Stroke survivors' views and experiences on impact of visual impairment.

PubMed

Rowe, Fiona J

2017-09-01

We sought to determine stroke survivors' views on impact of stroke-related visual impairment to quality of life. Stroke survivors with visual impairment, more than 1 year post stroke onset, were recruited. Semistructured biographical narrative interviews were audio-recorded and transcribed verbatim. A thematic approach to analysis of the qualitative data was adopted. Transcripts were systematically coded using NVivo10 software. Thirty-five stroke survivors were interviewed across the UK: 16 females, 19 males; aged 20-75 years at stroke onset. Five qualitative themes emerged: "Formal care," "Symptoms and self," "Adaptations," "Daily life," and "Information." Where visual problems existed, they were often not immediately recognized as part of the stroke syndrome and attributed to other causes such as migraine. Many participants did not receive early vision assessment or treatment for their visual problems. Visual problems included visual field loss, double vision, and perceptual problems. Impact of visual problems included loss in confidence, being a burden to others, increased collisions/accidents, and fear of falling. They made many self-identified adaptations to compensate for visual problems: magnifiers, large print, increased lighting, use of white sticks. There was a consistent lack of support and provision of information about visual problems. Poststroke visual impairment causes considerable impact to daily life which could be substantially improved by simple measures including early formal visual assessment, management and advice on adaptive strategies and self-management options. Improved education about poststroke visual impairment for the public and clinicians could aid earlier diagnosis of visual impairments.

Sexual function in post-stroke patients: considerations for rehabilitation.

PubMed

Rosenbaum, Talli; Vadas, Dor; Kalichman, Leonid

2014-01-01

While the rehabilitation goals of post-stroke patients include improving quality of life and returning to functional activities, the extent to which sexual activity is addressed as part of the standard rehabilitation process is unknown. Moreover, the specific sexual concerns of stroke patients, including the effect of stroke on intimate relationships and sexuality of the partner, the ability to physically engage in sex, and the effect of psychological components such as role identity, depression, and anxiety on sexuality, all warrant examination by rehabilitation professionals. The aim of this study is to examine the existing literature on sexuality and stroke patients in order to better understand how the sexual lives of stroke patients and their partners are affected and to provide recommendations to rehabilitation professionals for addressing sexuality as part of treatment. Narrative review, PubMed, PEDro, ISI Web of Science, and Google Scholar databases (inception-December 2012) were searched for the key words "stroke," "sexual dysfunction," "sexuality," "quality of life," and their combination. All relevant articles in English and secondary references were reviewed. We report the results of the literature review. Sexual dysfunction and decreased sexual satisfaction are common in the post-stroke population and are related to physical, psychosocial, and relational factors. However, they are not adequately addressed in post-stroke rehabilitation. As sexual function is an important component to quality of life and activities of daily living, physicians and rehabilitation specialists, including physical, occupational, and speech therapists, should receive training in addressing sexuality in the treatment of post-stroke patients. Sexologists and sex therapists should be an integral part of the rehabilitation team. © 2013 International Society for Sexual Medicine.

Activity limitations and participation restrictions experienced by people with stroke in Musanze district in Rwanda.

PubMed

Urimubenshi, Gerard

2015-09-01

Stroke is a major cause of long-term disability. Information regarding the limitations in activity and participation experienced by patients with stroke in a specific setting such as Musanze district in Rwanda would assist to develop the rehabilitation programmes that would take into consideration the functional challenges experienced post stroke. To explore the activity limitations and participation restrictions experienced by people with stroke in Musanze district in Rwanda. A qualitative phenomenological approach using in-depth face-to-face interviews with 10 participants was employed to gather the data that was analyzed using a qualitative thematic approach. The themes that arose as activity limitations included limitations in walking, self care, and domestic life activities. The themes related to participation restrictions as expressed by the participants were inability to return to previous occupation, decreased social interactions and inability to participate in religious activities. The current study findings highlight the need for interventions to improve the functional status of stroke survivors.

From dictatorship to a reluctant democracy: stroke therapists talking about self-management

PubMed Central

Kilbride, Cherry

2014-01-01

Purpose Self-management is being increasingly promoted within chronic conditions including stroke. Concerns have been raised regarding professional ownership of some programmes, yet little is known of the professional’s experience. This paper aims to present the views of trained therapists about the utility of a specific self-management approach in stroke rehabilitation. Method Eleven stroke therapists trained in the self-management approach participated in semi-structured interviews. These were audio recorded, transcribed verbatim and analysed thematically. Results Two overriding themes emerged. The first was the sense that in normal practice therapists act as “benign dictators”, committed to help their patients, but most comfortable when they, the professional, are in control. Following the adoption of the self-management approach therapists challenged themselves to empower stroke survivors to take control of their own recovery. However, therapists had to confront many internal and external challenges in this transition of power resulting in the promotion of a somewhat “reluctant democracy”. Conclusions This study illustrates that stroke therapists desire a more participatory approach to rehabilitation. However, obstacles challenged the successful delivery of this goal. If self-management is an appropriate model to develop in post stroke pathways, then serious consideration must be given to how and if these obstacles can be overcome. Implications for Rehabilitation Stroke therapists perceive that self-management is appropriate for encouraging ownership of rehabilitation post stroke. Numerous obstacles were identified as challenging the implementation of self-management post stroke. These included: professional models, practices and expectations; institutional demands and perceived wishes of stroke survivors. For self-management to be effectively implemented by stroke therapists, these obstacles must be considered and overcome. This should be as part of an integrated therapy service, rather than as an add-on. PMID:23594054

From dictatorship to a reluctant democracy: stroke therapists talking about self-management.

PubMed

Norris, Meriel; Kilbride, Cherry

2014-01-01

Self-management is being increasingly promoted within chronic conditions including stroke. Concerns have been raised regarding professional ownership of some programmes, yet little is known of the professional's experience. This paper aims to present the views of trained therapists about the utility of a specific self-management approach in stroke rehabilitation. Eleven stroke therapists trained in the self-management approach participated in semi-structured interviews. These were audio recorded, transcribed verbatim and analysed thematically. Two overriding themes emerged. The first was the sense that in normal practice therapists act as "benign dictators", committed to help their patients, but most comfortable when they, the professional, are in control. Following the adoption of the self-management approach therapists challenged themselves to empower stroke survivors to take control of their own recovery. However, therapists had to confront many internal and external challenges in this transition of power resulting in the promotion of a somewhat "reluctant democracy". This study illustrates that stroke therapists desire a more participatory approach to rehabilitation. However, obstacles challenged the successful delivery of this goal. If self-management is an appropriate model to develop in post stroke pathways, then serious consideration must be given to how and if these obstacles can be overcome. Stroke therapists perceive that self-management is appropriate for encouraging ownership of rehabilitation post stroke. Numerous obstacles were identified as challenging the implementation of self-management post stroke. These included: professional models, practices and expectations; institutional demands and perceived wishes of stroke survivors. For self-management to be effectively implemented by stroke therapists, these obstacles must be considered and overcome. This should be as part of an integrated therapy service, rather than as an add-on.

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

PubMed

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

2016-03-01

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

Study of Stroke Incidence in the Aseer Region, Southwestern Saudi Arabia.

PubMed

Alhazzani, Adel A; Mahfouz, Ahmed A; Abolyazid, Ahmed Y; Awadalla, Nabil J; Aftab, Razia; Faraheen, Aesha; Khalil, Shamsun Nahar

2018-01-26

Recent data regarding first-stroke incidence in Saudi Arabia in general and in the Aseer region in particular are scarce and even lacking. The aim of this work was to study the first-time stroke incidence in the Aseer region, southwestern Saudi Arabia. All first-stroke patients admitted to all hospitals in the Aseer region over a one-year period (January through December 2016) were included. Stroke patients outside the Aseer region were excluded from the study. The incidence per 100,000 patients and the concomitant 95% CI (Confidence Intervals) were computed. The present study included 1249 first-time stroke patients and calculated an overall minimal incidence rate of hospitalized first-time stroke of 57.64 per 100,000 persons per year (95% CI: 57.57-57.70). A steady increase was noticed depending on the patients' age, reaching a figure of 851.81 (95% CI: 849.2-854.5) for those patients aged 70 years and more. Overall, the incidence rate for females (48.14; 95% CI: 48.04-48.24) was lower compared to males (65.52; 95% CI: 65.1-66.0). Taking into consideration the expected rise of the elderly because of the prominent medical services provided by the Saudi government, leading to a subsequent change in the horizontal and vertical age distribution structure of the population, an increase in the number of stroke patients is expected. It is suggested to establish a nationwide stroke surveillance system in the Kingdom, with the objective to report, analyze, and maintain an updated overview of the stroke status in Saudi Arabia.

Hemorrhagic and ischemic strokes compared: stroke severity, mortality, and risk factors.

PubMed

Andersen, Klaus Kaae; Olsen, Tom Skyhøj; Dehlendorff, Christian; Kammersgaard, Lars Peter

2009-06-01

Stroke patients with hemorrhagic (HS) and ischemic strokes were compared with regard to stroke severity, mortality, and cardiovascular risk factors. A registry started in 2001, with the aim of registering all hospitalized stroke patients in Denmark, now holds information for 39,484 patients. The patients underwent an evaluation including stroke severity (Scandinavian Stroke Scale), CT, and cardiovascular risk factors. They were followed-up from admission until death or censoring in 2007. Independent predictors of death were identified by means of a survival model based on 25,123 individuals with a complete data set. Of the patients 3993 (10.1%) had HS. Stroke severity was almost linearly related to the probability of having HS (2% in patients with the mildest stroke and 30% in those with the most severe strokes). Factors favoring ischemic strokes vs HS were diabetes, atrial fibrillation, previous myocardial infarction, previous stroke, and intermittent arterial claudication. Smoking and alcohol consumption favored HS, whereas age, sex, and hypertension did not herald stroke type. Compared with ischemic strokes, HS was associated with an overall higher mortality risk (HR, 1.564; 95% CI, 1.441-1.696). The increased risk was, however, time-dependent; initially, risk was 4-fold, after 1 week it was 2.5-fold, and after 3 weeks it was 1.5-fold. After 3 months stroke type did not correlate to mortality. Strokes are generally more severe in patients with HS. Within the first 3 months after stroke, HS is associated with a considerable increase of mortality, which is specifically associated with the hemorrhagic nature of the lesion.

Determinants of Emergency Medical Services Utilization Among Acute Ischemic Stroke Patients in Hubei Province in China.

PubMed

Yin, Xiaoxv; Yang, Tingting; Gong, Yanhong; Zhou, Yanfeng; Li, Wenzhen; Song, Xingyue; Wang, Mengdie; Hu, Bo; Lu, Zuxun

2016-03-01

Emergency medical services (EMS) can effectively shorten the prehospital delay for patients with acute ischemic stroke. This study aimed to investigate EMS utilization and its associated factors in patients with acute ischemic stroke in China. A cross-sectional study was conducted from October 1, 2014, to January 31, 2015, which included 2096 patients admitted for acute ischemic stroke from 66 hospitals in Hubei province in China. A multivariable stepwise logistic regression model was undertaken to identify the factors associated with EMS utilization. Of the 2096 participants, only 323 cases (15.4%) used EMS. Those acute ischemic stroke patients who previously used EMS (odds ratio [OR] =9.8), whose National Institutes of Health Stroke Scale score was ≥10 (OR=3.7), who lived in urban communities (OR=2.5), who had sudden onset of symptoms (OR=2.4), who experienced their first stroke (OR=1.8), and who recognized initial symptom as stroke (OR=1.4) were more likely to use EMS. Additionally, when acute ischemic stroke patients' stroke symptom were noticed first by others (OR=2.1), rather than by the patients, EMS was more likely to be used. A very low proportion of patients with acute ischemic stroke used the EMS in Hubei province in China. Considerable education programs are required regarding knowledge of potential symptoms and the importance of EMS for stroke. © 2016 American Heart Association, Inc.

