roberto; Russo, Giovanna; Guarnaschelli, Caterina; Ferretti, Chiara; Calabrese, Gianluigi

2017-12-01

Prediction of outcome after stroke rehabilitation may help clinicians in decision-making and planning rehabilitation care. We developed and validated a predictive tool to estimate the probability of achieving improvement in physical functioning (model 1) and a level of independence requiring no more than supervision (model 2) after stroke rehabilitation. The models were derived from 717 patients admitted for stroke rehabilitation. We used multivariable logistic regression analysis to build each model. Then, each model was prospectively validated in 875 patients. Model 1 included age, time from stroke occurrence to rehabilitation admission, admission motor and cognitive Functional Independence Measure scores, and neglect. Model 2 included age, male gender, time since stroke onset, and admission motor and cognitive Functional Independence Measure score. Both models demonstrated excellent discrimination. In the derivation cohort, the area under the curve was 0.883 (95% confidence intervals, 0.858-0.910) for model 1 and 0.913 (95% confidence intervals, 0.884-0.942) for model 2. The Hosmer-Lemeshow χ 2 was 4.12 ( P =0.249) and 1.20 ( P =0.754), respectively. In the validation cohort, the area under the curve was 0.866 (95% confidence intervals, 0.840-0.892) for model 1 and 0.850 (95% confidence intervals, 0.815-0.885) for model 2. The Hosmer-Lemeshow χ 2 was 8.86 ( P =0.115) and 34.50 ( P =0.001), respectively. Both improvement in physical functioning (hazard ratios, 0.43; 0.25-0.71; P =0.001) and a level of independence requiring no more than supervision (hazard ratios, 0.32; 0.14-0.68; P =0.004) were independently associated with improved 4-year survival. A calculator is freely available for download at https://goo.gl/fEAp81. This study provides researchers and clinicians with an easy-to-use, accurate, and validated predictive tool for potential application in rehabilitation research and stroke management. © 2017 American Heart Association, Inc.

The State-of-the-Science on Somatosensory Function and Its Impact on Daily Life in Adults and Older Adults, and Following Stroke: A Scoping Review.

PubMed

Carey, Leeanne M; Lamp, Gemma; Turville, Megan

2016-04-01

The aim was to identify and synthesize research evidence about how adults and older adults process somatosensory information in daily activities, and the interventions available to regain somatosensory function following stroke. We developed two interacting concept maps to address the research questions. The scoping review was conducted from 2005 to 2015 across Web of Science, AMED, CINAHL, Embase, Medline, and PsychInfo databases. Search terms included somatosensory, perception, performance, participation, older adult, stroke, intervention, discrimination, learning, and neuroplasticity. Contributions from 103 articles for Concept 1 and 14 articles for Concept 2 are reported. Measures of somatosensory processing, performance, and participation used are identified. Interventions available to treat somatosensory loss are summarized in relation to approach, outcome measures, and theory/mechanisms underlying. A gap exists in the current understanding of how somatosensory function affects the daily lives of adults. A multidisciplinary approach that includes performance and participation outcomes is recommended to advance the field. © The Author(s) 2016.

Characteristics of bilateral hand function in individuals with unilateral dystonia due to perinatal stroke: sensory and motor aspects

PubMed Central

de Campos, Ana Carolina; Kukke, Sahana N.; Hallett, Mark; Alter, Katharine E.; Damiano, Diane L.

2014-01-01

We assessed bilateral motor and sensory function in individuals with upper limb dystonia due to unilateral perinatal stroke and explored interrelationships of motor function and sensory ability. Reach kinematics and tactile sensation were measured in seven participants with dystonia and nine healthy volunteers. The dystonia group had poorer motor (hold time, reach time, shoulder/elbow correlation) and sensory (spatial discrimination, stereognosis) outcomes than the control group on the non-dominant side. On the dominant side, only sensation (spatial discrimination, stereognosis) was poorer in the dystonia group compared to the control group. In the dystonia group, although sensory and motor outcomes were uncorrelated, dystonia severity was related to poorer stereognosis, longer hold and reach times, and decreased shoulder/elbow coordination. Findings of bilateral sensory deficits in dystonia may be explained by neural reorganization. Visual compensation for somatosensory changes in the non-stroke hemisphere may explain the lack of bilateral impairments in reaching. PMID:24396131

Right hemisphere grey matter structure and language outcomes in chronic left hemisphere stroke.

PubMed

Xing, Shihui; Lacey, Elizabeth H; Skipper-Kallal, Laura M; Jiang, Xiong; Harris-Love, Michelle L; Zeng, Jinsheng; Turkeltaub, Peter E

2016-01-01

The neural mechanisms underlying recovery of language after left hemisphere stroke remain elusive. Although older evidence suggested that right hemisphere language homologues compensate for damage in left hemisphere language areas, the current prevailing theory suggests that right hemisphere engagement is ineffective or even maladaptive. Using a novel combination of support vector regression-based lesion-symptom mapping and voxel-based morphometry, we aimed to determine whether local grey matter volume in the right hemisphere independently contributes to aphasia outcomes after chronic left hemisphere stroke. Thirty-two left hemisphere stroke survivors with aphasia underwent language assessment with the Western Aphasia Battery-Revised and tests of other cognitive domains. High-resolution T1-weighted images were obtained in aphasia patients and 30 demographically matched healthy controls. Support vector regression-based multivariate lesion-symptom mapping was used to identify critical language areas in the left hemisphere and then to quantify each stroke survivor's lesion burden in these areas. After controlling for these direct effects of the stroke on language, voxel-based morphometry was then used to determine whether local grey matter volumes in the right hemisphere explained additional variance in language outcomes. In brain areas in which grey matter volumes related to language outcomes, we then compared grey matter volumes in patients and healthy controls to assess post-stroke plasticity. Lesion-symptom mapping showed that specific left hemisphere regions related to different language abilities. After controlling for lesion burden in these areas, lesion size, and demographic factors, grey matter volumes in parts of the right temporoparietal cortex positively related to spontaneous speech, naming, and repetition scores. Examining whether domain general cognitive functions might explain these relationships, partial correlations demonstrated that grey matter volumes in these clusters related to verbal working memory capacity, but not other cognitive functions. Further, grey matter volumes in these areas were greater in stroke survivors than healthy control subjects. To confirm this result, 10 chronic left hemisphere stroke survivors with no history of aphasia were identified. Grey matter volumes in right temporoparietal clusters were greater in stroke survivors with aphasia compared to those without history of aphasia. These findings suggest that the grey matter structure of right hemisphere posterior dorsal stream language homologues independently contributes to language production abilities in chronic left hemisphere stroke, and that these areas may undergo hypertrophy after a stroke causing aphasia. © The Author (2015). Published by Oxford University Press on behalf of the Guarantors of Brain. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

[Vein thromboembolism prevention in stroke patients].

PubMed

Savić, Dejan; Savić, Ljiljana

2010-01-01

Having in mind the rate of occurrence and clinical importance, venous thromboembolism implies venous thrombosis and pulmonary embolism as a result of embolisation of the thrombotic particles from deep veins or pelvic veins. Venous thrombosis of the deep veins may result in chronic vein insufficiency, but the primary medical problem is the possibility of development of pulmonary embolism which may cause permanent respiratory function damage or even fatal outcome. The high incidence of deep vein thrombosis (30% clinically and up to 50% subclinically) in acute stroke hemiparetic and bed ridden patients within two weeks from the onset and 1-2% pulmonary embolism with the fatal outcome in the first month clinically and 17% of all fatal outcomes in postmortem investigations present a necessity for the early venous thromboembolism prevention. On the other hand, the most powerful prevention strategy--anticoagulation has important limitations in acute stroke patients: almost impossible to be used in cerebral haemorrhage and a great risk for the development of haemorrhagic transformation in cerebral infarction. The fact that other prevention strategies have limited value requires an estimation of effectivity-risk ratio in venous thromboembolism prevention in stroke. Venous thromboembolism prevention in stroke patients is necessary because of a greater risk for venous thromboembolism in these patients according to the nature of illness and functional disability, but also a problem because of limited possibility to recommend the proper medicament according to the risk of serious complications. The necessity of preventing venous thromboembolism and estimation of effectivity-risk ratio in stroke patients, beside plenty of studies and consensus conferences, remain individual and often very difficult.

Anticholinergic load negatively correlates with recovery of cognitive activities of daily living for geriatric patients after stroke in the convalescent stage.

PubMed

Kose, E; Hirai, T; Seki, T; Hidaka, S; Hamamoto, T

2018-05-16

Anticholinergic drugs are associated with risks of falls, confusion and cognitive dysfunction. However, the effect of anticholinergic drug use on rehabilitation outcomes after a stroke is poorly documented. We therefore aimed to establish whether the anticholinergic load was associated with functional recovery among geriatric patients convalescing after stroke. Consecutive geriatric stroke patients admitted and discharged from a convalescence rehabilitation ward between 2010 and 2016 were included in this retrospective cohort study. Anticholinergic load was assessed by the Anticholinergic Risk Scale (ARS), and functional recovery was assessed by the Functional Independence Measure (FIM). The primary outcome was cognitive FIM (FIM-C) gain, but we also assessed the interaction of other putative factors identified from univariate analysis. Multivariate analyses were performed, adjusting for confounding factors. We included 418 participants (171 males, 247 females) with a median age of 78 years (interquartile range, 72-84 years). Multiple regression analysis revealed that ARS change, length of stay, and epilepsy were independently and negatively correlated with cognitive FIM gain. Multiple logistic regression analysis indicated that the "Comprehension" and "Memory" items of the cognitive FIM gain were independently and negatively associated with anticholinergic load. A causal relationship cannot be established, but increased ARS scores during hospitalization may predict limited cognitive functional improvement in geriatric patients after stroke. Alternatively, cognitive impairment may lead to increased use of anticholinergic drugs. © 2018 John Wiley & Sons Ltd.

Novel Stroke Therapeutics: Unraveling Stroke Pathophysiology and Its Impact on Clinical Treatments

PubMed Central

George, Paul M.; Steinberg, Gary K.

2016-01-01

Stroke remains a leading cause of death and disability in the world. Over the past few decades our understanding of the pathophysiology of stroke has increased, but greater insight is required to advance the field of stroke recovery. Clinical treatments have improved in the acute time window, but long-term therapeutics remain limited. Complex neural circuits damaged by ischemia make restoration of function after stroke difficult. New therapeutic approaches, including cell transplantation or stimulation, focus on reestablishing these circuits through multiple mechanisms to improve circuit plasticity and remodeling. Other research targets intact networks to compensate for damaged regions. This review highlights several important mechanisms of stroke injury and describes emerging therapies aimed at improving clinical outcomes. PMID:26182415

Combined electrical stimulation and exercise for swallow rehabilitation post-stroke: a pilot randomized control trial.

PubMed

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

2018-03-01

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 posture, rather than direct physical rehabilitation of the swallowing function. Transcutaneous neuromuscular electrical stimulation (NMES) is a promising rehabilitation technology that can be used to stimulate swallowing; however, findings regarding efficacy have been conflicting. This pilot randomized controlled study involving three UK sites compared the efficacy of the Ampcare Effective Swallowing Protocol (ESP), combining NMES with swallow-strengthening exercises, with usual care in order to clarify evidence on NMES in the treatment of dysphagia post-stroke. A further objective was to pilot recruitment procedures and outcome measures in order to inform the design of a full-scale trial. Thirty patients were recruited and randomized into either (1) usual speech and language therapy dysphagia care; or (2) Ampcare ESP, receiving treatment 5 days/week for 4 weeks. Outcome measures included: the Functional Oral Intake Scale (FOIS), the Rosenbek Penetration-Aspiration Scale (PAS) and patient-reported outcomes (Swallow Related Quality of Life-SWAL-QOL). Thirty patients were recruited; 15 were randomized to the Ampcare ESP intervention arm and 15 to usual care. A greater proportion (75%, or 9/12) of patients receiving Ampcare ESP improved compared with 57% (or 8/14) of the usual-care group. Patients receiving Ampcare ESP also made clinically meaningful change (a comparative benefit of 1.5 on the FOIS, and on the PAS: 1.35 for diet and 0.3 for fluids) compared with usual care. The intervention group also reported much better outcome satisfaction. The pilot demonstrated successful recruitment, treatment safety and tolerability and clinically meaningful outcome improvements, justifying progression to a fully powered study. It also showed clinically meaningful treatment trends for the Ampcare ESP intervention. © 2017 Royal College of Speech and Language Therapists.

Cluster Randomized Controlled Trial

PubMed Central

Young, John; Chapman, Katie; Nixon, Jane; Patel, Anita; Holloway, Ivana; Mellish, Kirste; Anwar, Shamaila; Breen, Rachel; Knapp, Martin; Murray, Jenni; Farrin, Amanda

2015-01-01

Background and Purpose— We developed a new postdischarge system of care comprising a structured assessment covering longer-term problems experienced by patients with stroke and their carers, linked to evidence-based treatment algorithms and reference guides (the longer-term stroke care system of care) to address the poor longer-term recovery experienced by many patients with stroke. Methods— A pragmatic, multicentre, cluster randomized controlled trial of this system of care. Eligible patients referred to community-based Stroke Care Coordinators were randomized to receive the new system of care or usual practice. The primary outcome was improved patient psychological well-being (General Health Questionnaire-12) at 6 months; secondary outcomes included functional outcomes for patients, carer outcomes, and cost-effectiveness. Follow-up was through self-completed postal questionnaires at 6 and 12 months. Results— Thirty-two stroke services were randomized (29 participated); 800 patients (399 control; 401 intervention) and 208 carers (100 control; 108 intervention) were recruited. In intention to treat analysis, the adjusted difference in patient General Health Questionnaire-12 mean scores at 6 months was −0.6 points (95% confidence interval, −1.8 to 0.7; P=0.394) indicating no evidence of statistically significant difference between the groups. Costs of Stroke Care Coordinator inputs, total health and social care costs, and quality-adjusted life year gains at 6 months, 12 months, and over the year were similar between the groups. Conclusions— This robust trial demonstrated no benefit in clinical or cost-effectiveness outcomes associated with the new system of care compared with usual Stroke Care Coordinator practice. Clinical Trial Registration— URL: http://www.controlled-trials.com. Unique identifier: ISRCTN 67932305. PMID:26152298

Effectiveness of Wii-based rehabilitation in stroke: A randomized controlled study.

PubMed

Karasu, Ayça Utkan; Batur, Elif Balevi; Karataş, Gülçin Kaymak

2018-05-08

To investigate the efficacy of Nintendo Wii Fit®-based balance rehabilitation as an adjunc-tive therapy to conventional rehabilitation in stroke patients. During the study period, 70 stroke patients were evaluated. Of these, 23 who met the study criteria were randomly assigned to either the experimental group (n = 12) or the control group (n = 11) by block randomization. Primary outcome measures were Berg Balance Scale, Functional Reach Test, Postural Assessment Scale for Stroke Patients, Timed Up and Go Test and Static Balance Index. Secondary outcome measures were postural sway, as assessed with Emed-X, Functional Independence Measure Transfer and Ambulation Scores. An evaluator who was blinded to the groups made assessments immediately before (baseline), immediately after (post-treatment), and 4 weeks after completion of the study (follow-up). Group-time interaction was significant in the Berg Balance Scale, Functional Reach Test, anteroposterior and mediolateral centre of pressure displacement with eyes open, anteroposterior centre of pressure displacement with eyes closed, centre of pressure displacement during weight shifting to affected side, to unaffected side and total centre of pressure displacement during weight shifting. Demonstrating significant group-time interaction in those parameters suggests that, while both groups exhibited significant improvement, the experimental group showed greater improvement than the control group. Virtual reality exercises with the Nintendo Wii system could represent a useful adjunctive therapy to traditional treatment to improve static and dynamic balance in stroke patients.

The Efficacy of Balance Training with Video Game-Based Therapy in Subacute Stroke Patients: A Randomized Controlled Trial

PubMed Central

Tramontano, Marco; Shofany, Jacob; Iemma, Antonella; Musicco, Massimo; Paolucci, Stefano; Caltagirone, Carlo

2014-01-01

The video game-based therapy emerged as a potential valid tool in improving balance in several neurological conditions with controversial results, whereas little information is available regarding the use of this therapy in subacute stroke patients. The aim of this study was to investigate the efficacy of balance training using video game-based intervention on functional balance and disability in individuals with hemiparesis due to stroke in subacute phase. Fifty adult stroke patients participated to the study: 25 subjects were randomly assigned to balance training with Wii Fit, and the other 25 subjects were assigned to usual balance therapy. Both groups were also treated with conventional physical therapy (40 min 2 times/day). The main outcome was functional balance (Berg Balance Scale-BBS), and secondary outcomes were disability (Barthel Index-BI), walking ability (Functional Ambulation Category), and walking speed (10-meters walking test). Wii Fit training was more effective than usual balance therapy in improving balance (BBS: 53 versus 48, P = 0.004) and independency in activity of daily living (BI: 98 versus 93, P = 0.021). A balance training performed with a Wii Fit as an add on to the conventional therapy was found to be more effective than conventional therapy alone in improving balance and reducing disability in patients with subacute stroke. PMID:24877116

Stroke-induced immunosuppression and poststroke infection

PubMed Central

Shi, Kaibin; Wood, Kristofer; Shi, Fu-Dong; Wang, Xiaoying; Liu, Qiang

2018-01-01

Infections occur commonly after stroke and are strongly associated with an unfavourable functional outcome of these patients. Approaches for effective management of poststroke infection remain scarce, presenting an urgent need for preventive anti-infection strategies for patients who have suffered a stroke. Emerging evidence indicates that stroke impairs systemic immune responses and increases the susceptibility to infections, suggesting that the modification of impaired immune defence could be beneficial. In this review, we summarised previous attempts to prevent poststroke infections using prophylactic antibiotics and the current understanding of stroke-induced immunosuppression. Further elucidation of the immune mechanisms of stroke will pave the way to tailored design of new treatment to combat poststroke infection via modifying the immune system. PMID:29600006

Is there more valuable information in PWI datasets for a voxel-wise acute ischemic stroke tissue outcome prediction than what is represented by typical perfusion maps?

NASA Astrophysics Data System (ADS)

Forkert, Nils Daniel; Siemonsen, Susanne; Dalski, Michael; Verleger, Tobias; Kemmling, Andre; Fiehler, Jens

2014-03-01

The acute ischemic stroke is a leading cause for death and disability in the industry nations. In case of a present acute ischemic stroke, the prediction of the future tissue outcome is of high interest for the clinicians as it can be used to support therapy decision making. Within this context, it has already been shown that the voxel-wise multi-parametric tissue outcome prediction leads to more promising results compared to single channel perfusion map thresholding. Most previously published multi-parametric predictions employ information from perfusion maps derived from perfusion-weighted MRI together with other image sequences such as diffusion-weighted MRI. However, it remains unclear if the typically calculated perfusion maps used for this purpose really include all valuable information from the PWI dataset for an optimal tissue outcome prediction. To investigate this problem in more detail, two different methods to predict tissue outcome using a k-nearest-neighbor approach were developed in this work and evaluated based on 18 datasets of acute stroke patients with known tissue outcome. The first method integrates apparent diffusion coefficient and perfusion parameter (Tmax, MTT, CBV, CBF) information for the voxel-wise prediction, while the second method employs also apparent diffusion coefficient information but the complete perfusion information in terms of the voxel-wise residue functions instead of the perfusion parameter maps for the voxel-wise prediction. Overall, the comparison of the results of the two prediction methods for the 18 patients using a leave-one-out cross validation revealed no considerable differences. Quantitatively, the parameter-based prediction of tissue outcome led to a mean Dice coefficient of 0.474, while the prediction using the residue functions led to a mean Dice coefficient of 0.461. Thus, it may be concluded from the results of this study that the perfusion parameter maps typically derived from PWI datasets include all valuable perfusion information required for a voxel-based tissue outcome prediction, while the complete analysis of the residue functions does not add further benefits for the voxel-wise tissue outcome prediction and is also computationally more expensive.

Assessing the predictive value of a neuropsychological model on concurrent function in acute stroke recovery and rehabilitation.

PubMed

Leitner, Damian; Miller, Harry; Libben, Maya

2018-06-25

Few studies have examined the relationship between cognition and function for acute stroke inpatients utilizing comprehensive methods. This study aimed to assess the relationship of a neuropsychological model, above and beyond a baseline model, with concurrent functional status across multiple domains in the early weeks of stroke recovery and rehabilitation. Seventy-four acute stroke patients were administered a comprehensive neuropsychological assessment. Functional domains of ability, adjustment, and participation were assessed using the Mayo-Portland Adaptability Inventory - 4 (MPAI-4). Hierarchical linear regression was used to assess a neuropsychological model comprised of cognitive tests scores on domains of executive function, memory, and visuospatial-constructional skills (VSC), after accounting for a baseline model comprised of common demographic and stroke variants used to predict outcome. The neuropsychological model was significantly associated, above and beyond the baseline model, with MPAI-4 Ability, Participation, and Total scores (all p-values < .05). The strength of association varied across functional domains. Analyzing tests of executive function, the Color Trails Test-Part 2 predicted MPAI-4 Participation (β = -.46, p = .001), and Total score (β = -.32, p = .02). Neuropsychological assessment contributes independently to the determination of multiple domains of functional function, above and beyond common medical variants of stroke, in the early weeks of recovery and rehabilitation. Multiple tests of executive function are recommended to develop a greater appreciation of a patient's concurrent functional abilities.

Shaping Early Reorganization of Neural Networks Promotes Motor Function after Stroke

PubMed Central

Volz, L. J.; Rehme, A. K.; Michely, J.; Nettekoven, C.; Eickhoff, S. B.; Fink, G. R.; Grefkes, C.

2016-01-01

Neural plasticity is a major factor driving cortical reorganization after stroke. We here tested whether repetitively enhancing motor cortex plasticity by means of intermittent theta-burst stimulation (iTBS) prior to physiotherapy might promote recovery of function early after stroke. Functional magnetic resonance imaging (fMRI) was used to elucidate underlying neural mechanisms. Twenty-six hospitalized, first-ever stroke patients (time since stroke: 1–16 days) with hand motor deficits were enrolled in a sham-controlled design and pseudo-randomized into 2 groups. iTBS was administered prior to physiotherapy on 5 consecutive days either over ipsilesional primary motor cortex (M1-stimulation group) or parieto-occipital vertex (control-stimulation group). Hand motor function, cortical excitability, and resting-state fMRI were assessed 1 day prior to the first stimulation and 1 day after the last stimulation. Recovery of grip strength was significantly stronger in the M1-stimulation compared to the control-stimulation group. Higher levels of motor network connectivity were associated with better motor outcome. Consistently, control-stimulated patients featured a decrease in intra- and interhemispheric connectivity of the motor network, which was absent in the M1-stimulation group. Hence, adding iTBS to prime physiotherapy in recovering stroke patients seems to interfere with motor network degradation, possibly reflecting alleviation of post-stroke diaschisis. PMID:26980614

Solitaire™ with the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke (SWIFT PRIME) trial: protocol for a randomized, controlled, multicenter study comparing the Solitaire revascularization device with IV tPA with IV tPA alone in acute ischemic stroke.

PubMed

Saver, Jeffrey L; Goyal, Mayank; Bonafe, Alain; Diener, Hans-Christoph; Levy, Elad I; Pereira, Vitor M; Albers, Gregory W; Cognard, Christophe; Cohen, David J; Hacke, Werner; Jansen, Olav; Jovin, Tudor G; Mattle, Heinrich P; Nogueira, Raul G; Siddiqui, Adnan H; Yavagal, Dileep R; Devlin, Thomas G; Lopes, Demetrius K; Reddy, Vivek; du Mesnil de Rochemont, Richard; Jahan, Reza

2015-04-01

Early reperfusion in patients experiencing acute ischemic stroke is critical, especially for patients with large vessel occlusion who have poor prognosis without revascularization. Solitaire™ stent retriever devices have been shown to immediately restore vascular perfusion safely, rapidly, and effectively in acute ischemic stroke patients with large vessel occlusions. The aim of the study was to demonstrate that, among patients with large vessel, anterior circulation occlusion who have received intravenous tissue plasminogen activator, treatment with Solitaire revascularization devices reduces degree of disability 3 months post stroke. The study is a global multicenter, two-arm, prospective, randomized, open, blinded end-point trial comparing functional outcomes in acute ischemic stroke patients who are treated with either intravenous tissue plasminogen activator alone or intravenous tissue plasminogen activator in combination with the Solitaire device. Up to 833 patients will be enrolled. Patients who have received intravenous tissue plasminogen activator are randomized to either continue with intravenous tissue plasminogen activator alone or additionally proceed to neurothrombectomy using the Solitaire device within six-hours of symptom onset. The primary end-point is 90-day global disability, assessed with the modified Rankin Scale (mRS). Secondary outcomes include mortality at 90 days, functional independence (mRS ≤ 2) at 90 days, change in National Institutes of Health Stroke Scale at 27 h, reperfusion at 27 h, and thrombolysis in cerebral infarction 2b/3 flow at the end of the procedure. Statistical analysis will be conducted using simultaneous success criteria on the overall distribution of modified Rankin Scale (Rankin shift) and proportions of subjects achieving functional independence (mRS 0-2). © 2015 The Authors. International Journal of Stroke published by John Wiley & Sons Ltd on behalf of World Stroke Organization.

The use of a biplot in studying outcomes after stroke.

PubMed

De Wit, Liesbet; Molas, Marek; Dejaeger, Eddy; De Weerdt, Willy; Feys, Hilde; Jenni, Walter; Lincoln, Nadina; Putman, Koen; Schupp, Wilfried; Lesaffre, Emmanuel

2009-10-01

This study aimed to unravel the multidimensional profile of stroke outcomes by investigating the global correlation structure of motor, functional, and emotional problems of patients, as well as their caregivers' strain, at 6 months after stroke. Potential differential associations based on patients' level of functioning on admission to the rehabilitation center were analyzed. Data were collected within the CERISE-study (Collaborative Evaluation of Rehabilitation in Stroke across Europe). Six months after stroke, the Rivermead Motor Assessment (RMA), Extended Activities of Daily Living (EADL), Hospital Anxiety and Depression Scale-Anxiety (HADS-A) and Hospital Anxiety and Depression Scale-Depression (HADS-D), EuroQol-Health State (EQ-HS), EuroQol-Visual Analogue Scale (EQ-VAS), and Caregiver Strain Index (CSI) were administered. Patients were classified into 3 categories according to their Barthel Index (BI) score on admission to the rehabilitation center. Principal component analysis was carried out, and a biplot was constructed. Data were available on 510 patients. One cluster was formed by RMA and EADL, and a second one by HADS-A, HADS-D, and EQ-VAS. EQ-HS was situated between these two. CSI formed a third dimension. Patients with low BI scores on admission to the rehabilitation center had higher HADS-A and HADS-D scores 6 months after stroke. High BI scores were associated with large variations in HADS-A and HADS-D scores. This novel biplot strategy for rehabilitation studies revealed 2 clusters: one of motor/functional problems and one of emotional problems. Patients with mild functional deficit measured on admission to the rehabilitation center can suffer from mild to severe anxiety and depression at 6 months poststroke. Screening for emotional disorders in all patients is recommended.

Severity of unilateral spatial neglect is an independent predictor of functional outcome after acute inpatient rehabilitation in individuals with right hemispheric stroke.

PubMed

Di Monaco, Marco; Schintu, Selene; Dotta, Manuela; Barba, Sonia; Tappero, Rosa; Gindri, Patrizia

2011-08-01

To investigate the relationship between severity of unilateral spatial neglect (USN) and functional recovery in activities of daily living after a right-hemisphere stroke. Observational study. Rehabilitation hospital in Italy. We investigated 107 of 131 inpatients with right-hemisphere stroke who were consecutively admitted to our rehabilitation hospital. Not applicable. To assess USN severity, conventional and nonconventional Behavioral Inattention Tests (BITs) were performed at admission to inpatient rehabilitation at a median of 19 days after stroke occurrence. FIM was performed both on admission to and discharge from inpatient rehabilitation to assess functional autonomy. FIM efficiency (improvement of FIM score per day of stay length) and FIM effectiveness (proportion of potential improvement achieved) were calculated. Fifty-four (50.5%) of the 107 patients were affected by USN. In these 54 patients, both conventional and nonconventional BIT scores were significantly correlated with FIM scores assessed at discharge from rehabilitation: ρ values were .385 (P=.004) and .396 (P=.003), respectively. After adjustment for 7 potential confounders, including FIM scores before rehabilitation, we found a significant positive association between either conventional or nonconventional BIT scores and FIM scores after rehabilitation (r=.276, P=.047 and r=.296, P=.033, respectively), FIM efficiency (r=.315, P=.022 and r=.307, P=.025, respectively), and FIM effectiveness (r=.371, P=.006 and r=.306, P=.026, respectively). Data support the independent prognostic role of USN severity assessed at admission to inpatient rehabilitation after a right-hemisphere stroke. Models aimed at predicting the functional outcome in stroke survivors may benefit from inclusion of USN severity. Copyright © 2011 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.

Clinical Predictors of Attention and Executive Functioning Outcomes in Children After Perinatal Arterial Ischemic Stroke.

PubMed

Bosenbark, Danielle D; Krivitzky, Lauren; Ichord, Rebecca; Vossough, Arastoo; Bhatia, Aashim; Jastrzab, Laura E; Billinghurst, Lori

2017-04-01

Children with perinatal arterial ischemic stroke (PAIS) are at risk for later neurocognitive and behavioral deficits, yet the clinical predictors of these outcomes are understudied. We examined the influence of clinical and infarct characteristics on attention and executive functioning in children following PAIS. Forty children born at term (≥37 weeks' gestation) with PAIS (28 with neonatal arterial ischemic stroke and 12 with presumed PAIS) underwent a comprehensive neuropsychological battery at age three to 16 years (median age 7.2 years; 58% male) to assess attention and executive functioning. Parents also completed questionnaires regarding real-world functioning. Clinical variables including perinatal stroke subtype, infarct characteristics (location, laterality, and volume), and the presence of comorbid epilepsy were ascertained from the medical record. Presumed PAIS, larger infarct volume, and comorbid epilepsy negatively influenced the performance on attention and executive functioning measures. These clinical variables were also associated with greater functional problems on parent reports, including a higher frequency of attention-deficit/hyperactivity disorder symptoms and greater difficulties in some subdomains of executive functioning. Infarct location and laterality were not associated with performance measures or parental report of functioning. Although all children with PAIS are at risk for later deficits in attention and executive functioning, those with presumed PAIS, larger infarct size, and comorbid epilepsy appear to be the most vulnerable. As they approach and reach school age, these children should undergo neuropsychological assessment to ensure timely implementation of therapeutic interventions and behavioral strategies. Copyright © 2017 Elsevier Inc. All rights reserved.

Stroke outcomes in Northern Scotland: does rurality really matter?

PubMed

O'Neill, N P; Godden, D J

2003-01-01

Stroke is the third leading cause of death in Scotland after coronary heart disease and cancer and is a major cause of long-term disability. There is evidence in other clinical conditions such as asthma, diabetic retinopathy, and cancer that rural residents may have poorer outcomes, due to relative inaccessibility of health-service provision or because the disease is at a more advanced stage at diagnosis. However, the evidence-base for stroke care and outcomes in remote and rural areas is small and the subject matter is under-researched. This study was designed to examine, over a one-year period, the incidence and outcome of stroke occurring in the Highlands and Islands of Scotland, a large geographical area with many rural and remote settlements. The study explored whether stroke care and outcome was affected by remoteness and rurality. The study was a prospective, community-based, observational survey. Patients in Highland and the Islands (Orkney, Shetland and the Western Isles) suffering first-ever stroke during a 12-month period (from 1 May 2001 to 30 April 2002) were included. All practitioners from health and social care sectors, residential homes, voluntary and charitable organisations were encouraged to notify the researchers of any individual they suspected or knew had a first-ever stroke within the designated time period. Data on 'limitation in activities' (formerly 'level of disability') and service provision were collected using questionnaires and proformas at 1, 3 and 6 months post-stroke from several sources. These included individual patients and carers, health and social care professionals, residential homes, voluntary organisations, and charitable organisations. The analysis focused on location at time of follow up, limitation in activities and service provision. Outcomes were compared across different settlement categories. Settlements were classified as urban/accessible, remote rural and very remote, based on the Scottish Household Survey. In all, 303 patients with a suspected first-ever stroke were notified to the study. The resulting crude incidence of reported stroke was 1.1 per 1000. From the notifications, 239 patients were sent a consent form, of whom 118 agreed to participate in the study. The final dataset, after exclusions for incorrect diagnosis, deaths and other reasons, was derived from 85 patients. Among these, patients from remote rural and very remote settlements were over-represented, when compared to all patients notified. The majority of patients returned home from acute hospitals during the study period and the likelihood of returning home was not related to settlement category. However, a greater proportion of patients in remote rural settlements were admitted to community hospitals and remained there at 6 months. Approximately two-thirds had some degree of disability (or limitation in activities) after their stroke. One-third of patients classed themselves as independent across all time points. Overall, the Barthel Index score increased over time (ie, patients experienced a reduction in disability) with the average score at 1 month post-stroke being 82.5 (range 0-100), at 3 months 85 (range 5-100), and at 6 months 90 (range 5-100). Uptake of services was similar across all settlement categories, with low levels of use at 6-months post-stroke. In particular, few patients used social-support and stroke-specific services, for example Chest, Heart and Stroke Scotland, and Stroke Nurse services. The proportion of patients using any service at 1, 3 and 6 months did not differ between settlement categories. Rural patients did not therefore appear disadvantaged in service provision. The low incidence of reported stroke may have been due to a number of reasons including: death prior to notification; diagnostic uncertainty; stroke severity--failure to notify very mild or very severe stroke cases; and inadequate reporting of patients managed at home. The greater proportion of patients in remote rural settlements being admitted to community hospitals and remaining there at 6 months may reflect greater availability of community hospital places in this settlement category, but may also be influenced by stroke severity. The low uptake of rehabilitation and support services generally, combined with the relatively poor functional outcome of our patients, suggests that there may be an unmet need for rehabilitation. However, rural patients did not appear specifically disadvantaged. Our study indicates that patients developing a first-time stroke in remote and rural areas of the Highlands and Islands of Scotland are not disadvantaged compared to those in urban/accessible areas, with respect to outcome or to the utilization of health and social care services. However, functional outcomes could be improved for patients in all settlement categories.

Relationship between diffusion tensor fractional anisotropy and motor outcome in patients with hemiparesis after corona radiata infarct.

PubMed

Koyama, Tetsuo; Marumoto, Kohei; Miyake, Hiroji; Domen, Kazuhisa

2013-11-01

This study examined the relationship between fractional anisotropy (FA) values of magnetic resonance-diffusion tensor imaging (DTI) and motor outcome (1 month after onset) in 15 patients with hemiparesis after ischemic stroke of corona radiata lesions. DTI data were obtained on days 14-18. FA values within the cerebral peduncle were analyzed using a computer-automated method. Motor outcome of hemiparesis was evaluated according to Brunnstrom stage (BRS; 6-point scale: severe to normal) for separate shoulder/elbow/forearm, wrist/hand, and lower extremity functions. The ratio of FA values in the affected hemisphere to those in the unaffected hemisphere (rFA) was assessed in relation to the BRS data (Spearman rank correlation test, P<.05). rFA values ranged from .715 to 1.002 (median=.924). BRS ranged from 1 to 6 (median=4) for shoulder/elbow/forearm, from 1 to 6 (median=5) for wrist/hand, and from 2 to 6 (median=4) for the lower extremities. Analysis revealed statistically significant relationships between rFA and upper extremity functions (correlation coefficient=.679 for shoulder/elbow/forearm and .706 for wrist/hand). Although slightly less evident, the relationship between rFA and lower extremity function was also statistically significant (correlation coefficient=.641). FA values within the cerebral peduncle are moderately associated with the outcome of both upper and lower extremity functions, suggesting that DTI may be applicable for outcome prediction in stroke patients with corona radiata infarct. Copyright © 2013 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Sequencing bilateral robot-assisted arm therapy and constraint-induced therapy improves reach to press and trunk kinematics in patients with stroke.