Synthetic cannabis and acute ischemic stroke.

PubMed

Bernson-Leung, Miya E; Leung, Lester Y; Kumar, Sandeep

2014-01-01

An association between marijuana use and stroke has been previously reported. However, the health risks of newer synthetic cannabinoid compounds are less well known. We describe 2 cases that introduce a previously unreported association between synthetic cannabis use and ischemic stroke in young adults. A 22-year-old woman presented with dysarthria, left hemiplegia, and left hemianesthesia within hours of first use of synthetic cannabis. She was healthy and without identified stroke risk factors other than oral contraceptive use and a patent foramen ovale without venous thromboses. A 26-year-old woman presented with nonfluent aphasia, left facial droop, and left hemianesthesia approximately 12 hours after first use of synthetic cannabis. Her other stroke risk factors included migraine with aura, oral contraceptive use, smoking, and a family history of superficial thrombophlebitis. Both women were found to have acute, large-territory infarctions of the right middle cerebral artery. Our 2 cases had risk factors for ischemic stroke but were otherwise young and healthy and the onset of their deficits occurred within hours after first-time exposure to synthetic cannabis. Synthetic cannabis use is an important consideration in the investigation of stroke in young adults. Copyright © 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Eating difficulties among stroke patients in the acute state: a descriptive, cross-sectional, comparative study.

PubMed

Medin, Jörgen; Windahl, Jenny; von Arbin, Magnus; Tham, Kerstin; Wredling, Regina

2011-09-01

To examine eating difficulties among stroke patients - a comparison between women and men. Gender differences have been reported in studies of stroke, but the findings are inconclusive and few of these studies have specifically focused on gender differences in eating difficulties. This study was a descriptive, cross-sectional, comparative study. Patients with stroke were recruited at a general hospital in Sweden. To detect eating difficulties, individual observations of the patients were made during one meal using a structured observation protocol. Assessment also included measurements of nutritional and oral status, degree of independence, stroke severity, neglect and well-being. One hundred and four patients (53·8% women) were included in the study. The proportion of stroke patients with one or more eating difficulties was 81·7%. The most common eating difficulties were 'managing food on the plate' (66·3%), 'food consumption' (54·8%) and 'sitting position' (45·2%). Women had lower 'food consumption', more severe stroke (p = 0·003), worse functional status (p = 0·001) and lower quality of life (QoL) (p=0·038) than men. More women than men were malnourished and living alone. After adjustment for functional status and motor arm, the odds ratio of having difficulties with food consumption was four times higher among women than men (1·7-9·4, confidence interval 95%). More women than men with stroke suffered from inadequate food consumption. The women had more severe strokes, experienced poorer QoL and showed lower functional status than the men. In the rehabilitation process of women with stroke, these factors should be taken into consideration. Structured observation of meals, including assessment of food consumption, might be necessary in acute stroke care to detect patients, especially women, who might need closer supervision and nutritional intervention. © 2011 Blackwell Publishing Ltd.

Hospital Variation in Functional Recovery After Stroke.

PubMed

Bettger, Janet Prvu; Thomas, Laine; Liang, Li; Xian, Ying; Bushnell, Cheryl D; Saver, Jeffrey L; Fonarow, Gregg C; Peterson, Eric D

2017-01-01

Functional status is a key patient-centric outcome, but there are little data on whether functional recovery post-stroke varies among hospitals. This study examined the distribution of functional status 3 months after stroke, determined whether these outcomes vary among hospitals, and identified hospital characteristics associated with better (or worse) functional outcomes. Observational analysis of the AVAIL study (Adherence Evaluation After Ischemic Stroke-Longitudinal) included 2083 ischemic stroke patients enrolled from 82 US hospitals participating in Get With The Guidelines-Stroke and AVAIL. The primary outcome was dependence or death at 3 months (modified Rankin Scale [mRS] score of 3-6). Secondary outcomes included functional dependence (mRS score of 3-5), disabled (mRS score of 2-5), and mRS evaluated as a continuous score. By 3 months post-discharge, 36.5% of patients were functionally dependent or dead. Rates of dependence or death varied widely by discharging hospitals (range: 0%-67%). After risk adjustment, patients had lower rates of 3-month dependence or death when treated at teaching hospitals (odds ratio, 0.72; 95% confidence interval, 0.54-0.96) and certified primary stroke centers (odds ratio, 0.69; 95% confidence interval, 0.53-0.91). In contrast, a composite measure of hospital-level adherence to acute stroke care performance metrics, stroke volume, and bed size was not associated with downstream patient functional status. Findings were robust across mRS end points and sensitivity analyses. One third of acute ischemic stroke patients were functionally dependent or dead 3 months postacute stroke; functional recovery rates varied considerably among hospitals, supporting the need to better determine which care processes can maximize functional outcomes. © 2017 American Heart Association, Inc.

Picture This: Exploring the Lived Experience of High-Functioning Stroke Survivors Using Photovoice.

PubMed

Maratos, Marie; Huynh, Linh; Tan, Julia; Lui, Jordon; Jarus, Tal

2016-07-01

An increasing number of high-functioning stroke survivors are present with minimal functional impairments and are often discharged with reduced access to community reintegration. Our objectives were to explore the lived experience of high-functioning stroke survivors and to identify gaps in community and rehabilitation services. Photovoice was used with five high-functioning stroke survivors to photo-document their experiences. A modified inductive thematic analysis was used, and meanings behind the photographs were elicited through four focus group sessions followed by photography exhibitions. Five themes emerged: lack of understanding and consideration for persons with disability, emotional and behavioral impacts after stroke, self-reliance and dependence on others, importance of appropriate and accessible services, and financial determinants of quality of life. By including service users' voices; investing in adapted, community-based programs; and providing educational programs for creating attitudinal change among service providers, the polarization between who can and cannot access services will be reduced. © The Author(s) 2016.

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.

A comparative study of patients' activities and interactions in a stroke unit before and after reconstruction-The significance of the built environment.

PubMed

Anåker, Anna; von Koch, Lena; Sjöstrand, Christina; Bernhardt, Julie; Elf, Marie

2017-01-01

Early mobilization and rehabilitation, multidisciplinary stroke expertise and comprehensive therapies are fundamental in a stroke unit. To achieve effective and safe stroke care, the physical environment in modern stroke units should facilitate the delivery of evidence-based care. Therefore, the purpose of this study was to explore patients' activities and interactions in a stroke unit before the reconstruction of the physical environment, while in a temporary location and after reconstruction. This case study examined a stroke unit as an integrated whole. The data were collected using a behavioral mapping technique at three different time points: in the original unit, in the temporary unit and in the new unit. A total of 59 patients were included. The analysis included field notes from observations of the physical environment and examples from planning and design documents. The findings indicated that in the new unit, the patients spent more time in their rooms, were less active, and had fewer interactions with staff and family than the patients in the original unit. The reconstruction involved a change from a primarily multi-bed room design to single-room accommodations. In the new unit, the patients' lounge was located in a far corner of the unit with a smaller entrance than the patients' lounge in the old unit, which was located at the end of a corridor with a noticeable entrance. Changes in the design of the stroke unit may have influenced the patients' activities and interactions. This study raises the question of how the physical environment should be designed in the future to facilitate the delivery of health care and improve outcomes for stroke patients. This research is based on a case study, and although the results should be interpreted with caution, we strongly recommend that environmental considerations be included in future stroke guidelines.

Caregiver burden, productivity loss, and indirect costs associated with caring for patients with poststroke spasticity

PubMed Central

Ganapathy, Vaidyanathan; Graham, Glenn D; DiBonaventura, Marco D; Gillard, Patrick J; Goren, Amir; Zorowitz, Richard D

2015-01-01

Objective Many stroke survivors experience poststroke spasticity and the related inability to perform basic activities, which necessitates patient management and treatment, and exerts a considerable burden on the informal caregiver. The current study aims to estimate burden, productivity loss, and indirect costs for caregivers of stroke survivors with spasticity. Methods Internet survey data were collected from 153 caregivers of stroke survivors with spasticity including caregiving time and difficulty (Oberst Caregiver Burden Scale), Work Productivity and Activity Impairment measures, and caregiver and patient characteristics. Fractional logit models examined predictors of work-related restriction, and work losses were monetized (2012 median US wages). Results Mean Oberst Caregiver Burden Scale time and difficulty scores were 46.1 and 32.4, respectively. Employed caregivers (n=71) had overall work restriction (32%), absenteeism (9%), and presenteeism (27%). Caregiver characteristics, lack of nursing home coverage, and stroke survivors’ disability predicted all work restriction outcomes. The mean total lost-productivity cost per employed caregiver was US$835 per month (>$10,000 per year; 72% attributable to presenteeism). Conclusion These findings demonstrate the substantial burden of caring for stroke survivors with spasticity illustrating the societal and economic impact of stroke that extends beyond the stroke survivor. PMID:26609225

More outcomes than trials: a call for consistent data collection across stroke rehabilitation trials.

PubMed

Ali, M; English, C; Bernhardt, J; Sunnerhagen, K S; Brady, M

2013-01-01

Stroke survivors experience complex combinations of impairments, activity limitations, and participation restrictions. The essential components of stroke rehabilitation remain elusive. Determining efficacy in randomized controlled trials (RCTs) is challenging; there is no commonly agreed primary outcome measure for rehabilitation trials. Clinical guidelines depend on proof of efficacy in RCTs and meta-analyses. However, diverse trial aims, differing methods, inconsistent data collection, and use of multiple assessment tools hinder comparability across trials. Consistent data collection in acute stroke trials has facilitated meta-analyses to inform trial design and clinical practice. With few exceptions, inconsistent data collection has hindered similar progress in stroke rehabilitation research. There is an urgent need for the routine collection of a core dataset of common variables in rehabilitation trials. The European Stroke Organisation Outcomes Working Group, the National Institutes of Neurological Disorders and Stroke Common Data Elements project, and the Collaborative Stroke Audit and Research project have called for consistency in data collection in stroke trials. Standardizing data collection can decrease study start up times, facilitate data sharing, and inform clinical guidelines. Although achieving consensus on which outcome measures to use in stroke rehabilitation trials is a considerable task, perhaps a feasible starting point is to achieve consistency in the collection of data on demography, stroke severity, and stroke onset to inclusion times. Longer term goals could include the development of a consensus process to establish the core dataset. This should be endorsed by researchers, funders, and journal editors in order to facilitate sustainable change. © 2012 The Authors. International Journal of Stroke © 2012 World Stroke Organization.

MRI-Based Neuroanatomical Predictors of Dysphagia, Dysarthria, and Aphasia in Patients with First Acute Ischemic Stroke
.

PubMed

Flowers, Heather L; AlHarbi, Mohammed A; Mikulis, David; Silver, Frank L; Rochon, Elizabeth; Streiner, David; Martino, Rosemary

2017-01-01

Due to the high post-stroke frequency of dysphagia, dysarthria, and aphasia, we developed comprehensive neuroanatomical, clinical, and demographic models to predict their presence after acute ischemic stroke. The sample included 160 randomly selected first-ever stroke patients with confirmed infarction on magnetic resonance imaging from 1 tertiary stroke center. We documented acute lesions within 12 neuroanatomical regions and their associated volumes. Further, we identified concomitant chronic brain disease, including atrophy, white matter hyperintensities, and covert strokes. We developed predictive models using logistic regression with odds ratios (OR) and their 95% confidence intervals (95% CI) including demographic, clinical, and acute and chronic neuroanatomical factors. Predictors of dysphagia included medullary (OR 6.2, 95% CI 1.5-25.8), insular (OR 4.8, 95% CI 2.0-11.8), and pontine (OR 3.6, 95% CI 1.2-10.1) lesions, followed by brain atrophy (OR 3.0, 95% CI 1.04-8.6), internal capsular lesions (OR 2.9, 95% CI 1.2-6.6), and increasing age (OR 1.4, 95% CI 1.1-1.8). Predictors of dysarthria included pontine (OR 7.8, 95% CI 2.7-22.9), insular (OR 4.5, 95% CI 1.8-11.4), and internal capsular (OR 3.6, 95% CI 1.6-7.9) lesions. Predictors of aphasia included left hemisphere insular (OR 34.4, 95% CI 4.2-283.4), thalamic (OR 6.2, 95% CI 1.6-24.4), and cortical middle cerebral artery (OR 4.7, 95% CI 1.5-14.2) lesions. Predicting outcomes following acute stroke is important for treatment decisions. Determining the risk of major post-stroke impairments requires consideration of factors beyond lesion localization. Accordingly, we demonstrated interactions between localized and global brain function for dysphagia and elucidated common lesion locations across 3 debilitating impairments.
. © 2017 The Author(s)
. Published by S. Karger AG, Basel.

Canadian Association of Emergency Physicians position statement on acute ischemic stroke.

PubMed

Harris, Devin; Hall, Christopher; Lobay, Kevin; McRae, Andrew; Monroe, Tanya; Perry, Jeffrey J; Shearing, Anthony; Wollam, Gabe; Goddard, Tom; Lang, Eddy

2015-03-01

The CAEP Stroke Practice Committee was convened in the spring of 2013 to revisit the 2001 policy statement on the use of thrombolytic therapy in acute ischemic stroke. The terms of reference of the panel were developed to include national representation from urban academic centres as well as community and rural centres from all regions of the country. Membership was determined by attracting recognized stroke leaders from across the country who agreed to volunteer their time towards the development of revised guidance on the topic. The guideline panel elected to adopt the GRADE language to communicate guidance after review of existing systematic reviews and international clinical practice guidelines. Stroke neurologists from across Canada were engaged to work alongside panel members to develop guidance as a dyad-based consensus when possible. There was no unique systematic review performed to support this guidance, rather existing efficacy data was relied upon. After a series of teleconferences and face to face meetings, a draft guideline was developed and presented to the CAEP board in June of 2014. The panel noted the development of significant new evidence to inform a number of clinical questions related to acute stroke management. In general terms the recommendations issued by the CAEP Stroke Practice Committee are supportive of the use of thrombolytic therapy when treatment can be administered within 3 hours of symptom onset. The committee is also supportive of system-level changes including pre-hospital interventions, the transport of patients to dedicated stroke centers when possible and tele-health measures to support thrombolytic therapy in a timely window. Of note, after careful deliberation, the panel elected to issue a conditional recommendation against the use of thrombolytic therapy in the 3–4.5 hour window. The view of the committee was that as a result of a narrow risk benefit balance, one that is considerably narrower than the same considerations under 3 hours, a significant number of informed patients and families would opt against the risk of early intracranial hemorrhage and the possibility of increased 90-day mortality that is not seen for more timely treatment. Furthermore, the frequently impaired nature of patients suffering an acute stroke and the difficulties in asking families to make life and death decisions in a highly time-sensitive context led the panel to restrict a strong endorsement of thrombolytic to the 3 hour outermost limit. The committee noted as well that Health Canada has not approved a thrombolytic agent beyond a three hour window in acute ischemic stroke.

Family caregivers' experience of activities of daily living handling in older adult with stroke: a qualitative research in the Iranian context.

PubMed

Hesamzadeh, Ali; Dalvandi, Asghar; Bagher Maddah, Sadat; Fallahi Khoshknab, Masoud; Ahmadi, Fazlollah; Mosavi Arfa, Nazila

2017-09-01

Patients with stroke require additional support from family to live independently in the area of activities of daily living. Family members are usually the main caregivers of stroke patients. Comprehensive explanation of ADL handling from family caregivers' view is lacking. This study explores and describes family caregivers' experiences about the strategies to handle activities of daily living (ADL) dependency of elderly patient with stroke in the Iranian context. A qualitative content analysis approach was conducted to analyse data. Nineteen family caregivers participated in the study from multiple physiotherapy clinics of physiotherapy in Sari (Iran) between September 2013 and May 2014. Data were generated through in-depth interviews, and content analysis method was used to analyse the data and determine themes. The findings show that family caregivers manage the ADL dependency of their elderly stroke patients through seven strategies including encouraging physical movements, providing personal hygiene, nutritional consideration, facilitating religious activities, filling leisure time, and facilitating transfer and assisting in financial issues. Family has an important role in handling of elderly stroke patients' ADL dependency. Health practitioners can take benefit from the findings to help the stroke families play more active role in the handling ADL dependency of their patients after stroke. © 2016 Nordic College of Caring Science.

Summary of evidence-based guideline update: Prevention of stroke in nonvalvular atrial fibrillation

PubMed Central

Culebras, Antonio; Messé, Steven R.; Chaturvedi, Seemant; Kase, Carlos S.; Gronseth, Gary

2014-01-01

Objective: To update the 1998 American Academy of Neurology practice parameter on stroke prevention in nonvalvular atrial fibrillation (NVAF). How often do various technologies identify previously undetected NVAF? Which therapies reduce ischemic stroke risk with the least risk of hemorrhage, including intracranial hemorrhage? The complete guideline on which this summary is based is available as an online data supplement to this article. Methods: Systematic literature review; modified Delphi process recommendation formulation. Major conclusions: In patients with recent cryptogenic stroke, cardiac rhythm monitoring probably detects occult NVAF. In patients with NVAF, dabigatran, rivaroxaban, and apixaban are probably at least as effective as warfarin in preventing stroke and have a lower risk of intracranial hemorrhage. Triflusal plus acenocoumarol is likely more effective than acenocoumarol alone in reducing stroke risk. Clopidogrel plus aspirin is probably less effective than warfarin in preventing stroke and has a lower risk of intracranial bleeding. Clopidogrel plus aspirin as compared with aspirin alone probably reduces stroke risk but increases the risk of major hemorrhage. Apixaban is likely more effective than aspirin for decreasing stroke risk and has a bleeding risk similar to that of aspirin. Major recommendations: Clinicians might obtain outpatient cardiac rhythm studies in patients with cryptogenic stroke to identify patients with occult NVAF (Level C) and should routinely offer anticoagulation to patients with NVAF and a history of TIA/stroke (Level B). Specific patient considerations will inform anticoagulant selection in patients with NVAF judged to need anticoagulation. PMID:24566225

The long-term nutritional status in stroke patients and its predictive factors.

PubMed

Paquereau, Julie; Allart, Etienne; Romon, Monique; Rousseaux, Marc

2014-07-01

Malnutrition is common in the first few months after stroke and contributes to a poor overall outcome. We analyzed long-term weight changes and their predictive factors. A total of 71 first-ever stroke patients were included in the study and examined (1) their weight on admission to the acute stroke unit (usual weight [UW]), on admission to the rehabilitation unit, on discharge from the rehabilitation unit, and then 1 year or more after the stroke (median time: 2.5 years), (2) the presence of malnutrition after stroke, and (3) possible predictive factors, namely, sociodemographic factors, clinical characteristics (concerning the stroke, the patient's current neurologic status and the presence of diabetes mellitus and depression), and the present nutritional state (including eating difficulties, anorexia, and changes in food intake and food preferences). Body weight fell (4.0 kg) during the patients' stay in the stroke unit, increased moderately in the rehabilitation unit (2.0 kg), and returned to the UW by the long-term measurement. However, at the last observation, 40.1% of the patients weighed markedly less than their UW, 38.0% weighed markedly more, and 21.1% were relatively stable. Predictors of weight change were a change in preferences for sweet food products and a change in food intake. Malnutrition was frequent (47.9%) and associated with reduced food intake, residence in an institution, and diabetes mellitus. Malnutrition was highly prevalent, with an important role of change in food intake and food preferences, which could result from brain lesions and specific regimens. Living in an institution needs consideration, as its negative effects can be prevented. Copyright © 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Microbiological Etiologies of Pneumonia Complicating Stroke: A Systematic Review.

PubMed

Kishore, Amit K; Vail, Andy; Jeans, Adam R; Chamorro, Angel; Di Napoli, Mario; Kalra, Lalit; Langhorne, Peter; Roffe, Christine; Westendorp, Willeke; Nederkoorn, Paul J; Garau, Javier; van de Beek, Diederik; Montaner, Joan; Woodhead, Mark; Meisel, Andreas; Smith, Craig J

2018-06-18

Identifying the causal pathogens of pneumonia complicating stroke is challenging, and antibiotics used are often broad spectrum, without recourse to the microbiological cause. We aimed to review existing literature to identify organisms responsible for pneumonia complicating stroke, before developing a consensus-based approach to antibiotic treatment. A systematic literature review of multiple electronic databases using predefined search criteria was undertaken, in accordance with Cochrane and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidance. Published studies of hospitalized adults with ischemic stroke, intracerebral hemorrhage, or both, which identified microbiological etiologies for pneumonia complicating stroke up to January 1, 2017, were considered. Analysis included summary statistics and random-effects meta-analysis where appropriate. Fifteen studies (40% ischemic stroke, 60% ischemic stroke and intracerebral hemorrhage) involving 7968 patients were included. Reported occurrence of pneumonia varied considerably between studies (2%-63%) with a pooled frequency of 23% (95% confidence interval, 14%-34%; I 2 =99%). Where reported (60%), the majority of pneumonia occurred within 1 week of stroke (78%). Reported frequency of positive culture data (15%-88%) varied widely. When isolated, aerobic Gram-negative bacilli (38%) and Gram-positive cocci (16%) were most frequently cultured; commonly isolated organisms included Enterobacteriaceae (21.8%: Klebsiella pneumoniae , 12.8% and Escherichia coli, 9%), Staphylococcus aureus (10.1%), Pseudomonas aeruginosa (6%), Acinetobacter baumanii (4.6%), and Streptococcus pneumoniae (3.5%). Sputum was most commonly used to identify pathogens, in isolation (40%) or in conjunction with tracheal aspirate (15%) or blood culture (20%). Although the analysis was limited by small and heterogeneous study populations, limiting determination of microbiological causality, this review suggests aerobic Gram-negative bacilli and Gram-positive cocci are frequently associated with pneumonia complicating stroke. This supports the need for appropriately designed studies to determine microbial cause and a consensus-based approach in antibiotic usage and further targeted antibiotic treatment trials for enhanced antibiotic stewardship. © 2018 American Heart Association, Inc.

Direct medical cost of stroke in Singapore.