PubMed

Hsieh, Yu-wei; Liing, Rong-jiuan; Lin, Keh-chung; Wu, Ching-yi; Liou, Tsan-hon; Lin, Jui-chi; Hung, Jen-wen

2016-03-22

The combination of robot-assisted therapy (RT) and a modified form of constraint-induced therapy (mCIT) shows promise for improving motor function of patients with stroke. However, whether the changes of motor control strategies are concomitant with the improvements in motor function after combination of RT and mCIT (RT + mCIT) is unclear. This study investigated the effects of the sequential combination of RT + mCIT compared with RT alone on the strategies of motor control measured by kinematic analysis and on motor function and daily performance measured by clinical scales. The study enrolled 34 patients with chronic stroke. The data were derived from part of a single-blinded randomized controlled trial. Participants in the RT + mCIT and RT groups received 20 therapy sessions (90 to 105 min/day, 5 days for 4 weeks). Patients in the RT + mCIT group received 10 RT sessions for first 2 weeks and 10 mCIT sessions for the next 2 weeks. The Bi-Manu-Track was used in RT sessions to provide bilateral practice of wrist and forearm movements. The primary outcome was kinematic variables in a task of reaching to press a desk bell. Secondary outcomes included scores on the Wolf Motor Function Test, Functional Independence Measure, and Nottingham Extended Activities of Daily Living. All outcome measures were administered before and after intervention. RT + mCIT and RT demonstrated different benefits on motor control strategies. RT + mCIT uniquely improved motor control strategies by reducing shoulder abduction, increasing elbow extension, and decreasing trunk compensatory movement during the reaching task. Motor function and quality of the affected limb was improved, and patients achieved greater independence in instrumental activities of daily living. Force generation at movement initiation was improved in the patients who received RT. A combination of RT and mCIT could be an effective approach to improve stroke rehabilitation outcomes, achieving better motor control strategies, motor function, and functional independence of instrumental activities of daily living. ClinicalTrials.gov. NCT01727648.

Factors influencing prognosis and functional outcome one year after a first-time stroke in a Caribbean population.

PubMed

Galanth, Sophie; Tressieres, Benoit; Lannuzel, Annie; Foucan, Patrick; Alecu, Cosmin

2014-11-01

To evaluate functional outcome and quality of life 1 year poststroke in a Caribbean population. Prospective study of patients with a first hemispheric stroke admitted consecutively between December 2010 and February 2011. The patients were evaluated (1) in the emergency department, (2) when discharged from the hospital, and (3) 1 year poststroke. A university hospital. Of the 140 consecutive patients with stroke, 78 (42% women, 24.4% hemorrhagic stroke) were included in the study. None. Patients were evaluated using the National Institutes of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS), FIM, and Medical Outcomes Study 36-Item Short-Form Health Survey. The mean age of the participants was 62.1±17.7 years; 70.5% of patients had hypertension, 29.4% had diabetes, and 23.6% had chronic renal failure. At 1 year poststroke, the mortality rate was 29.4%, and the recurrence rate 2.6%. We evaluated 39 of the 55 survivors (71%). Score evolution (emergency department vs 1y later) is as follows: for the NIHSS, it was 6.2±4.9 versus 3.3±3.9 (z=-3.578; P<.001); and for the mRS score ≤2, it was 54.2% versus 66.7% (χ(2)=14.182; P=.25). The FIM score on discharge from the hospital versus 1 year later was 103.2±28.2 versus 101.7±31.5 (z=-1.008; P=.313). Multivariate analysis showed that aphasia, hemianopia, and incontinence significantly influenced the 1-year FIM score (P<.001). Quality of life, a patient-reported outcome measure of health-related quality of life, was significantly altered concerning vitality, role physical, and role emotional. One year after a first stroke, despite significant improvement of neurologic impairment, the level of dependency did not change and quality of life was altered. Aphasia, hemianopia, and incontinence significantly influenced functional state. Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.

Nursing staffs self-perceived outcome from a rehabilitation 24/7 educational programme - a mixed-methods study in stroke care.

PubMed

Loft, M I; Esbensen, B A; Kirk, K; Pedersen, L; Martinsen, B; Iversen, H; Mathiesen, L L; Poulsen, I

2018-01-01

During the past two decades, attempts have been made to describe nurses' contributions to the rehabilitation of inpatients following stroke. There is currently a lack of interventions that integrate the diversity of nurses' role and functions in stroke rehabilitation and explore their effect on patient outcomes. Using a systematic evidence- and theory-based design, we developed an educational programme, Rehabilitation 24/7, for nursing staff working in stroke rehabilitation aiming at two target behaviours; working systematically with a rehabilitative approach in all aspects of patient care and working deliberately and systematically with patients' goals. The aim of this study was to assess nursing staff members' self-perceived outcome related to their capability, opportunity and motivation to work with a rehabilitative approach after participating in the stroke Rehabilitation 24/7 educational programme. A convergent mixed-method design was applied consisting of a survey and semi-structured interviews. Data collection was undertaken between February and June 2016. Data from the questionnaires ( N  = 33) distributed before and after the intervention were analysed using descriptive statistics and Wilcoxon sign rank test. The interviews ( N  = 10) were analysed using deductive content analysis. After analysing questionnaires and interviews separately, the results were merged in a side by side comparison presented in the discussion. The results from both the quantitative and qualitative analyses indicate that the educational programme shaped the target behaviours that we aimed to change by addressing the nursing staff's capability, opportunity and motivation and hence could strengthen the nursing staff's contribution to inpatient stroke rehabilitation. A number of behaviours changed significantly, and the qualitative results indicated that the staff experienced increased focus on their role and functions in rehabilitation practice. Our study provides an understanding of the outcome of the Rehabilitation 24/7 educational programme on nursing staff's behaviours. A mixed-methods approach provided extended knowledge of the changes in the nursing staff members' self-percived behaviours after the intervention. These changes suggest that educating the nursing staff on rehabilitation using the Rehabilitation 24/7 programme strengthened their knowledge and beliefs about rehabilitation, goal-setting as well as their role and functions .

A case-control study of the effectiveness of tissue plasminogen activator on 6 month patients--reported outcomes and health care utilization.

PubMed

Lang, Catherine E; Bland, Marghuretta D; Cheng, Nuo; Corbetta, Maurizio; Lee, Jin-Moo

2014-01-01

We examined the benefit of tissue plasminogen activator (tPA), delivered as part of usual stroke management, on patient-reported outcomes and health care utilization. Using a case control design, patients who received tPA as part of usual stroke management were compared with patients who would have received tPA had they arrived to the hospital within the therapeutic time window. Data were collected from surveys 6 months after stroke using standardized patient-reported outcome measures and questions about health care utilization. Demographic and medical data were acquired from hospital records. Patients were matched on stroke severity, age, race, and gender. Matching was done with 1:2 ratio of tPA to controls. Results were compared between groups with 1-tailed tests because of a directionally specific hypothesis in favor of the tPA group. The tPA (n = 78) and control (n = 156) groups were matched across variables, except for stroke severity, which was better in the control group; subsequent analyses controlled for this mismatch. The tPA group reported better physical function, communication, cognitive ability, depressive symptomatology, and quality of life/participation compared with the control group. Fewer people in the tPA group reported skilled nursing facility stays, emergency department visits, and rehospitalizations after their stroke compared with controls. Reports of other postacute services were not different between groups. Although it is known that tPA reduces disability, this is the first study to demonstrate the effectiveness of tPA in improving meaningful, patient-reported outcomes. Thus, use of tPA provides a large benefit to the daily lives of people with ischemic stroke. Copyright © 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Racial Differences in Neurocognitive Outcomes Post-Stroke: The Impact of Healthcare Variables.

PubMed

Johnson, Neco X; Marquine, Maria J; Flores, Ilse; Umlauf, Anya; Baum, Carolyn M; Wong, Alex W K; Young, Alexis C; Manly, Jennifer J; Heinemann, Allen W; Magasi, Susan; Heaton, Robert K

2017-09-01

The present study examined differences in neurocognitive outcomes among non-Hispanic Black and White stroke survivors using the NIH Toolbox-Cognition Battery (NIHTB-CB), and investigated the roles of healthcare variables in explaining racial differences in neurocognitive outcomes post-stroke. One-hundred seventy adults (91 Black; 79 White), who participated in a multisite study were included (age: M=56.4; SD=12.6; education: M=13.7; SD=2.5; 50% male; years post-stroke: 1-18; stroke type: 72% ischemic, 28% hemorrhagic). Neurocognitive function was assessed with the NIHTB-CB, using demographically corrected norms. Participants completed measures of socio-demographic characteristics, health literacy, and healthcare use and access. Stroke severity was assessed with the Modified Rankin Scale. An independent samples t test indicated Blacks showed more neurocognitive impairment (NIHTB-CB Fluid Composite T-score: M=37.63; SD=11.67) than Whites (Fluid T-score: M=42.59, SD=11.54; p=.006). This difference remained significant after adjusting for reading level (NIHTB-CB Oral Reading), and when stratified by stroke severity. Blacks also scored lower on health literacy, reported differences in insurance type, and reported decreased confidence in the doctors treating them. Multivariable models adjusting for reading level and injury severity showed that health literacy and insurance type were statistically significant predictors of the Fluid cognitive composite (p<.001 and p=.02, respectively) and significantly mediated racial differences on neurocognitive impairment. We replicated prior work showing that Blacks are at increased risk for poorer neurocognitive outcomes post-stroke than Whites. Health literacy and insurance type might be important modifiable factors influencing these differences. (JINS, 2017, 23, 640-652).

Racial Differences in Neurocognitive Outcomes Post-Stroke: The Impact of Healthcare Variables

PubMed Central

Johnson, N.; Marquine, M.J.; Flores, I.; Umlauf, A.; Baum, C.; Wong, A.W.K.; Young, A.C.; Manly, J.J.; Heinemann, A.W.; Magasi, S.; Heaton, R.K.

2017-01-01

Objective The present study examined differences in neurocognitive outcomes among non-Hispanic Black and White stroke survivors utilizing the NIH Toolbox-Cognition Battery (NIHTB-CB), and investigated the roles of healthcare variables in explaining racial differences in neurocognitive outcomes post-stroke. Method One-hundred-seventy adults (91 Black; 79 White), who participated in a multisite study were included (Age: M=56.4, SD=12.6; Education: M=13.7, SD=2.5; 50% male; Years post-stroke: 1–18; Stroke type: 72% ischemic, 28% hemorrhagic). Neurocognitive function was assessed with the NIHTB-CB, using demographically-corrected norms. Participants completed measures of socio-demographic characteristics, health literacy, and healthcare use and access. Stroke severity was assessed with the modified Rankin Scale. Results An independent samples t-test indicated Blacks showed more neurocognitive impairment (NIHTB-CB Fluid Composite T-score: M=37.63 SD=11.67) than Whites (Fluid T-score: M=42.59, SD=11.54; p=.006). This difference remained significant after adjusting for reading level (NIHTB-CB Oral Reading), and when stratified by stroke severity. Blacks also scored lower on health literacy, reported differences in insurance type, and reported decreased confidence in the doctors treating them. Multivariable models adjusting for reading level and injury severity showed that health literacy and insurance type were statistically significant predictors of the Fluid cognitive composite (p<.001 and p=.02, respectively) and significantly mediated racial differences on neurocognitive impairment. Conclusion We replicated prior work showing that Blacks are at increased risk for poorer neurocognitive outcomes post-stroke than Whites. Health literacy and insurance type might be important modifiable factors influencing these differences. PMID:28660849

Modulation of brain plasticity in stroke: a novel model for neurorehabilitation.

PubMed

Di Pino, Giovanni; Pellegrino, Giovanni; Assenza, Giovanni; Capone, Fioravante; Ferreri, Florinda; Formica, Domenico; Ranieri, Federico; Tombini, Mario; Ziemann, Ulf; Rothwell, John C; Di Lazzaro, Vincenzo

2014-10-01

Noninvasive brain stimulation (NIBS) techniques can be used to monitor and modulate the excitability of intracortical neuronal circuits. Long periods of cortical stimulation can produce lasting effects on brain function, paving the way for therapeutic applications of NIBS in chronic neurological disease. The potential of NIBS in stroke rehabilitation has been of particular interest, because stroke is the main cause of permanent disability in industrial nations, and treatment outcomes often fail to meet the expectations of patients. Despite promising reports from many clinical trials on NIBS for stroke recovery, the number of studies reporting a null effect remains a concern. One possible explanation is that the interhemispheric competition model--which posits that suppressing the excitability of the hemisphere not affected by stroke will enhance recovery by reducing interhemispheric inhibition of the stroke hemisphere, and forms the rationale for many studies--is oversimplified or even incorrect. Here, we critically review the proposed mechanisms of synaptic and functional reorganization after stroke, and suggest a bimodal balance-recovery model that links interhemispheric balancing and functional recovery to the structural reserve spared by the lesion. The proposed model could enable NIBS to be tailored to the needs of individual patients.

Very early social support following mild stroke is associated with emotional and behavioral outcomes three months later.

PubMed

Villain, Marie; Sibon, Igor; Renou, Pauline; Poli, Mathilde; Swendsen, Joel

2017-01-01

To investigate whether social contact and support received during hospitalization for acute ischemic stroke predict depression and daily life functioning three months later. Prospective observational study using Ecological Momentary Assessments to evaluate the number of social contacts as well as social support received from family, friends and medical staff within 24 hours following admission for stroke. Patients also monitored depression symptoms and behavior in real-time and in daily life contexts three months later. A university hospital acute stroke unit. Thirty-four mild ischemic stroke patients. None. One-day Ecological Momentary Assessments immediately following stroke collected information concerning perceived social support, number of social contacts and depression symptoms. Ecological Momentary Assessments was repeated three months later and addressed depression levels as well as activities of daily living, such as working, cooking, shopping and housework. The number of social interactions received at hospitalization did not predict three-month outcomes. However, a better quality of moral support from friends and family immediately after stroke was associated with decreases in later depression levels ( p = 0.041) and increases in activities of daily living ( p = 0.011). Material support from friends and family was associated with increases in activities of daily living ( p = 0.012). No effect was observed for support received from medical staff. Patient perceptions of better support quality, and not quantity, immediately following mild stroke, are associated with better behavioral and emotional outcomes three months later.

Validation of the DRAGON score in 12 stroke centers in anterior and posterior circulation.

PubMed

Strbian, Daniel; Seiffge, David J; Breuer, Lorenz; Numminen, Heikki; Michel, Patrik; Meretoja, Atte; Coote, Skye; Bordet, Régis; Obach, Victor; Weder, Bruno; Jung, Simon; Caso, Valeria; Curtze, Sami; Ollikainen, Jyrki; Lyrer, Philippe A; Eskandari, Ashraf; Mattle, Heinrich P; Chamorro, Angel; Leys, Didier; Bladin, Christopher; Davis, Stephen M; Köhrmann, Martin; Engelter, Stefan T; Tatlisumak, Turgut

2013-10-01

The DRAGON score predicts functional outcome in the hyperacute phase of intravenous thrombolysis treatment of ischemic stroke patients. We aimed to validate the score in a large multicenter cohort in anterior and posterior circulation. Prospectively collected data of consecutive ischemic stroke patients who received intravenous thrombolysis in 12 stroke centers were merged (n=5471). We excluded patients lacking data necessary to calculate the score and patients with missing 3-month modified Rankin scale scores. The final cohort comprised 4519 eligible patients. We assessed the performance of the DRAGON score with area under the receiver operating characteristic curve in the whole cohort for both good (modified Rankin scale score, 0-2) and miserable (modified Rankin scale score, 5-6) outcomes. Area under the receiver operating characteristic curve was 0.84 (0.82-0.85) for miserable outcome and 0.82 (0.80-0.83) for good outcome. Proportions of patients with good outcome were 96%, 93%, 78%, and 0% for 0 to 1, 2, 3, and 8 to 10 score points, respectively. Proportions of patients with miserable outcome were 0%, 2%, 4%, 89%, and 97% for 0 to 1, 2, 3, 8, and 9 to 10 points, respectively. When tested separately for anterior and posterior circulation, there was no difference in performance (P=0.55); areas under the receiver operating characteristic curve were 0.84 (0.83-0.86) and 0.82 (0.78-0.87), respectively. No sex-related difference in performance was observed (P=0.25). The DRAGON score showed very good performance in the large merged cohort in both anterior and posterior circulation strokes. The DRAGON score provides rapid estimation of patient prognosis and supports clinical decision-making in the hyperacute phase of stroke care (eg, when invasive add-on strategies are considered).

Functional strength training and movement performance therapy produce analogous improvement in sit-to-stand early after stroke: early-phase randomised controlled trial.

PubMed

Kerr, A; Clark, A; Cooke, E V; Rowe, P; Pomeroy, V M

2017-09-01

Restoring independence in the sit-to-stand (STS) task is an important objective for stroke rehabilitation. It is not known if a particular intervention, strength training or therapy focused on movement performance is more likely to improve STS recovery. This study aimed to compare STS outcomes from functional strength training, movement performance therapy and conventional therapy. Randomised controlled trial. Acute stroke units. Medically well patients (n=93) with recent (<42 days) stroke. The mean age of patients was 68.8 years, mean time post ictus was 33.5 days, 54 (58%) were male, 20 showed neglect (22%) and 37 (40%) had a left-sided brain lesion. Six weeks of either conventional therapy, functional strength training or movement performance therapy. Subjects were allocated to groups on a random basis. STS ability, timing, symmetry, co-ordination, smoothness and knee velocity were measured at baseline, outcome (after 6 weeks of intervention) and follow-up (3 months after outcome). No significant differences were found between the groups. All three groups improved their STS ability, with 88% able to STS at follow-up compared with 56% at baseline. Few differences were noted in quality of movement, with only symmetry when rising showing significantly greater improvement in the movement performance therapy group; this benefit was not evident at follow-up. Recovery of the STS movement is consistently good during stroke rehabilitation, irrespective of the type of therapy experienced. Changes in quality of movement did not differ according to group allocation, indicating that the type of therapy is less important. Clinical trial registration number NCT00322192. Copyright © 2016 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.

Transcranial direct current stimulation (tDCS) for improving capacity in activities and arm function after stroke: a network meta-analysis of randomised controlled trials.

PubMed

Elsner, Bernhard; Kwakkel, Gert; Kugler, Joachim; Mehrholz, Jan

2017-09-13

Transcranial Direct Current Stimulation (tDCS) is an emerging approach for improving capacity in activities of daily living (ADL) and upper limb function after stroke. However, it remains unclear what type of tDCS stimulation is most effective. Our aim was to give an overview of the evidence network regarding the efficacy and safety of tDCS and to estimate the effectiveness of the different stimulation types. We performed a systematic review of randomised trials using network meta-analysis (NMA), searching the following databases until 5 July 2016: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, AMED, Web of Science, and four other databases. We included studies with adult people with stroke. We compared any kind of active tDCS (anodal, cathodal, or dual, that is applying anodal and cathodal tDCS concurrently) regarding improvement of our primary outcome of ADL capacity, versus control, after stroke. CRD42016042055. We included 26 studies with 754 participants. Our NMA showed evidence of an effect of cathodal tDCS in improving our primary outcome, that of ADL capacity (standardized mean difference, SMD = 0.42; 95% CI 0.14 to 0.70). tDCS did not improve our secondary outcome, that of arm function, measured by the Fugl-Meyer upper extremity assessment (FM-UE). There was no difference in safety between tDCS and its control interventions, measured by the number of dropouts and adverse events. Comparing different forms of tDCS shows that cathodal tDCS is the most promising treatment option to improve ADL capacity in people with stroke.

Outcome and periprocedural time management in referred versus directly admitted stroke patients treated with thrombectomy.

PubMed

Weber, Ralph; Reimann, Gernot; Weimar, Christian; Winkler, Angela; Berger, Klaus; Nordmeyer, Hannes; Hadisurya, Jeffrie; Brassel, Friedhelm; Kitzrow, Martin; Krogias, Christos; Weber, Werner; Busch, Elmar W; Eyding, Jens

2016-03-01

After thrombectomy has shown to be effective in acute stroke patients with large vessel occlusion, the potential benefit of secondary referral for such an intervention needs to be validated. We aimed to compare consecutive stoke patients directly admitted and treated with thrombectomy at a neurointerventional centre with patients secondarily referred for such a procedure from hospitals with a stroke unit. Periprocedure times and mortality in 300 patients primarily treated in eight neurointerventional centres were compared with 343 patients referred from nine other hospitals in a prospective multicentre study of a German neurovascular network. Data on functional outcome at 3 months was available in 430 (76.4%) patients. In-hospital mortality (14.8% versus 11.7%, p = 0.26) and 3 months mortality (21.9% versus 24.1%, p = 0.53) were not statistically different in both patient groups despite a significant shorter symptom to groin puncture time in directly admitted patients, which was mainly caused by a longer interfacility transfer time. We found a nonsignificant trend for better functional outcome at 3 months in directly admitted patients (modified Rankin Scale 0-2, 44.0% versus 35.7%, p = 0.08). Our results show that a drip-and-ship thrombectomy concept can be effectively organized in a metropolitan stroke network. Every effort should be made to speed up the emergency interfacility transfer to a neurointerventional centre in stroke patients eligible for thrombectomy after initial brain imaging.

Surgical decompression for space-occupying cerebral infarction (the Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema Trial [HAMLET]): a multicentre, open, randomised trial.

PubMed

Hofmeijer, Jeannette; Kappelle, L Jaap; Algra, Ale; Amelink, G Johan; van Gijn, Jan; van der Worp, H Bart

2009-04-01

Patients with space-occupying hemispheric infarctions have a poor prognosis, with case fatality rates of up to 80%. In a pooled analysis of randomised trials, surgical decompression within 48 h of stroke onset reduced case fatality and improved functional outcome; however, the effect of surgery after longer intervals is unknown. The aim of HAMLET was to assess the effect of decompressive surgery within 4 days of the onset of symptoms in patients with space-occupying hemispheric infarction. Patients with space-occupying hemispheric infarction were randomly assigned within 4 days of stroke onset to surgical decompression or best medical treatment. The primary outcome measure was the modified Rankin scale (mRS) score at 1 year, which was dichotomised between good (0-3) and poor (4-6) outcome. Other outcome measures were the dichotomy of mRS score between 4 and 5, case fatality, quality of life, and symptoms of depression. Analysis was by intention to treat. This trial is registered, ISRCTN94237756. Between November, 2002, and October, 2007, 64 patients were included; 32 were randomly assigned to surgical decompression and 32 to best medical treatment. Surgical decompression had no effect on the primary outcome measure (absolute risk reduction [ARR] 0%, 95% CI -21 to 21) but did reduce case fatality (ARR 38%, 15 to 60). In a meta-analysis of patients in DECIMAL (DEcompressive Craniectomy In MALignant middle cerebral artery infarction), DESTINY (DEcompressive Surgery for the Treatment of malignant INfarction of the middle cerebral arterY), and HAMLET who were randomised within 48 h of stroke onset, surgical decompression reduced poor outcome (ARR 16%, -0.1 to 33) and case fatality (ARR 50%, 34 to 66). Surgical decompression reduces case fatality and poor outcome in patients with space-occupying infarctions who are treated within 48 h of stroke onset. There is no evidence that this operation improves functional outcome when it is delayed for up to 96 h after stroke onset. The decision to perform the operation should depend on the emphasis patients and relatives attribute to survival and dependency.

Prognostic value of blood interleukin-6 in the prediction of functional outcome after stroke: a systematic review and meta-analysis.

PubMed

Bustamante, Alejandro; Sobrino, Tomás; Giralt, Dolors; García-Berrocoso, Teresa; Llombart, Victor; Ugarriza, Iratxe; Espadaler, Marc; Rodríguez, Noelia; Sudlow, Cathie; Castellanos, Mar; Smith, Craig J; Rodríguez-Yánez, Manuel; Waje-Andreassen, Ulrike; Tanne, David; Oto, Jun; Barber, Mark; Worthmann, Hans; Wartenberg, Katja E; Becker, Kyra J; Chakraborty, Baidarbhi; Oh, Seung-Hun; Whiteley, William N; Castillo, José; Montaner, Joan

2014-09-15

We aimed to quantify the association of blood interleukin-6 (IL-6) concentrations with poor outcome after stroke and its added predictive value over clinical information. Meta-analysis of 24 studies confirmed this association with a weighted mean difference of 3.443 (1.592-5.294) pg/mL, despite high heterogeneity and publication bias. Individual participant data including 4112 stroke patients showed standardized IL-6 levels in the 4th quartile were independently associated with poor outcome (OR=2.346 (1.814-3.033), p<0.0001). However, the additional predictive value of IL-6 was moderate (IDI=1.5%, NRI=5.35%). Overall these results indicate an unlikely translation of IL-6 into clinical practice for this purpose. Copyright © 2014 Elsevier B.V. All rights reserved.

What does best evidence tell us about robotic gait rehabilitation in stroke patients: A systematic review and meta-analysis.

PubMed

Bruni, Maria Federica; Melegari, Corrado; De Cola, Maria Cristina; Bramanti, Alessia; Bramanti, Placido; Calabrò, Rocco Salvatore

2018-02-01

Studies about electromechanical-assisted devices proved the validity and effectiveness of these tools in gait rehabilitation, especially if used in association with conventional physiotherapy in stroke patients. The aim of this study was to compare the effects of different robotic devices in improving post-stroke gait abnormalities. A computerized literature research of articles was conducted in the databases MEDLINE, PEDro, COCHRANE, besides a search for the same items in the Library System of the University of Parma (Italy). We selected 13 randomized controlled trials, and the results were divided into sub-acute stroke patients and chronic stroke patients. We selected studies including at least one of the following test: 10-Meter Walking Test, 6-Minute Walk Test, Timed-Up-and-Go, 5-Meter Walk Test, and Functional Ambulation Categories. Stroke patients who received physiotherapy treatment in combination with robotic devices, such as Lokomat or Gait Trainer, were more likely to reach better results, compared to patients who receive conventional gait training alone. Moreover, electromechanical-assisted gait training in association with Functional Electrical Stimulations produced more benefits than the only robotic treatment (-0.80 [-1.14; -0.46], p > .05). The evaluation of the results confirm that the use of robotics can positively affect the outcome of a gait rehabilitation in patients with stroke. The effects of different devices seems to be similar on the most commonly outcome evaluated by this review. Copyright © 2017 Elsevier Ltd. All rights reserved.

Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Stroke: South Asian Experience.

PubMed

Kamran, Saadat; Akhtar, Naveed; Salam, Abdul; Alboudi, Ayman; Rashid, Hiba; Kamran, Kainat; Khan, Rabia Ali; Mirza, Mohsin Khalid; Ahmed, Arsalan; Own, Ahmed M A; Al Rukun, Sohail; Inshasi, Jihad; Deleu, Dirk; Al Sulaiti, Ghanim; Shuaib, Ashfaq

2017-10-01

The randomized trials showed improved outcome and reduced mortality in malignant middle cerebral artery (MMCA) undergoing Decompressive hemicraniectomy (DHC) within 48 hours of stroke onset. Despite high prevalence of stroke, especially in younger individuals, high and short-term mortality from stroke in South Asian and Middle East, there is little published data on DHC in patients with MMCA stroke. This is a retrospective, multicenter cross-sectional study to measure outcome following DHC using the modified Rankin Scale (mRS) and dichotomized as favorable (mRS ≤ 4) or unfavorable (mRS > 4), at 3 months. In total, 137 patients underwent DHC. At 90 days, mortality was 16.8%; 61.3% of patients survived with an mRS of 4 or less and 38.7% had an mRS greater than 4. Age (55 years), diabetes (P = .004), hypertension (P = .021), pupillary abnormality (P = .048), uncal herniation (P = .007), temporal lobe involvement (P = .016), additional infarction (MCA + anterior cerebral artery, posterior cerebral artery) (P = .001), and infarction growth rates (P = .025) were significantly higher in patients with unfavorable prognosis in univariate analysis. Multivariate analysis showed age, additional infarction, septum pellucidum deviation greater than 1 cm, and uncal herniation to be associated with a significantly poor prognosis. Time to surgery had no impact on outcome (P = .109). Similar to the results of the studies from the West, DHC Improves functional outcome in predominantly South Asian patients with MMCA Stroke. Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Increased benefit of alteplase in patients with ischemic stroke and a high body temperature.

PubMed

de Ridder, Inger; den Hertog, Heleen; van Gemert, Maarten; Dippel, Diederik; van der Worp, Bart

2013-01-01

In observational studies, a high body temperature has been associated with unfavorable outcome. In in vitro studies, the fibrinolytic activity of alteplase decreased 5% per degree Celsius reduction in temperature. The modifying effect of body temperature on treatment with alteplase in patients with acute ischemic stroke is unclear. We assessed the influence of baseline body temperature on the effect of alteplase on functional outcome in patients with acute ischemic stroke, included in the Paracetamol (Acetaminophen) in Stroke (PAIS) trial. PAIS was a randomized, double-blind clinical trial to assess the effect of high-dose paracetamol on functional outcome in patients with acute stroke. For this study, we selected all patients with ischemic stroke and randomization within 6 h of symptom onset. We estimated the effect of treatment with alteplase on the modified Rankin Scale score at 3 months with ordinal logistic regression, stratified by baseline body temperature. We made adjustments for confounding factors and expressed associations as adjusted odds ratios (aOR) with 95% confidence intervals (CI). We also tested for interaction between treatment with alteplase and body temperature. We included 647 of the 1,400 patients in PAIS in our study. Treatment with alteplase was associated with improved functional outcome at 3 months (aOR 1.51, 95% CI 1.09-2.08). In the 286 patients (44%) with a baseline body temperature of 37.0°C or higher, alteplase was associated with a larger effect (aOR 2.13, 95% CI 1.28-3.45) than in patients with a temperature below 37.0°C (aOR 1.11, 95% CI 0.71-1.69). A test for interaction between body temperature and alteplase did not reach statistical significance (p = 0.18). Patients with ischemic stroke and a high body temperature may have a larger benefit of treatment with alteplase than patients with lower body temperatures. These findings are in line with those from in vitro studies, in which lowering temperature decreased the fibrinolytic activity of the enzyme alteplase. This interaction should be explored further in randomized clinical trials of thrombolytic therapy or modification of body temperature. Trials of therapeutic hypothermia should be controlled for treatment with thrombolytics, and trials of thrombolytic treatment should consider body temperature as a potential effect modifier. Copyright © 2013 S. Karger AG, Basel.

Is management of hyperglycaemia in acute phase stroke still a dilemma?

PubMed

Savopoulos, C; Kaiafa, G; Kanellos, I; Fountouki, A; Theofanidis, D; Hatzitolios, A I

2017-05-01

Close monitoring of blood glucose levels during the immediate post-acute stroke phase is of great clinical value, as there is evidence that the risk of neurological deterioration is associated with both hyper- and hypoglycaemia. The aim of this review paper is to summarise the evidence on post-stroke blood glucose management and its impact on clinical outcomes, during the early post-acute stage. Post-stroke hyperglycaemia has been associated with increased cerebral oedema, haemorrhagic transformation, lower likelihood of recanalisation and deteriorating neurological state. Thus, hyperglycaemia during an acute stroke may result in poorer clinical outcomes, infarct progression, poor functional recovery and increased mortality rates. Although hypoglycaemia may also lead to poorer outcomes via further brain injury, it can be readily reversed by glucose administration. In most patients, the goal of regular treatment is euglycaemia and for acute-stroke patients, a reasonable approach is to target control of glucose level at 100-150 mg/dL. Both hypoglycaemia and hyperglycaemia may lead to further brain injury and clinical deterioration; that is the reason these conditions should be avoided after stroke. Yet, when correcting hyperglycaemia, great care should be taken not to switch the patient into hypoglycaemia, and subsequently aggressive insulin administration treatment should be avoided. Early identification and prompt management of hyperglycaemia, especially in acute ischaemic stroke, is recommended. Although the appropriate level of blood glucose during acute stroke is still debated, a reasonable approach is to keep the patient in a mildly hyperglycaemic state, rather than risking hypoglycaemia, using continuous glucose monitoring.

Assessment of Comorbidity Burden and its Association With Functional Rehabilitation Outcome After Stroke or Hip Fracture: A Systematic Review and Meta-Analysis.

PubMed

Kabboord, Anouk D; van Eijk, Monica; Fiocco, Marta; van Balen, Romke; Achterberg, Wilco P

2016-11-01

A well-grounded functional prognosis during triage for rehabilitation is important, especially in older patients who experience the burden of comorbidity. However, it remains unclear what impact comorbidity has on functional outcome after rehabilitation. To investigate the associations between comorbidity indexes and functional outcome after inpatient stroke or hip fracture rehabilitation. Furthermore, to identify which method of comorbidity assessment best reveals this relationship. Systematic review and meta-analysis. An extensive search in PubMed, EMBASE, COCHRANE, Web of Science, and CINAHL of cited references and gray literature was carried out on March 4, 2016. This meta-analysis was conducted in agreement with the guidelines for Preferred Reporting Items for Systematic reviews and Meta-Analyses. Studies were included if participants were adult patients with a stroke or hip fracture, participants received inpatient rehabilitation, comorbidity was assessed with a valid index, and functional status was an outcome measure. Two reviewers independently extracted data; according to the predefined data extraction plan, included studies were independently evaluated on risk of bias. Twenty studies were eligible for review, and 7 studies were included in the meta-analysis. The pooled correlation between comorbidity and functional status at discharge was -0.43 [-0.69; -0.06]. Presence and strength of correlations differed between comorbidity indexes. Charlson index: range = 0.0 to -0.88 and 0%-1% explained variance (%var). Cumulative illness rating scale (CIRS) total or cumulative: range = -0.02 to -0.34 and unknown %var. CIRS-severity index: range = -0.25 to -0.40 and 12-16 %var. Comorbidity-severity index: range = -0.39 and -0.47 and 5 %var. Liu index: range = -0.28 to -0.50 and 4-7 %var. When the index contained a severity weighting, the associations were more evident. An association between comorbidity burden and functional outcome exists, albeit modest. Assessment of severity weighted comorbidity is preferred for estimating the functional prognosis after stroke and hip fracture rehabilitation. Copyright © 2016 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.

Systematic Review of Parameters of Stimulation, Clinical Trial Design Characteristics, and Motor Outcomes in Non-Invasive Brain Stimulation in Stroke

PubMed Central

Adeyemo, Bamidele O.; Simis, Marcel; Macea, Debora Duarte; Fregni, Felipe

2012-01-01

Introduction/Objectives: Repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation are two powerful non-invasive neuromodulatory therapies that have the potential to alter and evaluate the integrity of the corticospinal tract. Moreover, recent evidence has shown that brain stimulation might be beneficial in stroke recovery. Therefore, investigating and investing in innovative therapies that may improve neurorehabilitative stroke recovery are next steps in research and development. Participants/Materials and Methods: This article presents an up-to-date systematic review of the treatment effects of rTMS and tDCS on motor function. A literary search was conducted, utilizing search terms “stroke” and “transcranial stimulation.” Items were excluded if they failed to: (1) include stroke patients, (2) study motor outcomes, or (3) include rTMS/tDCS as treatments. Other exclusions included: (1) reviews, editorials, and letters, (2) animal or pediatric populations, (3) case reports or sample sizes ≤2 patients, and (4) primary outcomes of dysphagia, dysarthria, neglect, or swallowing. Results: Investigation of PubMed English Database prior to 01/01/2012 produced 695 applicable results. Studies were excluded based on the aforementioned criteria, resulting in 50 remaining studies. They included 1314 participants (1282 stroke patients and 32 healthy subjects) evaluated by motor function pre- and post-tDCS or rTMS. Heterogeneity among studies’ motor assessments was high and could not be accounted for by individual comparison. Pooled effect sizes for the impact of post-treatment improvement revealed consistently demonstrable improvements after tDCS and rTMS therapeutic stimulation. Most studies provided limited follow-up for long-term effects. Conclusion: It is apparent from the available studies that non-invasive stimulation may enhance motor recovery and may lead to clinically meaningful functional improvements in the stroke population. Only mild to no adverse events have been reported. Though results have been positive results, the large heterogeneity across articles precludes firm conclusions. PMID:23162477

Niaspan increases axonal remodeling after stroke in type 1 diabetes rats✩

PubMed Central

Yan, Tao; Chopp, Michael; Ye, Xinchun; Liu, Zhongwu; Zacharek, Alex; Cui, Yisheng; Roberts, Cynthia; Buller, Ben; Chen, Jieli

2012-01-01

Background and objective We investigated axonal plasticity in the bilateral motor cortices and the long term therapeutic effect of Niaspan on axonal remodeling after stroke in type-1 diabetic (T1DM) rats. Experimental approaches T1DM was induced in young adult male Wistar rats via injection of streptozotocin. T1DM rats were subjected to 2 h transient middle cerebral artery occlusion (MCAo) and were treated with 40 mg/kg Niaspan or saline starting 24 h after MCAo and daily for 28 days. Anterograde tracing using biotinylated dextran amine (BDA) injected into the contralateral motor cortex was performed to assess axonal sprouting in the ipsilateral motor cortex area. Functional outcome, SMI-31 (a pan-axonal microfilament marker), Bielschowsky silver and synaptophysin expression were measured. In vitro studies using primary cortical neuron (PCN) cultures and in vivo BDA injection into the brain to anterogradely label axons and terminals were employed. Results Niaspan treatment of stroke in T1DM–MCAo rats significantly improved functional outcome after stroke and increased SMI-31, Bielschowsky silver and synaptophysin expression in the ischemic brain compared to saline treated T1DM–MCAo rats (p<0.05). Using BDA to anterograde label axons and terminals, Niaspan treatment significantly increased axonal density in ipsilateral motor cortex in T1DM–MCAo rats (p<0.05, n=7/group). Niacin treatment of PCN significantly increased Ang1 expression under high glucose condition. Niacin and Ang1 significantly increased neurite outgrowth, and anti-Ang1 antibody marginally attenuated Niacin induced neurite outgrowth (p=0.06, n=6/group) in cultured PCN under high glucose condition. Conclusion Niaspan treatment increased ischemic brain Ang1 expression and promoted axonal remodeling in the ischemic brain as well as improved functional outcome after stroke. Ang1 may partially contribute to Niaspan-induced axonal remodeling after stroke in T1DM-rats. PMID:22266016

[Training and experience in stroke units].

PubMed

Arenillas, J F

2008-01-01

The social and sanitary benefits provided by stroke units can not be achieved without an adequate training and learning process. This dynamic process consists of the progressive acquisition of: a) a greater degree of expertise in stroke management by the stroke team; b) better coordination between the stroke team, extrahospitalary emergency medical systems, and other in-hospital professionals involved in stroke assistance, and c) more human and technological resources dedicated to improve attention to stroke patients. The higher degree of experience in a stroke unit will have an effect: a) improving (time and quality) the diagnostic process in acute stroke patients; b) increasing the proportion of patients treated with thrombolysis; c) reducing extra and intrahospitalary latencies to stroke treatment, and d) improving stroke outcome in terms of reducing mortality and increasing functional independence. Finally, comprehensive stroke centers will achieve a higher degree of organizational complexity that will permit a global assessment of the most advanced aspects in stroke management, including education and research.

Association of hyperglycemia, systolic and diastolic hypertension, and hyperthermia relative to baseline in the acute phase of stroke with poor outcome after intravenous thrombolysis.

PubMed

Forlivesi, Stefano; Micheletti, Nicola; Tomelleri, Giampaolo; Bovi, Paolo; Cappellari, Manuel

2018-03-01

: In the acute phase of ischemic stroke, the trend of some physiological variables, such as blood glucose (BG), blood pressure, and body temperature (BT), might influence outcome. We aimed to assess the association of hyperglycemia, systolic and diastolic hypertension, and hyperthermia relative to baseline BG, systolic blood pressure, diastolic blood pressure and BT, respectively, in the first 12 h with poor outcome after intravenous thrombolysis (IVT). We conducted a retrospective analysis of data prospectively collected from 200 consecutive anterior ischemic stroke patients treated with IVT. Outcome measures were no neurological improvement at 24 h (National Institutes of Health Stroke Scale (NIHSS) score at 24 h ≥NIHSS score at baseline), and unfavorable functional outcome [modified Rankin Scale (mRS) score 3-6] at 3 months. No neurological improvement at 24 h was noted in 52 (26%) patients and mRS 3-6 at 3 months in 68 (34%) patients. The multivariate analyses showed that odds ratios (ORs) for no neurological improvement at 24 h were higher in patients with hyperglycemia relative to baseline [OR 3.50, 95% confidence interval (CI) 1.43-8.57, P = 0.006], and hyperthermia relative to baseline (OR 2.88, 95% CI 1.20-6.91, P = 0.018). OR for 3-month mRS score 3-6 was higher in patients with hyperthermia relative to baseline (OR 3.05, 95% CI 1.20-7.74, P = 0.019). Hyperglycemia and hyperthermia relative to baseline in the first 12 h after IVT are associated with no neurological improvement at 24 h. Hyperthermia relative to baseline is also associated with unfavorable functional outcome at 3 months.

Endothelial dysfunction, vascular disease and stroke: the ARTICO study.

PubMed

Roquer, J; Segura, T; Serena, J; Castillo, J

2009-01-01

Endothelial dysfunction is a fundamental step in the atherosclerotic disease process. Its presence is a risk factor for the development of clinical events, and may represent a marker of atherothrombotic burden. Also, endothelial dysfunction contributes to enhanced plaque vulnerability, may trigger plaque rupture, and favors thrombus formation. The assessment of endothelial vasomotion is a useful marker of atherosclerotic vascular disease. There are different methods to assess endothelial function: endothelium-dependent vasodilatation brachial flow-mediated dilation, cerebrovascular reactivity to L-arginine, and the determination of some biomarkers such as microalbuminuria, platelet function, and C-reactive protein. Endothelial dysfunction has been observed in stroke patients and has been related to stroke physiopathology, stroke subtypes, clinical severity and outcome. Resting ankle-brachial index (ABI) is also considered an indicator of generalized atherosclerosis, and a low ABI is associated with an increase in stroke incidence in the elderly. Despite all these data, there are no studies analyzing the predictive value of ABI for new cardiovascular events in patients after suffering an acute ischemic stroke. ARTICO is an ongoing prospective, observational, multicenter study being performed in 50 Spanish hospitals. The aim of the ARTICO study is to evaluate the prognostic value of a pathological ABI (

How do somatosensory deficits in the arm and hand relate to upper limb impairment, activity, and participation problems after stroke? A systematic review.

PubMed

Meyer, Sarah; Karttunen, Auli H; Thijs, Vincent; Feys, Hilde; Verheyden, Geert

2014-09-01

The association between somatosensory impairments and outcome after stroke remains unclear. The aim of this study was to systematically review the available literature on the relationship between somatosensory impairments in the upper limb and outcome after stroke. The electronic databases PubMed, CINAHL, EMBASE, Cochrane Library, PsycINFO, and Web of Science were systematically searched from inception until July 2013. Studies were included if adult patients with stroke (minimum n=10) were examined with reliable and valid measures of somatosensation in the upper limb to investigate the relationship with upper limb impairment, activity, and participation measures. Exclusion criteria included measures of somatosensation involving an overall score for upper and lower limb outcome and articles including only lower limb outcomes. Eligibility assessment, data extraction, and quality evaluation were completed by 2 independent reviewers. A cutoff score of ≥65% of the maximal quality score was used for further inclusion in this review. Six articles met all inclusion criteria. Two-point discrimination was shown to be predictive for upper limb dexterity, and somatosensory evoked potentials were shown to have predictive value in upper limb motor recovery. Proprioception was significantly correlated with perceived level of physical activity and social isolation and had some predictive value in functional movements of the upper limb. Finally, the combination of light touch and proprioception impairment was shown to be significantly related to upper limb motor recovery as well as handicap situations during activities of daily living. Heterogeneity of the included studies warrants caution when interpreting results. Large variation in results was found due to heterogeneity of the studies. However, somatosensory deficits were shown to have an important role in upper limb motor and functional performance after stroke. © 2014 American Physical Therapy Association.

High-Intensity Interval Training After Stroke: An Opportunity to Promote Functional Recovery, Cardiovascular Health, and Neuroplasticity.

PubMed

Crozier, Jennifer; Roig, Marc; Eng, Janice J; MacKay-Lyons, Marilyn; Fung, Joyce; Ploughman, Michelle; Bailey, Damian M; Sweet, Shane N; Giacomantonio, Nicholas; Thiel, Alexander; Trivino, Michael; Tang, Ada

2018-04-01

Stroke is the leading cause of adult disability. Individuals poststroke possess less than half of the cardiorespiratory fitness (CRF) as their nonstroke counterparts, leading to inactivity, deconditioning, and an increased risk of cardiovascular events. Preserving cardiovascular health is critical to lower stroke risk; however, stroke rehabilitation typically provides limited opportunity for cardiovascular exercise. Optimal cardiovascular training parameters to maximize recovery in stroke survivors also remains unknown. While stroke rehabilitation recommendations suggest the use of moderate-intensity continuous exercise (MICE) to improve CRF, neither is it routinely implemented in clinical practice, nor is the intensity always sufficient to elicit a training effect. High-intensity interval training (HIIT) has emerged as a potentially effective alternative that encompasses brief high-intensity bursts of exercise interspersed with bouts of recovery, aiming to maximize cardiovascular exercise intensity in a time-efficient manner. HIIT may provide an alternative exercise intervention and invoke more pronounced benefits poststroke. To provide an updated review of HIIT poststroke through ( a) synthesizing current evidence; ( b) proposing preliminary considerations of HIIT parameters to optimize benefit; ( c) discussing potential mechanisms underlying changes in function, cardiovascular health, and neuroplasticity following HIIT; and ( d) discussing clinical implications and directions for future research. Preliminary evidence from 10 studies report HIIT-associated improvements in functional, cardiovascular, and neuroplastic outcomes poststroke; however, optimal HIIT parameters remain unknown. Larger randomized controlled trials are necessary to establish ( a) effectiveness, safety, and optimal training parameters within more heterogeneous poststroke populations; (b) potential mechanisms of HIIT-associated improvements; and ( c) adherence and psychosocial outcomes.

Assessing neuro-motor recovery in a stroke survivor with high-resolution EEG, robotics and Virtual Reality.

PubMed

Comani, Silvia; Schinaia, Lorenzo; Tamburro, Gabriella; Velluto, Lucia; Sorbi, Sandro; Conforto, Silvia; Guarnieri, Biancamaria

2015-01-01

One post-stroke patient underwent neuro-motor rehabilitation of one upper limb with a novel system combining a passive robotic device, Virtual Reality training applications and high resolution electroencephalography (HR-EEG). The outcome of the clinical tests and the evaluation of the kinematic parameters recorded with the robotic device concurred to highlight an improved motor recovery of the impaired limb despite the age of the patient, his compromised motor function, and the start of rehabilitation at the 3rd week post stroke. The time frequency and functional source analysis of the HR-EEG signals permitted to quantify the functional changes occurring in the brain in association with the rehabilitation motor tasks, and to highlight the recovery of the neuro-motor function.

Enhanced Thalamic Functional Connectivity with No fMRI Responses to Affected Forelimb Stimulation in Stroke-Recovered Rats.

PubMed

Shim, Woo H; Suh, Ji-Yeon; Kim, Jeong K; Jeong, Jaeseung; Kim, Young R

2016-01-01

Neurological recovery after stroke has been extensively investigated to provide better understanding of neurobiological mechanism, therapy, and patient management. Recent advances in neuroimaging techniques, particularly functional MRI (fMRI), have widely contributed to unravel the relationship between the altered neural function and stroke-affected brain areas. As results of previous investigations, the plastic reorganization and/or gradual restoration of the hemodynamic fMRI responses to neural stimuli have been suggested as relevant mechanisms underlying the stroke recovery process. However, divergent study results and modality-dependent outcomes have clouded the proper interpretation of variable fMRI signals. Here, we performed both evoked and resting state fMRI (rs-fMRI) to clarify the link between the fMRI phenotypes and post-stroke functional recovery. The experiments were designed to examine the altered neural activity within the contra-lesional hemisphere and other undamaged brain regions using rat models with large unilateral stroke, which despite the severe injury, exhibited nearly full recovery at ∼6 months after stroke. Surprisingly, both blood oxygenation level-dependent and blood volume-weighted (CBVw) fMRI activities elicited by electrical stimulation of the stroke-affected forelimb were completely absent, failing to reveal the neural origin of the behavioral recovery. In contrast, the functional connectivity maps showed highly robust rs-fMRI activity concentrated in the contra-lesional ventromedial nucleus of thalamus (VM). The negative finding in the stimuli-induced fMRI study using the popular rat middle cerebral artery model denotes weak association between the fMRI hemodynamic responses and neurological improvement. The results strongly caution the indiscreet interpretation of stroke-affected fMRI signals and demonstrate rs-fMRI as a complementary tool for efficiently characterizing stroke recovery.

The efficacy of SMART Arm training early after stroke for stroke survivors with severe upper limb disability: a protocol for a randomised controlled trial.

PubMed

Brauer, Sandra G; Hayward, Kathryn S; Carson, Richard G; Cresswell, Andrew G; Barker, Ruth N

2013-07-02

Recovery of upper limb function after stroke is poor. The acute to subacute phase after stroke is the optimal time window to promote the recovery of upper limb function. The dose and content of training provided conventionally during this phase is however, unlikely to be adequate to drive functional recovery, especially in the presence of severe motor disability. The current study concerns an approach to address this shortcoming, through evaluation of the SMART Arm, a non-robotic device that enables intensive and repetitive practice of reaching by stroke survivors with severe upper limb disability, with the aim of improving upper limb function. The outcomes of SMART Arm training with or without outcome-triggered electrical stimulation (OT-stim) to augment movement and usual therapy will be compared to usual therapy alone. A prospective, assessor-blinded parallel, three-group randomised controlled trial is being conducted. Seventy-five participants with a first-ever unilateral stroke less than 4 months previously, who present with severe arm disability (three or fewer out of a possible six points on the Motor Assessment Scale [MAS] Item 6), will be recruited from inpatient rehabilitation facilities. Participants will be randomly allocated to one of three dose-matched groups: SMART Arm training with OT-stim and usual therapy; SMART Arm training without OT-stim and usual therapy; or usual therapy alone. All participants will receive 20 hours of upper limb training over four weeks. Blinded assessors will conduct four assessments: pre intervention (0-weeks), post intervention (4-weeks), 26 weeks and 52 weeks follow-up. The primary outcome measure is MAS item 6. All analyses will be based on an intention-to-treat principle. By enabling intensive and repetitive practice of a functional upper limb task during inpatient rehabilitation, SMART Arm training with or without OT-stim in combination with usual therapy, has the potential to improve recovery of upper limb function in those with severe motor disability. The immediate and long-term effects of SMART Arm training on upper limb impairment, activity and participation will be explored, in addition to the benefit of training with or without OT-stim to augment movement when compared to usual therapy alone. ACTRN12608000457347.

Effectiveness of enhanced communication therapy in the first four months after stroke for aphasia and dysarthria: a randomised controlled trial.

PubMed

Bowen, Audrey; Hesketh, Anne; Patchick, Emma; Young, Alys; Davies, Linda; Vail, Andy; Long, Andrew F; Watkins, Caroline; Wilkinson, Mo; Pearl, Gill; Ralph, Matthew A Lambon; Tyrrell, Pippa

2012-07-13

To assess the effectiveness of enhanced communication therapy in the first four months after stroke compared with an attention control (unstructured social contact). Externally randomised, pragmatic, parallel, superiority trial with blinded outcome assessment. Twelve UK hospital and community stroke services. 170 adults (mean age 70 years) randomised within two weeks of admission to hospital with stroke (December 2006 to January 2010) whom speech and language therapists deemed eligible, and 135 carers. Enhanced, agreed best practice, communication therapy specific to aphasia or dysarthria, offered by speech and language therapists according to participants' needs for up to four months, with continuity from hospital to community. Comparison was with similarly resourced social contact (without communication therapy) from employed visitors. Primary outcome was blinded, functional communicative ability at six months on the Therapy Outcome Measure (TOM) activity subscale. Secondary outcomes (unblinded, six months): participants' perceptions on the Communication Outcomes After Stroke scale (COAST); carers' perceptions of participants from part of the Carer COAST; carers' wellbeing on Carers of Older People in Europe Index and quality of life items from Carer COAST; and serious adverse events. Therapist and visitor contact both had good uptake from service users. An average 22 contacts (intervention or control) over 13 weeks were accepted by users. Impairment focused therapy was the approach most often used by the speech and language therapists. Visitors most often provided general conversation. In total, 81/85 of the intervention group and 72/85 of the control group completed the primary outcome measure. Both groups improved on the TOM activity subscale. The estimated six months group difference was not statistically significant, with 0.25 (95% CI -0.19 to 0.69) points in favour of therapy. Sensitivity analyses that adjusted for chance baseline imbalance further reduced this difference. Per protocol analyses rejected a possible dilution of treatment effect from controls declining their allocation and receiving usual care. There was no added benefit of therapy on secondary outcome measures, subgroup analyses (such as aphasia), or serious adverse events, although the latter were less common after intervention (odds ratio 0.42 (95% CI 0.16 to 1.1)). Communication therapy had no added benefit beyond that from everyday communication in the first four months after stroke. Future research should evaluate reorganised services that support functional communication practice early in the stroke pathway. This project was funded by the NIHR Health Technology Assessment programme (project No 02/11/04) and is published in full in Health Technology Assessment 2012;16(26):1-160. ISRCTN78617680.

Association of follow-up infarct volume with functional outcome in acute ischemic stroke: a pooled analysis of seven randomized trials.

PubMed

Boers, Anna M M; Jansen, Ivo G H; Beenen, Ludo F M; Devlin, Thomas G; San Roman, Luis; Heo, Ji Hoe; Ribó, Marc; Brown, Scott; Almekhlafi, Mohammed A; Liebeskind, David S; Teitelbaum, Jeanne; Lingsma, Hester F; van Zwam, Wim H; Cuadras, Patricia; du Mesnil de Rochemont, Richard; Beaumont, Marine; Brown, Martin M; Yoo, Albert J; van Oostenbrugge, Robert J; Menon, Bijoy K; Donnan, Geoffrey A; Mas, Jean Louis; Roos, Yvo B W E M; Oppenheim, Catherine; van der Lugt, Aad; Dowling, Richard J; Hill, Michael D; Davalos, Antoni; Moulin, Thierry; Agrinier, Nelly; Demchuk, Andrew M; Lopes, Demetrius K; Aja Rodríguez, Lucia; Dippel, Diederik W J; Campbell, Bruce C V; Mitchell, Peter J; Al-Ajlan, Fahad S; Jovin, Tudor G; Madigan, Jeremy; Albers, Gregory W; Soize, Sebastien; Guillemin, Francis; Reddy, Vivek K; Bracard, Serge; Blasco, Jordi; Muir, Keith W; Nogueira, Raul G; White, Phil M; Goyal, Mayank; Davis, Stephen M; Marquering, Henk A; Majoie, Charles B L M

2018-04-07

Follow-up infarct volume (FIV) has been recommended as an early indicator of treatment efficacy in patients with acute ischemic stroke. Questions remain about the optimal imaging approach for FIV measurement. To examine the association of FIV with 90-day modified Rankin Scale (mRS) score and investigate its dependency on acquisition time and modality. Data of seven trials were pooled. FIV was assessed on follow-up (12 hours to 2 weeks) CT or MRI. Infarct location was defined as laterality and involvement of the Alberta Stroke Program Early CT Score regions. Relative quality and strength of multivariable regression models of the association between FIV and functional outcome were assessed. Dependency of imaging modality and acquisition time (≤48 hours vs >48 hours) was evaluated. Of 1665 included patients, 83% were imaged with CT. Median FIV was 41 mL (IQR 14-120). A large FIV was associated with worse functional outcome (OR=0.88(95% CI 0.87 to 0.89) per 10 mL) in adjusted analysis. A model including FIV, location, and hemorrhage type best predicted mRS score. FIV of ≥133 mL was highly specific for unfavorable outcome. FIV was equally strongly associated with mRS score for assessment on CT and MRI, even though large differences in volume were present (48 mL (IQR 15-131) vs 22 mL (IQR 8-71), respectively). Associations of both early and late FIV assessments with outcome were similar in strength (ρ=0.60(95% CI 0.56 to 0.64) and ρ=0.55(95% CI 0.50 to 0.60), respectively). In patients with an acute ischemic stroke due to a proximal intracranial occlusion of the anterior circulation, FIV is a strong independent predictor of functional outcome and can be assessed before 48 hours, oneither CT or MRI. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Interhospital Transfer Before Thrombectomy Is Associated With Delayed Treatment and Worse Outcome in the STRATIS Registry (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke)

PubMed Central

Saver, Jeffrey L.; Zaidat, Osama O.; Jahan, Reza; Aziz-Sultan, Mohammad Ali; Klucznik, Richard P.; Haussen, Diogo C.; Hellinger, Frank R.; Yavagal, Dileep R.; Yao, Tom L.; Liebeskind, David S.; Jadhav, Ashutosh P.; Gupta, Rishi; Hassan, Ameer E.; Martin, Coleman O.; Bozorgchami, Hormozd; Kaushal, Ritesh; Nogueira, Raul G.; Gandhi, Ravi H.; Peterson, Eric C.; Dashti, Shervin R.; Given, Curtis A.; Mehta, Brijesh P.; Deshmukh, Vivek; Starkman, Sidney; Linfante, Italo; McPherson, Scott H.; Kvamme, Peter; Grobelny, Thomas J.; Hussain, Muhammad S.; Thacker, Ike; Vora, Nirav; Chen, Peng Roc; Monteith, Stephen J.; Ecker, Robert D.; Schirmer, Clemens M.; Sauvageau, Eric; Abou-Chebl, Alex; Derdeyn, Colin P.; Maidan, Lucian; Badruddin, Aamir; Siddiqui, Adnan H.; Dumont, Travis M.; Alhajeri, Abdulnasser; Taqi, M. Asif; Asi, Khaled; Carpenter, Jeffrey; Boulos, Alan; Jindal, Gaurav; Puri, Ajit S.; Chitale, Rohan; Deshaies, Eric M.; Robinson, David H.; Kallmes, David F.; Baxter, Blaise W.; Jumaa, Mouhammad A.; Sunenshine, Peter; Majjhoo, Aniel; English, Joey D.; Suzuki, Shuichi; Fessler, Richard D.; Delgado Almandoz, Josser E.; Martin, Jerry C.; Mueller-Kronast, Nils H.

2017-01-01

Background: Endovascular treatment with mechanical thrombectomy (MT) is beneficial for patients with acute stroke suffering a large-vessel occlusion, although treatment efficacy is highly time-dependent. We hypothesized that interhospital transfer to endovascular-capable centers would result in treatment delays and worse clinical outcomes compared with direct presentation. Methods: STRATIS (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke) was a prospective, multicenter, observational, single-arm study of real-world MT for acute stroke because of anterior-circulation large-vessel occlusion performed at 55 sites over 2 years, including 1000 patients with severe stroke and treated within 8 hours. Patients underwent MT with or without intravenous tissue plasminogen activator and were admitted to endovascular-capable centers via either interhospital transfer or direct presentation. The primary clinical outcome was functional independence (modified Rankin Score 0–2) at 90 days. We assessed (1) real-world time metrics of stroke care delivery, (2) outcome differences between direct and transfer patients undergoing MT, and (3) the potential impact of local hospital bypass. Results: A total of 984 patients were analyzed. Median onset-to-revascularization time was 202.0 minutes for direct versus 311.5 minutes for transfer patients (P<0.001). Clinical outcomes were better in the direct group, with 60.0% (299/498) achieving functional independence compared with 52.2% (213/408) in the transfer group (odds ratio, 1.38; 95% confidence interval, 1.06–1.79; P=0.02). Likewise, excellent outcome (modified Rankin Score 0–1) was achieved in 47.4% (236/498) of direct patients versus 38.0% (155/408) of transfer patients (odds ratio, 1.47; 95% confidence interval, 1.13–1.92; P=0.005). Mortality did not differ between the 2 groups (15.1% for direct, 13.7% for transfer; P=0.55). Intravenous tissue plasminogen activator did not impact outcomes. Hypothetical bypass modeling for all transferred patients suggested that intravenous tissue plasminogen activator would be delayed by 12 minutes, but MT would be performed 91 minutes sooner if patients were routed directly to endovascular-capable centers. If bypass is limited to a 20-mile radius from onset, then intravenous tissue plasminogen activator would be delayed by 7 minutes and MT performed 94 minutes earlier. Conclusions: In this large, real-world study, interhospital transfer was associated with significant treatment delays and lower chance of good outcome. Strategies to facilitate more rapid identification of large-vessel occlusion and direct routing to endovascular-capable centers for patients with severe stroke may improve outcomes. Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02239640. PMID:28943516

Interhospital Transfer Before Thrombectomy Is Associated With Delayed Treatment and Worse Outcome in the STRATIS Registry (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke).

PubMed

Froehler, Michael T; Saver, Jeffrey L; Zaidat, Osama O; Jahan, Reza; Aziz-Sultan, Mohammad Ali; Klucznik, Richard P; Haussen, Diogo C; Hellinger, Frank R; Yavagal, Dileep R; Yao, Tom L; Liebeskind, David S; Jadhav, Ashutosh P; Gupta, Rishi; Hassan, Ameer E; Martin, Coleman O; Bozorgchami, Hormozd; Kaushal, Ritesh; Nogueira, Raul G; Gandhi, Ravi H; Peterson, Eric C; Dashti, Shervin R; Given, Curtis A; Mehta, Brijesh P; Deshmukh, Vivek; Starkman, Sidney; Linfante, Italo; McPherson, Scott H; Kvamme, Peter; Grobelny, Thomas J; Hussain, Muhammad S; Thacker, Ike; Vora, Nirav; Chen, Peng Roc; Monteith, Stephen J; Ecker, Robert D; Schirmer, Clemens M; Sauvageau, Eric; Abou-Chebl, Alex; Derdeyn, Colin P; Maidan, Lucian; Badruddin, Aamir; Siddiqui, Adnan H; Dumont, Travis M; Alhajeri, Abdulnasser; Taqi, M Asif; Asi, Khaled; Carpenter, Jeffrey; Boulos, Alan; Jindal, Gaurav; Puri, Ajit S; Chitale, Rohan; Deshaies, Eric M; Robinson, David H; Kallmes, David F; Baxter, Blaise W; Jumaa, Mouhammad A; Sunenshine, Peter; Majjhoo, Aniel; English, Joey D; Suzuki, Shuichi; Fessler, Richard D; Delgado Almandoz, Josser E; Martin, Jerry C; Mueller-Kronast, Nils H

2017-12-12

Endovascular treatment with mechanical thrombectomy (MT) is beneficial for patients with acute stroke suffering a large-vessel occlusion, although treatment efficacy is highly time-dependent. We hypothesized that interhospital transfer to endovascular-capable centers would result in treatment delays and worse clinical outcomes compared with direct presentation. STRATIS (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke) was a prospective, multicenter, observational, single-arm study of real-world MT for acute stroke because of anterior-circulation large-vessel occlusion performed at 55 sites over 2 years, including 1000 patients with severe stroke and treated within 8 hours. Patients underwent MT with or without intravenous tissue plasminogen activator and were admitted to endovascular-capable centers via either interhospital transfer or direct presentation. The primary clinical outcome was functional independence (modified Rankin Score 0-2) at 90 days. We assessed (1) real-world time metrics of stroke care delivery, (2) outcome differences between direct and transfer patients undergoing MT, and (3) the potential impact of local hospital bypass. A total of 984 patients were analyzed. Median onset-to-revascularization time was 202.0 minutes for direct versus 311.5 minutes for transfer patients ( P <0.001). Clinical outcomes were better in the direct group, with 60.0% (299/498) achieving functional independence compared with 52.2% (213/408) in the transfer group (odds ratio, 1.38; 95% confidence interval, 1.06-1.79; P =0.02). Likewise, excellent outcome (modified Rankin Score 0-1) was achieved in 47.4% (236/498) of direct patients versus 38.0% (155/408) of transfer patients (odds ratio, 1.47; 95% confidence interval, 1.13-1.92; P =0.005). Mortality did not differ between the 2 groups (15.1% for direct, 13.7% for transfer; P =0.55). Intravenous tissue plasminogen activator did not impact outcomes. Hypothetical bypass modeling for all transferred patients suggested that intravenous tissue plasminogen activator would be delayed by 12 minutes, but MT would be performed 91 minutes sooner if patients were routed directly to endovascular-capable centers. If bypass is limited to a 20-mile radius from onset, then intravenous tissue plasminogen activator would be delayed by 7 minutes and MT performed 94 minutes earlier. In this large, real-world study, interhospital transfer was associated with significant treatment delays and lower chance of good outcome. Strategies to facilitate more rapid identification of large-vessel occlusion and direct routing to endovascular-capable centers for patients with severe stroke may improve outcomes. URL: https://www.clinicaltrials.gov. Unique identifier: NCT02239640. © 2017 The Authors.

Autologous intravenous bone marrow mononuclear cell therapy for patients with subacute ischaemic stroke: A pilot study

PubMed Central

Prasad, Kameshwar; Mohanty, Sujata; Bhatia, Rohit; Srivastava, M.V.P.; Garg, Ajay; Srivastava, Achal; Goyal, Vinay; Tripathi, Manjari; Kumar, Amit; Bal, Chandrashekar; Vij, Aarti; Mishra, Nalini Kant

2012-01-01

Background & objectives: Bone marrow mononuclear cell therapy has emerged as one of the option for the treatment of Stroke. Several preclinical studies have shown that the treatment with mononuclear cell (MNCs) can reduce the infarct size and improve the functional outcome. We evaluated the feasibility, safety and clinical outcome of administering bone marrow mononuclear cell (MNCs) intravenously to patients with subacute ischaemic stroke. Methods: In a non-randomized phase-I clinical study, 11 consecutive, eligible and consenting patients, aged 30-70 yr with ischaemic stroke involving anterior circulation within 7 to 30 days of onset of stroke were included. Bone marrow was aspirated from iliac crest and the harvested mononuclear cells were infused into antecubital vein. Outcomes measured for safety included immediate reactions after cell infusion and evidence of tumour formation at one year in whole body PET scan. Patients were followed at week 1, 4-6, 24 and 52 to determine clinical progress using National Institute of Health Stroke Scale (NIHSS), Barthel Index (BI), modified Rankin Scale (mRS), MRI, EEG and PET. Feasibility outcomes included target-dose feasibility. Favourable clinical outcome was defined as mRS score of 2 or less or BI score of 75 to 100 at six months after stem cell therapy. Results: Between September 2006 and April 2007, 11 patients were infused with bone-marrow mononuclear cells (mean 80 million with CD-34+ mean 0.92 million). Protocol was target-dose feasible in 9 patients (82%). FDG-PET scan at 24 and 52 wk in nine patients did not reveal evidence of tumour formation. Seven patients had favourable clinical outcome. Interpretation & conclusions: Intravenous bone marrow mononuclear cell therapy appears feasible and safe in patients with subacute ischaemic stroke. Further, a randomized controlled trial to examine its efficacy is being conducted. PMID:22960888

ENGAGE: Guided Activity-Based Gaming in Neurorehabilitation after Stroke: A Pilot Study

PubMed Central

Reinthal, Ann; Szirony, Kathy; Clark, Cindy; Swiers, Jeffrey; Kellicker, Michelle; Linder, Susan

2012-01-01

Introduction. Stroke is a leading cause of disability in healthy adults. The purpose of this pilot study was to assess the feasibility and outcomes of a novel video gaming repetitive practice paradigm, (ENGAGE) enhanced neurorehabilitation: guided activity-based gaming exercise. Methods. Sixteen individuals at least three months after stroke served as participants. All participants received concurrent outpatient therapy or took part in a stroke exercise class and completed at least 500 minutes of gaming. Primary baseline and posttest outcome measures included the Wolf motor function test (WMFT) and the Fugl-Meyer assessment (FMA). ENGAGE uses a game selection algorithm providing focused, graded activity-based repetitive practice that is highly individualized and directed. The Wilcoxon signed ranks test was used to determine statistical significance. Results. There were improvements in the WMFT (P = 0.003) and the FMA (P = 0.002) that exceeded established values of minimal clinically important difference. Conclusions. ENGAGE was feasible and an effective adjunct to concurrent therapy after stroke. PMID:22593835

Time to Reperfusion and Treatment Effect for Acute Ischemic Stroke: A Randomized Clinical Trial.

PubMed

Fransen, Puck S S; Berkhemer, Olvert A; Lingsma, Hester F; Beumer, Debbie; van den Berg, Lucie A; Yoo, Albert J; Schonewille, Wouter J; Vos, Jan Albert; Nederkoorn, Paul J; Wermer, Marieke J H; van Walderveen, Marianne A A; Staals, Julie; Hofmeijer, Jeannette; van Oostayen, Jacques A; Lycklama À Nijeholt, Geert J; Boiten, Jelis; Brouwer, Patrick A; Emmer, Bart J; de Bruijn, Sebastiaan F; van Dijk, Lukas C; Kappelle, L Jaap; Lo, Rob H; van Dijk, Ewoud J; de Vries, Joost; de Kort, Paul L M; van den Berg, J S Peter; van Hasselt, Boudewijn A A M; Aerden, Leo A M; Dallinga, René J; Visser, Marieke C; Bot, Joseph C J; Vroomen, Patrick C; Eshghi, Omid; Schreuder, Tobien H C M L; Heijboer, Roel J J; Keizer, Koos; Tielbeek, Alexander V; den Hertog, Heleen M; Gerrits, Dick G; van den Berg-Vos, Renske M; Karas, Giorgos B; Steyerberg, Ewout W; Flach, H Zwenneke; Marquering, Henk A; Sprengers, Marieke E S; Jenniskens, Sjoerd F M; Beenen, Ludo F M; van den Berg, René; Koudstaal, Peter J; van Zwam, Wim H; Roos, Yvo B W E M; van Oostenbrugge, Robert J; Majoie, Charles B L M; van der Lugt, Aad; Dippel, Diederik W J

2016-02-01

Intra-arterial treatment (IAT) for acute ischemic stroke caused by intracranial arterial occlusion leads to improved functional outcome in patients treated within 6 hours after onset. The influence of treatment delay on treatment effect is not yet known. To evaluate the influence of time from stroke onset to the start of treatment and from stroke onset to reperfusion on the effect of IAT. The Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands (MR CLEAN) was a multicenter, randomized clinical open-label trial of IAT vs no IAT in 500 patients. The time to the start of treatment was defined as the time from onset of symptoms to groin puncture (TOG). The time from onset of treatment to reperfusion (TOR) was defined as the time to reopening the vessel occlusion or the end of the procedure in cases for which reperfusion was not achieved. Data were collected from December 3, 2010, to June 3, 2014, and analyzed (intention to treat) from July 1, 2014, to September 19, 2015. Main outcome was the modified Rankin Scale (mRS) score for functional outcome (range, 0 [no symptoms] to 6 [death]). Multiple ordinal logistic regression analysis estimated the effect of treatment and tested for the interaction of time to randomization, TOG, and TOR with treatment. The effect of treatment as a risk difference on reaching independence (mRS score, 0-2) was computed as a function of TOG and TOR. Calculations were adjusted for age, National Institutes of Health Stroke Scale score, previous stroke, atrial fibrillation, diabetes mellitus, and intracranial arterial terminus occlusion. Among 500 patients (58% male; median age, 67 years), the median TOG was 260 (interquartile range [IQR], 210-311) minutes; median TOR, 340 (IQR, 274-395) minutes. An interaction between TOR and treatment (P = .04) existed, but not between TOG and treatment (P = .26). The adjusted risk difference (95% CI) was 25.9% (8.3%-44.4%) when reperfusion was reached at 3 hours, 18.8% (6.6%-32.6%) at 4 hours, and 6.7% (0.4%-14.5%) at 6 hours. For every hour of reperfusion delay, the initially large benefit of IAT decreases; the absolute risk difference for a good outcome is reduced by 6% per hour of delay. Patients with acute ischemic stroke require immediate diagnostic workup and IAT in case of intracranial arterial vessel occlusion. trialregister.nl Identifier: NTR1804.

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.

Greater stroke severity predominates over all other factors for the worse outcome of cardioembolic stroke.

PubMed

Hong, Keun-Sik; Lee, Juneyoung; Bae, Hee-Joon; Lee, Ji Sung; Kang, Dong-Wha; Yu, Kyung-Ho; Han, Moon-Ku; Cho, Yong-Jin; Song, Pamela; Park, Jong-Moo; Oh, Mi-Sun; Koo, Jaseong; Lee, Byung-Chul

2013-11-01

Cardioembolic (CE) strokes are more disabling and more fatal than non-CE strokes. Multiple prognostic factors have been recognized, but the magnitude of their relative contributions has not been well explored. Using a prospective stroke outcome database, we compared the 3-month outcomes of CE and non-CE strokes. We assessed the relative contribution of each prognostic factor of initial stroke severity, poststroke complications, and baseline characteristics with multivariable analyses and model fitness improvement using -2 log-likelihood and Nagelkerke R2. This study included 1233 patients with acute ischemic stroke: 193 CE strokes and 1040 non-CE strokes. Compared with the non-CE group, CE group had less modified Rankin Scale (mRS) 0-2 outcomes (47.2% versus 68.5%; odds ratio [95% confidence interval], .41 [.30-.56]), less mRS 0-1 outcomes (33.7% versus 53.5%; .44 [.32-.61]), more mRS 5-6 outcomes (32.1% versus 10.9%; 3.88 [2.71-5.56]), and higher mortality (19.2% versus 5.2%; 4.33 [2.76-6.80]) at 3 months. When adjusting either baseline characteristics or poststroke complications, the outcome differences between the 2 groups remained significant. However, adjusting initial National Institute of Health Stroke Scale (NIHSS) score alone abolished all outcome differences except for mortality. For mRS 0-2 outcomes, the decrement of -2 log-likelihood and the Nagelkerke R2 of the model adjusting initial NIHSS score alone approached 70.2% and 76.7% of the fully adjusting model. Greater stroke severity predominates over all other factors for the worse outcome of CE stroke. Primary prevention and more efficient acute therapy for stroke victims should be given top priorities to reduce the burden of CE strokes. Copyright © 2013 National Stroke Association. Published by Elsevier Inc. All rights reserved.

A crossover pilot study evaluating the functional outcomes of two different types of robotic movement training in chronic stroke survivors using the arm exoskeleton BONES.