PubMed

Ng, Charmaine Shuyu; Toh, Matthias Paul Han Sim; Ng, Jiaying; Ko, Yu

2015-10-01

Globally, stroke is recognized as one of the main causes of long-term disability, accounting for approximately 5·7 million deaths each year. It is a debilitating and costly chronic condition that consumes about 2-4% of total healthcare expenditure. To estimate the direct medical cost associated with stroke in Singapore in 2012 and to determine associated predictors. The National Healthcare Group Chronic Disease Management System database was used to identify patients with stroke between the years 2006 and 2012. Estimated stroke-related costs included hospitalizations, accident and emergency room visits, outpatient physician visits, laboratory tests, and medications. A total of 700 patients were randomly selected for the analyses. The mean annual direct medical cost was found to be S$12 473·7, of which 93·6% were accounted for by inpatient services, 4·9% by outpatient services, and 1·5% by A&E services. Independent determinants of greater total costs were stroke types, such as ischemic stroke (P = 0·005), subarachnoid hemorrhage (P < 0·001) and intracerebral haemorrhage (P < 0·001), shorter poststroke period, more than one complications (P = 0·045), and a greater number of comorbidities (P = 0·001). There is a considerable economic burden associated with stroke in Singapore. The type of stroke, length of poststroke period, and stroke complications and comorbidities are found to be associated with the total costs. Efforts to reduce inpatient costs and to allocate health resources to focus on the primary prevention of stroke should become a priority. © 2015 World Stroke Organization.

Assessment and provision of rehabilitation among patients hospitalized with acute ischemic stroke in China: Findings from the China National Stroke Registry II.

PubMed

Bettger, Janet Prvu; Li, Zixiao; Xian, Ying; Liu, Liping; Zhao, Xingquan; Li, Hao; Wang, Chunxue; Wang, Chunjuan; Meng, Xia; Wang, Anxin; Pan, Yuesong; Peterson, Eric D; Wang, Yilong; Wang, Yongjun

2017-04-01

Background Stroke rehabilitation improves functional recovery among stroke patients. However, little is known about clinical practice in China regarding the assessment and provision of rehabilitation among patients with acute ischemic stroke. Aims We examined the frequency and determinants of an assessment for rehabilitation among acute ischemic stroke patients from the China National Stroke Registry II. Methods Data for 19,294 acute ischemic stroke patients admitted to 219 hospitals from June 2012 to January 2013 were analyzed. The multivariable logistic regression model with the generalized estimating equation method accounting for in-hospital clustering was used to identify patient and hospital factors associated with having a rehabilitation assessment during the acute hospitalization. Results Among 19,294 acute ischemic stroke patients, 11,451 (59.4%) were assessed for rehabilitation. Rates of rehabilitation assessment varied among 219 hospitals (IQR 41.4% vs 81.5%). In the multivariable analysis, factors associated with increased likelihood of a rehabilitation assessment ( p < 0.05) included disability prior to stroke, higher NIHSS on admission, receipt of a dysphagia screen, deep venous thrombosis prophylaxis, carotid vessel imaging, longer length of stay, and treatment at a hospital with a higher number of hospital beds (per 100 units). In contrast, patients with a history of atrial fibrillation and hospitals with higher number of annual stroke discharges (per 100 patients) were less likely to receive rehabilitation assessment during the acute stroke hospitalization. Conclusions Rehabilitation assessment among acute ischemic stroke patients was suboptimal in China. Rates varied considerably among hospitals and support the need to improve adherence to recommended care for stroke survivors.

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

Motion-aware stroke volume quantification in 4D PC-MRI data of the human aorta.

PubMed

Köhler, Benjamin; Preim, Uta; Grothoff, Matthias; Gutberlet, Matthias; Fischbach, Katharina; Preim, Bernhard

2016-02-01

4D PC-MRI enables the noninvasive measurement of time-resolved, three-dimensional blood flow data that allow quantification of the hemodynamics. Stroke volumes are essential to assess the cardiac function and evolution of different cardiovascular diseases. The calculation depends on the wall position and vessel orientation, which both change during the cardiac cycle due to the heart muscle contraction and the pumped blood. However, current systems for the quantitative 4D PC-MRI data analysis neglect the dynamic character and instead employ a static 3D vessel approximation. We quantify differences between stroke volumes in the aorta obtained with and without consideration of its dynamics. We describe a method that uses the approximating 3D segmentation to automatically initialize segmentation algorithms that require regions inside and outside the vessel for each temporal position. This enables the use of graph cuts to obtain 4D segmentations, extract vessel surfaces including centerlines for each temporal position and derive motion information. The stroke volume quantification is compared using measuring planes in static (3D) vessels, planes with fixed angulation inside dynamic vessels (this corresponds to the common 2D PC-MRI) and moving planes inside dynamic vessels. Seven datasets with different pathologies such as aneurysms and coarctations were evaluated in close collaboration with radiologists. Compared to the experts' manual stroke volume estimations, motion-aware quantification performs, on average, 1.57% better than calculations without motion consideration. The mean difference between stroke volumes obtained with the different methods is 7.82%. Automatically obtained 4D segmentations overlap by 85.75% with manually generated ones. Incorporating motion information in the stroke volume quantification yields slight but not statistically significant improvements. The presented method is feasible for the clinical routine, since computation times are low and essential parts run fully automatically. The 4D segmentations can be used for other algorithms as well. The simultaneous visualization and quantification may support the understanding and interpretation of cardiac blood flow.

Caregivers of Alzheimer's Disease and Stroke Patients: Immunological and Psychological Considerations.

ERIC Educational Resources Information Center

Reese, Dawn R.; And Others

1994-01-01

Examined psychological and immunological changes among 25 caregivers of Alzheimer's disease (AD) patients, 25 caregivers of stroke patients, and 25 noncaregivers. Found that AD caregiving group was more psychologically distressed than stroke group, and both caregiving groups were more psychologically distressed than controls. Found no differences…

[Blood pressure lowering therapy for mild hypertensive patients with a history of stroke].

PubMed

Ishikawa, Eiichi; Ibayashi, Setsuro

2008-08-01

Hypertension is the primary and one of the major risk factors for stroke. Many hypertensive patients with a history of stroke might have mild to moderate hypertension at the same time. In order to prevent recurrence of cardiovascular diseases including stroke, we should lower their blood pressure levels, carefully and slowly below less than 140/90 mmHg or much lower. Additionally, the patients having any occlusion or stenoses in their carotid and/or intracranial arteries, or even in old-old patients with atherosclerosis, might need further consideration for the cerebral blood flow insufficiency in the course of blood pressure lowering therapy. Although the advantages of inhibitors of renin-angiotensin system are lionized these days (advertisement based medicine: ABM), we should never forget to select more favorable antihypertensive drugs for each patient in case by case (individual based medicine: IBM), to get the definite blood pressure lowering effects without worsening any complications. We also need further gathering of many evidences in a net-work-meta-analysis way, on blood pressure lowering therapy in those hypertensive patients with a history of stroke (evidence based medicine: EBM).

Intrinsic factors influencing help-seeking behaviour in an acute stroke situation.

PubMed

Zock, Elles; Kerkhoff, Henk; Kleyweg, Ruud Peter; van de Beek, Diederik

2016-09-01

The proportion of stroke patients eligible for intravenous or intra-arterial treatment is still limited because many patients do not seek medical help immediately after stroke onset. The aim of our study was to explore which intrinsic factors and considerations influence help-seeking behaviour of relatively healthy participants, confronted with stroke situations. Semi-structured interviews were conducted with 25 non-stroke participants aged 50 years or older. We presented 5 clinical stroke situations as if experienced by the participants themselves. Recognition and interpretation of symptoms were evaluated and various factors influencing help-seeking behaviour were explored in-depth. We used the thematic synthesis method for data analysis. Five themes influencing help-seeking behaviour in a stroke situation were identified: influence of knowledge, views about seriousness, ideas about illness and health, attitudes towards others and beliefs about the emergency medical system. A correct recognition of stroke symptoms or a correct interpretation of the stroke situations did not automatically result in seeking medical help. Interestingly, similar factors could lead to different types of actions between participants. Many intrinsic, as well as social and environmental factors are of influence on help-seeking behaviour in an acute stroke situation. All these factors seem to play a complex role in help-seeking behaviour with considerable inter-individual variations. Accomplishing more patients eligible for acute stroke treatment, future research should focus on better understanding of all factors at various levels grounded in a theory of help-seeking behaviour.

Systemic risk score evaluation in ischemic stroke patients (SCALA): a prospective cross sectional study in 85 German stroke units.

PubMed

Weimar, Christian; Goertler, Michael; Röther, Joachim; Ringelstein, E Bernd; Darius, Harald; Nabavi, Darius Günther; Kim, In-Ha; Theobald, Karlheinz; Diener, Han-Christoph

2007-11-01

Stratification of patients with transient ischemic attack (TIA) or ischemic stroke (IS) by risk of recurrent stroke can contribute to optimized secondary prevention. We therefore aimed to assess cardiovascular risk factor profiles of consecutive patients hospitalized with TIA/IS to stratify the risk of recurrent stroke according to the Essen Stroke Risk Score (ESRS) and of future cardiovascular events according to the ankle brachial index (ABI) as a marker of generalized atherosclerosis In this cross-sectional observational study, 85 neurological stroke units throughout Germany documented cardiovascular risk factor profiles of 10 consecutive TIA/IS patients on standardized questionnaires. Screening for PAD was done with Doppler ultrasonography to calculate the ABI. A total of 852 patients (57% men) with a mean age of 67+/-12.4 years were included of whom 82.9 % had IS. The median National Institutes of Health stroke sum score was 4 (TIA: 1). Arterial hypertension was reported in 71%, diabetes mellitus in 26%, clinical PAD in 10%, and an ABI < or = 0.9 in 51%. An ESRS > or = 3 was observed in 58%, which in two previous retrospective analyses corresponded to a recurrent stroke risk of > or = 4%/year. The correlation between the ESRS and the ABI was low (r = 0.21). A high proportion of patients had asymptomatic atherosclerotic disease and a considerable risk of recurrent stroke according to the ABI and ESRS category. The prognostic accuracy as well as the potential benefit of various risk stratification scores in secondary stroke prevention require validation in a larger prospective study.

Thinking About Better Speech: Mental Practice for Stroke-Induced Motor Speech Impairments

PubMed Central

Page, Stephen J.; Harnish, Stacy

2012-01-01

Background Mental practice (MP) is a mind-body technique in which physical movements are cognitively rehearsed. It has shown efficacy in reducing the severity of a number of neurological impairments. Aims In the present review, we highlight recent developments in MP research, and the basis for MP use after stroke-induced motor speech disorders. Main Contribution In this review, we: (a) propose a novel conceptual model regarding the development of learned nonuse in people with motor speech impairments; (b) review the rationale and efficacy of MP for reducing the severity of stroke-induced impairments; (c) review evidence demonstrating muscular and neural activations during and following MP use; (d) review evidence showing that MP increases skill acquisition, use, and function in stroke; (e) review literature regarding neuroplasticity after stroke, including MP-induced neuroplasticity and the neural substrates underlying motor and language reacquisition; and (f) based on the above, review the rationale and clinical application of MP for stroke-induced motor speech impairments. Conclusions Support for MP use includes decades of MP neurobiological and behavioral efficacy data in a number of populations. Most recently, these data have expanded to the application of MP in neurological populations. Given increasingly demanding managed care environments, efficacious strategies that can be easily administered are needed. We also encounter clinicians who aspire to use MP, but their protocols do not contain several of the elements shown to be fundamental to effective MP implementation. Given shortfalls of some conventional aphasia and motor speech rehabilitative techniques, and uncertainty regarding optimal MP implementation, this paper introduces the neurophysiologic bases for MP, the evidence for MP use in stroke rehabilitation, and discusses its applications and considerations in patients with stroke-induced motor speech impairments. PMID:22308050

Targeted delivery of growth factors in ischemic stroke animal models.