PubMed

Milot, Marie-Hélène; Spencer, Steven J; Chan, Vicky; Allington, James P; Klein, Julius; Chou, Cathy; Bobrow, James E; Cramer, Steven C; Reinkensmeyer, David J

2013-12-19

To date, the limited degrees of freedom (DOF) of most robotic training devices hinders them from providing functional training following stroke. We developed a 6-DOF exoskeleton ("BONES") that allows movement of the upper limb to assist in rehabilitation. The objectives of this pilot study were to evaluate the impact of training with BONES on function of the affected upper limb, and to assess whether multijoint functional robotic training would translate into greater gains in arm function than single joint robotic training also conducted with BONES. Twenty subjects with mild to moderate chronic stroke participated in this crossover study. Each subject experienced multijoint functional training and single joint training three sessions per week, for four weeks, with the order of presentation randomized. The primary outcome measure was the change in Box and Block Test (BBT). The secondary outcome measures were the changes in Fugl-Meyer Arm Motor Scale (FMA), Wolf Motor Function Test (WMFT), Motor Activity Log (MAL), and quantitative measures of strength and speed of reaching. These measures were assessed at baseline, after each training period, and at a 3-month follow-up evaluation session. Training with the robotic exoskeleton resulted in significant improvements in the BBT, FMA, WMFT, MAL, shoulder and elbow strength, and reaching speed (p < 0.05); these improvements were sustained at the 3 month follow-up. When comparing the effect of type of training on the gains obtained, no significant difference was noted between multijoint functional and single joint robotic training programs. However, for the BBT, WMFT and MAL, inequality of carryover effects were noted; subsequent analysis on the change in score between the baseline and first period of training again revealed no difference in the gains obtained between the types of training. Training with the 6 DOF arm exoskeleton improved motor function after chronic stroke, challenging the idea that robotic therapy is only useful for impairment reduction. The pilot results presented here also suggest that multijoint functional robotic training is not decisively superior to single joint robotic training. This challenges the idea that functionally-oriented games during training is a key element for improving behavioral outcomes. NCT01050231.

Baduanjin Exercise for Stroke Rehabilitation: A Systematic Review with Meta-Analysis of Randomized Controlled Trials

PubMed Central

Wang, Chaoyi; Chen, Xiaoan; Wang, Huiru

2018-01-01

Objective: The purpose of this review was to objectively evaluate the effects of Baduanjin exercise on rehabilitative outcomes in stroke patients. Methods: Both Chinese and English electronic databases were searched for potentially relevant trials. Two review authors independently screened eligible trials against the inclusion criteria, extracted data, and assessed the methodological quality by using the revised PEDro scale. Meta-analysis was only performed for balance function. Results: In total, there were eight randomized controlled trials selected in this systematic review. The aggregated result of four trials has shown a significant benefit in favor of Baduanjin on balance function (Hedges’ g = 2.39, 95% CI 2.14 to 2.65, p < 0.001, I2 = 61.54). Additionally, Baduanjin exercise effectively improved sensorimotor function of lower extremities and ability of daily activities as well as reduced depressive level, leading to improved quality of life. Conclusion: Baduanjin exercise as an adjunctive and safe method may be conducive to help stroke patients achieve the best possible short-term outcome and should be integrated with mainstream rehabilitation programs. More rigorous randomized controlled trials with long-term intervention periods among a large sample size of stroke patients are needed to draw a firm conclusion regarding the rehabilitative effects for this population. PMID:29584623

Combined central and peripheral stimulation to facilitate motor recovery after stroke: the effect of number of sessions on outcome.

PubMed

Lindenberg, Robert; Zhu, Lin L; Schlaug, Gottfried

2012-06-01

Proof-of-principle studies have demonstrated transient beneficial effects of transcranial direct current stimulation (tDCS) on motor function in stroke patients, mostly after single treatment sessions. To assess the efficacy of multiple treatment sessions on motor outcome. The authors examined the effects of two 5-day intervention periods of bihemispheric tDCS and simultaneous occupational/physical therapy on motor function in a group of 10 chronic stroke patients. The first 5-day period yielded an increase in Upper-Extremity Fugl-Meyer (UE-FM) scores by 5.9 ± 2.4 points (16.6% ± 10.6%). The second 5-day period resulted in further meaningful, although significantly lower, gains with an additional improvement of 2.3 ± 1.4 points in UE-FM compared with the end of the first 5-day period (5.5% ± 4.2%). The overall mean change after the 2 periods was 8.2 ± 2.2 points (22.9% ± 11.4%). The results confirm the efficacy of bihemispheric tDCS in combination with peripheral sensorimotor stimulation. Furthermore, they demonstrate that the effects of multiple treatment sessions in chronic stroke patients may not necessarily lead to a linear response function, which is of relevance for the design of experimental neurorehabilitation trials.

Influence of the rehabilitation outcome on returning to drive after neurological impairment.

PubMed

Čižman, Urša Š; Vidmar, Gaj; Drnovšek, Petra

2017-06-01

In traumatic brain injury (TBI) and stroke rehabilitation, the question of reintegration of the driver into traffic is faced very often. Driving is an important domain and for some patients, return to driving represents a crucial event for community inclusion. The aim of our study was to examine the utility of Glasgow Coma Scale within the first 24 h of injury and the Functional Independence Measure (FIM) at rehabilitation admission for predicting the return to driving. We included 72 patients after TBI or stroke. Driving outcome was assessed in terms of being allowed to drive without restrictions as opposed to failing the test or being allowed to drive with restrictions. We examined two samples: the TBI patients only and the entire sample including patients after stroke. The results indicate that for TBI patients, Glasgow Coma Scale and motor FIM could be predictors of driving outcome; in the entire sample, the unrestricted driving outcome was also associated with a high score on the FIM motor scale. Early prediction of return to driving after TBI and stroke is important for the patients, their families and the rehabilitation teams to set realistic goals that enable the best possible reintegration after rehabilitation.

Cognitive Outcome following Unilateral Arterial Ischaemic Stroke in Childhood: Effects of Age at Stroke and Lesion Location

ERIC Educational Resources Information Center

Westmacott, Robyn; Askalan, Rand; MacGregor, Daune; Anderson, Peter; deVeber, Gabrielle

2010-01-01

Aim: Plasticity in the developing brain is a controversial issue. Although language and motor function often recover remarkably well following early brain injury, recent evidence suggests that damage to the developing brain results in significant long-term neuropsychological impairment. Our aim was to investigate the relationship among age at…

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke.

PubMed

Pollock, A; Baer, G; Pomeroy, V; Langhorne, P

2007-01-24

There are a number of different approaches to physiotherapy treatment following stroke that, broadly speaking, are based on neurophysiological, motor learning and orthopaedic principles. Some physiotherapists base their treatment on a single approach, while others use a mixture of components from a number of different approaches. To determine if there is a difference in the recovery of postural control and lower limb function in patients with stroke if physiotherapy treatment is based on orthopaedic or neurophysiological or motor learning principles, or on a mixture of these treatment principles. We searched the Cochrane Stroke Group Trials Register (last searched May 2005), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2005), MEDLINE (1966 to May 2005), EMBASE (1980 to May 2005) and CINAHL (1982 to May 2005). We contacted experts and researchers with an interest in stroke rehabilitation. Randomised or quasi-randomised controlled trials of physiotherapy treatment approaches aimed at promoting the recovery of postural control and lower limb function in adult participants with a clinical diagnosis of stroke. Outcomes included measures of disability, motor impairment or participation. Two review authors independently categorised the identified trials according to the inclusion and exclusion criteria, documented their methodological quality, and extracted the data. Twenty-one trials were included in the review, five of which were included in two comparisons. Eight trials compared a neurophysiological approach with another approach; eight compared a motor learning approach with another approach; and eight compared a mixed approach with another approach. A mixed approach was significantly more effective than no treatment or placebo control for improving functional independence (standardised mean difference (SMD) 0.94, 95% confidence intervals (CI) 0.08 to 1.80). There was no significant evidence that any single approach had a better outcome than any other single approach or no treatment control. There is evidence that physiotherapy intervention, using a mix of components from different approaches, is significantly more effective than no treatment or placebo control in the recovery of functional independence following stroke. There is insufficient evidence to conclude that any one physiotherapy approach is more effective in promoting recovery of lower limb function or postural control following stroke than any other approach. We recommend that future research should concentrate on investigating the effectiveness of clearly described individual techniques and task-specific treatments, regardless of their historical or philsophical origin.

Rehabilitation of arm function after stroke. Literature review.

PubMed

Oujamaa, L; Relave, I; Froger, J; Mottet, D; Pelissier, J-Y

2009-04-01

In the recent literature we can find many articles dealing with upper extremity rehabilitation in stroke patients. New techniques, still under evaluation, are becoming the practical applications for the concept of post-stroke brain plasticity. This literature review focuses on controlled randomized studies, reviews and meta-analyses published in the English language from 2004 to 2008. The research was conducted in MEDLINE with the following keywords: "upper limb", "stroke", "rehabilitation". We reviewed 66 studies. The main therapeutic strategies are: activation of the ipsilesional motor cortex, inhibition of the contralesional motor cortex and modulation of the sensory afferents. Keeping a cortical representation of the upper limb distal extremity could prevent the learned non-use phenomenon. The modulation of sensory afferents is then proposed: distal cutaneous electrostimulation, anesthesia of the healthy limb, mirror therapy, virtual reality. Intensifying the rehabilitation care means increasing the total hours of rehabilitation dedicated to the paretic limb (proprioceptive stimulation and repetitive movements). This specific rehabilitation is facilitated by robot-aided therapy in the active-assisted mode, neuromuscular electrostimulation and bilateral task training. Intensifying the rehabilitation training program significantly improves the arm function outcome when performed during subacute stroke rehabilitation (< six months). Ipsilesional neurostimulation as well as mental practice optimize the effect of repetitive gestures for slight motor impairments. Contralesional neurostimulation or anesthesia of the healthy hand both improve the paretic hand's dexterity via a decrease of the transcallosal inhibition. This pathophysiological mechanism could also explain the positive impact of constraint-induced movement therapy (CI therapy) in an environmental setting for chronic stroke patients. To ensure a positive functional outcome, stroke rehabilitation programs are based on task-oriented repetitive training. This literature review shows that exercising the hemiparetic hand and wrist is essential in all stages of a stroke rehabilitation program. New data stemming from neurosciences suggest that ipsilesional corticospinal excitability should be a priority.

Renal impairment in stroke patients: A comparison between the haemorrhagic and ischemic variants.

PubMed

Shrestha, Pratyush; Thapa, Shalima; Shrestha, Shikher; Lohani, Subash; Bk, Suresh; MacCormac, Oscar; Thapa, Lekhjung; Devkota, Upendra Prasad

2017-01-01

Background: Renal impairment is regularly seen in hospitalized stroke patients, affecting the outcome of patients, as well as causing difficulties in their management. A prospective cohort study was conducted to assess the trend of renal function in hospitalized ischemic and haemorrhagic stroke patients. The incidence of renal impairment in these subgroups, the contributing factors and the need for renal replacement in renal impaired patients was evaluated. Methods: Alternate day renal function testing was performed in hospitalized stroke patients. Estimated glomerular filtration rate (e-GFR) was calculated and the trend of renal function in the two stroke subgroups (haemorrhagic and ischemic) was assessed, with renal impairment defined as e-GFR < 60mL/ minute per 1.73m 2 . Results: Among 52 patients, 25 had haemorrhagic stroke (mean age 59.81 ± 14.67) and 27 had ischemic stroke (mean age 56.12 ± 13.08). The mean e-GFR (mL/minute per 1.732m 2 ) at admission in the haemorrhagic stroke subgroup was 64.79 ± 25.85 compared to 86.04 ± 26.09 in the ischemic stroke subgroup (p=0.005). Sixteen out of 25 (64%) patients in the haemorrhagic stroke subgroup and 9 out of 27 (33.3%) patients in the ischemic subgroup developed renal impairment (p=0.027). The location of the bleed (p=0.8), volume of hematoma (p=0.966) and surgical intervention (p=0.4) did not predispose the patients to renal impairment. One out of 16 patients with haemorrhagic stroke (who eventually died), and 2 out of 9 patients with ischemic stroke required renal replacement. Conclusion : Renal impairment is commonly seen in stroke patients, more so in patients who suffered haemorrhagic strokes.  The impairment, however, is transient and rarely requires renal replacement therapy.

Recovery and rehabilitation after stroke.

PubMed

Brown, Allen W; Schultz, Billie A

2010-11-01

Most individuals survive stroke and age with its consequences. Rehabilitation becomes the dominant medical need soon after onset, and coordinated rehabilitation services using evidence-based interventions determined by patient need are of primary importance in affecting outcome and quality of life. This discussion will focus on the natural history of recovery after stroke and the changes in brain organization that support behavioral improvement during recovery, then review established and emerging therapeutic approaches directed at improving independent functional performance and quality of life. © Thieme Medical Publishers.

Evaluating a complex intervention with a single outcome may not be a good idea: an example from a randomised trial of stroke case management.

PubMed

Mayo, Nancy E; Scott, Susan

2011-11-01

to estimate the extent to which a case-management intervention for persons newly discharged into the community following an acute stroke effected a change in stroke outcome in comparison with usual care. a re-analysis of stratified, balanced, randomised clinical trial. five university-affiliated acute-care hospitals in Montreal, Quebec, Canada. a total of 190 persons (mean age 70 years) returning home directly from the acute-care hospital following a first or recurrent stroke with a need for health-care supervision post-discharge because of low function, co-morbidity or isolation. for 6 weeks following discharge a nurse case manager delivered, depending on need, over 50 different nursing interventions (range 2-15 per person), which targeted physical, emotional and psychological impairments, role participation restrictions and health perception. seven of the SF-36 subscales were used to measure the targeted constructs, at the post-intervention and 6 month evaluations. Seven binary response variables were created with a change of 10 points the criterion for individual response. Generalised estimating equations, equivalent to a logistic regression for multiple outcomes, were used. the odds of responding to one or more outcomes was 41% greater in the intervention group than in the control group [odds ratio (OR): 1.41; 95% confidence interval (CI): 1.11-1.79]. an analysis considering the complexity of the intervention and outcomes targeted indicated effectiveness of the nurse case-management post-stroke, whereas the traditional one outcome analysis did not.

Functional improvements following the use of the NVT Vision Rehabilitation program for patients with hemianopia following stroke.

PubMed

Hayes, Allison; Chen, Celia S; Clarke, Gayle; Thompson, Annette

2012-01-01

The incidence of visual deficits following stroke ranges from 20%-68% and has significant impact on activities of daily living. The NVT system is a compensatory visual scanning training program that consists of combined static and mobility training and transfer to activities of daily living. The study aims to evaluate functional changes following the NVT program for people who have homonymous hemianopia (HH) following stroke. Interventional case series of 13 consecutive participants with HH undergoing NVT vision rehabilitation. The primary outcome measure was the number of targets missed on a standardized Mobility Assessment Course (MAC). Other outcome measures included assessment of visual scanning, vision specific Quality of Life questionnaires and reading performance. The average number of targets (sd) missed on the MAC course was 39.6 ± 20.9% before intervention, 27.5 ± 16.3% immediately post intervention and 20.8 ± 15.5% at 3 months post rehabilitation. The study showed a statistically significant trend in improvement in mobility related subscales of National Eye Institute Visual Function Questionnaire-NEI VFQ-25 (p=0.003) and the Veteran Affairs Low Vision Visual Function Questionnaire-VA LVFQ-48 (p=0.036) at 3 months post rehabilitation. The NVT intervention resulted in functional improvements in mobility post rehabilitation. The NVT training showed improvement in vision specific quality of life. There is a need for standardised vision therapy intervention, in conjunction with existing rehabilitation services, for patients with stroke and traumatic brain injury.

Effects of virtual reality intervention on upper limb motor function and activity of daily living in patients with lesions in different regions of the brain

PubMed Central

Jung, Sang-Mi; Choi, Won-Ho

2017-01-01

[Purpose] This study aimed to investigate whether a virtual reality (VR) intervention has an influence in improving the motor function and activities of daily living (ADLs) in patients with lesions in different regions of the brain. [Subjects and Methods] Eleven subjects with hemiplegic stroke were recruited in this study, which was conducted from January to February, 2017. They received a VR intervention once a day for 30 min, 5 times a week for 4 weeks. The Fugl-Meyer Assessment (FMA) and the Korean version of the Modified Barthel Index (K-MBI) were used to assess the post-stroke patients’ motor function and ADLs, respectively. [Results] There were significant differences in pre- and post-test outcomes of the Arm and Coordination and Speed (CS) in the FMA and K-MBI in the middle cerebral artery group (MCAG). Moreover, there were significant differences in all sub-tests of FMA and K-MBI in the Basal ganglia group (BGG). In addition, there were significant differences in the pre-test outcomes of Arm and pre- and post-test outcomes of Hand in the FMA between the two groups. [Conclusion] This study revealed that VR intervention improved the upper limb motor function and ADLs of post-stroke patients, especially those in the BGG. PMID:29643584

Survivors of chronic stroke - participant evaluations of commercial gaming for rehabilitation.

PubMed

Paquin, Kate; Crawley, Jamie; Harris, Jocelyn E; Horton, Sean

2016-10-01

There has been an increase in research on the effect that virtual reality (VR) can have on physical rehabilitation following stroke. However, research exploring participant perceptions of VR for post-stroke rehabilitation has been limited. Semi-structured interviews were conducted with 10 chronic stroke participants (10 males, mean age = 72.1, mean time since injury = 38.6 mos.) who had recently completed an upper extremity VR stroke rehabilitation programme. Four main themes emerged: 'the VR experience,' 'functional outcomes,' 'instruction,' and the 'future of VR in stroke rehabilitation,' along with nine sub-themes. Participants illustrated the positive impact that VR training had on their functional abilities as well as their confidence towards completing activities of daily living (ADL). Participants also expressed the need for increased rehabilitation opportunities within the community. Overall, participants were optimistic about their experience with VR training and all reported that they had perceived functional gain. VR is an enjoyable rehabilitation tool that can increase a stroke survivor's confidence towards completing ADL. Implications for Rehabilitation Although there is an increase in rehabilitation programmes geared towards those with chronic stroke, we must also consider the participants' perception of those programmes. Incorporating participant feedback may increase enjoyment and adherence to the rehabilitation programmes. The VR experience, as well as provision of feedback and instruction, are important aspects to consider when developing a VR programme for stroke survivors. VR for rehabilitation may be a feasible tool for increasing the survivors' confidence in completing ADL post-stroke.

Arterial stiffness and stroke: de-stiffening strategy, a therapeutic target for stroke

PubMed Central

Chen, Yajing; Shen, Fanxia; Liu, Jianrong; Yang, Guo-Yuan

2017-01-01

Stroke is the second leading cause of mortality and morbidity worldwide. Early intervention is of great importance in reducing disease burden. Since the conventional risk factors cannot fully account for the pathogenesis of stroke, it is extremely important to detect useful biomarkers of the vascular disorder for appropriate intervention. Arterial stiffness, a newly recognised reliable feature of arterial structure and function, is demonstrated to be associated with stroke onset and serve as an independent predictor of stroke incidence and poststroke functional outcomes. In this review article, different measurements of arterial stiffness, especially pressure wave velocity, were discussed. We explained the association between arterial stiffness and stroke occurrence by discussing the secondary haemodynamic changes. We reviewed clinical data that support the prediction role of arterial stiffness on stroke. Despite the lack of long-term randomised double-blind controlled therapeutic trials, it is high potential to reduce stroke prevalence through a significant reduction of arterial stiffness (which is called de-stiffening therapy). Pharmacological interventions or lifestyle modification that can influence blood pressure, arterial function or structure in either the short or long term are promising de-stiffening therapies. Here, we summarised different de-stiffening strategies including antihypertension drugs, antihyperlipidaemic agents, chemicals that target arterial remodelling and exercise training. Large and well-designed clinical trials on de-stiffening strategy are needed to testify the prevention effect for stroke. Novel techniques such as modern microscopic imaging and reliable animal models would facilitate the mechanistic analyses in pathophysiology, pharmacology and therapeutics. PMID:28959494

Comparing language outcomes in monolingual and bilingual stroke patients

PubMed Central

Parker Jones, ‘Ōiwi; Grogan, Alice; Crinion, Jenny; Rae, Johanna; Ruffle, Louise; Leff, Alex P.; Seghier, Mohamed L.; Price, Cathy J.; Green, David W.

2015-01-01

Post-stroke prognoses are usually inductive, generalizing trends learned from one group of patients, whose outcomes are known, to make predictions for new patients. Research into the recovery of language function is almost exclusively focused on monolingual stroke patients, but bilingualism is the norm in many parts of the world. If bilingual language recruits qualitatively different networks in the brain, prognostic models developed for monolinguals might not generalize well to bilingual stroke patients. Here, we sought to establish how applicable post-stroke prognostic models, trained with monolingual patient data, are to bilingual stroke patients who had been ordinarily resident in the UK for many years. We used an algorithm to extract binary lesion images for each stroke patient, and assessed their language with a standard tool. We used feature selection and cross-validation to find ‘good’ prognostic models for each of 22 different language skills, using monolingual data only (174 patients; 112 males and 62 females; age at stroke: mean = 53.0 years, standard deviation = 12.2 years, range = 17.2–80.1 years; time post-stroke: mean = 55.6 months, standard deviation = 62.6 months, range = 3.1–431.9 months), then made predictions for both monolinguals and bilinguals (33 patients; 18 males and 15 females; age at stroke: mean = 49.0 years, standard deviation = 13.2 years, range = 23.1–77.0 years; time post-stroke: mean = 49.2 months, standard deviation = 55.8 months, range = 3.9–219.9 months) separately, after training with monolingual data only. We measured group differences by comparing prediction error distributions, and used a Bayesian test to search for group differences in terms of lesion-deficit associations in the brain. Our models distinguish better outcomes from worse outcomes equally well within each group, but tended to be over-optimistic when predicting bilingual language outcomes: our bilingual patients tended to have poorer language skills than expected, based on trends learned from monolingual data alone, and this was significant (P < 0.05, corrected for multiple comparisons) in 13/22 language tasks. Both patient groups appeared to be sensitive to damage in the same sets of regions, though the bilinguals were more sensitive than the monolinguals. PMID:25688076

White matter structural connectivity is associated with sensorimotor function in stroke survivors☆

PubMed Central

Kalinosky, Benjamin T.; Schindler-Ivens, Sheila; Schmit, Brian D.

2013-01-01

Purpose Diffusion tensor imaging (DTI) provides functionally relevant information about white matter structure. Local anatomical connectivity information combined with fractional anisotropy (FA) and mean diffusivity (MD) may predict functional outcomes in stroke survivors. Imaging methods for predicting functional outcomes in stroke survivors are not well established. This work uses DTI to objectively assess the effects of a stroke lesion on white matter structure and sensorimotor function. Methods A voxel-based approach is introduced to assess a stroke lesion's global impact on motor function. Anatomical T1-weighted and diffusion tensor images of the brain were acquired for nineteen subjects (10 post-stroke and 9 age-matched controls). A manually selected volume of interest was used to alleviate the effects of stroke lesions on image registration. Images from all subjects were registered to the images of the control subject that was anatomically closest to Talairach space. Each subject's transformed image was uniformly seeded for DTI tractography. Each seed was inversely transformed into the individual subject space, where DTI tractography was conducted and then the results were transformed back to the reference space. A voxel-wise connectivity matrix was constructed from the fibers, which was then used to calculate the number of directly and indirectly connected neighbors of each voxel. A novel voxel-wise indirect structural connectivity (VISC) index was computed as the average number of direct connections to a voxel's indirect neighbors. Voxel-based analyses (VBA) were performed to compare VISC, FA, and MD for the detection of lesion-induced changes in sensorimotor function. For each voxel, a t-value was computed from the differences between each stroke brain and the 9 controls. A series of linear regressions was performed between Fugl-Meyer (FM) assessment scores of sensorimotor impairment and each DTI metric's log number of voxels that differed from the control group. Results Correlation between the logarithm of the number of significant voxels in the ipsilesional hemisphere and total Fugl-Meyer score was moderate for MD (R2 = 0.512), and greater for VISC (R2 = 0.796) and FA (R2 = 0.674). The slopes of FA (p = 0.0036), VISC (p = 0.0005), and MD (p = 0.0199) versus the total FM score were significant. However, these correlations were driven by the upper extremity motor component of the FM score (VISC: R2 = 0.879) with little influence of the lower extremity motor component (FA: R2 = 0.177). Conclusion The results suggest that a voxel-wise metric based on DTI tractography can predict upper extremity sensorimotor function of stroke survivors, and that supraspinal intraconnectivity may have a less dominant role in lower extremity function. PMID:24179827

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.

The Elsevier trophoblast research award lecture: Impacts of placental growth factor and preeclampsia on brain development, behaviour, and cognition.

PubMed

Rätsep, Matthew T; Hickman, Andrew F; Croy, B Anne

2016-12-01

Preeclampsia (PE) is a significant gestational disorder affecting 3-5% of all human pregnancies. In many PE pregnancies, maternal plasma is deficient in placental growth factor (PGF), a placentally-produced angiokine. Beyond immediate fetal risks associated with acute termination of the pregnancy, offspring of PE pregnancies (PE-F1) have higher long-term risks for hypertension, stroke, and cognitive impairment compared to F1s from uncomplicated pregnancies. At present, mechanisms that explain PE-F1 gains in postpartum risks are poorly understood. Our laboratory found that mice genetically-deleted for Pgf have altered fetal and adult brain vascular development. This is accompanied by sexually dimorphic alterations in anatomic structure in the adult Pgf -/- brain and impaired cognitive functions. We hypothesize that cerebrovascular and neurological aberrations occur in fetuses exposed to the progressive development of PE and that these brain changes impair cognitive functioning, enhance risk for stroke, elevate severity of stroke, and lead to worse stroke outcomes. These brain and placental outcomes may be linked to down-regulated PGF gene expression in early pre-implantation embryos, prior to gastrulation. This review explores our hypothesis that there are mechanistic links between low PGF detection in maternal plasma prodromal to PE, PE, and altered brain vascular, structural, and functional development amongst PE-F1s. We also include a summary of preliminary outcomes from a pilot study of 7-10 year old children that is the first to report magnetic resonance imaging, magnetic resonance angiography, and functional brain region assessment by eye movement control studies in PE-F1s. Copyright © 2016 Elsevier Ltd. All rights reserved.

Assessment of intracranial collaterals on CT angiography in anterior circulation acute ischemic stroke.

PubMed

Yeo, L L L; Paliwal, P; Teoh, H L; Seet, R C; Chan, B P; Ting, E; Venketasubramanian, N; Leow, W K; Wakerley, B; Kusama, Y; Rathakrishnan, R; Sharma, V K

2015-02-01

Intracranial collaterals influence the prognosis of patients treated with intravenous tissue plasminogen activator in acute anterior circulation ischemic stroke. We compared the methods of scoring collaterals on pre-tPA brain CT angiography for predicting functional outcomes in acute anterior circulation ischemic stroke. Two hundred consecutive patients with acute anterior circulation ischemic stroke treated with IV-tPA during 2010-2012 were included. Two independent neuroradiologists evaluated intracranial collaterals by using the Miteff system, Maas system, the modified Tan scale, and the Alberta Stroke Program Early CT Score 20-point methodology. Good and extremely poor outcomes at 3 months were defined by modified Rankin Scale scores of 0-1 and 5-6 points, respectively. Factors associated with good outcome on univariable analysis were younger age, female sex, hypertension, diabetes mellitus, atrial fibrillation, small infarct core (ASPECTS ≥8), vessel recanalization, lower pre-tPA NIHSS scores, and good collaterals according to Tan methodology, ASPECTS methodology, and Miteff methodology. On multivariable logistic regression, only lower NIHSS scores (OR, 1.186 per point; 95% CI, 1.079-1.302; P = .001), recanalization (OR, 5.599; 95% CI, 1.560-20.010; P = .008), and good collaterals by the Miteff method (OR, 3.341; 95% CI, 1.203-5.099; P = .014) were independent predictors of good outcome. Poor collaterals by the Miteff system (OR, 2.592; 95% CI, 1.113-6.038; P = .027), Maas system (OR, 2.580; 95% CI, 1.075-6.187; P = .034), and ASPECTS method ≤5 points (OR, 2.685; 95% CI, 1.156-6.237; P = .022) were independent predictors of extremely poor outcomes. Only the Miteff scoring system for intracranial collaterals is reliable for predicting favorable outcome in thrombolyzed acute anterior circulation ischemic stroke. However, poor outcomes can be predicted by most of the existing methods of scoring intracranial collaterals. © 2015 by American Journal of Neuroradiology.

Associations Between Collateral Status and Thrombus Characteristics and Their Impact in Anterior Circulation Stroke.

PubMed

Alves, Heitor C; Treurniet, Kilian M; Dutra, Bruna G; Jansen, Ivo G H; Boers, Anna M M; Santos, Emilie M M; Berkhemer, Olvert A; Dippel, Diederik W J; van der Lugt, Aad; van Zwam, Wim H; van Oostenbrugge, Robert J; Lingsma, Hester F; Roos, Yvo B W E M; Yoo, Albert J; Marquering, Henk A; Majoie, Charles B L M

2018-02-01

Thrombus characteristics and collateral score are associated with functional outcome in patients with acute ischemic stroke. It has been suggested that they affect each other. The aim of this study is to evaluate the association between clot burden score, thrombus perviousness, and collateral score and to determine whether collateral score influences the association of thrombus characteristics with functional outcome. Patients with baseline thin-slice noncontrast computed tomography and computed tomographic angiography images from the MR CLEAN trial (Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands) were included (n=195). Collateral score and clot burden scores were determined on baseline computed tomographic angiography. Thrombus attenuation increase was determined by comparing thrombus density on noncontrast computed tomography and computed tomographic angiography using a semiautomated method. The association of collateral score with clot burden score and thrombus attenuation increase was evaluated with linear regression. Mediation and effect modification analyses were used to assess the influence of collateral score on the association of clot burden score and thrombus attenuation increase with functional outcome. A higher clot burden score (B=0.063; 95% confidence interval, 0.008-0.118) and a higher thrombus attenuation increase (B=0.014; 95% confidence interval, 0.003-0.026) were associated with higher collateral score. Collateral score mediated the association of clot burden score with functional outcome. The association between thrombus attenuation increase and functional outcome was modified by the collateral score, and this association was stronger in patients with moderate and good collaterals. Patients with lower thrombus burden and higher thrombus perviousness scores had higher collateral score. The positive effect of thrombus perviousness on clinical outcome was only present in patients with moderate and high collateral scores. URL: http://www.trialregister.nl. Unique identifier: NTR1804 and URL: http://www.controlled-trials.com Unique identifier: ISRCTN10888758. © 2018 The Authors.

Long-term behavioral deficits and recovery after transient ischemia in middle-aged rats: Effects of behavioral testing.

PubMed

Yousuf, Seema; Atif, Fahim; Sayeed, Iqbal; Tang, Huiling; Wang, Jun; Stein, Donald G

2015-01-01

Most pre-clinical stroke studies address the acute phase after injury, with less attention to long-term effects of injury, treatment, and experimental testing itself. We addressed these questions: 1) Will functional deficits persist up to 8 weeks following transient stroke in older animals? 2) Will functional deficits resolve spontaneously, with time and/or repeated behavioral testing? Male Sprague-Dawley rats (12 months) were pre-trained on behavioral tasks to provide baseline data and then underwent transient middle artery occlusion (tMCAO) or sham surgery. We measured motor, sensory, cognitive and gait impairments over 8 weeks, and the extent of hemispheric brain infarction. One cohort underwent behavioral testing once at 8 weeks post-stroke (LT); a second cohort (RLT) was tested at 3, 6 and 8 weeks post-stroke. Significant deficits were exhibited in all functional outcomes in both cohorts after 8 weeks. We observed some recovery in some behavioral parameters in both cohorts at 8 weeks. Deficits persist for at least 8 weeks after tMCAO. The greater spontaneous recovery seen in the RLT groups suggest that repeated testing did reduce the severity of these stroke-induced impairments. These findings have implications for designing future studies of agents to induce long-term functional recovery following stroke.

Mirror therapy and treadmill training for a patient with chronic stroke: A case report.

PubMed

Broderick, Patrick; Horgan, Frances; Blake, Catherine; Hickey, Paula; O'Reilly, Joanne; Ehrensberger, Monika; Simpson, Daniel; Roberts, David; Monaghan, Kenneth

2018-03-28

A large proportion of patients with chronic stroke have permanent lower limb functional disability leading to reduced levels of independent mobility. Individually, both mirror therapy and treadmill training have been shown to improve aspects of lower limb functioning in patients with stroke. This case report examined whether a new combination of both interventions would lead to improvements in lower limb functional disability for a patient with chronic stroke. The participant was a 50-year-old female who had a left middle cerebral artery infarction (47 months' post stroke). Due to hemiparesis, she had lower limb motor impairment and gait deficits. The participant engaged in a combination of mirror therapy and treadmill training for 30 minutes per day, 3 days per week, for 4 weeks. Modified Ashworth Scale, Fugl-Meyer Assessment-Lower Extremity and the 10 m Walk Test demonstrated clinically meaningful change. The 6 Minute Walk Test did not demonstrate meaningful change. The positive outcomes from this new combination therapy for this participant are encouraging given the relatively small dose of training and indicate the potential benefit of mirror therapy as an adjunct to treadmill training for enhancing lower limb muscle tone, motor function and walking velocity in patients with chronic stroke.

Current status of intravenous thrombolysis for acute ischemic stroke in Asia.

PubMed

Sharma, Vijay K; Ng, Kay W P; Venketasubramanian, Narayanaswamy; Saqqur, Maher; Teoh, Hock L; Kaul, Subash; Srivastava, Padma M V; Sergentanis, Theodoris; Suwanwela, Nijasri; Nguyen, Thang H; Lawrence Wong, K S; Chan, Bernard P L

2011-12-01

Data regarding thrombolysis for acute ischemic stroke in Asia are scarce and only a small percentage of patients are thrombolysed. The dose of intravenous tissue plasminogen activator (IV-tPA) in Asia remains controversial. Case-controlled observation studies in Asia included only Japanese patients and suggested the clinical efficacy and safety of low-dose IV-tPA (0.6 mg/kg body weight; max 60 mg) comparable to standard dose (0.9 mg/kg body weight; max. 90 mg). Reduced treatment cost, lower symptomatic intracerebral hemorrhage risk and comparable efficacy encouraged many Asian centers to adopt low-dose or even variable-dose IV-tPA regimens. We evaluated various Asian thrombolysis studies and compared with SITS-MOST registry and NINDS trial. We included the published studies on acute ischemic stroke thrombolysis in Asia. Unadjusted relative risks and 95% Confidence intervals were calculated for each study. Pooled estimates from random effects models were used because the tests for heterogeneity were significant. We found only 18 publications regarding acute ischemic stroke thrombolysis in Asia that included total of 9300 patients. Owing to ethnic differences, stroke severity, small number of cases in individual reports, outcome measures and tPA dose regimes, it is difficult to compare these studies. Functional outcomes were almost similar (to Japanese studies) when lower-dose IV-tPA was used in non-Japanese populations across Asia. Interestingly, with standard dose IV-tPA, considerably better functional outcomes were observed, without increasing symptomatic intracerebral hemorrhage rates. Variable dose regimens of IV-tPA are used across Asia without any reliable or established evidence. Establishing a uniform IV-tPA regimen is essential since the rapid improvements in health-care facilities and public awareness are expected to increase the rates of thrombolysis in Asia. © 2011 The Authors. International Journal of Stroke © 2011 World Stroke Organization.

Changes in structural integrity are correlated with motor and functional recovery after post-stroke rehabilitation.

PubMed

Fan, Yang-teng; Lin, Keh-chung; Liu, Ho-ling; Chen, Yao-liang; Wu, Ching-yi

2015-01-01

Diffusion tensor imaging (DTI) studies indicate the structural integrity of the ipsilesional corticospinal tract (CST) and the transcallosal motor tract, which are closely linked to stroke recovery. However, the individual contribution of these 2 fibers on different levels of outcomes remains unclear. Here, we used DTI tractography to investigate whether structural changes of the ipsilesional CST and the transcallosal motor tracts associate with motor and functional recovery after stroke rehabilitation. Ten participants with post-acute stroke underwent the Fugl-Meyer Assessment (FMA), the Wolf Motor Function Test (WMFT), the Functional Independence Measure (FIM), and DTI before and after bilateral robotic training. All participants had marked improvements in motor performance, functional use of the affected arm, and independence in daily activities. Increased fractional anisotropy (FA) in the ipsilesional CST and the transcallosal motor tracts was noted from pre-treatment to the end of treatment. Participants with higher pre-to-post differences in FA values of the transcallosal motor tracts had greater gains in the WMFT and the FIM scores. A greater improvement on the FMA was coupled with increased FA changes along the ipsilesional CST. These findings suggest 2 different structural indicators for post-stroke recovery separately at the impairment-based and function-based levels.

Five-year Prognosis after Mild to Moderate Ischemic Stroke by Stroke Subtype: A Multi-Clinic Registry Study

PubMed Central

Lv, Yumei; Fang, Xianghua; Asmaro, Karam; Liu, Hongjun; Zhang, Xinqing; Zhang, Hongmei; Qin, Xiaoming; Ji, Xunming

2013-01-01

Background and Purpose Mild to moderate ischemic stroke is a common presentation in the outpatient setting. Among the various subtypes of stroke, lacunar infarction (LI) is generally very common. Currently, little is known about the long-term prognosis and factors associated with the prognosis between LI and non-LI. This study aims to compare the risk of death and acute cardiovascular events between patients with LI and non-LI, and identify potential risk factors associated with these outcomes. Methods A total of 710 first-ever ischemic stroke patients (LI: 474, non-LI: 263) from 18 clinics were recruited consecutively from 2003 to 2004. They were prospectively followed-up until the end of 2008. Hazard ratios and 95% confidence intervals were calculated using multivariable Cox proportional hazards regression. Results After a 5-year follow up, 54 deaths and 96 acute cardiovascular events occurred. Recurrent stroke was the most common cause of death (19 cases, 35.18%) and new acute cardiovascular events (75 cases, 78.13%). There were no significant differences between patients with LI and non-LI in their risks of death, new cardiovascular events, and recurrent stroke after adjusting for age, sex, hypertension, diabetes, cardiac diseases, body mass index, dyslipidemia, smoking, alcohol consumption, ADL dependence, and depressive symptoms. Among the modifiable risk factors, diabetes, hypertension, ADL dependency, and symptoms of depression were independent predictors of poor outcomes in patients with LI. In non-LI patients, however, no modifiable risk factors were detected for poor outcomes. Conclusion Long-term outcomes did not differ significantly between LI and non-LI patients. Detecting and managing vascular risk factors and depression as well as functional rehabilitation may improve the prognoses of LI patients. PMID:24223696

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.

Predictive validity of the Sødring Motor Evaluation of Stroke Patients (SMES).

PubMed

Wyller, T B; Sødring, K M; Sveen, U; Ljunggren, A E; Bautz-Holter, E

1996-12-01

The Sødring Motor Evaluation of Stroke Patients (SMES) has been developed as an instrument for the evaluation by physiotherapists of motor function and activities in stroke patients. The predictive validity of the instrument was studied in a consecutive sample of 93 acute stroke patients, assessed in the acute phase and after one year. The outcome measures were: survival, residence at home or in institution, the Barthel ADL index (dichotomized at 19/20), and the Frenchay Activities Index (FAI) (dichotomized at 9/10). The SMES, scored in the acute phase, demonstrated a marginally significant predictive power regarding survival, but was a highly significant predictor regarding the other outcomes. The adjusted odds ratio for a good versus a poor outcome for patients in the upper versus the lower tertile of the SMES arm subscore was 5.4 (95% confidence interval 0.9-59) for survival, 11.5 (2.1-88) for living at home, 86.3 (11-infinity) for a high Barthel score, and 31.4 (5.2-288) for a high FAI score. We conclude that SMES has high predictive validity.

Effectiveness of two rehabilitation strategies provided by nurses for stroke patients in Mexico.

PubMed

Torres-Arreola, Laura del Pilar; Doubova Dubova, Svetlana Vladislavovna; Hernandez, Sergio F; Torres-Valdez, Laura E; Constantino-Casas, Norma P; Garcia-Contreras, Fernando; Torres-Castro, Sara

2009-11-01

Rehabilitation strategies have been developed to improve functional state in stroke patients. The main objective of this study was to evaluate the effectiveness of the early rehabilitation at hospital and its continuity at home provided by nurses, on the functional recovery of basic and social activities in stroke patients compared with conventional care. A randomised clinical trial was carried out in three general hospitals of the Mexican Institute of Social Security (IMSS) in Mexico City between April 2003-May 2004. Stroke patients. Two rehabilitation strategies provided by nurses for stroke patients were compared: physiotherapy plus caregiver education in rehabilitation (strategy 1, S1) vs. education alone (strategy 2, S2). The main outcome variables were the basic (Barthel index) and social (Frenchay activities index) activities of daily living, of each patient. Age, sex, morbidity, stroke symptoms, complications, neurological damage (Canadian Scale), cognitive state (mini-mental state examination questionnaire) and duration of hospitalisation were defined as the control variables. Patients were evaluated at baseline and months one, three and six thereafter. One hundred and ten patients with ischaemic stroke were enrolled and randomised; 59 were assigned to S1 and 51 to S2. Comparison of the outcome variables showed that patients improved significantly over time, but no differences were observed between groups. We observed no significant difference in strategy performance with regard to the basic and instrumental activities of daily living. Participants who received physiotherapy with additional caregiver education benefit no more than those whose caregivers received education alone. Those countries that do not have integral rehabilitation programmes for stroke patients should understand their importance and budget resources for them. Meanwhile, both caregiver education and nurses trained in specific care and physiotherapy are alternatives that benefit these patients.

NOR-SASS (Norwegian Sonothrombolysis in Acute Stroke Study): Randomized Controlled Contrast-Enhanced Sonothrombolysis in an Unselected Acute Ischemic Stroke Population.

PubMed

Nacu, Aliona; Kvistad, Christopher E; Naess, Halvor; Øygarden, Halvor; Logallo, Nicola; Assmus, Jörg; Waje-Andreassen, Ulrike; Kurz, Kathinka D; Neckelmann, Gesche; Thomassen, Lars

2017-02-01

The NOR-SASS (Norwegian Sonothrombolysis in Acute Stroke Study) aimed to assess effect and safety of contrast-enhanced ultrasound treatment in an unselected acute ischemic stroke population. Patients treated with intravenous thrombolysis within 4.5 hours after symptom onset were randomized 1:1 to either contrast-enhanced sonothrombolysis (CEST) or sham CEST. A visible arterial occlusion on baseline computed tomography angiography was not a prerequisite for inclusion. Pulse-wave 2 MHz ultrasound was given for 1 hour and contrast (SonoVue) as an infusion for ≈30 minutes. Magnetic resonance imaging and angiography were performed after 24 to 36 hours. Primary study end points were neurological improvement at 24 hours defined as National Institutes of Health Stroke Scale score 0 or reduction of ≥4 National Institutes of Health Stroke Scale points compared with baseline National Institutes of Health Stroke Scale and favorable functional outcome at 90 days defined as modified Rankin scale score 0 to 1. A total of 183 patients were randomly assigned to either CEST (93 patient) or sham CEST (90 patients). The rates of symptomatic intracerebral hemorrhage, asymptomatic intracerebral hemorrhage, or mortality were not increased in the CEST group. Neurological improvement at 24 hours and functional outcome at 90 days was similar in the 2 groups both in the intention-to-treat analysis and in the per-protocol analysis. CEST is safe among unselected ischemic stroke patients with or without a visible occlusion on computed tomography angiography and with varying grades of clinical severity. There was, however, statistically no significant clinical effect of sonothrombolysis in this prematurely stopped trial. URL: http://www.clinicaltrials.gov. Unique identifier: NCT01949961. © 2016 The Authors.

The value of adding mirror therapy for upper limb motor recovery of subacute stroke patients: a randomized controlled trial.

PubMed

Invernizzi, M; Negrini, S; Carda, S; Lanzotti, L; Cisari, C; Baricich, A

2013-06-01

Upper limb paresis remains a relevant challenge in stroke rehabilitation. To evaluate if adding mirror therapy (MT) to conventional therapy (CT) can improve motor recovery of the upper limb in subacute stroke patients. Prospective, single-center, single-blind, randomised, controlled trial. Subacute stroke patients referred to a Physical and Rehabilitation Medicine Unit between October 2009 and August 2011. Twenty-six subacute stroke patients (time from stroke <4 weeks) with upper limb paresis (Motricity Index ≤ 77). Patients were randomly allocated to the MT (N.=13) or to the CT group (N.=13). Both followed a comprehensive rehabilitative treatment. In addition, MT Group had 30 minutes of MT while the CT group had 30 minutes of sham therapy. Action Research Arm Test (ARAT) was the primary outcome measures. Motricity Index (MI) and the Functional Independence Measure (FIM) were the secondary outcome measures. After one month of treatment patients of both groups showed statistically significant improvements in all the variables measured (P<0.05). Moreover patients of the MT group had greater improvements in the ARAT, MI and FIM values compared to CT group (P<0.01, Glass's Δ Effect Size: 1.18). No relevant adverse event was recorded during the study. MT is a promising and easy method to improve motor recovery of the upper limb in subacute stroke patients. While MT use has been advocated for acute patients with no or negligible motor function, it can be usefully extended to patients who show partial motor recovery. The easiness of implementation, the low cost and the acceptability makes this therapy an useful tool in stroke rehabilitation.

[Morbidity and mortality after intensive care management of hemorrhagic stroke in Djibouti].

PubMed

Benois, A; Raynaud, L; Coton, T; Petitjeans, F; Hassan, A; Ilah, A; Sergent, H; Grassin, F; Leberre, J

2009-02-01

Prospective data on management and outcome of stroke in Africa is scarce. The purpose of this prospective descriptive study is to present epidemiologic, clinical and outcome data for a series of patients with hemorrhagic stroke in Djibouti. All patients admitted to the intensive care unit of the Bouffard Medical-Surgical Center in Djibouti for cerebral hemorrhage documented by CT-scan of the brain were recruited in this study. A total of 18 patients including 16 men were enrolled. The median patient age in this series was 51.5 years [range, 20-72]. The median duration of intensive care was 3 days [range, 1-38]. Mean Glasgow score at time of admission was 9 [range, 3-14]. Five patients were brought in by emergency medical airlift. The main risk factors for stroke were arterial hypertension, smoking, and regular khat use. Mechanical ventilation was performed in 10 patients with a survival rate of 40%. Six patients (33%) died in the intensive care unit. Hospital mortality within one month was 39% and mortality at 6 months was 44.4%. One-year survival for patients with a Glasgow score < or = 7 at the time of admission was 33%. Arterial hypertension, khat use, and smoking appeared to be major risk factors for male Djiboutians. Neurologic intensive care techniques provided hospital mortality rates similar to those reported in hospitals located in Western countries. Functional outcome in local survivors appeared to be good despite the absence of functional intensive care. These data argue against the passive, fatalistic approach to management of hemorrhagic stroke and for primary prevention of cardiovascular risk factors.

Protocol for a prospective collaborative systematic review and meta-analysis of individual patient data from randomized controlled trials of vasoactive drugs in acute stroke: The Blood pressure in Acute Stroke Collaboration, stage-3.

PubMed

Sandset, Else Charlotte; Sanossian, Nerses; Woodhouse, Lisa J; Anderson, Craig; Berge, Eivind; Lees, Kennedy R; Potter, John F; Robinson, Thompson G; Sprigg, Nikola; Wardlaw, Joanna M; Bath, Philip M

2018-01-01

Rationale Despite several large clinical trials assessing blood pressure lowering in acute stroke, equipoise remains particularly for ischemic stroke. The "Blood pressure in Acute Stroke Collaboration" commenced in the mid-1990s focussing on systematic reviews and meta-analysis of blood pressure lowering in acute stroke. From the start, Blood pressure in Acute Stroke Collaboration planned to assess safety and efficacy of blood pressure lowering in acute stroke using individual patient data. Aims To determine the optimal management of blood pressure in patients with acute stroke, including both intracerebral hemorrhage and ischemic stroke. Secondary aims are to assess which clinical and therapeutic factors may alter the optimal management of high blood pressure in patients with acute stroke and to assess the effect of vasoactive treatments on hemodynamic variables. Methods and design Individual patient data from randomized controlled trials of blood pressure management in participants with ischemic stroke and/or intracerebral hemorrhage enrolled during the ultra-acute (pre-hospital), hyper-acute (<6 h), acute (<48 h), and sub-acute (<168 h) phases of stroke. Study outcomes The primary effect variable will be functional outcome defined by the ordinal distribution of the modified Rankin Scale; analyses will also be carried out in pre-specified subgroups to assess the modifying effects of stroke-related and pre-stroke patient characteristics. Key secondary variables will include clinical, hemodynamic and neuroradiological variables; safety variables will comprise death and serious adverse events. Discussion Study questions will be addressed in stages, according to the protocol, before integrating these into a final overreaching analysis. We invite eligible trials to join the collaboration.

IL-23 (Interleukin-23)-Producing Conventional Dendritic Cells Control the Detrimental IL-17 (Interleukin-17) Response in Stroke.

PubMed

Gelderblom, Mathias; Gallizioli, Mattia; Ludewig, Peter; Thom, Vivien; Arunachalam, Priyadharshini; Rissiek, Björn; Bernreuther, Christian; Glatzel, Markus; Korn, Thomas; Arumugam, Thiruma Valavan; Sedlacik, Jan; Gerloff, Christian; Tolosa, Eva; Planas, Anna M; Magnus, Tim

2018-01-01

Inflammatory mechanisms can exacerbate ischemic tissue damage and worsen clinical outcome in patients with stroke. Both αβ and γδ T cells are established mediators of tissue damage in stroke, and the role of dendritic cells (DCs) in inducing the early events of T cell activation and differentiation in stroke is not well understood. In a murine model of experimental stroke, we defined the immune phenotype of infiltrating DC subsets based on flow cytometry of surface markers, the expression of ontogenetic markers, and cytokine levels. We used conditional DC depletion, bone marrow chimeric mice, and IL-23 (interleukin-23) receptor-deficient mice to further explore the functional role of DCs. We show that the ischemic brain was rapidly infiltrated by IRF4 + /CD172a + conventional type 2 DCs and that conventional type 2 DCs were the most abundant subset in comparison with all other DC subsets. Twenty-four hours after ischemia onset, conventional type 2 DCs became the major source of IL-23, promoting neutrophil infiltration by induction of IL-17 (interleukin-17) in γδ T cells. Functionally, the depletion of CD11c + cells or the genetic disruption of the IL-23 signaling abrogated both IL-17 production in γδ T cells and neutrophil infiltration. Interruption of the IL-23/IL-17 cascade decreased infarct size and improved neurological outcome after stroke. Our results suggest a central role for interferon regulatory factor 4-positive IL-23-producing conventional DCs in the IL-17-dependent secondary tissue damage in stroke. © 2017 American Heart Association, Inc.

A randomized trial testing the superiority of a post-discharge care management model for stroke survivors

PubMed Central

Allen, Kyle; Hazelett, Susan; Jarjoura, David; Hua, Keding; Wright, Kathy; Weinhardt, Janice; Kropp, Denise

2009-01-01

Objective To evaluate whether comprehensive post-discharge care management for stroke survivors is superior to organized acute stroke unit care with enhanced discharge planning in improving a profile of health and well-being. Methods This was a randomized trial of a comprehensive post-discharge care management intervention for ischemic stroke patients with NIH Stroke Scale scores ≥1 discharged from an acute stroke unit. An Advanced Practice Nurse (APN) performed an in-home assessment for the intervention group from which an Interdisciplinary Team developed patient-specific care plans. The APN worked with the primary care physician (PCP) and patient to implement the plan over the next 6 months. Main outcome measures The intervention and usual care groups were compared using a global and closed hypothesis testing strategy. Outcomes fell into 5 domains: 1) Neuromotor Function, 2) Institution Time or Death, 3) Quality of Life, 4) Management of Risk, and 5) Stroke Knowledge and Lifestyle. Results Treatment effect was near zero standard deviations for all but the stroke knowledge and lifestyle domain which showed a significant effect of the intervention (p=0.0003). Conclusions Post discharge care management was not more effective than organized stroke unit care with enhanced discharge planning in most domains in this population. The intervention did, however, fill a post-discharge knowledge gap. PMID:19900646

Kinematic measures for upper limb motor assessment during robot-mediated training in patients with severe sub-acute stroke.

PubMed

Duret, Christophe; Courtial, Ophélie; Grosmaire, Anne Gaelle

2016-01-01

Kinematic assessments are increasingly used as motor outcome measures during upper limb robot-assisted training, in addition to clinical scales. However, their relevance has not been evaluated much. Thirty-eight patients with severe sub-acute stroke (age 56 ± 17 [19-87] years; time since stroke, 55 ± 22 days) carried out 16 sessions (average 3/week, 35 ± 15 days) of upper limb robot-assisted training combined with standard therapy. Pre/post motor performance was evaluated using the Fugl-Meyer Assessment scale, Motor Status Scale (MSS) and kinematic measures. Motor outcomes were compared and relationships between clinical and kinematic outcomes were analyzed. All clinical and kinematic outcomes improved after training (p <  0.01). FM score increased from 17.7 ± 10.0 to 28.6 ± 15.4. All baseline kinematic measures were strongly correlated with clinical scores. Correlations between clinical and kinematic changes were moderate (r = -0.65 for change in FM Proximal score and change in accuracy measure). However, smoothness and accuracy indicators were shown to be responsive measures. This study demonstrated that baseline kinematic measures and their pre/post training changes were significantly correlated with clinical motor outcome measures. However, even if kinematic measures are valid for the evaluation of motor impairment we cannot propose to substitute common clinical measures of motor function which also evaluate functional abilities of the upper limb.

Explicit Consideration of Baseline Factors to Assess Recombinant Tissue-Type Plasminogen Activator Response With Respect to Race and Sex

PubMed Central

Mandava, Pitchaiah; Murthy, Santosh B.; Munoz, Melody; McGuire, Dawn; Simon, Roger P.; Alexandrov, Andrei V.; Albright, Karen C.; Boehme, Amelia K.; Martin-Schild, Sheryl; Martini, Sharyl; Kent, Thomas A.

2017-01-01

Background and Purpose Sex and race reportedly influence outcome after recombinant tissue-type plasminogen activator (rtPA). It is, however, unclear whether baseline imbalances (eg, stroke severity) or lack of response to thrombolysis is responsible. We applied balancing methods to test the hypothesis that race and sex influence outcome after rtPA independent of baseline conditions. Methods We mapped group outcomes from the National Institute of Neurological Disorders and Stroke (NINDS) dataset based on race and sex onto a surrogate-control function to assess differences from expected outcomes at their respective National Institutes of Health Stroke Scale and age. Outcomes were also compared for subjects matched individually on key baseline factors using NINDS and 2 recent datasets from southeastern United States. Results At similar National Institutes of Health Stroke Scale and age, 90-day good outcomes (modified Rankin Score, 0–2) in NINDS were similarly improved after rtPA for white men and women. There was a strong trend for improvement in black men. Conversely, black women treated with rtPA showed response rates no different from the controls. After baseline matching, there were nonsignificant trends in outcomes except for significantly fewer good outcomes in black versus matched white women (37% versus 63%; P=0.027). Pooling the 3 datasets showed a similar trend for poorer short-term outcome for black women (P=0.054; modified Rankin Score, 0–1). Conclusions Matching for key baseline factors indicated that race and sex influence outcome most strikingly in black women who demonstrated poorest outcomes after rtPA. This finding supports the hypothesis that poor response to rtPA, rather than differences in baseline conditions, contributes to the worse outcome. This finding requires prospective confirmation. PMID:23674524

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.

[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.

Dietary intake, nutritional status and rehabilitation outcomes of stroke patients in hospital.

PubMed

Nip, W F R; Perry, L; McLaren, S; Mackenzie, A

2011-10-01

Nutrition affects rehabilitation through its influence on physical and mental functioning, although little attention has been paid to effects on rehabilitation outcomes. The present study aimed to describe nutritional status and food consumption in stroke patients within 2 weeks of hospital admission and before discharge, as well as to investigate the effects of nutritional and dietary factors on rehabilitation outcomes. One hundred patients from a consecutive cohort admitted to a metropolitan hospital with acute stroke were recruited and assessed by a single researcher, with 38 reassessed at discharge. Nutritional status was assessed using Mini-Nutritional Assessment and anthropometric indices and dietary intake was assessed by 1-day weighed dietary records. Rehabilitation outcomes were changes in Barthel index scores and the rehabilitation efficiency index. Few (n = 9; 10%) consumed ≥100% of the estimated average requirement (EAR) for energy within 2 weeks of admission and 13 (33%) had energy intakes <50% of EAR before discharge. A small but increasing proportion (7% at admission, 13% at discharge) were identified as being malnourished across the inpatient stay. Younger age, lower Barthel index and a higher energy intake in the early stages of admission predicted the extent and rate of restoration of functional abilities by discharge (F = 7.503, P = 0.001; F = 14.558, P < 0.001). Given a general finding of nutritional deterioration identified for these patients, as well as the identification of energy intake as a modifiable influence on the extent and rate of recovery, there is clearly scope for the multidisciplinary development of nutritional support for stroke patients to improve rehabilitation outcomes. © 2011 The Authors. Journal of Human Nutrition and Dietetics © 2011 The British Dietetic Association Ltd.

Value of Computed Tomographic Perfusion-Based Patient Selection for Intra-Arterial Acute Ischemic Stroke Treatment.

PubMed

Borst, Jordi; Berkhemer, Olvert A; Roos, Yvo B W E M; van Bavel, Ed; van Zwam, Wim H; van Oostenbrugge, Robert J; van Walderveen, Marianne A A; Lingsma, Hester F; van der Lugt, Aad; Dippel, Diederik W J; Yoo, Albert J; Marquering, Henk A; Majoie, Charles B L M

2015-12-01

The utility of computed tomographic perfusion (CTP)-based patient selection for intra-arterial treatment of acute ischemic stroke has not been proven in randomized trials and requires further study in a cohort that was not selected based on CTP. Our objective was to study the relationship between CTP-derived parameters and outcome and treatment effect in patients with acute ischemic stroke because of a proximal intracranial arterial occlusion. We included 175 patients who underwent CTP in the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in The Netherlands (MR CLEAN). Association of CTP-derived parameters (ischemic-core volume, penumbra volume, and percentage ischemic core) with outcome was estimated with multivariable ordinal logistic regression as an adjusted odds ratio for a shift in the direction of a better outcome on the modified Rankin Scale. Interaction between CTP-derived parameters and treatment effect was determined using multivariable ordinal logistic regression. Interaction with treatment effect was also tested for mismatch (core <70 mL; penumbra core >1.2; penumbra core >10 mL). The adjusted odds ratio for improved functional outcome for ischemic core, percentage ischemic core, and penumbra were 0.79 per 10 mL (95% confidence interval: 0.71-0.89; P<0.001), 0.82 per 10% (95% confidence interval: 0.66-0.90; P=0.002), and 0.97 per 10 mL (96% confidence interval: 0.92-1.01; P=0.15), respectively. No significant interaction between any of the CTP-derived parameters and treatment effect was observed. We observed no significant interaction between mismatch and treatment effect. CTP seems useful for predicting functional outcome, but cannot reliably identify patients who will not benefit from intra-arterial therapy. © 2015 American Heart Association, Inc.

Does English proficiency impact on health outcomes for inpatients undergoing stroke rehabilitation?

PubMed

Davies, Sarah E; Dodd, Karen J; Tu, April; Zucchi, Emiliano; Zen, Stefania; Hill, Keith D

2016-07-01

To determine whether English proficiency and/or the frequency of interpreter use impacts on health outcomes for inpatient stroke rehabilitation. Retrospective case-control study. People admitted for inpatient stroke rehabilitation. A high English proficiency group comprised people with native or near native English proficiency (n = 80), and a low English proficiency group comprised people who preferred a language other than English (n = 80). Length of stay (LOS), discharge destination and Functional Independence Measure (FIM). The low English proficiency group showed a greater improvement in FIM from admission to discharge (p = 0.04). No significant differences were found between groups in LOS, discharge destination and number of encounters with allied health professionals. Increased interpreter usage improved FIM efficiency but did not significantly alter other outcomes. English proficiency does not appear to impact on health outcomes in inpatient rehabilitation with a primarily in-house professional interpreter service. However, there is a need for a larger powered study to confirm these findings. Implications for rehabilitation People with low English proficiency undergoing inpatient stroke rehabilitation in a setting with a primarily in-house professional interpreter service, achieved similar outcomes to those with high English proficiency irrespective of frequency of interpreter usage. A non-significant increase of 4 days length of stay was observed in the low English proficiency group compared to the high English proficiency group. For patients with low English proficiency, greater change in Functional Independence Measure efficiency scores was observed for those with higher levels of interpreter use relative to those with low interpreter use. Clinicians should optimise use of interpreters with patients with low English proficiency when possible.

Mapping causal functional contributions derived from the clinical assessment of brain damage after stroke.

PubMed

Zavaglia, Melissa; Forkert, Nils D; Cheng, Bastian; Gerloff, Christian; Thomalla, Götz; Hilgetag, Claus C

2015-01-01

Lesion analysis reveals causal contributions of brain regions to mental functions, aiding the understanding of normal brain function as well as rehabilitation of brain-damaged patients. We applied a novel lesion inference technique based on game theory, Multi-perturbation Shapley value Analysis (MSA), to a large clinical lesion dataset. We used MSA to analyze the lesion patterns of 148 acute stroke patients together with their neurological deficits, as assessed by the National Institutes of Health Stroke Scale (NIHSS). The results revealed regional functional contributions to essential behavioral and cognitive functions as reflected in the NIHSS, particularly by subcortical structures. There were also side specific differences of functional contributions between the right and left hemispheric brain regions which may reflect the dominance of the left hemispheric syndrome aphasia in the NIHSS. Comparison of MSA to established lesion inference methods demonstrated the feasibility of the approach for analyzing clinical data and indicated its capability for objectively inferring functional contributions from multiple injured, potentially interacting sites, at the cost of having to predict the outcome of unknown lesion configurations. The analysis of regional functional contributions to neurological symptoms measured by the NIHSS contributes to the interpretation of this widely used standardized stroke scale in clinical practice as well as clinical trials and provides a first approximation of a 'map of stroke'.

Evaluation of Patient and Proxy Responses on the Activity Measure for Post Acute Care

PubMed Central

Jette, Alan M.; Ni, Pengsheng; Rasch, Elizabeth K.; Appelman, Jed; Sandel, M. Elizabeth; Terdiman, Joseph; Chan, Leighton

2012-01-01

Background and Purpose Our objective was to examine the agreement between adult patients with stroke and family member or clinician proxies in Activity Measure for Post Acute Care (AM-PAC) summary scores for daily activity, basic mobility, and applied cognitive function. Methods This study involved 67 patients with stroke admitted to a hospital within the Kaiser Permanente of Northern California system and were participants in a parent study on stroke outcomes. Each participant and proxy respondent completed the AM-PAC by personal or telephone interview at the point of hospital discharge and/or during one or more transitions to different post-acute care settings. Results The results suggest that for patients with a stroke proxy AM-PAC data are robust for family or clinician proxy assessment of basic mobility function, clinician proxy assessment of daily activity function, but less robust for family proxy assessment of daily activity function and for all proxy groups’ assessment of applied cognitive function. The pattern of disagreement between patient and proxy was, on average, relatively small and random. There was little evidence of systematic bias between proxy and patient reports of their functional status. The degree of concordance between patient and proxy was similar for those with moderate to severe strokes compared with mild strokes. Conclusions Patient and proxy ratings on the AM-PAC achieved adequate agreement for use in stroke research where using proxy respondents could reduce sample selection bias. The AM-PAC data can be implemented across institutional as well as community care settings while achieving precision and reducing respondent burden. PMID:22343646

Change in cognitive performance is associated with functional recovery during post-acute stroke rehabilitation: a multi-centric study from intermediate care geriatric rehabilitation units of Catalonia.

PubMed

Pérez, Laura Mónica; Inzitari, Marco; Roqué, Marta; Duarte, Esther; Vallés, Elisabeth; Rodó, Montserrat; Gallofré, Miquel

2015-10-01

Recovery after a stroke is determined by a broad range of neurological, functional and psychosocial factors. Evidence regarding these factors is not well established, in particular influence of cognition changes during rehabilitation. We aimed to investigate whether selective characteristics, including cognitive performance and its change over time, modulate functional recovery with home discharge in stroke survivors admitted to post-acute rehabilitation units. We undertook a multicenter cohort study, including all patients discharged from acute wards to any geriatric rehabilitation unit in Catalonia-Spain during 2008. Patients were assessed for demographics, clinical and functional variables using Conjunt Mínim Bàsic de Dades dels Recursos Sociosanitaris (CMBD-RSS), which adapts the Minimum Data Set tool used in America's nursing homes. Baseline-to-discharge change in cognition was calculated on repeated assessments using the Cognitive Performance Scale (CPS, range 0-6, best-worst cognition). The multivariable effect of these factors was analyzed in relation to the outcome. 879 post-stroke patients were included (mean age 77.48 ± 10.18 years, 52.6% women). A worse initial CPS [OR (95% CI) = 0.851 (0.774-0.935)] and prevalent fecal incontinence [OR (95% CI) = 0.560 (0.454-0.691)] reduced the likelihood of returning home with functional improvement; whereas improvement of CPS, baseline to discharge, [OR (95% CI) = 1.348 (1.144-1.588)], more rehabilitation days within the first 2 weeks [OR (95% CI) = 1.011 (1.006-1.015)] and a longer hospital stay [OR (95% CI) = 1.011 (1.006-1.015)] were associated with the outcome. In our sample, different clinical characteristics, including cognitive function and its improvement over time, are associated with functional improvement in stroke patients undergoing rehabilitation. Our results might provide information to further studies aimed at exploring the influence of cognition changes during rehabilitation.

Serum Uric Acid, Kidney Function and Acute Ischemic Stroke Outcomes in Elderly Patients: A Single-Cohort, Perspective Study

PubMed Central

Falsetti, Lorenzo; Capeci, William; Tarquinio, Nicola; Viticchi, Giovanna; Silvestrini, Mauro; Catozzo, Vania; Fioranelli, Agnese; Buratti, Laura; Pellegrini, Francesco

2017-01-01

Chronic kidney disease and hyperuricemia have been associated to an increased risk and a worse prognosis in acute ischemic stroke. Several mechanisms, including platelet dysfunction, coagulation disorders, endothelial dysfunction, inflammation, and an increased risk of atrial fibrillation could be implicated. The role of serum uric acid in this setting is still object of debate. We enrolled all the consecutive patients admitted to our department for acute ischemic stroke. Cox regression analysis was used to evaluate the risk of in-hospital death considering serum uric acid levels and all the comorbidities. In the overall sample, hyperuricemia was independently associated to an increased risk of in-hospital mortality. This effect was stronger in patients with chronic kidney disease while, in the group of patients with normal renal function, the relationship between hyperuricemia and increased stroke mortality was not confirmed. Hyperuricemia could be associated to higher in-hospital mortality for ischemic stroke among elderly patients when affected by kidney disease. Survival does not seem to be affected by hyperuricemia in patients with normal kidney function. PMID:28461885

Acupuncture treatment for ischaemic stroke in young adults: protocol for a randomised, sham-controlled clinical trial

PubMed Central

Chen, Lifang; Fang, Jianqiao; Jin, Xiaoming; Keeler, Crystal Lynn; Gao, Hong; Fang, Zhen; Chen, Qin

2016-01-01

Introduction Stroke in young adults is not uncommon. Although the overall incidence of stroke has been recently declining, the incidence of stroke in young adults is increasing. Traditional vascular risk factors are the main cause of young ischaemic stroke. Acupuncture has been shown to benefit stroke rehabilitation and ameliorate the risk factors for stroke. The aims of this study were to determine whether acupuncture treatment will be effective in improving the activities of daily living (ADL), motor function and quality of life (QOL) in patients of young ischaemic stroke, and in preventing stroke recurrence by controlling blood pressure, lipids and body weight. Methods and analysis In this randomised, sham-controlled, participant-blinded and assessor-blinded clinical trial, 120 patients between 18 and 45 years of age with a recent (within 1 month) ischaemic stroke will be randomised for an 8-week acupuncture or sham acupuncture treatment. The primary outcome will be the Barthel Index for ADL. The secondary outcomes will include the Fugl-Meyer Assessment for motor function; the World Health Organization Quality of Life BREF (WHOQOL-BREF) for QOL; and risk factors that are measured by ambulatory blood pressure, the fasting serum lipid, body mass index and waist circumference. Incidence of adverse events and long-term mortality and recurrence rate during a 10-year and 30-year follow-up will also be investigated. Ethics and dissemination Ethics approval was obtained from the Ethics Committee of The Third Affiliated Hospital of Zhejiang Chinese Medical University. Protocol V.3 was approved in June 2013. The results will be disseminated in a peer-reviewed journal and presented at international congresses. The results will also be disseminated to patients by telephone during follow-up calls enquiring on the patient's post-study health status. Trial registration number ChiCTR-TRC- 13003317; Pre-results. PMID:26739742

Progressive deficit in isolated pontine infarction: the association with etiological subtype, lesion topography and outcome.

PubMed

Gökçal, Elif; Niftaliyev, Elvin; Baran, Gözde; Deniz, Çiğdem; Asil, Talip

2017-09-01

It is important to predict progressive deficit (PD) in isolated pontine infarction, a relatively common problem of clinical stroke practice. Traditionally, lacunar infarctions are known with their progressive course. However, few studies have analyzed the branch atheromatous disease subtype as a subtype of lacunar infarction, separately. There are also conflicting results regarding the relationship with the topography of lesion and PD. In this study, we classified etiological subtypes and lesion topography in isolated pontine infarction and aimed to investigate the association of etiological subtypes, lesion topography and clinical outcome with PD. We analyzed demographics, laboratory parameters, and risk factors of 120 patients having isolated pontine infarction and admitted within 24 h retrospectively. PD was defined as an increase in the National Institutes of Health Stroke scale ≥2 units in 5 days after onset. Patients were classified as following: large artery disease (LAA), basilar artery branch disease (BABD) and small vessel disease (SVD). Upper, middle and lower pontine infarcts were identified longitudinally. Functional outcome at 3 months was determined according to modified Rankin scores. Of 120 patients, 41.7% of the patients were classified as BABD, 30.8% as SVD and 27.5% as LAA. 23 patients (19.2%) exhibited PD. PD was significantly more frequent in patient with BABD (p 0.006). PD was numerically higher in patients with lower pontine infarction. PD was associated with BABD and poor functional outcome. It is important to discriminate the BABD neuroradiologically from other stroke subtypes to predict PD which is associated with poor functional outcome in patients with isolated pontine infarctions.

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.

Medicare claims indicators of healthcare utilization differences after hospitalization for ischemic stroke: Race, gender, and caregiving effects.

PubMed

Roth, David L; Sheehan, Orla C; Huang, Jin; Rhodes, James D; Judd, Suzanne E; Kilgore, Meredith; Kissela, Brett; Bettger, Janet Prvu; Haley, William E

2016-10-01

Background Differences in healthcare utilization after stroke may partly explain race or gender differences in stroke outcomes and identify factors that might reduce post-acute stroke care costs. Aim To examine systematic differences in Medicare claims for healthcare utilization after hospitalization for ischemic stroke in a US population-based sample. Methods Claims were examined over a six-month period after hospitalization for 279 ischemic stroke survivors 65 years or older from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. Statistical analyses examined differences in post-acute healthcare utilization, adjusted for pre-stroke utilization, as a function of race (African-American vs. White), gender, age, stroke belt residence, income, Medicaid dual-eligibility, Charlson comorbidity index, and whether the person lived with an available caregiver. Results After adjusting for covariates, women were more likely than men to receive home health care and to use emergency department services during the post-acute care period. These effects were maintained even after further adjustment for acute stroke severity. African-Americans had more home health care visits than Whites among patients who received some home health care. Having a co-residing caregiver was associated with reduced acute hospitalization length of stay and fewer post-acute emergency department and primary care physician visits. Conclusions Underutilization of healthcare after stroke does not appear to explain poorer long-term stroke outcomes for women and African-Americans in this epidemiologically-derived sample. Caregiver availability may contribute to reduced formal care and cost during the post-acute period.

Influence of racial differences on outcomes after thrombolytic therapy in acute ischemic stroke.