PubMed

Rhim, Taiyoun; Lee, Minhyung

2016-01-01

Ischemic stroke is caused by reduced blood supply and leads to loss of brain function. The reduced oxygen and nutrient supply stimulates various physiological responses, including induction of growth factors. Growth factors prevent neuronal cell death, promote neovascularization, and induce cell growth. However, the concentration of growth factors is not sufficient to recover brain function after the ischemic damage, suggesting that delivery of growth factors into the ischemic brain may be a useful treatment for ischemic stroke. In this review, various approaches for the delivery of growth factors to ischemic brain tissue are discussed, including local and targeting delivery systems. To develop growth factor therapy for ischemic stroke, important considerations should be taken into account. First, growth factors may have possible side effects. Thus, concentration of growth factors should be restricted to the ischemic tissues by local administration or targeted delivery. Second, the duration of growth factor therapy should be optimized. Growth factor proteins may be degraded too fast to have a high enough therapeutic effect. Therefore, delivery systems for controlled release or gene delivery may be useful. Third, the delivery systems to the brain should be optimized according to the delivery route.

Understanding the Experience of Stroke: A Mixed-Method Research Agenda

PubMed Central

Clarke, Philippa

2009-01-01

The use of both quantitative and qualitative strategies to examine a single research question has been a subject of considerable controversy and still remains a largely uncommon practice in the sociology of health and illness. Yet, when seeking to understand the meaning of a chronic disabling condition in later life from a social psychological perspective, a mixed-method approach is likely to provide the most comprehensive picture. This article provides an overview of the usefulness and appropriateness of a mixed-method approach to understanding the stroke experience. I comment on the current state of research on the experience of stroke, including epistemological and ontological orientations. Using real data examples, I address paradigmatic assumptions, methods of integration, as well as challenges and pitfalls in integrating methods. I conclude by considering future directions in this field of research. PMID:19386828

Effective assessments of electroencephalography during stroke recovery: contemporary approaches and considerations.

PubMed

Iyer, Kartik K

2017-11-01

Stroke is one of the leading causes of permanent disability worldwide, relying conventionally on extended periods of physiotherapy to recover functional ability. While neuroimaging techniques and emerging neurorehabilitation paradigms have advanced our understanding of pathophysiological mechanisms underlying stroke, recent evidence has renewed focus on quantifying features of cortical activity present in electroencephalography recordings to greatly enhance our understanding of stroke treatment and recovery. This Neuro Forum article reviews these key advances and discusses the importance of quantifying electroencephalography in future assessments of stroke survivors. Copyright © 2017 the American Physiological Society.

Dignity realization of patients with stroke in hospital care: A grounded theory.

PubMed

Rannikko, Sunna; Stolt, Minna; Suhonen, Riitta; Leino-Kilpi, Helena

2017-01-01

Dignity is seen as an important but complex concept in the healthcare context. In this context, the discussion of dignity includes concepts of other ethical principles such as autonomy and privacy. Patients consider dignity to cover individuality, patient's feelings, communication, and the behavior of healthcare personnel. However, there is a lack of knowledge concerning the realization of patients' dignity in hospital care and the focus of the study is therefore on the realization of dignity of the vulnerable group of patients with stroke. The aim of the study was to create a theoretical construct to describe the dignity realization of patients with stroke in hospital care. Research design and participants: Patients with stroke (n = 16) were interviewed in 2015 using a semi-structured interview containing open questions concerning dignity. The data were analyzed using constant comparison of Grounded Theory. Ethical considerations: Ethical approval for the research was obtained from the Ethics Committee of the University. The permission for the research was given by the hospital. Informed consent was obtained from participants. The "Theory of Dignity Realization of Patients with Stroke in Hospital Care" consists of a core category including generic elements of the new situation and dignity realization types. The core category was identified as "Dignity in a new situation" and the generic elements as health history, life history, individuality and stroke. Dignity of patients with stroke is realized through specific types of realization: person-related dignity type, control-related dignity type, independence-related dignity type, social-related dignity type, and care-related dignity type. The theory has similar elements with the previous literature but the whole construct is new. The theory reveals possible special characteristics in dignity realization of patients with stroke. For healthcare personnel, the theory provides a frame for a better understanding and recognition of how dignity of patients with stroke is realized.

Acute ischemic cerebrovascular events on antiplatelet therapy: what is the optimal prevention strategy?

PubMed

Milionis, Haralampos; Michel, Patrik

2013-01-01

Even though patients who develop ischemic stroke despite taking antiplatelet drugs represent a considerable proportion of stroke hospital admissions, there is a paucity of data from investigational studies regarding the most suitable therapeutic intervention. There have been no clinical trials to test whether increasing the dose or switching antiplatelet agents reduces the risk for subsequent events. Certain issues have to be considered in patients managed for a first or recurrent stroke while receiving antiplatelet agents. Therapeutic failure may be due to either poor adherence to treatment, associated co-morbid conditions and diminished antiplatelet effects (resistance to treatment). A diagnostic work up is warranted to identify the etiology and underlying mechanism of stroke, thereby guiding further management. Risk factors (including hypertension, dyslipidemia and diabetes) should be treated according to current guidelines. Aspirin or aspirin plus clopidogrel may be used in the acute and early phase of ischemic stroke, whereas in the long-term, antiplatelet treatment should be continued with aspirin, aspirin/extended release dipyridamole or clopidogrel monotherapy taking into account tolerance, safety, adherence and cost issues. Secondary measures to educate patients about stroke, the importance of adherence to medication, behavioral modification relating to tobacco use, physical activity, alcohol consumption and diet to control excess weight should also be implemented.

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

PubMed

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

2018-01-15

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

Nocturnal periodic limb movements decrease antioxidant capacity in post-stroke women.

PubMed

Chen, C-Y; Yu, C-C; Chen, C-L

2016-04-01

Considerable evidence suggests that periodic limb movements during sleep (PLMS) are associated with cardiovascular risk and poor stroke outcome. However, the pathogenesis for this association in stroke patients remains largely unknown. This cross-sectional study enrolled 112 consecutive patients who were admitted to rehabilitation ward due to ischemic stroke. Polysomnography and laboratory tests for oxidative stress and inflammatory biomarkers including C-reactive protein, interleukin 6, total antioxidant capacity (TAC), and urinary 8-hydroxy-2-deoxyguanosine were conducted. Patients were stratified into three categories according to their PLMS index. Patients in the PLMS index ≥15 group were significantly older (P = 0.011), presented a significantly higher National Institute of Health Stroke Scale at stroke onset (P = 0.032), and lower Barthel index (P = 0.035) than patients in the PLMS index <5 group. The level of TAC differed significantly (P = 0.018) among the three groups. Multivariate linear regression analyses show that the PLMS index was negatively and independently correlated with TAC (P = 0.024) in women. Besides, multivariate logistic regression analyses also reveal that patients with a PLMS index ≥15 compared with the referent PLMS index <5 had a 7.58-fold increased relative hazard for stroke recurrence (odds ratio 7.58, [1.31-43.88], P = 0.024). This study suggests that PLMS was independently associated with decreased antioxidant capacity in women with ischemic stroke. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Royal College of Physicians Intercollegiate Stroke Working Party evidence-based guidelines for the secondary prevention of stroke through nutritional or dietary modification.

PubMed

Hookway, C; Gomes, F; Weekes, C E

2015-04-01

Each year, 15 million people worldwide and 110,000 people in England have a stroke. Having a stroke increases the risk of having another. There are a number of additional known risk factors that can be modified by diet. The present study aimed to systematically review key nutrients and diets and their role in secondary prevention, as well as provide evidence-based guidelines for use in clinical practice. The work was conducted as part of the process to develop the 4th edition of the Royal College of Physicians' (RCP) National Clinical Guideline (NCG) for Stroke. Questions were generated by the research team, in consultation with the Virtual Stroke Group, an online professional interest group, and the RCP Intercollegiate Stroke Working Party Guideline Development Group. Nine questions covering several individual nutrients and diet combinations were defined and searches conducted up until 31 October 2011 using five electronic databases (Embase, Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library and Web of Science). All included studies were assessed for quality and risk of bias using van Tulder criteria for randomised controlled trials (RCTs) and Quality of Reporting of Meta-analyses (QUORUM) criteria for systematic reviews. Of 4287 abstracts were identified, 79 papers were reviewed and 29 systematic reviews and RCTs were included to provide evidence for the secondary prevention components of the guidelines. For each question, evidence statements, recommendations and practical considerations were developed. This systematic review process has resulted in the development of evidence-based guidelines for use in clinical practice and has identified areas for further research. © 2014 The British Dietetic Association Ltd.

Yield of ultra-rapid carotid ultrasound and stroke specialist assessment in patients with TIA and minor stroke: an Italian TIA service audit.

PubMed

Gulli, Giosuè; Peron, Elisa; Ricci, Giorgio; Formaglio, Eva; Micheletti, Nicola; Tomelleri, Giampaolo; Moretto, Giuseppe

2014-12-01

In Italy the vast majority of TIA and minor strokes are seen in the A&E. Early diagnosis and management of TIA and minor stroke in this setting is habitually difficult and often lead to cost-ineffective hospital admissions. We set up an ultra-rapid TIA service run by neurovascular physicians based on early specialist assessment and ultrasound vascular imaging. We audit the clinical effectiveness and feasibility of the service and the impact of this service on TIA and minor strokes hospital admissions. We compared the rate of TIA and minor stroke admissions/discharges in the year before (T0) and in the year during which the TIA service was operating (T1). At T1 57 patients had specialist evaluation and 51 (89.5 %) of them were discharged home. Two (3.5 %) patients had recurrent symptoms after discharge. Seven had a pathological carotid Doppler ultrasound. Four of them had hospital admission and subsequent carotid endoarterectomy within a week. Taking the whole neurology department into consideration at T1 there was a 30-41 % reduction in discharges of patients with TIA or minor stroke. Taking the stroke unit section into consideration at T1 there was a 25 % reduction in admissions of patients with NIHSS score <4 and 40 % reduction in admissions of patients with Barthel Index above 80. The model of TIA service we implemented based on ultra-rapid stroke physician assessment and carotid ultrasound investigation is feasible and clinically valid. Indirect evidence suggests that it reduced the rate of expensive TIA/minor stroke hospital admissions.

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.

Dysarthria following stroke: the patient's perspective on management and rehabilitation.