PubMed

Mishra, Nishant K; Mandava, Pitchaiah; Chen, Christopher; Grotta, James; Lees, Kennedy R; Kent, Thomas A

2014-07-01

The National Institutes of Neurological Disorders and Stroke and the European Co-operative Acute Stroke III trials enrolled a largely Caucasian population, but the results are often extrapolated onto non-Caucasians. A limited number of nonrandomized studies have proposed that non-Caucasian patients show differential response to tissue plasminogen activator. We examined if non-Caucasian patients of mixed national origin within the Virtual International Stroke Trials Archives neuroprotection trials responded differently to tissue plasminogen activator compared with Caucasians. We matched patients within each race-subtype for age, baseline National Institutes of Health Stroke Scales, and diabetes status, and excluded outliers. We tested for an interaction of race ethnicity with tissue plasminogen activator on predicting outcomes at α = 0·05. We compared 90-day ordinal outcome (modified Rankin Scale; primary analysis) and dichotomized outcomes (modified Rankin Scale 0-1; modified Rankin Scale 0-2; survival) within individual race ethnicity. One thousand nine hundred forty-six thrombolysed patients (125 Blacks, 39 Asians, and 1821 Caucasians) were matched with 1946 non-thrombolysed patients in each race ethnicity group. Postmatching, there were no imbalances in baseline National Institutes of Health Stroke Scales and age between the groups (P > 0·05). The interaction of tissue plasminogen activator with race ethnicity was nonsignificant in ordinal (P = 0·4) and in dichotomized outcome models (P > 0·05). Ordinal odds for improved outcomes were 1·5 for all patients (P < 0·05). Ordinal odds for Caucasians were 1·5 (P < 0·05); for Blacks, 2·1 (P < 0·05); and for Asians, 1·2 (P > 0·05; 1·6 after 1:2 matching with nonthrombolysed, because of small numbers). Dichotomized functional outcomes improved after thrombolysis overall, in Caucasians, in Blacks (modified Rankin Scale 0-2 only), and in Asians (after 1:2 matching; P > 0·05). Odds for survival were consistent across all groups. These results do not suggest a differential response to tissue plasminogen activator based on race ethnicity. Among Asians, data were particularly sparse, and results should be interpreted with caution. © 2013 The Authors. International Journal of Stroke © 2013 World Stroke Organization.

The effect of brain atrophy on outcome after a large cerebral infarction.

PubMed

Lee, Sang Hyung; Oh, Chang Wan; Han, Jung Ho; Kim, Chae-Yong; Kwon, O-Ki; Son, Young-Je; Bae, Hee-Joon; Han, Moon-Ku; Chung, Young Seob

2010-12-01

We retrospectively evaluated the effect of brain atrophy on the outcome of patients after a large cerebral infarct. Between June 2003 and Oct 2008, 134 of 2975 patients with stroke were diagnosed as having a large cerebral infarct. The mean age of the patients was 70 (21-95) y. The mean infarct volume was 223.6±95.2 cm(3) (46.0-491.0). The inter-caudate distance (ICD) was calculated as an indicator of brain atrophy by measuring the hemi-ICD of the intact side and then multiplying by two to account for brain swelling at the infarct site. The mean ICD was 18.0±4.8 mm (9.6-37.6). Forty-nine (36.6%) patients experienced a malignant clinical outcome (MCO) during management in the hospital. Thirty-one (23.1%) patients had a favourable functional outcome (FO) (modified Rankin scale (mRS) ≤3) and 49 (36.6%) had an acceptable functional outcome (AO) (mRS≤4) at 6 months after stroke onset. In the multivariate analysis, brain atrophy (ICD≥20 mm) had a significant and independent protective effect on MCO (p=0.003; OR=0.137; 95% CI 0.037 to 0.503). With respect to FO, the age and infarct volume reached statistical significance (p<0.001, OR=0.844, 95% CI 0.781 to 0.913; p=0.006, OR=0.987, 95% CI 0.977 to 0.996, respectively). Brain atrophy (ICD≥20 mm) was negatively associated only with AO (p=0.022; OR=0.164; 95% CI 0.035 to 0.767). Brain atrophy may have an association with clinical outcome after a large stroke by a trend of saving patients from an MCO but also by interfering with their functional recovery.

Long-term outcome of vertebral artery origin stenosis in patients with acute ischemic stroke

PubMed Central

2013-01-01

Background Vertebral artery origin (VAO) stenosis is occasionally observed in patients who have acute ischemic stroke. We investigated the long-term outcomes and clinical significance of VAO stenosis in patients with acute ischemic stroke. Methods We performed a prospective observational study using a single stroke center registry to investigate the risk of recurrent stroke and vascular outcomes in patients with acute ischemic stroke and VAO stenosis. To relate the clinical significance of VAO stenosis to the vascular territory of the index stroke, patients were classified into an asymptomatic VAO stenosis group and a symptomatic VAO stenosis group. Results Of the 774 patients who had acute ischemic stroke, 149 (19.3%) of them had more than 50% stenosis of the VAO. During 309 patient-years of follow-up (mean, 2.3 years), there were 7 ischemic strokes, 6 hemorrhagic strokes, and 2 unknown strokes. The annual event rates were 0.97% for posterior circulation ischemic stroke, 4.86% for all stroke, and 6.80% for the composite cardiovascular outcome. The annual event rate for ischemic stroke in the posterior circulation was significantly higher in patients who had symptomatic VAO stenosis than in patients who had asymptomatic stenosis (1.88% vs. 0%, p = 0.046). In a multivariate analysis, the hazard ratio, per one point increase of the Essen Stroke Risk Score (ESRS) for the composite cardiovascular outcome, was 1.46 (95% CI, 1.02-2.08, p = 0.036). Conclusions Long-term outcomes of more than 50% stenosis of the VAO in patients with acute ischemic stroke were generally favorable. Additionally, ESRS was a predictor for the composite cardiovascular outcome. Asymptomatic VAO stenosis may not be a specific risk factor for recurrent ischemic stroke in the posterior circulation. However, VAO stenosis may require more clinical attention as a potential source of recurrent stroke when VAO stenosis is observed in patients who have concurrent ischemic stroke in the posterior circulation. PMID:24215371

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).

Microbleeds, Cerebral Hemorrhage, and Functional Outcome After Stroke Thrombolysis: Individual Patient Data Meta-Analysis.

PubMed

Charidimou, Andreas; Turc, Guillaume; Oppenheim, Catherine; Yan, Shenqiang; Scheitz, Jan F; Erdur, Hebun; Klinger-Gratz, Pascal P; El-Koussy, Marwan; Takahashi, Wakoh; Moriya, Yusuke; Wilson, Duncan; Kidwell, Chelsea S; Saver, Jeffrey L; Sallem, Asma; Moulin, Solene; Edjlali-Goujon, Myriam; Thijs, Vincent; Fox, Zoe; Shoamanesh, Ashkan; Albers, Gregory W; Mattle, Heinrich P; Benavente, Oscar R; Jäger, H Rolf; Ambler, Gareth; Aoki, Junya; Baron, Jean-Claude; Kimura, Kazumi; Kakuda, Wataru; Takizawa, Shunya; Jung, Simon; Nolte, Christian H; Lou, Min; Cordonnier, Charlotte; Werring, David J

2017-07-18

We assessed whether the presence, number, and distribution of cerebral microbleeds (CMBs) on pre-intravenous thrombolysis MRI scans of acute ischemic stroke patients are associated with an increased risk of intracerebral hemorrhage (ICH) or poor functional outcome. We performed an individual patient data meta-analysis, including prospective and retrospective studies of acute ischemic stroke treated with intravenous tissue-type plasminogen activator. Using multilevel mixed-effects logistic regression, we investigated associations of pre-treatment CMB presence, burden (1, 2-4, ≥5, and >10), and presumed pathogenesis (cerebral amyloid angiopathy defined as strictly lobar CMBs and noncerebral amyloid angiopathy) with symptomatic ICH, parenchymal hematoma (within [parenchymal hemorrhage, PH] and remote from the ischemic area [remote parenchymal hemorrhage, PHr]), and poor 3- to 6-month functional outcome (modified Rankin score >2). In 1973 patients from 8 centers, the crude prevalence of CMBs was 526 of 1973 (26.7%). A total of 77 of 1973 (3.9%) patients experienced symptomatic ICH, 210 of 1806 (11.6%) experienced PH, and 56 of 1720 (3.3%) experienced PHr. In adjusted analyses, patients with CMBs (compared with those without CMBs) had increased risk of PH (odds ratio: 1.50; 95% confidence interval: 1.09-2.07; P =0.013) and PHr (odds ratio: 3.04; 95% confidence interval: 1.73-5.35; P <0.001) but not symptomatic ICH. Both cerebral amyloid angiopathy and noncerebral amyloid angiopathy patterns of CMBs were associated with PH and PHr. Increasing CMB burden category was associated with the risk of symptomatic ICH ( P =0.014), PH ( P =0.013), and PHr ( P <0.00001). Five or more and >10 CMBs independently predicted poor 3- to 6-month outcome (odds ratio: 1.85; 95% confidence interval: 1.10-3.12; P =0.020; and odds ratio: 3.99; 95% confidence interval: 1.55-10.22; P =0.004, respectively). Increasing CMB burden is associated with increased risk of ICH (including PHr) and poor 3- to 6-month functional outcome after intravenous thrombolysis for acute ischemic stroke. © 2017 American Heart Association, Inc.

Clinical prediction models for mortality and functional outcome following ischemic stroke: A systematic review and meta-analysis

PubMed Central

Crayton, Elise; Wolfe, Charles; Douiri, Abdel

2018-01-01

Objective We aim to identify and critically appraise clinical prediction models of mortality and function following ischaemic stroke. Methods Electronic databases, reference lists, citations were searched from inception to September 2015. Studies were selected for inclusion, according to pre-specified criteria and critically appraised by independent, blinded reviewers. The discrimination of the prediction models was measured by the area under the curve receiver operating characteristic curve or c-statistic in random effects meta-analysis. Heterogeneity was measured using I2. Appropriate appraisal tools and reporting guidelines were used in this review. Results 31395 references were screened, of which 109 articles were included in the review. These articles described 66 different predictive risk models. Appraisal identified poor methodological quality and a high risk of bias for most models. However, all models precede the development of reporting guidelines for prediction modelling studies. Generalisability of models could be improved, less than half of the included models have been externally validated(n = 27/66). 152 predictors of mortality and 192 predictors and functional outcome were identified. No studies assessing ability to improve patient outcome (model impact studies) were identified. Conclusions Further external validation and model impact studies to confirm the utility of existing models in supporting decision-making is required. Existing models have much potential. Those wishing to predict stroke outcome are advised to build on previous work, to update and adapt validated models to their specific contexts opposed to designing new ones. PMID:29377923

The Adherence eValuation After Ischemic Stroke Longitudinal (AVAIL) registry: design, rationale, and baseline patient characteristics.

PubMed

Bushnell, Cheryl; Zimmer, Louise; Schwamm, Lee; Goldstein, Larry B; Clapp-Channing, Nancy; Harding, Tina; Drew, Laura; Zhao, Xin; Peterson, Eric

2009-03-01

Approximately one third of the 780,000 people in the United States who have a stroke each year have recurrent events. Although efficacious secondary prevention measures are available, levels of adherence to these strategies in patients who have had stroke are largely unknown. Understanding medication-taking behavior in this population is an important step to optimizing the appropriate use of proven secondary preventive therapies and reducing the risk of recurrent stroke. The Adherence eValuation After Ischemic Stroke Longitudinal (AVAIL) registry is a prospective study of adherence to stroke prevention medications from hospital discharge to 1 year in patients admitted with stroke or transient ischemic attack. The primary outcomes are medication usage as determined by patient interviews after 3 and 12 months. Potential patient-, provider-, and system-level barriers to persistence of medication use are also collected. Secondary outcomes include the rates of recurrent stroke or transient ischemic attack, vascular events, and rehospitalization and functional status as measured by the modified Rankin score. The AVAIL enrolled about 2,900 subjects from 106 hospitals from July 2006 through July 2008. The 12-month follow-up will be completed in August 2009. The AVAIL registry will document the current state of adherence and persistence to stroke prevention medications among a nationwide sample of patients. These data will be used to design interventions to improve the quality of care post acute hospitalization and reduce the risks of future stroke and cardiovascular events.

Association of activity changes in the primary sensory cortex with successful motor rehabilitation of the hand following stroke.

PubMed

Laible, Mona; Grieshammer, Steven; Seidel, Gundula; Rijntjes, Michel; Weiller, Cornelius; Hamzei, Farsin

2012-09-01

Previous studies demonstrated a posterior shift of activation toward the primary sensory cortex (S1) following stroke; however, any relationship between this posterior shift and clinical outcome measures for the affected hand function were unclear. The authors investigated the possible role of S1 in motor recovery. Assuming that previous studies examined inhomogeneous groups of patients, the authors selected participants with chronic stroke who had moderate hand paresis, normal sensory examination and somatosensory-evoked potentials, and no lesion within the S1, thalamus, or brain stem. Constraint-induced movement therapy (CIMT) was used to train the impaired hand. To relate fMRI (functional MRI) activation changes from baseline to post-CIMT, a correlation analysis was performed with changes of the Wolf Motor Function Test (WMFT) as a test for the hand function. A close relationship was found between increases in hand function and peak changes in activation within the ipsilesional S1. With a better outcome, greater increases in activation within the S1 were evident (P < .03; r = 0.73). In selected patients, the sensory network influences training-induced motor gains. This predictive knowledge of plasticity when applying CIMT may suggest strategies to enhance the effect of therapy, such as the addition of electrical stimulation to enhance S1 excitability.

Endovascular vs medical management of acute ischemic stroke

PubMed Central

Ding, Dale; Starke, Robert M.; Mehndiratta, Prachi; Crowley, R. Webster; Liu, Kenneth C.; Southerland, Andrew M.; Worrall, Bradford B.

2015-01-01

Objective: To compare the outcomes between endovascular and medical management of acute ischemic stroke in recent randomized controlled trials (RCT). Methods: A systematic literature review was performed, and multicenter, prospective RCTs published from January 1, 2013, to May 1, 2015, directly comparing endovascular therapy to medical management for patients with acute ischemic stroke were included. Meta-analyses of modified Rankin Scale (mRS) and mortality at 90 days and symptomatic intracranial hemorrhage (sICH) for endovascular therapy and medical management were performed. Results: Eight multicenter, prospective RCTs (Interventional Management of Stroke [IMS] III, Local Versus Systemic Thrombolysis for Acute Ischemic Stroke [SYNTHESIS] Expansion, Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy [MR RESCUE], Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands [MR CLEAN], Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness [ESCAPE], Extending the Time for Thrombolysis in Emergency Neurological Deficits–Intra-Arterial [EXTEND-IA], Solitaire With the Intention For Thrombectomy as Primary Endovascular Treatment [SWIFT PRIME], and Endovascular Revascularization With Solitaire Device Versus Best Medical Therapy in Anterior Circulation Stroke Within 8 Hours [REVASCAT]) comprising 2,423 patients were included. Meta-analysis of pooled data demonstrated functional independence (mRS 0–2) at 90 days in favor of endovascular therapy (odds ratio [OR] = 1.71; p = 0.005). Subgroup analysis of the 6 trials with large vessel occlusion (LVO) criteria also demonstrated functional independence at 90 days in favor of endovascular therapy (OR = 2.23; p < 0.00001). Subgroup analysis of the 5 trials that primarily utilized stent retriever devices (≥70%) in the intervention arm demonstrated functional independence at 90 days in favor of endovascular therapy (OR = 2.39; p < 0.00001). No difference was found for mortality at 90 days and sICH between endovascular therapy and medical management in all analyses and subgroup analyses. Conclusions: This meta-analysis provides strong evidence that endovascular intervention combined with medical management, including IV tissue plasminogen activator for eligible patients, improves the outcomes of appropriately selected patients with acute ischemic stroke in the setting of LVO. PMID:26537058

Thrombolysis and clinical outcome in patients with stroke after implementation of the Tyrol Stroke Pathway: a retrospective observational study.

PubMed

Willeit, Johann; Geley, Theresa; Schöch, Johannes; Rinner, Heinrich; Tür, Andreas; Kreuzer, Hans; Thiemann, Norbert; Knoflach, Michael; Toell, Thomas; Pechlaner, Raimund; Willeit, Karin; Klingler, Natalie; Praxmarer, Silvia; Baubin, Michael; Beck, Gertrud; Berek, Klaus; Dengg, Christian; Engelhardt, Klaus; Erlacher, Thomas; Fluckinger, Thomas; Grander, Wilhelm; Grossmann, Josef; Kathrein, Hermann; Kaiser, Norbert; Matosevic, Benjamin; Matzak, Heinrich; Mayr, Markus; Perfler, Robert; Poewe, Werner; Rauter, Alexandra; Schoenherr, Gudrun; Schoenherr, Hans-Robert; Schinnerl, Adolf; Spiss, Heinrich; Thurner, Theresa; Vergeiner, Gernot; Werner, Philipp; Wöll, Ewald; Willeit, Peter; Kiechl, Stefan

2015-01-01

Intravenous thrombolysis for ischaemic stroke remains underused worldwide. We aimed to assess whether our statewide comprehensive stroke management programme would improve thrombolysis use and clinical outcome in patients. In 2008-09, we designed the Tyrol Stroke Pathway, which provided information campaigns for the public and standardised the entire treatment pathway from stroke onset to outpatient rehabilitation. It was commenced in Tyrol, Austria, as a long-term routine-care programme and aimed to include all patients with stroke in the survey area. We focused on thrombolysis use and outcome in the first full 4 years of implementation (2010-13). We enrolled 4947 (99%) of 4992 patients with ischaemic stroke who were admitted to hospitals in Tyrol; 675 (14%) of the enrollees were treated with alteplase. Thrombolysis administration in Tyrol increased after programme implementation, from 160 of 1238 patients (12·9%, 95% CI 11·1-14·9) in 2010 to 213 of 1266 patients (16·8%, 14·8-19·0) in 2013 (ptrend 2010-13<0·0001). Differences in use of thrombolysis in the nine counties of Tyrol in 2010 (range, 2·2-22·6%) were reduced by 2013 (12·1-22·5%). Median statewide door-to-needle time decreased from 49 min (IQR 35-60) in 2010 to 44 min (29-60) in 2013; symptomatic post-thrombolysis intracerebral haemorrhages occurred in 28 of 675 patients (4·1%, 95% CI 2·8-5·9) during 2010-13. In four Austrian states without similar stroke programmes, thrombolysis administration remained stable or declined between 2010 and 2013 (mean reduction 14·4%, 95% CI 10·9-17·9). Although the 3-month mortality was not affected by our programme (137 [13%] of 1060 patients in 2010 vs 143 [13%] of 1069 patients in 2013), 3-month functional outcome significantly improved (modified Rankin Scale score 0-1 in 375 [40%] of 944 patients in 2010 vs 493 [53%] of 939 in 2013; score 0-2 in 531 [56%] patients in 2010 and 615 [65%] in 2013; ptrend 2010-13<0·0001). During the period of implementation of our comprehensive stroke management programme, thrombolysis administration increased and clinical outcome significantly improved, although mortality did not change. We hope that these results will guide health authorities and stroke physicians elsewhere when implementing similar programmes for patients with stroke. Reformpool of the Tyrolean Health Care Fund. Copyright © 2015 Elsevier Ltd. All rights reserved.

tDCS and Robotics on Upper Limb Stroke Rehabilitation: Effect Modification by Stroke Duration and Type of Stroke.

PubMed

Straudi, Sofia; Fregni, Felipe; Martinuzzi, Carlotta; Pavarelli, Claudia; Salvioli, Stefano; Basaglia, Nino

2016-01-01

Objective. The aim of this exploratory pilot study is to test the effects of bilateral tDCS combined with upper extremity robot-assisted therapy (RAT) on stroke survivors. Methods. We enrolled 23 subjects who were allocated to 2 groups: RAT + real tDCS and RAT + sham-tDCS. Each patient underwent 10 sessions (5 sessions/week) over two weeks. Outcome measures were collected before and after treatment: (i) Fugl-Meyer Assessment-Upper Extremity (FMA-UE), (ii) Box and Block Test (BBT), and (iii) Motor Activity Log (MAL). Results. Both groups reported a significant improvement in FMA-UE score after treatment (p < 0.01). No significant between-groups differences were found in motor function. However, when the analysis was adjusted for stroke type and duration, a significant interaction effect (p < 0.05) was detected, showing that stroke duration (acute versus chronic) and type (cortical versus subcortical) modify the effect of tDCS and robotics on motor function. Patients with chronic and subcortical stroke benefited more from the treatments than patients with acute and cortical stroke, who presented very small changes. Conclusion. The additional use of bilateral tDCS to RAT seems to have a significant beneficial effect depending on the duration and type of stroke. These results should be verified by additional confirmatory studies.

Outcome of endovascular treatment for acute basilar artery occlusion in the modern era: a single institution experience.

PubMed

Li, Chuanhui; Zhao, Wenbo; Wu, Chuanjie; Shang, Shuyi; Chen, Jian; Ren, Ming; Duan, Jiangang; Ma, Qingfeng; Li, Guilin; Zhang, Yunzhou; Zhang, Hongqi; Jiao, Liqun; Ji, Xunming

2018-06-01

The beneficial effect of endovascular treatment (EVT) for patients with acute basilar artery occlusion (ABAO) remains uncertain. The purpose of the present study was to evaluate clinical outcome of EVT for patients with ABAO and analyze prognostic factors of good outcome. From our prospectively established database, we reviewed all patients with ABAO receiving EVT during January 2014 to December 2016. Baseline characteristics and outcomes were evaluated. Favorable functional outcome was defined as modified Rankin Scale score of 0 to 3 assessed at 3-month follow-up. The association between clinical and procedural characteristics and functional outcome was assessed. Of the 68 patients included, 50 patients (73.5%) received mechanical thrombectomy with stent retriever device. Successful reperfusion (thrombolysis in cerebral infarction grades 2b-3) was achieved in 61 patients (89.7%). Overall favorable functional outcome was reached by 31 patients (45.6%). In univariate analysis, Glasgow Coma Scale sum score, baseline National Institutes of Health stroke scale score (NIHSS), and baseline glycemia level were identified predicting good clinical outcome. Multivariate analysis showed that lower NIHSS was the only independent risk factor of favorable functional outcome (OR 0.832; 95% CI, 0.715-0.968; p = 0.018). No difference of favorable outcomes was observed between the subgroups of time to EVT < 6 h and ≽ 6 h. Data in the present study suggests that EVT for ABAO patients should be reasonable within 24 h of symptom onset. The most important factor determining clinical outcome is initial stroke severity.

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.

A new electromechanical trainer for sensorimotor rehabilitation of paralysed fingers: A case series in chronic and acute stroke patients

PubMed Central

Hesse, Stefan; Kuhlmann, H; Wilk, J; Tomelleri, C; Kirker, Stephen GB

2008-01-01

Background The functional outcome after stroke is improved by more intensive or sustained therapy. When the affected hand has no functional movement, therapy is mainly passive movements. A novel device for repeating controlled passive movements of paralysed fingers has been developed, which will allow therapists to concentrate on more complicated tasks. A powered cam shaft moves the four fingers in a physiological range of movement. Methods After refining the training protocol in 2 chronic patients, 8 sub-acute stroke patients were randomised to receive additional therapy with the Finger Trainer for 20 min every work day for four weeks, or the same duration of bimanual group therapy, in addition to their usual rehabilitation. Results In the chronic patients, there was a sustained reduction in finger and wrist spasticity, but there was no improvement in active movements. In the subacute patients, mean distal Fugl-Meyer score (0–30) increased in the control group from 1.25 to 2.75 (ns) and 0.75 to 6.75 in the treatment group (p < .05). Median Modified Ashworth score increased 0/5 to 2/5 in the control group, but not in the treatment group, 0 to 0. Only one patient, in the treatment group, regained function of the affected hand. No side effects occurred. Conclusion Treatment with the Finger Trainer was well tolerated in sub-acute & chronic stroke patients, whose abnormal muscle tone improved. In sub-acute stroke patients, the Finger Trainer group showed small improvements in active movement and avoided the increase in tone seen in the control group. This series was too small to demonstrate any effect on functional outcome however. PMID:18771581

Granulocyte Colony Stimulating Factor and Physiotherapy after Stroke: Results of a Feasibility Randomised Controlled Trial: Stem Cell Trial of Recovery EnhanceMent after Stroke-3 (STEMS-3 ISRCTN16714730)

PubMed Central

Sprigg, Nikola; O’Connor, Rebecca; Woodhouse, Lisa; Krishnan, Kailash; England, Timothy J.; Connell, Louise A.; Walker, Marion F.; Bath, Philip M.

2016-01-01

Background Granulocyte-colony stimulating factor (G-CSF) mobilises endogenous haematopoietic stem cells and enhances recovery in experimental stroke. Recovery may also be dependent on an enriched environment and physical activity. G-CSF may have the potential to enhance recovery when used in combination with physiotherapy, in patients with disability late after stroke. Methods A pilot 2 x 2 factorial randomised (1:1) placebo-controlled trial of G-CSF (double-blind), and/or a 6 week course of physiotherapy, in 60 participants with disability (mRS >1), at least 3 months after stroke. Primary outcome was feasibility, acceptability and tolerability. Secondary outcomes included death, dependency, motor function and quality of life measured 90 and 365 days after enrolment. Results Recruitment to the trial was feasible and acceptable; of 118 screened patients, 92 were eligible and 32 declined to participate. 60 patients were recruited between November 2011 and July 2013. All participants received some allocated treatment. Although 29 out of 30 participants received all 5 G-CSF/placebo injections, only 7 of 30 participants received all 18 therapy sessions. G-CSF was well tolerated but associated with a tendency to more adverse events than placebo (16 vs 10 patients, p = 0.12) and serious adverse events (SAE) (9 vs 3, p = 0.10). On average, patients received 14 (out of 18 planned) therapy sessions, interquartile range [12, 17]. Only a minority (23%) of participants completed all physiotherapy sessions, a large proportion of sessions (114 of 540, 21%) were cancelled due to patient (94, 17%) and therapist factors (20, 4%). No significant differences in functional outcomes were detected in either the G-CSF or physiotherapy group at day 90 or 365. Conclusions Delivery of G-CSF is feasible in chronic stroke. However, the study failed to demonstrate feasibility for delivering additional physiotherapy sessions late after stroke therefore a definitive study using this trial design is not supported. Future work should occur earlier after stroke, alongside on-going clinical rehabilitation. Trial Registration ISRCTN.com ISRCTN16714730 PMID:27610616

Usability of Videogame-Based Dexterity Training in the Early Rehabilitation Phase of Stroke Patients: A Pilot Study.

PubMed

Vanbellingen, Tim; Filius, Suzanne J; Nyffeler, Thomas; van Wegen, Erwin E H

2017-01-01

Approximately 70-80% of stroke survivors have limited activities of daily living, mainly due to dexterous problems. Videogame-based training (VBT) along with virtual reality seems to be beneficial to train upper limb function. To evaluate the usability of VBT using the Leap Motion Controller (LMC) to train fine manual dexterity in the early rehabilitation phase of stroke patients as an add-on to conventional therapy. Additionally, this study aimed to estimate the feasibility and potential efficacy of the VBT. During 3 months, 64 stroke patients were screened for eligibility, 13 stroke patients were included (4 women and 9 men; age range: 24-91 years; mean time post stroke: 28.2 days). Nine sessions of 30 min VBT, three times per week as an add-on to conventional therapy with stroke inpatients. Primary outcome was the usability of the system measured with the System Usability Scale. Secondary outcomes concerning feasibility were the compliance rate calculated from the total time spent on the intervention (TT) compared to planned time, the opinion of participants via open-end questions, and the level of active participation measured with the Pittsburgh Rehabilitation Participation Scale. Regarding the potential efficacy secondary outcomes were: functional dexterity measured with the Nine Hole Peg Test (NHPT), subjective dexterity measured with the Dexterity Questionnaire 24, grip strength measured with the Jamar dynamometer, and motor impairment of the upper limb measured with the Fugl-Meyer Upper Extremity (FM-UE) scale. Primarily, the usability of the system was good to excellent. The patient's perception of usability remained stable over a mean period of 3 weeks of VBT. Secondly, the compliance rate was good, and the level of active participation varied between good and very good. The opinion of the participants revealed that despite individual differences, the overall impression of the therapy and device was good. Patients showed significant improvements in hand dexterity. No changes were found in motor impairment of the upper limb (FM-UE) during intervention. VBT using LMC is a usable rehabilitation tool to train dexterity in the early rehabilitation phase of stroke inpatients.

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.

Increased work and social engagement is associated with increased stroke specific quality of life in stroke survivors at 3 months and 12 months post-stroke: a longitudinal study of an Australian stroke cohort.

PubMed

Tse, Tamara; Binte Yusoff, Siti Zubaidah; Churilov, Leonid; Ma, Henry; Davis, Stephen; Donnan, Geoffrey Alan; Carey, Leeanne M

2017-09-01

There is a relative lack of longitudinal studies investigating stroke-specific outcomes and quality of life (QOL). This study aimed to identify which factors (level of disability, cognitive functioning, depressive symptoms, physical activity, and work and social engagement) were independently associated with each stroke-specific domain of QOL, adjusting for age and gender, at 3 months and 12 months post-stroke in an Australian cohort. Survivors of ischemic stroke were recruited from 18 sites of the STroke imAging pRevention and Treatment (START) longitudinal cohort study. Survivors were assessed at 3 months (n = 185) and 12 months (n = 170) post-stroke using the Stroke Impact Scale (SIS), modified Rankin Scale (mRS), Montreal Cognitive Assessment (MoCA), Montgomery-Asberg Depression Rating Scale, Rapid Assessment of Physical Activity, and Work and Social Adjustment Scale (WSAS). WSAS was independently associated with the SIS domains of: Physical Composite function; Participation; and Perceived Recovery at 3 months and 12 months and SIS domain of Emotion at 12 months post-stroke. The presence of depressive symptoms was independently associated with the SIS domains of: Memory and Thinking; and Emotion at 3 months. At 12 months post-stroke, mRS was independently associated with SIS domain of Physical Composite function and MoCA with SIS domain of Communication. Engaging in work and social activities is an important factor associated with stroke-specific domains of QOL over time. It is recommended that services focus on improving work and social engagement given their importance related to QOL in the first year of recovery post-stroke. Identifying and treating those with depressive symptoms may enhance QOL in the early months post-stroke. START-PrePARE Australian New Zealand Clinical Trials, www.anzctr.org.au , Registry number: ACTRN12610000987066. EXTEND ClinicalTrial.gov identifier: NCT00887328.

Importance and Difficulties of Pursuing rTMS Research in Acute Stroke

PubMed Central

Chappuis, Diane M.; Finkelstein, Marsha J.; Frost, Kate L.; Leuty, Lynette K.; McNulty, Allison L.; Oddsson, Lars I. E.; Seifert, Erin M.; Kimberley, Teresa J.

2017-01-01

Abstract Although much research has been done on repetitive transcranial magnetic stimulation (rTMS) in chronic stroke, only sparse research has been done in acute stroke despite the particularly rich potential for neuroplasticity in this stage. We attempted a preliminary clinical trial in one active, high-quality inpatient rehabilitation facility (IRF) in the -United States. But after enrolling only 4 patients in the grant period, the study was stopped because of low enrollment. The purpose of this paper is to offer a perspective describing the important physiologic rationale for including rTMS in the early phase of stroke, the reasons for our poor patient enrollment in our attempted study, and recommendations to help future studies succeed. We conclude that, if scientists and clinicians hope to enhance stroke outcomes, more attention must be directed to leveraging conventional rehabilitation with neuromodulation in the acute phase of stroke when the capacity for neuroplasticity is optimal. Difficulties with patient enrollment must be addressed by reassessing traditional inclusion and exclusion criteria. Factors that shorten patients’ length of stay in the IRF must also be reassessed at all policy-making levels to make ethical decisions that promote higher functional outcomes while retaining cost consciousness. PMID:28426872

The EXCITE Trial: Retention of Improved Upper Extremity Function Among Stroke Survivors Receiving CI Movement Therapy

PubMed Central

Wolf, Steven L.; Winstein, Carolee J.; Miller, J Phillip; Thompson, Paul A.; Taub, Edward; Uswatte, Gitendra; Morris, David; Blanton, Sarah; Nichols-Larsen, Deborah; Clark, Patricia C.

2008-01-01

Summary Background Constraint-Induced Movement therapy (CIMT) uses a variety of treatment components, including restricted use of the better upper extremity, to promote increased use of the contralesional limb for many hours each weekday over two consecutive weeks. The EXCITE Trial demonstrated the efficacy of this intervention for patients 3-9 months post-stroke who were followed for the next 12 months. We assessed the retention of improvements through 24 months. Method Measurements were made every four months for impaired upper extremity function (Wolf Motor Function Test - WMFT and Motor Activity Log - MAL) and health related quality of life (Stroke Impact Scale - SIS) amongst 106/222 participants randomized into one arm of the EXCITE Trial in which they received CIMT rather than usual and customary care. Findings There was no observed regression from the treatment effects observed at 12 months after treatment during the next 12 months for the primary outcome measures of WMFT and MAL. In fact, the additional changes were in the direction of increased therapeutic effect. For the strength components of the WMFT the changes were significant (P < .05) Secondary outcome variables, including the SIS, exhibited a similar pattern. Interpretation Mild to moderately impaired patients who are 3-9 months post-stroke demonstrate substantial improvement in functional use of the paretic upper extremity and quality of life 2 years after receiving a 2-week CIMT intervention. Thus this intervention has persistent benefits. PMID:18077218

Social Ties and Cognitive Recovery after Stroke: Does Social Integration Promote Cognitive Resilience?

PubMed Central

Glymour, M. Maria; Weuve, Jennifer; Fay, Martha E.; Glass, Thomas; Berkman, Lisa F.

2008-01-01

Background/Aims Little is known about the possible effects of social resources on stroke survivors’ level and change in cognitive outcomes. Understanding this association may help us identify strategies to improve stroke recovery and help elucidate the etiology of dementia. Methods We examined the relationship of social ties and social support to cognitive function and cognitive change 6 months after stroke. Participants in the Families in Recovery from Stroke Trial (FIRST) (n = 272) were interviewed approximately 17 days (baseline) and 6 months (follow-up) after stroke. Cognition was assessed with the Mini Mental State Examination (MMSE) and a summary battery of 7 neuropsychological tests. Median-based regression was used to model cognitive outcomes by level of baseline intimate, personal and organizational social ties and received emotional and instrumental support. Results Baseline social ties and emotional sup- port independently predicted 6-month Cognitive Summary Scores. Emotional support also predicted greater improvements in Cognitive Summary Scores from baseline to the 6-month follow-up. No other social exposures predicted improvements in the MMSE or the Cognitive Summary. Conclusions Our results suggest that emotional support may promote cognitive resilience while social ties provide cognitive reserve that protects against impaired cognition after stroke. Social ties did not predict cognitive recovery however, so reverse causation cannot be ruled out. PMID:18535395

Predicting stroke outcome using DCE-CT measured blood velocity

NASA Astrophysics Data System (ADS)

Oosterbroek, Jaap; Bennink, Edwin; Dankbaar, Jan Willem; Horsch, Alexander D.; Viergever, Max A.; Velthuis, Birgitta K.; de Jong, Hugo W. A. M.

2015-03-01

CT plays an important role in the diagnosis of acute stroke patients. Dynamic contrast enhanced CT (DCE-CT) can estimate local tissue perfusion and extent of ischemia. However, hemodynamic information of the large intracranial vessels may also be obtained from DCE-CT data and may contain valuable diagnostic information. We describe a novel method to estimate intravascular blood velocity (IBV) in large cerebral vessels using DCE-CT data, which may be useful to help predict stroke outcome. DCE-CT scans from 34 patients with isolated M1 occlusions were included from a large prospective multi-center cohort study of patients with acute ischemic stroke. Gaussians fitted to the intravascular data yielded the time-to-peak (TTP) and cerebral-blood-volume (CBV). IBV was computed by taking the inverse of the TTP gradient magnitude. Voxels with a CBV of at least 10% of the CBV found in the arterial input function were considered part of a vessel. Mid-sagittal planes were drawn manually and averages of the IBV over all vessel-voxels (arterial and venous) were computed for each hemisphere. Mean-hemisphere IBV differences, mean-hemisphere TTP differences, and hemisphere vessel volume differences were used to differentiate between patients with good and bad outcome (modified Rankin Scale score <3 versus ≥3 at 90 days) using ROC analysis. AUCs from the ROC for IBV, TTP, and vessel volume were 0.80, 0.67 and 0.62 respectively. In conclusion, IBV was found to be a better predictor of patient outcome than the parameters used to compute it and may be a promising new parameter for stroke outcome prediction.

Outcome of stroke patients receiving different doses of recombinant tissue plasminogen activator.

PubMed

Ong, Cheung-Ter; Wong, Yi-Sin; Wu, Chi-Shun; Su, Yu-Hsiang

2017-01-01

Intravenous recombinant tissue plasminogen activator (tPA) at a dose of 0.9 mg/kg body weight is associated with a high hemorrhagic transformation (HT) rate. Low-dose tPA (0.6 mg/kg) may have a lower hemorrhage rate but the mortality and disability rates at 90 days cannot be confirmed as non-inferior to standard-dose tPA. Whether the doses 0.7 and 0.8 mg/kg have better efficacy and safety needs further investigation. Therefore, this study is to compare the efficacy and safety of each dose of tPA (0.6, 0.7, 0.8, and 0.9 mg/kg body weight) and to investigate the factors affecting early neurological improvement (ENI) and early neurological deterioration (END). For this observational study, data were obtained from 274 patients who received tPA thrombolytic therapy in Chia-Yi Christian Hospital stroke unit. The tPA dose was given at the discretion of each physician. The definition of ENI was a >8 point improvement (compared with baseline) at 24 h following thrombolytic therapy or an improvement in the National Institutes of Health Stroke Score (NIHSS) to 0 or 1 toward the end of tPA infusion. The definition of END was a >4 point increase in NIHSS (compared with baseline) within 24 h of tPA infusion. The primary objective was to investigate whether 0.7 and 0.8 mg/kg of tPA have higher ENI rate, lower END rate, and better outcome at 6 months. Poor outcome was defined as having a modified Rankin Scale of 3 to 6 (range, 0 [no symptoms] to 6 [death]). The secondary objective was to investigate whether low-dose tPA has a lower risk of intracerebral HT than that with standard-dose tPA. We also investigated the factors affecting ENI, END, HT, and 6-month outcome. A total of 274 patients were included during the study period, of whom 260 were followed up for >6 months. There was a trend for the HT rate to increase as the dose increased ( P =0.02). The symptomatic HT rate was not significantly different among the low-dose and standard-dose groups. The ENI and END ( P =0.52) were not significantly different among the four dosage groups. The clinical functional outcome at 6 months after stroke onset was poorer in the standard-dose group ( P =0.02). Stroke severity ( P <0.01), stroke type ( P =0.03), and diabetes mellitus ( P =0.04) affected the functional outcome at 6 months. Among the 274 patients receiving tPA thrombolytic therapy, the HT rate increased as dose increased. The symptomatic HT, ENI and END rates were not significantly different among the low-dose (0.6, 0.7, and 0.8 mg/kg) and standard-dose groups. Stroke severity (NIHSS >12), stroke type (cardioembolism and large artery atherosclerosis) and diabetes mellitus were associated with poor outcome at 6 months.

Mortality and Disability According to Baseline Blood Pressure in Acute Ischemic Stroke Patients Treated by Thrombectomy: A Collaborative Pooled Analysis.

PubMed

Maïer, Benjamin; Gory, Benjamin; Taylor, Guillaume; Labreuche, Julien; Blanc, Raphaël; Obadia, Michael; Abrivard, Marie; Smajda, Stanislas; Desilles, Jean-Philippe; Redjem, Hocine; Ciccio, Gabriele; Lukaszewicz, Anne Claire; Turjman, Francis; Riva, Roberto; Labeyrie, Paul Emile; Duhamel, Alain; Blacher, Jacques; Piotin, Michel; Lapergue, Bertrand; Mazighi, Mikael

2017-10-10

High blood pressure (BP) is associated with worse clinical outcomes in the setting of acute ischemic stroke, but the optimal blood pressure target is still a matter of debate. We aimed to study the association between baseline BP and mortality in acute ischemic stroke patients treated by mechanical thrombectomy. A total of 1332 acute ischemic stroke patients treated by mechanical thrombectomy were enrolled (from January 2012 to June 2016) in the ETIS (Endovascular Treatment in Ischemic Stroke) registry. Linear and polynomial logistic regression models were used to assess the association between BP and mortality and functional outcome at 90 days. Highest mortality was found at lower and higher baseline systolic blood pressure (SBP) values following a J- or U-shaped relationship, with a nadir at 157 mm Hg (95% confidence interval 143-170). When SBP values were categorized in 10-mm Hg increments, the odds ratio for all-cause mortality was 3.78 (95% confidence interval 1.50-9.55) for SBP<110 mm Hg and 1.81 (95% confidence interval 1.01-3.36) for SBP≥180 mm Hg using SBP≥150 to 160 mm Hg as reference. The rate of favorable outcome was the highest at low SBP values and lowest at high SBP values, with a nonlinear relationship; in unplanned exploratory analysis, an optimal threshold SBP≥177 mm Hg was found to predict unfavorable outcome (adjusted odds ratio 0.47; 95% confidence interval 0.31-0.70). In acute ischemic stroke patients treated by mechanical thrombectomy, baseline SBP is associated with all-cause mortality and favorable outcome. In contrast to mortality, favorable outcome rate was the highest at low SBP values and lowest at high SBP values. Further studies are warranted to confirm these findings. © 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

A randomized controlled trial of water-based exercise for cardiovascular fitness in individuals with chronic stroke

PubMed Central

Chu, Kelly S; Eng, Janice J; Dawson, Andrew S; Harris, Jocelyn E.; Ozkaplan, Atila; Gylfadóttir, Sif

2011-01-01

Objective To evaluate the effect of an 8-week water-based exercise program (experimental group) over an upper extremity function program (control group) to increase cardiovascular fitness within a community setting for individuals with stroke. Design Single-blind randomized controlled trial Setting Public community centre Participants 12 community-dwelling individuals who have had a stroke with mild to moderate motor deficits; volunteer sample Intervention Experimental and control groups participated in group exercise programs undertaken in one hour sessions, three times per week for 8 weeks. The experimental group undertook chest deep water exercises at targeted heart rates. The control group performed arm and hand exercises while sitting. Main Outcome Measures The primary outcome measure was cardiovascular fitness (VO2max). Secondary measures were maximal workload, muscle strength, gait speed, and the Berg Balance Score. Results The experimental group attained significant improvements over the control group in cardiovascular fitness, maximal workload, gait speed, and paretic lower extremity muscle strength. The relatively short program (8 weeks) of water-based exercise resulted in a large improvement (22%) in cardiovascular fitness in a small group of individuals with stroke with relatively high function. Conclusions A water-based exercise program can be undertaken in the community as a group program and may be an effective means to promote fitness in individuals with stroke. PMID:15179638

Validation of the Chinese Version of the Functional Oral Intake Scale (FOIS) Score in the Assessment of Acute Stroke Patients with Dysphagia.

PubMed

Zhou, Hongzhen; Zhu, Yafang; Zhang, Xiaomei

2017-01-01

This study aimed to validate the Chinese version of the Functional Oral Intake Scale (FOIS) score in acute stroke patients with dysphagia. A sample of 128 consecutive patients with acute stroke, admitted to Department of Neurology from April to October in 2016, completed the FOIS. The interrater reliability, criterion validity, discriminant validity, cross validation, and the sensitivity of FOIS scale were evaluated. Results showed that rater agreements were excellent for FOIS (Kw = 0.881, p < 0.001). A highly negative correlation between FOIS and WST (water swallow test) was detected (r = -0.937, p < 0.001). There was significant difference for FOIS level of patients with different evaluation outcomes (χ² = 126.551, p < 0.001). The FOIS evaluation results were significantly correlated with two physiological measures of swallowing. The Chinese version of the FOIS score is a reliable scale for evaluating the level of oral feeding function in patients with acute stroke.

Critical Role of the Sphingolipid Pathway in Stroke: a Review of Current Utility and Potential Therapeutic Targets.

PubMed

Sun, Na; Keep, Richard F; Hua, Ya; Xi, Guohua

2016-10-01

Sphingolipids are a series of cell membrane-derived lipids which act as signaling molecules and play a critical role in cell death and survival, proliferation, recognition, and migration. Sphingosine-1-phosphate acts as a key signaling molecule and regulates lymphocyte trafficking, glial cell activation, vasoconstriction, endothelial barrier function, and neuronal death pathways which plays a critical role in numerous neurological conditions. Stroke is a second leading cause of death all over the world and effective therapies are still in great demand, including ischemic stroke and hemorrhagic stroke as well as poststroke repair. Significantly, sphingolipid activities change after stroke and correlate with stroke outcome, which has promoted efforts to testify whether the sphingolipid pathway could be a novel therapeutic target in stroke. The sphingolipid metabolic pathway, the connection between the pathway and stroke, as well as therapeutic interventions to manipulate the pathway to reduce stroke-induced brain injury are discussed in this review.

A cross-sectional study of quality of life in incident stroke survivors in rural northern Tanzania.

PubMed

Howitt, Suzanne C; Jones, Matthew P; Jusabani, Ahmed; Gray, William K; Aris, Eric; Mugusi, Ferdinand; Swai, Mark; Walker, Richard W

2011-08-01

The aim of this study was to evaluate changes to, and predictors of, quality of life (QOL) in a community-based cohort of stroke survivors from an earlier stroke incidence study in rural northern Tanzania. Patients were assessed 1-5 years after their incident stroke. The study cohort was compared with an age- and sex-matched control group from the same rural district within a cross-sectional design. Patients and controls were asked a series of questions relating to their QOL [World Health Organization quality of life, abbreviated version (WHOQOL-BREF)], levels of anxiety and depression [hospital anxiety and depression (HAD) scale], cognitive function [community screening instrument for dementia (CSI-D) screening tool], socioeconomic status and demographic characteristics (e.g. age, sex, education and abode). Patients were further assessed for functional outcome and disability (Barthel index, modified Rankin scale), post-stroke care and psychosocial functioning. Patients (n = 58) were found to have significantly lower QOL than controls (n = 58) in all six domains of the WHOQOL-BREF. Gender, socioeconomic status, cognitive function and time elapsed since stroke were not associated with QOL. Older patients and those with more impaired motor function and disability (Barthel index, modified Rankin score) had significantly poorer physical health-related QOL. Greater anxiety and depression, reduced muscle power and less involvement in social events were significantly correlated with lower physical and psychological health-related QOL. To our knowledge, this is the first long-term study of QOL in survivors of incident stroke in Sub-Saharan Africa (SSA). Poorer QOL was associated with greater levels of physical disability, anxiety and depression and reduced social interaction. Demographic factors appear to be much less significant. Modifying these QOL predictors could be important in planning effective post-stroke care within a stretched healthcare system.

A treatment for a chronic stroke patient with a plegic hand combining CI therapy with conventional rehabilitation procedures: case report.

PubMed

Bowman, Mary H; Taub, Edward; Uswatte, Gitendra; Delgado, Adriana; Bryson, Camille; Morris, David M; McKay, Staci; Mark, Victor W

2006-01-01

Constraint-Induced Movement therapy (CI therapy) is a recognized rehabilitation approach for persons having stroke with mild to moderately severe motor upper extremity deficits. To date, no rehabilitation treatment protocol has been proven effective that addresses both motor performance and spontaneous upper extremity use in the life situation for chronic stroke participants having severe upper extremity impairment with no active finger extension or thumb abduction. This case report describes treatment of a chronic stroke participant with a plegic hand using a CI therapy protocol that combines CI therapy with selected occupational and physical therapy techniques. Treatment consisted of six sessions of adaptive equipment and upper extremity orthotics training followed by a three-week, six-hour daily intervention of CI therapy plus neurodevelopmental treatment. Outcome measures included the Motor Activity Log for very low functioning patients (Grade 5 MAL), upper extremity portion of the Fugl-Meyer Motor Assessment, Graded Wolf Motor Function Test - for very low functioning patients (gWMFT- Grade 5), and Modified Ashworth Scale. The participant showed improvement on each outcome measure with the largest improvement on the Grade 5 MAL. In follow-up, the participant had good retention of his gains in motor performance and use of his more affected arm for real world activities after 3 months; after a one-week brush-up at 3 months, and at one year post-treatment.

Feasibility of early functional rehabilitation in acute stroke survivors using the Balance-Bed—a technology that emulates microgravity

PubMed Central

Oddsson, Lars I. E.; Finkelstein, Marsha J.; Meissner, Sarah

2015-01-01

Evidence-based guidelines recommend early functional rehabilitation of stroke patients when risk of patient harm can be managed. Current tools do not allow balance training under load conditions sufficiently low for acute stroke patients. This single-arm pilot study tested feasibility and safety for acute stroke survivors to use “Balance-Bed”, a technology for balance exercises in supine initially developed to emulate microgravity effects on balance. Nine acute stroke patients (50–79 years) participated in 3–10 sessions over 16–46 days as part of their rehabilitation in a hospital inpatient setting. Standard inpatient measures of outcome were monitored where lack of progress from admission to discharge might indicate possible harm. Total FIM scores at admission (median 40, range 22–53) changed to (74, 50–96), Motor FIM scores from (23, 13–32) to (50, 32–68) and Berg Balance scores from (3, 0–6) to (19, 7–43) at discharge. Changes reached Minimal Clinical Important Difference for a sufficient proportion (>0.6) of the patients to indicate no harm to the patients. In addition, therapists reported the technology was safe, provided a positive experience for the patient and fit within the rehabilitation program. They reported the device should be easier to set up and exit. We conclude acute stroke patients tolerated Balance-Bed exercises such as standing on one or two legs, squats, stepping in place as well as balance perturbations provided by the therapist. We believe this is the first time it has been demonstrated that acute stroke patients can safely perform whole body balance training including balance perturbations as part of their rehabilitation program. Future studies should include a control group and compare outcomes from best practices to interventions using the Balance-Bed. In addition, the technology is relevant for countermeasure development for spaceflight and as a test-bed of balance function under microgravity-like conditions. PMID:26074789

Innovative STRoke Interactive Virtual thErapy (STRIVE) online platform for community-dwelling stroke survivors: a randomised controlled trial protocol.

PubMed

Johnson, Liam; Bird, Marie-Louise; Muthalib, Makii; Teo, Wei-Peng

2018-01-09

The STRoke Interactive Virtual thErapy (STRIVE) intervention provides community-dwelling stroke survivors access to individualised, remotely supervised progressive exercise training via an online platform. This trial aims to determine the clinical efficacy of the STRIVE intervention and its effect on brain activity in community-dwelling stroke survivors. In a multisite, assessor-blinded randomised controlled trial, 60 stroke survivors >3 months poststroke with mild-to-moderate upper extremity impairment will be recruited and equally randomised by location (Melbourne, Victoria or Launceston, Tasmania) to receive 8 weeks of virtual therapy (VT) at a local exercise training facility or usual care. Participants allocated to VT will perform 3-5 upper limb exercises individualised to their impairment severity and preference, while participants allocated to usual care will be asked to maintain their usual daily activities. The primary outcome measures will be upper limb motor function and impairment, which will be assessed using the Action Research Arm Test and Upper Extremity Fugl-Meyer, respectively. Secondary outcome measures include upper extremity function and spasticity, as measured by the box and block test and Modified AshworthScale, respectively, and task-related changes in bilateral sensorimotor cortex haemodynamics during hand reaching and wrist extension movements as measured by functional near-infrared spectroscopy. Quality of life will be measured using the Euro-Quality of Life-5 Dimension-5 Level Scale, and the Motor Activity Log-28 will be used to measure use of the hemiparetic arm. All measures will be assessed at baseline and immediately postintervention. The study was approved by the Deakin University Human Research Ethics Committee in May 2017 (No. 2017-087). The results will be disseminated in peer-reviewed journals and presented at major international stroke meetings. ACTRN12617000745347; Pre-results. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Innovative STRoke Interactive Virtual thErapy (STRIVE) online platform for community-dwelling stroke survivors: a randomised controlled trial protocol

PubMed Central

Bird, Marie-Louise; Muthalib, Makii

2018-01-01

Introduction The STRoke Interactive Virtual thErapy (STRIVE) intervention provides community-dwelling stroke survivors access to individualised, remotely supervised progressive exercise training via an online platform. This trial aims to determine the clinical efficacy of the STRIVE intervention and its effect on brain activity in community-dwelling stroke survivors. Methods and analysis In a multisite, assessor-blinded randomised controlled trial, 60 stroke survivors >3 months poststroke with mild-to-moderate upper extremity impairment will be recruited and equally randomised by location (Melbourne, Victoria or Launceston, Tasmania) to receive 8 weeks of virtual therapy (VT) at a local exercise training facility or usual care. Participants allocated to VT will perform 3–5 upper limb exercises individualised to their impairment severity and preference, while participants allocated to usual care will be asked to maintain their usual daily activities. The primary outcome measures will be upper limb motor function and impairment, which will be assessed using the Action Research Arm Test and Upper Extremity Fugl-Meyer, respectively. Secondary outcome measures include upper extremity function and spasticity, as measured by the box and block test and Modified AshworthScale, respectively, and task-related changes in bilateral sensorimotor cortex haemodynamics during hand reaching and wrist extension movements as measured by functional near-infrared spectroscopy. Quality of life will be measured using the Euro-Quality of Life-5 Dimension-5 Level Scale, and the Motor Activity Log-28 will be used to measure use of the hemiparetic arm. All measures will be assessed at baseline and immediately postintervention. Ethics and dissemination The study was approved by the Deakin University Human Research Ethics Committee in May 2017 (No. 2017–087). The results will be disseminated in peer-reviewed journals and presented at major international stroke meetings. Trial registration number ACTRN12617000745347; Pre-results. PMID:29317414

A family involvement and patient-tailored health management program in elderly Korean stroke patients' day care centers.

PubMed

Chang, Ae Kyung; Park, Yeon-Hwan; Fritschi, Cynthia; Kim, Mi Ja

2015-01-01

This study aimed to examine the effects of a family involvement and functional rehabilitation program in an adult day care center on elderly Korean stroke patients' perceived health, activities of daily living, instrumental activities of daily living, and cost of health services, and on family caregivers' satisfaction. Using one-group pre- and posttest design, dyads consisting of 19 elderly stroke patients and family caregivers participated in 12-week intervention, including involvement of family caregivers in day care services and patient-tailored health management. Outcomes of patients and caregivers were significantly improved (all p < .001). However, the cost of health services did not decrease significantly. This program improved functional levels and health perception of elderly stroke patients and caregivers' satisfaction. However, results must be interpreted with caution, because this was only a small, single-group pilot study. This program may be effective for elderly stroke patients and their caregivers. © 2013 Association of Rehabilitation Nurses.

Tailor-made rehabilitation approach using multiple types of hybrid assistive limb robots for acute stroke patients: A pilot study.

PubMed

Fukuda, Hiroyuki; Morishita, Takashi; Ogata, Toshiyasu; Saita, Kazuya; Hyakutake, Koichi; Watanabe, Junko; Shiota, Etsuji; Inoue, Tooru

2016-01-01

This article investigated the feasibility of a tailor-made neurorehabilitation approach using multiple types of hybrid assistive limb (HAL) robots for acute stroke patients. We investigated the clinical outcomes of patients who underwent rehabilitation using the HAL robots. The Brunnstrom stage, Barthel index (BI), and functional independence measure (FIM) were evaluated at baseline and when patients were transferred to a rehabilitation facility. Scores were compared between the multiple-robot rehabilitation and single-robot rehabilitation groups. Nine hemiplegic acute stroke patients (five men and four women; mean age 59.4 ± 12.5 years; four hemorrhagic stroke and five ischemic stroke) underwent rehabilitation using multiple types of HAL robots for 19.4 ± 12.5 days, and 14 patients (six men and eight women; mean age 63.2 ± 13.9 years; nine hemorrhagic stroke and five ischemic stroke) underwent rehabilitation using a single type of HAL robot for 14.9 ± 8.9 days. The multiple-robot rehabilitation group showed significantly better outcomes in the Brunnstrom stage of the upper extremity, BI, and FIM scores. To the best of the authors' knowledge, this is the first pilot study demonstrating the feasibility of rehabilitation using multiple exoskeleton robots. The tailor-made rehabilitation approach may be useful for the treatment of acute stroke.

Prediction of recovery of motor function after stroke.

PubMed

Stinear, Cathy

2010-12-01

Stroke is a leading cause of disability. The ability to live independently after stroke depends largely on the reduction of motor impairment and the recovery of motor function. Accurate prediction of motor recovery assists rehabilitation planning and supports realistic goal setting by clinicians and patients. Initial impairment is negatively related to degree of recovery, but inter-individual variability makes accurate prediction difficult. Neuroimaging and neurophysiological assessments can be used to measure the extent of stroke damage to the motor system and predict subsequent recovery of function, but these techniques are not yet used routinely. The use of motor impairment scores and neuroimaging has been refined by two recent studies in which these investigations were used at multiple time points early after stroke. Voluntary finger extension and shoulder abduction within 5 days of stroke predicted subsequent recovery of upper-limb function. Diffusion-weighted imaging within 7 days detected the effects of stroke on caudal motor pathways and was predictive of lasting motor impairment. Thus, investigations done soon after stroke had good prognostic value. The potential prognostic value of cortical activation and neural plasticity has been explored for the first time by two recent studies. Functional MRI detected a pattern of cortical activation at the acute stage that was related to subsequent reduction in motor impairment. Transcranial magnetic stimulation enabled measurement of neural plasticity in the primary motor cortex, which was related to subsequent disability. These studies open interesting new lines of enquiry. WHERE NEXT?: The accuracy of prediction might be increased by taking into account the motor system's capacity for functional reorganisation in response to therapy, in addition to the extent of stroke-related damage. Improved prognostic accuracy could also be gained by combining simple tests of motor impairment with neuroimaging, genotyping, and neurophysiological assessment of neural plasticity. The development of algorithms to guide the sequential combinations of these assessments could also further increase accuracy, in addition to improving rehabilitation planning and outcomes. Copyright © 2010 Elsevier Ltd. All rights reserved.

A Review of Transcranial Magnetic Stimulation and Multimodal Neuroimaging to Characterize Post-Stroke Neuroplasticity

PubMed Central

Auriat, Angela M.; Neva, Jason L.; Peters, Sue; Ferris, Jennifer K.; Boyd, Lara A.

2015-01-01

Following stroke, the brain undergoes various stages of recovery where the central nervous system can reorganize neural circuitry (neuroplasticity) both spontaneously and with the aid of behavioral rehabilitation and non-invasive brain stimulation. Multiple neuroimaging techniques can characterize common structural and functional stroke-related deficits, and importantly, help predict recovery of function. Diffusion tensor imaging (DTI) typically reveals increased overall diffusivity throughout the brain following stroke, and is capable of indexing the extent of white matter damage. Magnetic resonance spectroscopy (MRS) provides an index of metabolic changes in surviving neural tissue after stroke, serving as a marker of brain function. The neural correlates of altered brain activity after stroke have been demonstrated by abnormal activation of sensorimotor cortices during task performance, and at rest, using functional magnetic resonance imaging (fMRI). Electroencephalography (EEG) has been used to characterize motor dysfunction in terms of increased cortical amplitude in the sensorimotor regions when performing upper limb movement, indicating abnormally increased cognitive effort and planning in individuals with stroke. Transcranial magnetic stimulation (TMS) work reveals changes in ipsilesional and contralesional cortical excitability in the sensorimotor cortices. The severity of motor deficits indexed using TMS has been linked to the magnitude of activity imbalance between the sensorimotor cortices. In this paper, we will provide a narrative review of data from studies utilizing DTI, MRS, fMRI, EEG, and brain stimulation techniques focusing on TMS and its combination with uni- and multimodal neuroimaging methods to assess recovery after stroke. Approaches that delineate the best measures with which to predict or positively alter outcomes will be highlighted. PMID:26579069

Mexican Americans Receive Less Intensive Stroke Rehabilitation Than Non-Hispanic Whites.

PubMed

Morgenstern, Lewis B; Sais, Emma; Fuentes, Michael; Ifejika, Nneka L; Jiang, Xiaqing; Horn, Susan D; Case, Erin; Lisabeth, Lynda D

2017-06-01

Mexican Americans (MAs) have worse neurological, functional, and cognitive outcomes after stroke. Stroke rehabilitation is important for good outcome. In a population-based study, we sought to determine whether allocation of stroke rehabilitation services differed by ethnicity. Patients with stroke were identified as part of the Brain Attack Surveillance in Corpus Christi (BASIC) project, TX, USA. Cases were validated by physicians using source documentation. Patients were followed prospectively for 3 months after stroke to determine rehabilitation services and transitions. Descriptive statistics were used to depict the study population. Continuous baseline variables were compared using 2 sample t tests or Wilcoxon rank-sum tests by ethnicity. Categorical baseline variables were compared using χ 2 tests. Ethnic comparisons of rehabilitation services were compared using χ 2 tests, Fisher's exact tests, and logistic regression. Seventy-two subjects (50 MA and 22 non-Hispanic white [NHW]) were followed. Mean age, NHW-69 (SD 13), MA-66 (SD 11) years, sex (NHW 55% male, MA 50% male) and median presenting National Institutes of Health Stroke Scale did not differ significantly. There were no ethnic differences among the proportion of patients who were sent home without any rehabilitation services ( P =0.9). Among those who received rehabilitation, NHWs were more likely to get inpatient rehabilitation (73%) compared with MAs (30%), P =0.016. MAs (51%) were much more likely to receive home rehabilitation services compared with NHWs (0%) ( P =0.0017). In this population-based study, MAs were more likely to receive home-based rehabilitation, whereas NHWs were more likely to get inpatient rehabilitation. This disparity may, in part, explain the worse stroke outcome in MAs. © 2017 American Heart Association, Inc.

History of AIDS in HIV-Infected Patients Is Associated With Higher In-Hospital Mortality Following Admission for Acute Myocardial Infarction and Stroke.

PubMed

Okeke, Nwora Lance; Hicks, Charles B; McKellar, Mehri S; Fowler, Vance G; Federspiel, Jerome J

2016-06-15

Although human immunodeficiency virus (HIV)-infected persons are at increased risk for major cardiovascular events, short-term prognosis after these events is unclear. To determine the association between HIV infection and acute myocardial infarction (AMI) and stroke outcomes, we analyzed hospital discharge data from the Nationwide Inpatient Sample (NIS) between 2002 and 2012. Multivariable logistic regression was used to evaluate the association between HIV infection and in-hospital death after AMI or stroke. Overall, 18 369 785 AMI/stroke hospitalizations were included in the analysis. Patients with a history of AIDS were significantly more likely than uninfected patients to die during hospitalization after admission for AMI or stroke (odds ratio, 3.03 [95% confidence interval {CI}, 1.71-5.38] for AMI and 2.59 [95% CI, 1.97-3.41] for stroke). Additionally, patients with AIDS were more likely than HIV-uninfected patients to be discharged to nonhospital inpatient facilities after admission for AMI (OR, 3.14 [95% CI, 1.72-5.74]) or stroke (OR, 1.45; 95% CI, 1.12-1.87). There was a minimal difference in either outcome between HIV-infected patients without a history of AIDS and uninfected patients. Patients with a history of AIDS were significantly more likely than uninfected patients to die during hospitalization after admission for AMI or stroke. This disparity was not observed when infected patients without a history of AIDS were compared to uninfected patients, implying that preserving immune function may improve cardiovascular outcomes in HIV-infected persons. © The Author 2016. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail journals.permissions@oup.com.

Improving Adherence to Secondary Stroke Prevention Strategies Through Motivational Interviewing: Randomized Controlled Trial.

PubMed

Barker-Collo, Suzanne; Krishnamurthi, Rita; Witt, Emma; Feigin, Valery; Jones, Amy; McPherson, Kathryn; Starkey, Nicola; Parag, Varsha; Jiang, Yannan; Barber, P Alan; Rush, Elaine; Bennett, Derrick; Aroll, Bruce

2015-12-01

Stroke recurrence rates are high (20%-25%) and have not declined over past 3 decades. This study tested effectiveness of motivational interviewing (MI) for reducing stroke recurrence, measured by improving adherence to recommended medication and lifestyle changes compared with usual care. Single-blind, prospective phase III randomized controlled trial of 386 people with stroke assigned to either MI treatment (4 sessions at 28 days, 3, 6, and 9 months post stroke) or usual care; with outcomes assessed at 28 days, 3, 6, 9, and 12 months post stroke. Primary outcomes were change in systolic blood pressure and low-density lipoprotein cholesterol levels as indicators of adherence at 12 months. Secondary outcomes included self-reported adherence, new stroke, or coronary heart disease events (both fatal and nonfatal); quality of life (Short Form-36); and mood (Hospital Anxiety and Depression Scale). MI did not significantly change measures of blood pressure (mean difference in change, -0.2.35 [95% confidence interval, -6.16 to 1.47]) or cholesterol (mean difference in change, -0.0.12 [95% confidence interval, -0.30 to 0.06]). However, it had positive effects on self-reported medication adherence at 6 months (1.979; 95% confidence interval, 0.98-3.98; P=0.0557) and 9 months (4.295; 95% confidence interval, 1.56-11.84; P=0.0049) post stroke. Improvement across other measures was also observed, but the differences between MI and usual care groups were not statistically significant. MI improved self-reported medication adherence. All other effects were nonsignificant, though in the direction of a treatment effect. Further study is required to determine whether MI leads to improvement in other important areas of functioning (eg, caregiver burden). URL: http://www.anzctr.org.au. Unique identifier: ACTRN-12610000715077. © 2015 American Heart Association, Inc.

A pilot study of activity-based therapy in the arm motor recovery post stroke: a randomized controlled trial.

PubMed

Rabadi, Mh; Galgano, M; Lynch, D; Akerman, M; Lesser, M; Volpe, Bt

2008-12-01

To determine the efficacy of activity-based therapies using arm ergometer or robotic or group occupational therapy for motor recovery of the paretic arm in patients with an acute stroke (< or =4 weeks) admitted to an inpatient rehabilitation facility, and to obtain information to plan a large randomized controlled trial. Prospective, randomized controlled study. Stroke unit in a rehabilitation hospital. Thirty patients with an acute stroke (< or =4 weeks) who had arm weakness (Medical Research Council grade 2 or less at the shoulder joint). Occupational therapy (OT) group (control) (n = 10), arm ergometer (n = 10) or robotic (n = 10) therapy group. All patients received standard, inpatient, post-stroke rehabilitation training for 3 hours a day, plus 12 additional 40-minute sessions of the activity-based therapy. The primary outcome measures were discharge scores in the Fugl-Meyer Assessment Scale for upper limb impairment, Motor Status Scale, total Functional Independence Measure (FIM) and FIM-motor and FIM-cognition subscores. The three groups (OT group versus arm ergometer versus robotic) were comparable on clinical demographic measures except the robotic group was significantly older and there were more haemorrhagic stroke patients in the arm ergometer group. After adjusting for age, stroke type and outcome measures at baseline, a similar degree of improvement in the discharge scores was found in all of the primary outcome measures. This study suggests that activity-based therapies using an arm ergometer or robot when used over shortened training periods have the same effect as OT group therapy in decreasing impairment and improving disability in the paretic arm of severely affected stroke patients in the subacute phase.

The effects of mirror therapy with tasks on upper extremity function and self-care in stroke patients.

PubMed

Park, Youngju; Chang, Moonyoung; Kim, Kyeong-Mi; An, Duk-Hyun

2015-05-01

[Purpose] The purpose of this study was to determine the effects of mirror therapy with tasks on upper extremity unction and self-care in stroke patients. [Subjects] Thirty participants were randomly assigned to either an experimental group (n=15) or a control group (n=15). [Methods] Subjects in the experimental group received mirror therapy with tasks, and those in the control group received a sham therapy; both therapies were administered, five times per week for six weeks. The main outcome measures were the Manual Function Test for the paralyzed upper limb and the Functional Independence Measure for self-care performance. [Results] The experimental group had more significant gains in change scores compared with the control group after the intervention. [Conclusion] We consider mirror therapy with tasks to be an effective form of intervention for upper extremity function and self-care in stroke patients.

Cognitive rehabilitation for executive dysfunction in adults with stroke or other adult non-progressive acquired brain damage.

PubMed

Chung, Charlie S Y; Pollock, Alex; Campbell, Tanya; Durward, Brian R; Hagen, Suzanne

2013-04-30

Executive functions are the controlling mechanisms of the brain and include the processes of planning, initiation, organisation, inhibition, problem solving, self monitoring and error correction. They are essential for goal-oriented behaviour and responding to new and novel situations. A high number of people with acquired brain injury, including around 75% of stroke survivors, will experience executive dysfunction. Executive dysfunction reduces capacity to regain independence in activities of daily living (ADL), particularly when alternative movement strategies are necessary to compensate for limb weakness. Improving executive function may lead to increased independence with ADL. There are various cognitive rehabilitation strategies for training executive function used within clinical practice and it is necessary to determine the effectiveness of these interventions. To determine the effects of cognitive rehabilitation on executive dysfunction for adults with stroke or other non-progressive acquired brain injuries. We searched the Cochrane Stroke Group Trials Register (August 2012), the Cochrane Central Register of Controlled Trials (The Cochrane Library, August 2012), MEDLINE (1950 to August 2012), EMBASE (1980 to August 2012), CINAHL (1982 to August 2012), PsycINFO (1806 to August 2012), AMED (1985 to August 2012) and 11 additional databases. We also searched reference lists and trials registers, handsearched journals and conference proceedings, and contacted experts. We included randomised trials in adults after non-progressive acquired brain injury, where the intervention was specifically targeted at improving cognition including separable executive function data (restorative interventions), where the intervention was aimed at training participants in methods to compensate for lost executive function (compensative interventions) or where the intervention involved the training in the use of an adaptive technique for improving independence with ADL (adaptive interventions). The primary outcome was global executive function and the secondary outcomes were specific components of executive function, working memory, ADL, extended ADL, quality of life and participation in vocational activities. We included studies in which the comparison intervention was no treatment, a placebo intervention (i.e. a rehabilitation intervention that should not impact on executive function), standard care or another cognitive rehabilitation intervention. Two review authors independently screened abstracts, extracted data and appraised trials. We undertook an assessment of methodological quality for allocation concealment, blinding of outcome assessors, method of dealing with missing data and other potential sources of bias. Nineteen studies (907 participants) met the inclusion criteria for this review. We included 13 studies (770 participants) in meta-analyses (417 traumatic brain injury, 304 stroke, 49 other acquired brain injury) reducing to 660 participants once non-included intervention groups were removed from three and four group studies. We were unable to obtain data from the remaining six studies. Three studies (134 participants) compared cognitive rehabilitation with sensorimotor therapy. None reported our primary outcome; data from one study was available relating to secondary outcomes including concept formation and ADL. Six studies (333 participants) compared cognitive rehabilitation with no treatment or placebo. None reported our primary outcome; data from four studies demonstrated no statistically significant effect of cognitive rehabilitation on secondary outcomes. Ten studies (448 participants) compared two different cognitive rehabilitation approaches. Two studies (82 participants) reported the primary outcome; no statistically significant effect was found. Data from eight studies demonstrated no statistically significant effect on the secondary outcomes. We explored the effect of restorative interventions (10 studies, 468 participants) and compensative interventions (four studies, 128 participants) and found no statistically significant effect compared with other interventions. We identified insufficient high-quality evidence to reach any generalised conclusions about the effect of cognitive rehabilitation on executive function, or other secondary outcome measures. Further high-quality research comparing cognitive rehabilitation with no intervention, placebo or sensorimotor interventions is recommended.

Physiotherapy and physical functioning post-stroke: exercise habits and functioning 4 years later? Long-term follow-up after a 1-year long-term intervention period: a randomized controlled trial.

PubMed

Langhammer, Birgitta; Lindmark, Birgitta; Stanghelle, Johan K

2014-01-01

Physical activity is mandatory if patients are to remain healthy and independent after stroke. Maintenance of motor function, tone, grip strength, balance, mobility, gait, independence in personal and instrumental activities of daily living, health-related quality-of-life and an active lifestyle 4 years post-stroke. A prospective randomized controlled trial. Four years post-stroke, 37 of the 75 participating persons were eligible for follow-up; 19 (54.3%) from the intensive exercise group and 18 (45%) from the regular exercise group. Both groups were performing equally well with no significant differences in total scores on the BI (p = 0.3), MAS (p = 0.4), BBS (p = 0.1), TUG (p = 0.08), 6MWT (p = 0.1), bilateral grip strength (affected hand, p = 0.8; non-affected hand, p = 0.9) nor in the items of NHP (p > 0.005). Independence in performing the IADL was 40%, while 60% had help from relatives or community-based services. This longitudinal study shows that persons with stroke in two groups with different exercise regimes during the first year after stroke did not differ in long-term outcomes. Both groups maintained function and had a relatively active life style 4 years after the acute incident. The results underline the importance of follow-up testing and encouragement to exercise, to motivate and sustain physical activity patterns, to maintain physical function, not only in the acute but also in the chronic phase of stroke.

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.

Effect of aphasia on acute stroke outcomes.

PubMed

Boehme, Amelia K; Martin-Schild, Sheryl; Marshall, Randolph S; Lazar, Ronald M

2016-11-29

To determine the independent effects of aphasia on outcomes during acute stroke admission, controlling for total NIH Stroke Scale (NIHSS) scores and loss of consciousness. Data from the Tulane Stroke Registry were used from July 2008 to December 2014 for patient demographics, NIHSS scores, length of stay (LOS), complications (sepsis, deep vein thrombosis), and discharge modified Rankin Scale (mRS) score. Aphasia was defined as a score >1 on question 9 on the NIHSS on admission and hemiparesis as >1 on questions 5 or 6. Among 1,847 patients, 866 (46%) had aphasia on admission. Adjusting for NIHSS score and inpatient complications, those with aphasia had a 1.22 day longer LOS than those without aphasia, whereas those with hemiparesis (n = 1,225) did not have any increased LOS compared to those without hemiparesis. Those with aphasia had greater odds of having a complication (odds ratio [OR] 1.44, confidence interval [CI] 1.07-1.93, p = 0.0174) than those without aphasia, which was equivalent to those having hemiparesis (OR 1.47, CI 1.09-1.99, p = 0.0137). Controlling for NIHSS scores, aphasia patients had higher odds of discharge mRS 3-6 (OR 1.42 vs 1.15). Aphasia is independently associated with increased LOS and complications during the acute stroke admission, adding $2.16 billion annually to US acute stroke care. The presence of aphasia was more likely to produce a poor functional outcome than hemiparesis. These data suggest that further research is necessary to determine whether establishing adaptive communication skills can mitigate its consequences in the acute stroke setting. © 2016 American Academy of Neurology.