PubMed

Brady, Marian C; Clark, Alexander M; Dickson, Sylvia; Paton, Gillian; Barbour, Rosaline S

2011-10-01

To explore the perceptions of people with stroke-related dysarthria in relation to the management and rehabilitation of dysarthria. Qualitative semi-structured interviews. Community setting Subjects: Twenty-four people with an acquired dysarthria as a result of a stroke in the previous three years. All were living at home at the time of the interview. None exhibited a co-existing impairment (for example, aphasia, apraxia or cognitive impairment) that might have contributed to their communicative experiences. Participants described the considerable efforts they made to maximize their communicative effectiveness prior to, and during, communicative interactions. Activities described included careful articulation and vocal projection as well as more inconspicuous strategies including pre-planning interactions, focused, effortful speech and word substitution. Communication was facilitated by a range of strategies including drafting, rehearsal, manoeuvring and ongoing monitoring and repair. Self-led speech rehabilitation activities were functionally based and often undertaken regularly. Some novel reading-aloud and speaking-aloud activities were described. The quantity and nature of inconspicuous, internalized, cognitive activities people with dysarthria engage in to maximize their communicative effectiveness should be considered in evaluating the impact of dysarthria following stroke. Focusing upon externally observable characteristics alone is insufficient. Challenging, functionally relevant, patient-focused activities, materials and targets are more likely to be perceived by the patient as relevant and worthwhile and are thus more likely to ensure adherence to recommended rehabilitation activities.

Secondary stroke prevention services in Canada: a cross-sectional survey and geospatial analysis of resources, capacity and geographic access

PubMed Central

Jewett, Lauren; Harroud, Adil; Hill, Michael D.; Côté, Robert; Wein, Theodore; Smith, Eric E.; Gubitz, Gord; Demchuk, Andrew M.; Sahlas, Demetrios J.; Gladstone, David J.; Lindsay, M. Patrice

2018-01-01

Background: Rapid assessment and management of transient ischemic attacks and nondisabling strokes by specialized stroke prevention services reduces the risk of recurrent stroke and improves outcomes. In Canada, with its vast geography and with 16.8% of the population living in rural areas, access to these services is challenging, and considerable variation in access to care exists. The purpose of this multiphase study was to identify sites across Canada providing stroke prevention services, evaluate resource capacity and determine geographic access for Canadians. Methods: We developed a Stroke Prevention Services Resource Inventory that contained 22 questions on the organization and delivery of stroke prevention services and quality monitoring. The inventory ran from November 2015 to January 2016 and was administered online. We conducted a geospatial analysis to estimate access by drive times. Considerations were made for hours of operation and access within and across provincial borders. Results: A total of 123 stroke prevention sites were identified, of which 119 (96.7%) completed the inventory. Most (95) are designated stroke prevention or rapid assessment clinics. Of the 119 sites, 68 operate full time, and 39 operate less than 2.5 days per week. A total of 87.3% of the Canadian population has access to a stroke prevention service within a 1-hour drive; however, only 69.2% has access to a service that operates 5-7 days a week. Allowing provincial border crossing improves access (< 6-h drive) for those who are beyond a 6-hour drive within their home province (3.4%). Interpretation: Most Canadians have reasonable geographic access to stroke prevention services. Allowing patients to cross borders improves the existing access for many, particularly some remote communities along the Ontario-Quebec and British Columbia-Alberta borders. PMID:29472251

The effects of human finger and Chinese character on Chinese handwriting performance on mobile touch devices.

PubMed

Chen, Zhe; Rau, Pei-Luen Patrick; Chen, Cuiling

2014-05-01

The aim of the present study is to investigate Chinese handwriting on mobile touch devices, considering the effects of three characteristics of the human finger (type, length, and width) and three characteristics of Chinese characters (direction of the first stroke, number of strokes, and structure). Due to the popularity of touch devices in recent years, finger input for Chinese characters has attracted more attention from both industry and academia. However, previous studies have no systematical consideration on the effects of human finger and Chinese characters on Chinese handwriting performance. An experiment was reported in this article to illustrate the effects of the human finger and Chinese characters on the Chinese handwriting performance (i.e., input time, accuracy, number of protruding strokes, mental workload, satisfaction, and physical fatigue). The experiment results indicated that all six factors have significant effects on Chinese handwriting performance, especially on the input time, accuracy, and number of protruding strokes. Finger type, finger length, finger width, direction of the first stroke, number of strokes, and character structures are significantly influencing Chinese handwriting performance. These factors should be taken into more consideration in future research and the practical design for Chinese handwriting systems.

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

PubMed Central

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

2017-01-01

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

ABCC6 mutations and early onset stroke: Two cases of a typical Pseudoxanthoma Elasticum.

PubMed

Bertamino, Marta; Severino, Mariasavina; Grossi, Alice; Rusmini, Marta; Tortora, Domenico; Gandolfo, Carlo; Pederzoli, Silvia; Malattia, Clara; Picco, Paolo; Striano, Pasquale; Ceccherini, Isabella; Di Rocco, Maja

2018-04-12

Pseudoxanthoma elasticum (PXE) is a rare genetic disorder characterized by fragmented and mineralized elastic fibers in the mid-dermis of the skin, eye, digestive tract and cardiovascular system. Clinical presentation includes typical skin lesions, ocular angioid streaks, and multisystem vasculopathy. The age of onset varies considerably from infancy to old age, but the diagnosis is usually made in young adults due to frequent absence of pathognomonic skin and ocular manifestations in early childhood. We report two children with PXE presenting with isolated multisystem vasculopathy and early-onset stroke. In the first patient, diagnosis was delayed until typical dermatologic alterations appeared; in the second patient, next-generation sequencing (NGS) study led to early diagnosis and specific follow-up, underlying the crucial role in idiopathic pediatric stroke of early genetic testing using NGS-based panels. Copyright © 2018 European Paediatric Neurology Society. Published by Elsevier Ltd. All rights reserved.

Guidelines for the Management of Patients With Unruptured Intracranial Aneurysms: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association.

PubMed

Thompson, B Gregory; Brown, Robert D; Amin-Hanjani, Sepideh; Broderick, Joseph P; Cockroft, Kevin M; Connolly, E Sander; Duckwiler, Gary R; Harris, Catherine C; Howard, Virginia J; Johnston, S Claiborne Clay; Meyers, Philip M; Molyneux, Andrew; Ogilvy, Christopher S; Ringer, Andrew J; Torner, James

2015-08-01

The aim of this updated statement is to provide comprehensive and evidence-based recommendations for management of patients with unruptured intracranial aneurysms. Writing group members used systematic literature reviews from January 1977 up to June 2014. They also reviewed contemporary published evidence-based guidelines, personal files, and published expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulated recommendations using standard American Heart Association criteria. The guideline underwent extensive peer review, including review by the Stroke Council Leadership and Stroke Scientific Statement Oversight Committees, before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee. Evidence-based guidelines are presented for the care of patients presenting with unruptured intracranial aneurysms. The guidelines address presentation, natural history, epidemiology, risk factors, screening, diagnosis, imaging and outcomes from surgical and endovascular treatment. © 2015 American Heart Association, Inc.

Modelling of power lines in lightning incidence calculations

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

Mousa, A.M.; Srivastava, K.D.

1990-01-01

When applying the electrogeometric model to power lines to determine the frequency and characteristics of the collected lightning strokes, the power line has traditionally been represented by a set of horizontal wires, i.e. both the sag of the wires and the existence of the towers have been ignored. This approach has serious shortcomings including inability to determine the percentage of the strokes terminating on the towers, failure to correctly predict the effect of height on median current, and giving an approximate value for the number of collected strokes without telling the corresponding degree of error. This paper eliminates the abovemore » problems by presenting a computerized solution which takes into consideration the sag of the wires, the existence of the towers, and the inequality of the striking distances to towers and to wires. The features of the program are discussed in the paper, and some of its results are given.« less

The economic burden of ischemic stroke and major hemorrhage in medicare beneficiaries with nonvalvular atrial fibrillation: a retrospective claims analysis.

PubMed

Fitch, Kathryn; Broulette, Jonah; Kwong, Winghan Jacqueline

2014-06-01

Understanding the economic implications of oral anticoagulation therapy requires careful consideration of the risks and costs of stroke and major hemorrhage. The majority of patients with atrial fibrillation (AF) are aged ≥65 years, so focusing on the Medicare population is reasonable when discussing the risk for stroke. To examine the relative economic burden associated with stroke and major hemorrhage among Medicare beneficiaries who are newly diagnosed with nonvalvular atrial fibrillation (NVAF). This study was a retrospective analysis of a 5% sample of Medicare claims data for patients with NVAF from 2006 to 2008. Patients with NVAF without any claims of AF during the 12 months before the first (index) claim for AF in 2007 (baseline period) were identified and were classified into 4 cohorts during a 12-month follow-up period after the index date. These cohorts included (1) no claims for ischemic stroke or major hemorrhage (without stroke or hemorrhage); (2) no claims for ischemic stroke and ≥1 claims for major hemorrhage (hemorrhage only); (3) ≥1 claims for ischemic stroke and no major hemorrhage claims (stroke only); and (4) ≥1 claims each for ischemic stroke and for major hemorrhage (stroke and hemorrhage). The 1-year mean postindex total all-cause healthcare costs adjusted by the Centers for Medicare & Medicaid Services Hierarchical Condition Categories (HCC) score were compared among the study cohorts. Of the 9455 eligible patients included in this study, 3% (N = 261) of the patients had ischemic stroke claims only, 3% (N = 276) had hemorrhage claims only, and <1% (N = 13) had both during the follow-up period. The unadjusted follow-up healthcare costs were $63,781 and $64,596 per patient for the ischemic stroke only and the hemorrhage only cohorts, respectively, compared with $35,474 per patient for those without hemorrhage or stroke claims. After adjustment for HCC risk score, the mean incremental costs for patients with stroke claims only and hemorrhage claims only, relative to those without stroke or hemorrhage claims, were $26,776 (95% confidence interval [CI], $20,785-$32,767; P <.001) and $26,168 (95% CI, $20,375-$31,961; P <.001), respectively. The economic burden of managing patients with NVAF who experience ischemic stroke and hemorrhage were similarly significant during the first year after a diagnosis of NVAF. The burden of major bleeding complications on patients, clinicians, and payers should not be overlooked, and these complications should be considered in conjunction with the cost-savings associated with ischemic stroke risk reduction in future cost-benefit evaluations of oral anticoagulation therapy.

The Economic Burden of Ischemic Stroke and Major Hemorrhage in Medicare Beneficiaries with Nonvalvular Atrial Fibrillation: A Retrospective Claims Analysis

PubMed Central

Fitch, Kathryn; Broulette, Jonah; Kwong, Winghan Jacqueline

2014-01-01

Background Understanding the economic implications of oral anticoagulation therapy requires careful consideration of the risks and costs of stroke and major hemorrhage. The majority of patients with atrial fibrillation (AF) are aged ≥65 years, so focusing on the Medicare population is reasonable when discussing the risk for stroke. Objective To examine the relative economic burden associated with stroke and major hemorrhage among Medicare beneficiaries who are newly diagnosed with nonvalvular atrial fibrillation (NVAF). Methods This study was a retrospective analysis of a 5% sample of Medicare claims data for patients with NVAF from 2006 to 2008. Patients with NVAF without any claims of AF during the 12 months before the first (index) claim for AF in 2007 (baseline period) were identified and were classified into 4 cohorts during a 12-month follow-up period after the index date. These cohorts included (1) no claims for ischemic stroke or major hemorrhage (without stroke or hemorrhage); (2) no claims for ischemic stroke and ≥1 claims for major hemorrhage (hemorrhage only); (3) ≥1 claims for ischemic stroke and no major hemorrhage claims (stroke only); and (4) ≥1 claims each for ischemic stroke and for major hemorrhage (stroke and hemorrhage). The 1-year mean postindex total all-cause healthcare costs adjusted by the Centers for Medicare & Medicaid Services Hierarchical Condition Categories (HCC) score were compared among the study cohorts. Results: Of the 9455 eligible patients included in this study, 3% (N = 261) of the patients had ischemic stroke claims only, 3% (N = 276) had hemorrhage claims only, and <1% (N = 13) had both during the follow-up period. The unadjusted follow-up healthcare costs were $63,781 and $64,596 per patient for the ischemic stroke only and the hemorrhage only cohorts, respectively, compared with $35,474 per patient for those without hemorrhage or stroke claims. After adjustment for HCC risk score, the mean incremental costs for patients with stroke claims only and hemorrhage claims only, relative to those without stroke or hemorrhage claims, were $26,776 (95% confidence interval [CI], $20,785-$32,767; P <.001) and $26,168 (95% CI, $20,375-$31,961; P <.001), respectively. Conclusion The economic burden of managing patients with NVAF who experience ischemic stroke and hemorrhage were similarly significant during the first year after a diagnosis of NVAF. The burden of major bleeding complications on patients, clinicians, and payers should not be overlooked, and these complications should be considered in conjunction with the cost-savings associated with ischemic stroke risk reduction in future cost-benefit evaluations of oral anticoagulation therapy. PMID:25126372

International Survey on the Management of Wake-Up Stroke.

PubMed

de Castro-Afonso, Luís Henrique; Nakiri, Guilherme Seizem; Pontes-Neto, Octávio Marques; dos Santos, Antônio Carlos; Abud, Daniel Giansante

2016-01-01

Patients who wake up having experienced a stroke while asleep represent around 20% of acute stroke admissions. According to international guidelines for the management of acute stroke, patients presenting with wake-up stroke are not currently eligible to receive revascularization treatments. In this study, we aimed to assess the opinions of stroke experts about the management of patients with wake-up stroke by using an international multicenter electronic survey. This study consisted of 8 questions on wake-up stroke treatment. Two hundred invitations to participate in the survey were sent by e-mail. Fifty-nine participants started the survey, 4 dropped out before completing it, and 55 completed the full questionnaire. We had 55 participants from 22 countries. In this study, most stroke experts recommended a recanalization treatment for wake-up stroke. However, there was considerable disagreement among experts regarding the best brain imaging method and the best recanalization treatment. The results of ongoing randomized trials on wake-up stroke are urgently needed.

Acute [corrected] stroke thrombolysis: an update [corrected].

PubMed

Mehdiratta, Manu; Caplan, Louis R

2007-01-01

Acute stroke therapy took a major step forward in 1996 after the approval of Intravenous (IV) tissue plasminogen activator (t-PA) by the US Food and Drug Administration for patients presenting within 3 hours of the onset of stroke symptoms. Since that time, there have been considerable advances in imaging techniques as well as the advent of devices to help in the management of acute stroke patients. As a result, the arsenal to treat acute stroke has grown, and the field of stroke as a subspecialty of neurology has emerged. Despite these advances, only 3% to 8% of eligible patients with acute stroke in the United States are administered thrombolytics.(1) We herein review the use of thrombolytics in stroke and provide an overview of the imaging advances, new devices, and recent trials that are shaping modern stroke therapy. Finally, we provide a practical approach to the management of acute stroke, specifically for the practicing cardiologist, who may encounter stroke during cardiac catheterization, post myocardial infarction (MI), and in a variety of other settings.

How Do Speech-and-Language Therapists Address the Psychosocial Well-Being of People with Aphasia? Results of a UK Online Survey

ERIC Educational Resources Information Center

Northcott, Sarah; Simpson, Alan; Moss, Becky; Ahmed, Nafiso; Hilari, Katerina

2017-01-01

Background: The psychosocial impact of stroke and aphasia is considerable. Aims: To explore UK speech-and-language therapists' (SLTs) clinical practice in addressing the psychological and social needs of people with aphasia, including their experiences of working with mental health professionals. Methods & Procedures: A 22-item online survey…

The Evolution and Application of Cardiac Monitoring for Occult Atrial Fibrillation in Cryptogenic Stroke and TIA.

PubMed

Miller, Daniel J; Shah, Kavit; Modi, Sumul; Mahajan, Abhimanyu; Zahoor, Salman; Affan, Muhammad

2016-04-01

The evaluation of the stroke and transient ischemic attack (TIA) patient has been historically predominated by the initial evaluation in the hospital setting. As the etiology of stroke has eluded us in approximately one third of all acute events, the medical community has been eager to seek the answer to this mystery. In recent years, we have seen an explosion of innovations and trends allowing for a more detailed post stroke assessment strategy aimed at the identification of occult atrial fibrillation as the etiologic cause for the cryptogenic event. This has been achieved through the evolution and aggressive application and study of prolonged and advanced cardiac monitoring. This review is aimed to clarify and elucidate the standard and novel cardiac monitoring methods that have become available for use by the medical community and expected in the higher level care of cryptogenic stroke and TIA patients. These cardiac monitoring methods and devices are as heterogeneous as our patient population and have their own advantages and disadvantages. Many factors may be taken into consideration in choosing the appropriate cardiac monitoring method and are highlighted for consideration in this review. With a judicious approach to investigating the cryptogenic stroke population, and applying a wealth of novel treatment options, we may move forward into a new era of stroke prevention.

UK research spend in 2008 and 2012: comparing stroke, cancer, coronary heart disease and dementia

PubMed Central

Luengo-Fernandez, Ramon; Leal, Jose; Gray, Alastair

2015-01-01

Objective To assess UK governmental and charity research funding in 2012 for cancer, coronary heart disease (CHD), dementia and stroke, and to make comparisons with 2008 levels. Design Analysis of research expenditure. Setting United Kingdom. Main outcome measures We identified UK governmental agencies and charities providing health research funding to determine the 2012 levels of funding for cancer, CHD, dementia and stroke. Levels of research funding were compared to burden of disease measures, including prevalence, disability adjusted life years and economic burden. Results The combined research funding into cancer, CHD, dementia and stroke by governmental and charity organisations in 2012 was £856 million, of which £544 million (64%) was devoted to cancer, £166 million (19%) to CHD, £90 million (11%) to dementia and £56 million (7%) to stroke. For every £10 of health and social care costs attributable to each disease, cancer received £1.08 in research funding, CHD £0.65, stroke £0.19 and dementia £0.08. A considerable shift in the distribution of government research funding was observed between 2008 and 2012. In 2008, 66% of governmental research funding into the four conditions under study was devoted to cancer, 21% to CHD, 9% to dementia and 4% to stroke. In 2012, the proportions devoted to dementia and stroke had increased to 21% and 12%, respectively, with cancer accounting for 45% of total research spend. Conclusions Although there has been much progress by government to increase levels of research funding for dementia and stroke, these areas remain underfunded when compared with the burden of disease. PMID:25869683

Antithrombotic Therapy for Atrial Fibrillation

PubMed Central

You, John J.; Singer, Daniel E.; Howard, Patricia A.; Lane, Deirdre A.; Eckman, Mark H.; Fang, Margaret C.; Hylek, Elaine M.; Schulman, Sam; Go, Alan S.; Hughes, Michael; Spencer, Frederick A.; Manning, Warren J.; Halperin, Jonathan L.

2012-01-01

Background: The risk of stroke varies considerably across different groups of patients with atrial fibrillation (AF). Antithrombotic prophylaxis for stroke is associated with an increased risk of bleeding. We provide recommendations for antithrombotic treatment based on net clinical benefit for patients with AF at varying levels of stroke risk and in a number of common clinical scenarios. Methods: We used the methods described in the Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines article of this supplement. Results: For patients with nonrheumatic AF, including those with paroxysmal AF, who are (1) at low risk of stroke (eg, CHADS2 [congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, prior stroke or transient ischemic attack] score of 0), we suggest no therapy rather than antithrombotic therapy, and for patients choosing antithrombotic therapy, we suggest aspirin rather than oral anticoagulation or combination therapy with aspirin and clopidogrel; (2) at intermediate risk of stroke (eg, CHADS2 score of 1), we recommend oral anticoagulation rather than no therapy, and we suggest oral anticoagulation rather than aspirin or combination therapy with aspirin and clopidogrel; and (3) at high risk of stroke (eg, CHADS2 score of ≥ 2), we recommend oral anticoagulation rather than no therapy, aspirin, or combination therapy with aspirin and clopidogrel. Where we recommend or suggest in favor of oral anticoagulation, we suggest dabigatran 150 mg bid rather than adjusted-dose vitamin K antagonist therapy. Conclusions: Oral anticoagulation is the optimal choice of antithrombotic therapy for patients with AF at high risk of stroke (CHADS2 score of ≥ 2). At lower levels of stroke risk, antithrombotic treatment decisions will require a more individualized approach. PMID:22315271

UK research spend in 2008 and 2012: comparing stroke, cancer, coronary heart disease and dementia.

PubMed

Luengo-Fernandez, Ramon; Leal, Jose; Gray, Alastair

2015-04-13

To assess UK governmental and charity research funding in 2012 for cancer, coronary heart disease (CHD), dementia and stroke, and to make comparisons with 2008 levels. Analysis of research expenditure. United Kingdom. We identified UK governmental agencies and charities providing health research funding to determine the 2012 levels of funding for cancer, CHD, dementia and stroke. Levels of research funding were compared to burden of disease measures, including prevalence, disability adjusted life years and economic burden. The combined research funding into cancer, CHD, dementia and stroke by governmental and charity organisations in 2012 was £856 million, of which £544 million (64%) was devoted to cancer, £166 million (19%) to CHD, £90 million (11%) to dementia and £56 million (7%) to stroke. For every £10 of health and social care costs attributable to each disease, cancer received £1.08 in research funding, CHD £0.65, stroke £0.19 and dementia £0.08. A considerable shift in the distribution of government research funding was observed between 2008 and 2012. In 2008, 66% of governmental research funding into the four conditions under study was devoted to cancer, 21% to CHD, 9% to dementia and 4% to stroke. In 2012, the proportions devoted to dementia and stroke had increased to 21% and 12%, respectively, with cancer accounting for 45% of total research spend. Although there has been much progress by government to increase levels of research funding for dementia and stroke, these areas remain underfunded when compared with the burden of disease. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Rivaroxaban as an oral anticoagulant for stroke prevention in atrial fibrillation

PubMed Central

Turpie, Alexander GG

2014-01-01

Atrial fibrillation (AF) is the most common cardiac arrhythmia in the developed world and is associated with a fivefold increase in the risk of stroke, accounting for up to 15% of strokes in the general population. The European Society of Cardiology now recommends direct oral anticoagulants, such as rivaroxaban, apixaban, and dabigatran, in preference to vitamin K antagonist therapy for the prevention of stroke in patients with A F. This review focuses on the direct Factor Xa inhibitor rivaroxaban, summarizing the properties that make rivaroxaban appropriate for anticoagulant therapy in this indication (including its predictable pharmacokinetic and pharmacodynamic profile and once-daily dosing regimen) and describing data from the Phase III ROCKET AF trial, which showed once-daily rivaroxaban to be noninferior to warfarin for the prevention of stroke in patients with nonvalvular AF. In this trial, similar rates of major and nonmajor clinically relevant bleeding were observed; however, when compared with warfarin, rivaroxaban was associated with clinically significant reductions in intracranial and fatal bleeding. On the basis of these results, rivaroxaban was approved in both the United States and the European Union for the prevention of stroke and systemic embolism in patients with nonvalvular AF. Subanalyses of ROCKET AF data showed rivaroxaban to have consistent efficacy and safety across a wide range of patients, and studies to confirm these results in real-world settings are underway. This review also describes practical considerations for treatment with rivaroxaban in clinical practice (including dose reductions in specific high-risk patients, eg, those with renal impairment), recommendations for the transition from vitamin K antagonists to rivaroxaban, the management of bleeding events, and the measurement of rivaroxaban exposure. PMID:24711702

Interactions between Age, Sex, and Hormones in Experimental Ischemic Stroke

PubMed Central

Liu, Fudong; McCullough, Louise D.