Early Intensive Leg Training to Enhance Walking in Children With Perinatal Stroke: Protocol for a Randomized Controlled Trial.

PubMed

Hurd, Caitlin; Livingstone, Donna; Brunton, Kelly; Teves, Michelle; Zewdie, Ephrem; Smith, Allison; Ciechanski, Patrick; Gorassini, Monica A; Kirton, Adam; Watt, Man-Joe; Andersen, John; Yager, Jerome; Yang, Jaynie F

2017-08-01

Development of motor pathways is modulated by activity in these pathways, when they are maturing (ie, critical period). Perinatal stroke injures motor pathways, including the corticospinal tracts, reducing their activity and impairing motor function. Current intervention for the lower limb emphasizes passive approaches (stretching, braces, botulinum toxin injections). The study hypothesis was that intensive, early, child-initiated activity during the critical period will enhance connectivity of motor pathways to the legs and improve motor function. The study objective was to determine whether early intervention with intensive activity is better than standard care, intervention delivered during the proposed critical period is better than after, and the outcomes are different when the intervention is delivered by a physical therapist in an institution vs. a parent at home. A prospective, delay-group, single-blind, randomized controlled trial (RCT) and a parallel, cohort study of children living beyond commuting distance and receiving an intervention delivered by their parent. The RCT intervention was provided in university laboratories, and parent training was provided in the childs home. Children 8 months to 3 years old with MRI-confirmed perinatal ischemic stroke and early signs of hemiparesis. Intensive, play-based leg activity with weights for the affected leg and foot, 1 hour/day, 4 days/week for 12 weeks. The primary outcome was the Gross Motor Function Measure-66 score. Secondary outcomes were motion analysis of walking, full-day step counts, motor evoked potentials from transcranial magnetic stimulation, and patellar tendon reflexes. Inter-individual heterogeneity in the severity of the stroke and behavioral differences are substantial but measurable. Differences in intervention delivery and assessment scoring are minimized by standardization and training. The intervention, contrary to current practice, could change physical therapy interventions for children with perinatal stroke. © 2017 American Physical Therapy Association

Hospitalized hemorrhagic stroke patients with renal insufficiency: clinical characteristics, care patterns, and outcomes.

PubMed

Ovbiagele, Bruce; Schwamm, Lee H; Smith, Eric E; Grau-Sepulveda, Maria V; Saver, Jeffrey L; Bhatt, Deepak L; Hernandez, Adrian F; Peterson, Eric D; Fonarow, Gregg C

2014-10-01

There is a paucity of information on clinical characteristics, care patterns, and clinical outcomes for hospitalized intracerebral hemorrhage (ICH) patients with chronic kidney disease (CKD). We assessed characteristics, care processes, and in-hospital outcome among ICH patients with CKD in the Get With the Guidelines-Stroke (GWTG-Stroke) program. We analyzed 113,059 ICH patients hospitalized at 1472 US centers participating in the GWTG-Stroke program between January 2009 and December 2012. In-hospital mortality and use of 2 predefined ICH performance measures were examined based on glomerular filtration rate. Renal dysfunction was categorized as a dichotomous (+CKD = estimated glomerular filtration rate <60) or rank ordered variable as CKD (<60), and by clinical stage: (normal [≥90], mild [≥60-<90], moderate [≥30-<60], severe [≥15-<30], and/or kidney failure [<15 or dialysis]). There were 33,219 (29%) ICH patients with CKD. Patients with CKD were more likely to be older, female, and with comorbid conditions such as diabetes. Compared with patients with normal kidney function, those with CKD were slightly less likely to receive deep venous thrombosis (DVT) prophylaxis but similarly received discharge smoking cessation intervention. Inpatient mortality was also higher for those with CKD (adjusted odds ratio [OR], 1.47; 95% confidence interval [CI], 1.42-1.52), mild dysfunction (adjusted OR, 1.12; 95% CI, 1.08-1.16), moderate dysfunction (adjusted OR, 1.46; 95% CI, 1.39-1.53), severe dysfunction (adjusted OR, 1.96; 95% CI, 1.81-2.12), and kidney failure (adjusted OR, 2.22; 95% CI, 2.04-2.43) relative to those with normal renal function. Chronic kidney disease is present in nearly a third of patients hospitalized with ICH and is associated with slightly worse care and substantially higher mortality than those with normal renal function. Copyright © 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Novel model of direct and indirect cost-benefit analysis of mechanical embolectomy over IV tPA for large vessel occlusions: a real-world dollar analysis based on improvements in mRS.

PubMed

Mangla, Sundeep; O'Connell, Keara; Kumari, Divya; Shahrzad, Maryam

2016-01-20

Ischemic strokes result in significant healthcare expenditures (direct costs) and loss of quality-adjusted life years (QALYs) (indirect costs). Interventional therapy has demonstrated improved functional outcomes in patients with large vessel occlusions (LVOs), which are likely to reduce the economic burden of strokes. To develop a novel real-world dollar model to assess the direct and indirect cost-benefit of mechanical embolectomy compared with medical treatment with intravenous tissue plasminogen activator (IV tPA) based on shifts in modified Rankin scores (mRS). A cost model was developed including multiple parameters to account for both direct and indirect stroke costs. These were adjusted based upon functional outcome (mRS). The model compared IV tPA with mechanical embolectomy to assess the costs and benefits of both therapies. Direct stroke-related costs included hospitalization, inpatient and outpatient rehabilitation, home care, skilled nursing facilities, and long-term care facility costs. Indirect costs included years of life expectancy lost and lost QALYs. Values for the model cost parameters were derived from numerous resources and functional outcomes were derived from the MR CLEAN study as a reflective sample of LVOs. Direct and indirect costs and benefits for the two treatments were assessed using Microsoft Excel 2013. This cost-benefit model found a cost-benefit of mechanical embolectomy over IV tPA of $163 624.27 per patient and the cost benefit for 50 000 patients on an annual basis is $8 181 213 653.77. If applied widely within the USA, mechanical embolectomy will significantly reduce the direct and indirect financial burden of stroke ($8 billion/50 000 patients). 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/

The UK Functional Assessment Measure (UK FIM+FAM): Psychometric Evaluation in Patients Undergoing Specialist Rehabilitation following a Stroke from the National UK Clinical Dataset.

PubMed

Nayar, Meenakshi; Vanderstay, Roxana; Siegert, Richard J; Turner-Stokes, Lynne

2016-01-01

The UK Functional Assessment Measure (UKFIM+FAM) is the principal outcome measure for the UK Rehabilitation Outcomes Collaborative (UKROC) national database for specialist rehabilitation. Previously validated in a mixed neurorehabilitation cohort, this study is the first to explore its psychometric properties in a stroke population, and compare left and right hemispheric strokes (LHS vs RHS). We analysed in-patient episode data from 62 specialist rehabilitation units collated through the UKROC database 2010-2013. Complete data were analysed for 1,539 stroke patients (LHS: 588, RHS: 566 with clear localisation). For factor analysis, admission and discharge data were pooled and randomised into two equivalent samples; the first for exploratory factor analysis (EFA) using principal components analysis, and the second for confirmatory factor analysis (CFA). Responsiveness for each subject (change from admission to discharge) was examined using paired t-tests and differences between LHS and RHS for the entire group were examined using non-paired t-tests. EFA showed a strong general factor accounting for >48% of the total variance. A three-factor solution comprising motor, communication and psychosocial subscales, accounting for >69% total variance, provided acceptable fit statistics on CFA (Root Mean Square Error of Approximation was 0.08 and Comparative Fit Index/ Tucker Lewis Index 0.922/0.907). All three subscales showed significant improvement between admission and discharge (p<0.001) with moderate effect sizes (>0.5). Total scores between LHS and RHS were not significantly different. However, LHS showed significantly higher motor scores (Mean 5.7, 95%CI 2.7, 8.6 p<0.001), while LHS had significantly lower cognitive scores, primarily in the communication domain (-6.8 95%CI -7.7, -5.8 p<0.001). To conclude, the UK FIM+FAM has a three-factor structure in stroke, similar to the general neurorehabilitation population. It is responsive to change during in-patient rehabilitation, and distinguishes between LHS and RHS. This tool extends stroke outcome measurement beyond physical disability to include cognitive, communication and psychosocial function.

Gait training of patients after stroke using an electromechanical gait trainer combined with simultaneous functional electrical stimulation.

PubMed

Tong, Raymond K Y; Ng, Maple F W; Li, Leonard S W; So, Elaine F M

2006-09-01

This case report describes the implementation of gait training intervention that used an electromechanical gait trainer with simultaneous functional electrical stimulation (FES) for 2 patients with acute ischemic stroke. Two individuals with post-stroke hemiplegia of less than 6 weeks' duration participated in a 4-week gait training program as an adjunct to physical therapy received at a hospital. After the 4-week intervention, both patients were discharged from the hospital, and they returned after 6 months for a follow-up evaluation. By the end of the 4-week intervention, both patients had shown improvements in scores on the Barthel Index, Berg Balance Scale, Functional Ambulation Categories Scale, 5-m timed walking test, and Motricity Index. In the 6-month follow-up evaluation, both patients continued to have improvements in all outcome measures. This case report shows that, following the use of an electromechanical gait trainer simultaneously with FES, patients after acute stroke had improvements in gait performance, functional activities, balance, and motor control in the long term.

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

Transcranial direct current stimulation in post stroke aphasia and primary progressive aphasia: Current knowledge and future clinical applications.

PubMed

Sebastian, Rajani; Tsapkini, Kyrana; Tippett, Donna C

2016-06-13

The application of transcranial direct current stimulation (tDCS) in chronic post stroke aphasia is documented in a substantial literature, and there is some new evidence that tDCS can augment favorable language outcomes in primary progressive aphasia. Anodal tDCS is most often applied to the left hemisphere language areas to increase cortical excitability (increase the threshold of activation) and cathodal tDCS is most often applied to the right hemisphere homotopic areas to inhibit over activation in contralesional right homologues of language areas. Outcomes usually are based on neuropsychological and language test performance, following a medical model which emphasizes impairment of function, rather than a model which emphasizes functional communication. In this paper, we review current literature of tDCS as it is being used as a research tool, and discuss future implementation of tDCS as an adjuvant treatment to behavioral speech-language pathology intervention. We review literature describing non-invasive brain stimulation, the mechanism of tDCS, and studies of tDCS in aphasia and neurodegenerative disorders. We discuss future clinical applications. tDCS is a promising adjunct to traditional speech-language pathology intervention to address speech-language deficits after stroke and in the neurodegenerative disease, primary progressive aphasia. Limited data are available regarding how performance on these types of specific tasks translates to functional communication outcomes.

Transcranial Direct Current Stimulation in Post Stroke Aphasia and Primary Progressive Aphasia: Current Knowledge and Future Clinical Applications

PubMed Central

Sebastian, Rajani; Tsapkini, Kyrana; Tippett, Donna C.

2016-01-01

BACKGROUND The application of transcranial direct current stimulation (tDCS) in chronic post stroke aphasia is documented in a substantial literature, and there is some new evidence that tDCS can augment favorable language outcomes in primary progressive aphasia. Anodal tDCS is most often applied to the left hemisphere language areas to increase cortical excitability (increase the threshold of activation) and cathodal tDCS is most often applied to the right hemisphere homotopic areas to inhibit over activation in contralesional right homologues of language areas. Outcomes usually are based on neuropsychological and language test performance, following a medical model which emphasizes impairment of function, rather than a model which emphasizes functional communication. OBJECTIVE In this paper, we review current literature of tDCS as it is being used as a research tool, and discuss future implementation of tDCS as an adjuvant treatment to behavioral speech-language pathology intervention. METHODS We review literature describing non-invasive brain stimulation, the mechanism of tDCS, and studies of tDCS in aphasia and neurodegenerative disorders. We discuss future clinical applications. RESULTS/CONCLUSIONS tDCS is a promising adjunct to traditional speech-language pathology intervention to address speech-language deficits after stroke and in the neurodegenerative disease, primary progressive aphasia. Limited data are available regarding how performance on these types of specific tasks translates to functional communication outcomes. PMID:27314871

Using wireless technology in clinical practice: does feedback of daily walking activity improve walking outcomes of individuals receiving rehabilitation post-stroke? Study protocol for a randomized controlled trial

PubMed Central

2013-01-01

Background Regaining independent ambulation is the top priority for individuals recovering from stroke. Thus, physical rehabilitation post-stroke should focus on improving walking function and endurance. However, the amount of walking completed by individuals with stroke attending rehabilitation is far below that required for independent community ambulation. There has been increased interest in accelerometer-based monitoring of walking post-stroke. Walking monitoring could be integrated within the goal-setting process for those with ambulation goals in rehabilitation. The feedback from these devices can be downloaded to a computer to produce reports. The purpose of this study is to determine the effect of accelerometer-based feedback of daily walking activity during rehabilitation on the frequency and duration of walking post-stroke. Methods Participants will be randomly assigned to one of two groups: feedback or no feedback. Participants will wear accelerometers daily during in- and out-patient rehabilitation and, for participants in the feedback group, the participants’ treating physiotherapist will receive regular reports of walking activity. The primary outcome measures are the amount of daily walking completed, as measured using the accelerometers, and spatio-temporal characteristics of walking (e.g. walking speed). We will also examine goal attainment, satisfaction with progress towards goals, stroke self-efficacy, and community-integration. Discussion Increased walking activity during rehabilitation is expected to improve walking function and community re-integration following discharge. In addition, a focus on altering walking behaviour within the rehabilitation setting may lead to altered behaviour and increased activity patterns after discharge. Trial registration ClinicalTrials.gov NCT01521234 PMID:23865593

Effects of intensive arm training with the rehabilitation robot ARMin II in chronic stroke patients: four single-cases

PubMed Central

2009-01-01

Background Robot-assisted therapy offers a promising approach to neurorehabilitation, particularly for severely to moderately impaired stroke patients. The objective of this study was to investigate the effects of intensive arm training on motor performance in four chronic stroke patients using the robot ARMin II. Methods ARMin II is an exoskeleton robot with six degrees of freedom (DOF) moving shoulder, elbow and wrist joints. Four volunteers with chronic (≥ 12 months post-stroke) left side hemi-paresis and different levels of motor severity were enrolled in the study. They received robot-assisted therapy over a period of eight weeks, three to four therapy sessions per week, each session of one hour. Patients 1 and 4 had four one-hour training sessions per week and patients 2 and 3 had three one-hour training sessions per week. Primary outcome variable was the Fugl-Meyer Score of the upper extremity Assessment (FMA), secondary outcomes were the Wolf Motor Function Test (WMFT), the Catherine Bergego Scale (CBS), the Maximal Voluntary Torques (MVTs) and a questionnaire about ADL-tasks, progress, changes, motivation etc. Results Three out of four patients showed significant improvements (p < 0.05) in the main outcome. The improvements in the FMA scores were aligned with the objective results of MVTs. Most improvements were maintained or even increased from discharge to the six-month follow-up. Conclusion Data clearly indicate that intensive arm therapy with the robot ARMin II can significantly improve motor function of the paretic arm in some stroke patients, even those in a chronic state. The findings of the study provide a basis for a subsequent controlled randomized clinical trial. PMID:20017939

A cluster randomized trial to assess the effect of clinical pathways for patients with stroke: results of the clinical pathways for effective and appropriate care study

PubMed Central

2012-01-01

Background Clinical pathways (CPs) are used to improve the outcomes of acute stroke, but their use in stroke care is questionable, because the evidence on their effectiveness is still inconclusive. The objective of this study was to evaluate whether CPs improve the outcomes and the quality of care provided to patients after acute ischemic stroke. Methods This was a multicentre cluster-randomized trial, in which 14 hospitals were randomized to the CP arm or to the non intervention/usual care (UC) arm. Healthcare workers in the CP arm received 3 days of training in quality improvement of CPs and in use of a standardized package including information on evidence-based key interventions and indicators. Healthcare workers in the usual-care arm followed their standard procedures. The teams in the CP arm developed their CPs over a 6-month period. The primary end point was mortality. Secondary end points were: use of diagnostic and therapeutic procedures, implementation of organized care, length of stay, re-admission and institutionalization rates after discharge, dependency levels, and complication rates. Results Compared with the patients in the UC arm, the patients in the CP arm had a significantly lower risk of mortality at 7 days (OR = 0.10; 95% CI 0.01 to 0.95) and significantly lower rates of adverse functional outcomes, expressed as the odds of not returning to pre-stroke functioning in their daily life (OR = 0.42; 95 CI 0.18 to 0.98). There was no significant effect on 30-day mortality. Compared with the UC arm, the hospital diagnostic and therapeutic procedures were performed more appropriately in the CP arm, and the evidence-based key interventions and organized care were more applied in the CP arm. Conclusions CPs can significantly improve the outcomes of patients with ischemic patients with stroke, indicating better application of evidence-based key interventions and of diagnostic and therapeutic procedures. This study tested a new hypothesis and provided evidence on how CPs can work. Trial registration ClinicalTrials.gov ID: [NCT00673491]. PMID:22781160

Ultraearly assessed reperfusion status after middle cerebral artery recanalization predicting clinical outcome.

PubMed

Gölitz, P; Muehlen, I; Gerner, S T; Knossalla, F; Doerfler, A

2018-06-01

Mechanical thrombectomy has high evidence in stroke therapy; however, successful recanalization guarantees not a favorable clinical outcome. We aimed to quantitatively assess the reperfusion status ultraearly after successful middle cerebral artery (MCA) recanalization to identify flow parameters that potentially allow predicting clinical outcome. Sixty-seven stroke patients with acute MCA occlusion, undergoing recanalization, were enrolled. Using parametric color coding, a post-processing algorithm, pre-, and post-interventional digital subtraction angiography series were evaluated concerning the following parameters: pre- and post-procedural cortical relative time to peak (rTTP) of MCA territory, reperfusion time, and index. Functional long-term outcome was assessed by the 90-day modified Rankin Scale score (mRS; favorable: 0-2). Cortical rTTP was significantly shorter before (3.33 ± 1.36 seconds; P = .03) and after intervention (2.05 ± 0.70 seconds; P = .003) in patients with favorable clinical outcome. Additionally, age (P = .005) and initial National Institutes of Health Stroke Scale score (P = .02) were significantly different between the patients, whereas reperfusion index and time as well as initially estimated infarct size were not. In multivariate analysis, only post-procedural rTTP (P = .005) was independently associated with favorable clinical outcome. 2.29 seconds for post-procedural rTTP might be a threshold to predict favorable clinical outcome. Ultraearly quantitative assessment of reperfusion status after successful MCA recanalization reveals post-procedural cortical rTTP as possible independent prognostic value in predicting favorable clinical outcome, even determining a threshold value might be possible. In consequence, focusing stroke therapy on microcirculatory patency could be valuable to improve outcome. © 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

The Association of CHA2DS2-VASc Score and Blood Biomarkers with Ischemic Stroke Outcomes: The Belgrade Stroke Study

PubMed Central

Potpara, Tatjana S.; Polovina, Marija M.; Djikic, Dijana; Marinkovic, Jelena M.; Kocev, Nikola; Lip, Gregory Y. H.

2014-01-01

Background Many blood biomarkers have a positive association with stroke outcome, but adding blood biomarkers to the National Institutes of Health Stroke Scale (NIHSS) did not significantly improve its discriminatory ability. We investigated the association of the CHA2DS2-VASc score with unfavourable functional outcome (defined as a 30-day modified Rankin Scale [mRS] ≥3) in patients presenting with acute ischemic stroke (AIS), and examined whether the addition of blood biomarkers (troponin I [TnI], fibrinogen, C-reactive protein [CRP]) affects the model discriminatory ability. Methods We conducted an observational single-centre study of consecutive patients with AIS. All patients were admitted to hospital within 24 hours from the neurological symptoms onset. Results Of 240 patients (mean age 70.0±8.9 years), unfavourable 30-day outcome occurred in 92 (38.3%). Patients with mRS≥3 were older and more likely to have atrial fibrillation or other comorbidities (all p<0.001). They had higher levels of CRP, fibrinogen, TnI and higher CHA2DS2-VASc and CHADS2 scores (all p<0.05). The adjusted CHA2DS2-VASc score had excellent predictive ability for poor stroke outcome (c-statistic 0.982;95%CI,0.964–1.000, p<0.001). Whilst CRP had the highest sensitivity (83.7%), cardiac TnI was the most specific (97.3%) for prediction of poor stroke outcome (cut-off: >0.09µg/L). Compared with each of these biomarkers, CHA2DS2-VASc score had significantly better predictive ability for poor stroke outcome (c-statistic for CRP, Fibrinogen and TnI was 0.853;95%CI,0.802–0.895, 0.848;95%CI,0.796–0.891, and 0.792;95%CI,0.736–0.842, all p<0.001, respectively, versus 0.932;95%CI,0.892–0.960, p<0.001 for the CHA2DS2-VASc, all p for the comparisons<0.01). There was no significant difference in the predictive ability of the CHA2DS2-VASc score vs. combinations of the CHA2DS2-VASc and TnI or TnI, fibrinogen and CRP (z statistic 0.369, p = 0.7119; integrated discrimination index 0.00801 and 0.00172, respectively, both p>0.05). Conclusions The CHA2DS2-VASc score alone reliably predicts 30-day unfavourable outcome of stroke. Adding blood biomarkers to the CHA2DS2-VASc score did not significantly increase the predictive ability of the model. PMID:25184809

Effect of paracetamol (acetaminophen) on body temperature in acute stroke: A meta-analysis.

PubMed

Fang, Junjie; Chen, Chensong; Cheng, Hongsen; Wang, Ren; Ma, Linhao

2017-10-01

The objective of this study was to assess the efficacy of paracetamol (acetaminophen) on body temperature in acute stroke. Medline, Cochrane Central Register of Controlled Trials, EMBASE, Chinese BioMedical Literature Database, China National Knowledge Infrastructure, and the World Health Organization (WHO) International Clinical Trials Registry Platform were searched electronically. Relevant journals and references of studies included were hand-searched for randomized controlled trials (RCT) and controlled clinical trials (CCT) regarding the efficacy of paracetamol (acetaminophen) on body temperature in acute stroke. Two reviewers independently performed data extraction and quality assessment. Data were analyzed using RevMan 5.3 software by the Cochrane Collaboration. Five studies were included. To compare the efficacy of paracetamol (acetaminophen) in acute stroke, the pooled RR (Risk Ratio) and its 95% CI of body temperature reduction at 24h from the start of treatment were -0.3 (95% CI: -0.52 to -0.08), with statistical significance (P=0.007). Consistently, the pooled RR (Risk Ratio) and its 95% CI of body temperature at 24h from the start of treatment were -0.22 (-0.29, -0.15), with statistical significance (P<0.00001). When analyzing the body temperature reduction after 5days from the start of treatment, the pooled RR (Risk Ratio) and its 95% CI were 0.04 (95% CI: -0.20 to 0.29), with no statistical significance (P=0.73). For functional outcome (mRS≤2) analysis, the pooled RR and its 95% CI were 1.08 (0.88, 1.32), with no statistical significance (P=0.45). In addition, the difference of serious adverse events between acetaminophen and placebo was 0.86 (95% CI: 0.62 to 1.2), with no statistical significance (P=0.27). Acetaminophen was revealed to have some favorable influence in body temperature reduction in acute stroke, but showed no important effect on improving functional outcome and reducing adverse events of patients. What is already known on this subject? Paracetamol (acetaminophen) is one of the most commonly used antipyretic drugs and has some capability to reduce body temperature through acting on central nervous system. Acetaminophen showed some capability to decrease body temperature for acute stroke. Acetaminophen could not improve functional outcome and reduce adverse events of patients with acute stroke. Copyright © 2017 Elsevier Inc. All rights reserved.

Vinpocetine Inhibits NF-κB-Dependent Inflammation in Acute Ischemic Stroke Patients.

PubMed

Zhang, Fang; Yan, Chen; Wei, Changjuan; Yao, Yang; Ma, Xiaofeng; Gong, Zhongying; Liu, Shoufeng; Zang, Dawei; Chen, Jieli; Shi, Fu-Dong; Hao, Junwei

2018-04-01

Immunity and inflammation play critical roles in the pathogenesis of acute ischemic stroke. Therefore, immune intervention, as a new therapeutic strategy, is worthy of exploration. Here, we tested the inflammation modulator, vinpocetine, for its effect on the outcomes of stroke. For this multi-center study, we recruited 60 patients with anterior cerebral circulation occlusion and onset of stroke that had exceeded 4.5 h but lasted less than 48 h. These patients, after random division into two groups, received either standard management alone (controls) or standard management plus vinpocetine (30 mg per day intravenously for 14 consecutive days, Gedeon Richter Plc., Hungary). Vinpocetine treatment did not change the lymphocyte count; however, nuclear factor kappa-light-chain-enhancer of activated B cell activation was inhibited as seen not only by the increased transcription of IκBα mRNA but also by the impeded phosphorylation and degradation of IκBα and subsequent induction of pro-inflammatory mediators. These effects led to significantly reduced secondary lesion enlargement and an attenuated inflammation reaction. Compared to controls, patients treated with vinpocetine had a better recovery of neurological function and improved clinical outcomes during the acute phase and at 3-month follow-up. These findings identify vinpocetine as an inflammation modulator that could improve clinical outcomes after acute ischemic stroke. This study also indicated the important role of immunity and inflammation in the pathogenesis of acute ischemic stroke and the significance of immunomodulatory treatment. www.clinicaltrials.gov . Identifier: NCT02878772.

Evaluating the functional outcomes of ultrasound-guided botulinum toxin type A injections using the Euro-musculus approach for upper limb spasticity treatment in post-stroke patients; an observational study.

PubMed

Buyukavci, Raikan; Akturk, Semra; Ersoy, Yüksel

2018-02-07

Ultrasound-guided botulinum toxin type A injection is an effective treatment for spasticity. Euro-musculus spasticity approach is a new method for administering injections to the correct point of the correct muscle. The clinical outcomes of this practical approach is not yet available in the literature. The purpose of this study was to evaluate the effects on spasticity and the functional outcomes of ultrasound guided botulinum toxin type A injections via the Euro-musculus spasticity approach to treat upper limb spasticity in post-stroke patients. An observational study. Inpatient post-stroke patients. Twenty five post-stroke patients with post-stroke upper limb spasticity were recruited. The ultrasound-guided botulinum toxin type A injections were administered into the spastic target muscles using the Euro-musculus spasticity approach, and all of the patients were enrolled in rehabilitation programmes after the injections. This research included the innervation zone and injection site figures and ultrasound images of each muscle in the upper limb. The degree of spasticity was assessed via the Modified Ashworth Scale and the upper limb motor function via the Fugl Meyer Upper Extremity Scale at the baseline and 4 and 12 weeks after the botulinum toxin type A injection. Significant decreases in the Modified Ashworth Scale scores of the upper limb flexor muscle tone measured 4 and 12 weeks after the botulinum toxin type A injection were found when compared to the baseline scores (p<0.025). When compared with the baseline Fugl Meyer Upper Extremity subgroup scores, the sitting position, wrist and total scores at 4 and 12 weeks were significantly improved (p<0.025). However, only the Fugl Meyer Upper Extremity hand scores were significantly improved 12 weeks after the injection (p<0.025). Ultrasound-guided botulinum toxin type A injection via the Euro- musculus spasticity approach is a practical and effective method for administering injections to the correct point of the correct muscle. Ultrasound-guided botulinum toxin type A injections combined with rehabilitation programmes decrease spasticity and improve the upper extremity motor functions in stroke patients. This new approach for ultrasound- guided botulinum toxin type A injection is very practical and effective method for upper extremity spasticity.

Risk of intracerebral haemorrhage with alteplase after acute ischaemic stroke: a secondary analysis of an individual patient data meta-analysis.

PubMed

Whiteley, William N; Emberson, Jonathan; Lees, Kennedy R; Blackwell, Lisa; Albers, Gregory; Bluhmki, Erich; Brott, Thomas; Cohen, Geoff; Davis, Stephen; Donnan, Geoffrey; Grotta, James; Howard, George; Kaste, Markku; Koga, Masatoshi; von Kummer, Rüdiger; Lansberg, Maarten G; Lindley, Richard I; Lyden, Patrick; Olivot, Jean Marc; Parsons, Mark; Toni, Danilo; Toyoda, Kazunori; Wahlgren, Nils; Wardlaw, Joanna; Del Zoppo, Gregory J; Sandercock, Peter; Hacke, Werner; Baigent, Colin

2016-08-01

Randomised trials have shown that alteplase improves the odds of a good outcome when delivered within 4·5 h of acute ischaemic stroke. However, alteplase also increases the risk of intracerebral haemorrhage; we aimed to determine the proportional and absolute effects of alteplase on the risks of intracerebral haemorrhage, mortality, and functional impairment in different types of patients. We used individual patient data from the Stroke Thrombolysis Trialists' (STT) meta-analysis of randomised trials of alteplase versus placebo (or untreated control) in patients with acute ischaemic stroke. We prespecified assessment of three classifications of intracerebral haemorrhage: type 2 parenchymal haemorrhage within 7 days; Safe Implementation of Thrombolysis in Stroke Monitoring Study's (SITS-MOST) haemorrhage within 24-36 h (type 2 parenchymal haemorrhage with a deterioration of at least 4 points on National Institutes of Health Stroke Scale [NIHSS]); and fatal intracerebral haemorrhage within 7 days. We used logistic regression, stratified by trial, to model the log odds of intracerebral haemorrhage on allocation to alteplase, treatment delay, age, and stroke severity. We did exploratory analyses to assess mortality after intracerebral haemorrhage and examine the absolute risks of intracerebral haemorrhage in the context of functional outcome at 90-180 days. Data were available from 6756 participants in the nine trials of intravenous alteplase versus control. Alteplase increased the odds of type 2 parenchymal haemorrhage (occurring in 231 [6·8%] of 3391 patients allocated alteplase vs 44 [1·3%] of 3365 patients allocated control; odds ratio [OR] 5·55 [95% CI 4·01-7·70]; absolute excess 5·5% [4·6-6·4]); of SITS-MOST haemorrhage (124 [3·7%] of 3391 vs 19 [0·6%] of 3365; OR 6·67 [4·11-10·84]; absolute excess 3·1% [2·4-3·8]); and of fatal intracerebral haemorrhage (91 [2·7%] of 3391 vs 13 [0·4%] of 3365; OR 7·14 [3·98-12·79]; absolute excess 2·3% [1·7-2·9]). However defined, the proportional increase in intracerebral haemorrhage was similar irrespective of treatment delay, age, or baseline stroke severity, but the absolute excess risk of intracerebral haemorrhage increased with increasing stroke severity: for SITS-MOST intracerebral haemorrhage the absolute excess risk ranged from 1·5% (0·8-2·6%) for strokes with NIHSS 0-4 to 3·7% (2·1-6·3%) for NIHSS 22 or more (p=0·0101). For patients treated within 4·5 h, the absolute increase in the proportion (6·8% [4·0% to 9·5%]) achieving a modified Rankin Scale of 0 or 1 (excellent outcome) exceeded the absolute increase in risk of fatal intracerebral haemorrhage (2·2% [1·5% to 3·0%]) and the increased risk of any death within 90 days (0·9% [-1·4% to 3·2%]). Among patients given alteplase, the net outcome is predicted both by time to treatment (with faster time increasing the proportion achieving an excellent outcome) and stroke severity (with a more severe stroke increasing the absolute risk of intracerebral haemorrhage). Although, within 4·5 h of stroke, the probability of achieving an excellent outcome with alteplase treatment exceeds the risk of death, early treatment is especially important for patients with severe stroke. UK Medical Research Council, British Heart Foundation, University of Glasgow, University of Edinburgh. Copyright © 2016 Elsevier Ltd. All rights reserved.

Risk Factors, Etiological Classification, Topographical Location, and Outcome in Medullary Infarctions.

PubMed

Gökçal, Elif; Baran, Gözde; Niftaliyev, Elvin; Güzel, Vildan; Asil, Talip

2017-07-01

An understanding of the etiological mechanisms is important for therapeutic decisions and prognostic evaluation of patients with ischemic stroke. The object of this study was to evaluate the risk factors, etiological subtypes, and topography of lesion in patients with medullary infarctions (MIs). Besides, we also investigated early neurological deterioration, new vascular events, and functional outcome of all patients at 3-month follow-up. We analyzed our database consisting of patients who were diagnosed with acute MI and who were admitted within 24 hours of onset. Etiological classification of stroke was made on the basis of the Trial of Org 1972 in Acute Stroke Treatment criteria. All of the infarctions were grouped into anteromedial, anterolateral, lateral, and posterior arterial territories and also categorized into those involving the upper, middle, or lower medulla oblongata. Early neurological deterioration, major vascular events within the first 3 months of follow-up and modified Rankin Score at 3 months were reviewed. A total of 65 patients with medullary infarctions were reviewed. Involved arterial territories differed according to the etiological classification. Large artery atherosclerosis was the most common etiological subtype; however, small vessel disease was the most common subtype in medial MIs. The lesions involving the anteromedial territory were common in the upper medullary region, whereas the lesions involving the posterior and lateral territories were common in the lower medulla oblangata. Recurrent stroke was seen in the posterior and lateral territories; however, early progression and poor functional outcome were mostly seen in lesions involving the anteromedial territories.

Effectiveness of Commercial Gaming-Based Virtual Reality Movement Therapy on Functional Recovery of Upper Extremity in Subacute Stroke Patients

PubMed Central

Choi, Jun Hwan; Kim, Bo Ryun; Kim, Sun Mi; Im, Sang Hee; Lee, So Young; Hyun, Chul Woong

2014-01-01

Objective To investigate the effectiveness of commercial gaming-based virtual reality (VR) therapy on the recovery of paretic upper extremity in subacute stroke patients. Methods Twenty patients with the first-onset subacute stroke were enrolled and randomly assigned to the case group (n=10) and the control group (n=10). Primary outcome was measured by the upper limb score through the Fugl-Meyer Assessment (FMA-UL) for the motor function of both upper extremities. Secondary outcomes were assessed for motor function of both upper extremities including manual function test (MFT), box and block test (BBT), grip strength, evaluated for activities of daily living (Korean version of Modified Barthel Index [K-MBI]), and cognitive functions (Korean version of the Mini-Mental State Examination [K-MMSE] and continuous performance test [CPT]). The case group received commercial gaming-based VR therapy using Wii (Nintendo, Tokyo, Japan), and the control group received conventional occupational therapy (OT) for 30 minutes a day during the period of 4 weeks. All patients were evaluated before and after the 4-week intervention. Results There were no significant differences in the baseline between the two groups. After 4 weeks, both groups showed significant improvement in the FMA-UL, MFT, BBT, K-MBI, K-MMSE, and correct detection of auditory CPT. However, grip strength was improved significantly only in the case group. There were no significant intergroup differences before and after the treatment. Conclusion These findings suggested that the commercial gaming-based VR therapy was as effective as conventional OT on the recovery of upper extremity motor and daily living function in subacute stroke patients. PMID:25229027

Effectiveness of commercial gaming-based virtual reality movement therapy on functional recovery of upper extremity in subacute stroke patients.

PubMed

Choi, Jun Hwan; Han, Eun Young; Kim, Bo Ryun; Kim, Sun Mi; Im, Sang Hee; Lee, So Young; Hyun, Chul Woong

2014-08-01

To investigate the effectiveness of commercial gaming-based virtual reality (VR) therapy on the recovery of paretic upper extremity in subacute stroke patients. Twenty patients with the first-onset subacute stroke were enrolled and randomly assigned to the case group (n=10) and the control group (n=10). Primary outcome was measured by the upper limb score through the Fugl-Meyer Assessment (FMA-UL) for the motor function of both upper extremities. Secondary outcomes were assessed for motor function of both upper extremities including manual function test (MFT), box and block test (BBT), grip strength, evaluated for activities of daily living (Korean version of Modified Barthel Index [K-MBI]), and cognitive functions (Korean version of the Mini-Mental State Examination [K-MMSE] and continuous performance test [CPT]). The case group received commercial gaming-based VR therapy using Wii (Nintendo, Tokyo, Japan), and the control group received conventional occupational therapy (OT) for 30 minutes a day during the period of 4 weeks. All patients were evaluated before and after the 4-week intervention. There were no significant differences in the baseline between the two groups. After 4 weeks, both groups showed significant improvement in the FMA-UL, MFT, BBT, K-MBI, K-MMSE, and correct detection of auditory CPT. However, grip strength was improved significantly only in the case group. There were no significant intergroup differences before and after the treatment. These findings suggested that the commercial gaming-based VR therapy was as effective as conventional OT on the recovery of upper extremity motor and daily living function in subacute stroke patients.