2012-01-01

Age, sex, and gonadal hormones have profound effects on ischemic stroke outcomes, although how these factors impact basic stroke pathophysiology remains unclear. There is a plethora of inconsistent data reported throughout the literature, primarily due to differences in the species examined, the timing and methods used to evaluate injury, the models used, and confusion regarding differences in stroke incidence as seen in clinical populations versus effects on acute neuroprotection or neurorepair in experimental stroke models. Sex and gonadal hormone exposure have considerable independent impact on stroke outcome, but these factors also interact with each other, and the contribution of each differs throughout the lifespan. The contribution of sex and hormones to experimental stroke will be the focus of this review. Recent advances and our current understanding of age, sex, and hormone interactions in ischemic stroke with a focus on inflammation will be discussed. PMID:23068990

Community-based post-stroke service provision and challenges: a national survey of managers and inter-disciplinary healthcare staff in Ireland.

PubMed

Hickey, Anne; Horgan, Frances; O'Neill, Desmond; McGee, Hannah

2012-05-06

The extent of stroke-related disability typically becomes most apparent after patient discharge to the community. As part of the Irish National Audit of Stroke Care (INASC), a national survey of community-based allied health professionals and public health nurses was conducted. The aim was to document the challenges to service availability for patients with stroke in the community and to identify priorities for service improvement. The study was a cross-sectional tailored interview survey with key managerial and service delivery staff. As comprehensive listings of community-based health professionals involved in stroke care were not available, a cascade approach to information gathering was adopted. Representative regional managers for services incorporating stroke care (N = 7) and disciplinary allied health professional and public health nurse managers (N = 25) were interviewed (94% response rate). Results indicated a lack of formal, structured community-based services for stroke, with no designated clinical posts for stroke care across disciplines nationally. There was significant regional variation in availability of allied health professionals. Considerable inequity was identified in patient access to stroke services, with greater access, where available, for older patients (≥ 65 years). The absence of a stroke strategy and stroke prevalence statistics were identified as significant impediments to service planning, alongside organisational barriers limiting the recruitment of additional allied health professional staff, and lack of sharing of discipline-specific information on patients. This study highlighted major gaps in the provision of inter-disciplinary team community-based services for people with stroke in one country. Where services existed, they were generic in nature, rarely inter-disciplinary in function and deficient in input from salient disciplines. Challenges to optimal care included the need for strategic planning; increased funding of healthcare staff; increased team resources and teamwork; and removal of service provision barriers based on age. There were notably many challenges beyond funding. Similar evaluations in other healthcare systems would serve to provide comparative lessons to serve to tackle this underserved aspect of care for patients with stroke and their families.

Embolic Strokes of Unknown Source and Cryptogenic Stroke: Implications in Clinical Practice

PubMed Central

Nouh, Amre; Hussain, Mohammed; Mehta, Tapan; Yaghi, Shadi

2016-01-01

Up to a third of strokes are rendered cryptogenic or of undetermined etiology. This number is specifically higher in younger patients. At times, inadequate diagnostic workups, multiple causes, or an under-recognized etiology contributes to this statistic. Embolic stroke of undetermined source, a new clinical entity particularly refers to patients with embolic stroke for whom the etiology of embolism remains unidentified despite through investigations ruling out established cardiac and vascular sources. In this article, we review current classification and discuss important clinical considerations in these patients; highlighting cardiac arrhythmias and structural abnormalities, patent foramen ovale, paradoxical sources, and potentially under-recognized, vascular, inflammatory, autoimmune, and hematologic sources in relation to clinical practice. PMID:27047443

Tai Chi-based exercise program provided via telerehabilitation compared to home visits in a post-stroke population who have returned home without intensive rehabilitation: study protocol for a randomized, non-inferiority clinical trial

PubMed Central

2014-01-01

Background The incidence of strokes in industrialized nations is on the rise, particularly in the older population. In Canada, a minority of individuals who have had a stroke actually receive intensive rehabilitation because most stroke patients do not have access to services or because their motor recovery was judged adequate to return home. Thus, there is a considerable need to organize home-based rehabilitation services for everyone who has had a stroke. To meet this demand, telerehabilitation, particularly from a service center to the patient’s home, is a promising alternative approach that can help improve access to rehabilitation services once patients are discharged home. Methods/Design This non-inferiority study will include patients who have returned home post-stroke without requiring intensive rehabilitation. To be included in the study, participants will: 1) not be referred to an Intensive Functional Rehabilitation Unit, 2) have a Rankin score of 2 or 3, and 3) have a balance problem (Berg Balance Scale score between 46 and 54). Participants will be randomly assigned to either the teletreatment group or the home visits group. Except for the delivery mode, the intervention will be the same for both groups, that is, a personalized Tai Chi-based exercise program conducted by a trained physiotherapist (45-minute session twice a week for eight consecutive weeks). The main objective of this research is to test the non-inferiority of a Tai Chi-based exercise program provided via telerehabilitation compared to the same program provided in person at home in terms of effectiveness for retraining balance in individuals who have had a stroke but do not require intensive functional rehabilitation. The main outcome of this study is balance and mobility measured with the Community Balance and Mobility Scale. Secondary outcomes include physical and psychological capacities related to balance and mobility, participants’ quality of life, satisfaction with services received, and cost-effectiveness associated with the provision of both types of services. Study/trial registration ClinicalTrials.gov: NCT01848080 PMID:24479760

Tai Chi-based exercise program provided via telerehabilitation compared to home visits in a post-stroke population who have returned home without intensive rehabilitation: study protocol for a randomized, non-inferiority clinical trial.

PubMed

Tousignant, Michel; Corriveau, Hélène; Kairy, Dahlia; Berg, Katherine; Dubois, Marie-France; Gosselin, Sylvie; Swartz, Richard H; Boulanger, Jean-Martin; Danells, Cynthia

2014-01-30

The incidence of strokes in industrialized nations is on the rise, particularly in the older population. In Canada, a minority of individuals who have had a stroke actually receive intensive rehabilitation because most stroke patients do not have access to services or because their motor recovery was judged adequate to return home. Thus, there is a considerable need to organize home-based rehabilitation services for everyone who has had a stroke. To meet this demand, telerehabilitation, particularly from a service center to the patient's home, is a promising alternative approach that can help improve access to rehabilitation services once patients are discharged home. This non-inferiority study will include patients who have returned home post-stroke without requiring intensive rehabilitation. To be included in the study, participants will: 1) not be referred to an Intensive Functional Rehabilitation Unit, 2) have a Rankin score of 2 or 3, and 3) have a balance problem (Berg Balance Scale score between 46 and 54). Participants will be randomly assigned to either the teletreatment group or the home visits group. Except for the delivery mode, the intervention will be the same for both groups, that is, a personalized Tai Chi-based exercise program conducted by a trained physiotherapist (45-minute session twice a week for eight consecutive weeks). The main objective of this research is to test the non-inferiority of a Tai Chi-based exercise program provided via telerehabilitation compared to the same program provided in person at home in terms of effectiveness for retraining balance in individuals who have had a stroke but do not require intensive functional rehabilitation. The main outcome of this study is balance and mobility measured with the Community Balance and Mobility Scale. Secondary outcomes include physical and psychological capacities related to balance and mobility, participants' quality of life, satisfaction with services received, and cost-effectiveness associated with the provision of both types of services. ClinicalTrials.gov: NCT01848080.

Predicting fitness-to-drive following stroke using the Occupational Therapy - Driver Off Road Assessment Battery.

PubMed

Unsworth, Carolyn A; Baker, Anne; Lannin, Natasha; Harries, Priscilla; Strahan, Janene; Browne, Matthew

2018-02-28

It is difficult to determine if, or when, individuals with stroke are ready to undergo on-road fitness-to-drive assessment. The Occupational Therapy - Driver Off Road Assessment Battery was developed to determine client suitability to resume driving. The predictive validity of the Battery needs to be verified for people with stroke. Examine the predictive validity of the Occupational Therapy - Driver Off Road Assessment Battery for on-road performance among people with stroke. Off-road data were collected from 148 people post stroke on the Battery and the outcome of their on-road assessment was recorded as: fit-to-drive or not fit-to-drive. The majority of participants (76%) were able to resume driving. A classification and regression tree (CART) analysis using four subtests (three cognitive and one physical) from the Battery demonstrated an area under the curve (AUC) of 0.8311. Using a threshold of 0.5, the model correctly predicted 98/112 fit-to-drive (87.5%) and 26/36 people not fit-to-drive (72.2%). The three cognitive subtests from the Occupational Therapy - Driver Off Road Assessment Battery and potentially one of the physical tests have good predictive validity for client fitness-to-drive. These tests can be used to screen client suitability for proceeding to an on-road test following stroke. Implications for Rehabilitation: Following stroke, drivers should be counseled (including consideration of local legislation) concerning return to driving. The Occupational Therapy - Driver Off Road Assessment Battery can be used in the clinic to screen people for suitability to undertake on road assessment. Scores on four of the Occupational Therapy - Driver Off Road Assessment Battery subtests are predictive of resumption of driving following stroke.

A Case of Myopathy, Encephalopathy, Lactic Acidosis and Stroke-Like Episodes (MELAS) Syndrome with Intracardiac Thrombus [corrected].

PubMed

Joo, Jung-Chul; Seol, Myung Do; Yoon, Jin Won; Lee, Young Soo; Kim, Dong-Keun; Choi, Yong Hoon; Ahn, Hyo Seong; Cho, Wook Hyun

2013-03-01

Myopathy, encephalopathy, lactic acidosis and stroke-like episodes (MELAS) is a multisystem clinical syndrome manifested by mitochondrial myopathy, encephalopathy, lactic acidosis and recurrent stroke-like episodes. A 27-year-old female with MELAS syndrome presented with cerebral infarction. Echocardiography revealed a thrombus attached to the apex of the hypertrophied left ventricle, with decreased systolic function. The embolism of the intracardiac thrombus might have been the cause of stroke. There should be more consideration given to the increased possibility of intracardiac thrombus formation when a MELAS patient with cardiac involvement is encountered.

Blood pressure and stroke: an overview of published reviews.

PubMed

Lawes, Carlene M M; Bennett, Derrick A; Feigin, Valery L; Rodgers, Anthony

2004-04-01

The last few years have seen a considerable increase in the amount of information available concerning blood pressure (BP) and stroke associations. This article provides an overview of published reviews of the effects on stroke seen in trials of BP-lowering drugs and compares these with the results available from cohort studies. We present a review of major overviews of prospective cohort studies and an updated meta-analysis of >40 randomized controlled trials of BP lowering, which included >188 000 participants and approximately 6800 stroke events. Cohort studies now indicate that in the Asia Pacific region as well as in North America and Western Europe, each 10 mm Hg lower systolic BP is associated with a decrease in risk of stroke of approximately one third in subjects aged 60 to 79 years. The association is continuous down to levels of at least 115/75 mm Hg and is consistent across sexes, regions, and stroke subtypes and for fatal and nonfatal events. The proportional association is age dependent but is still strong and positive in those aged 80 years. Data from randomized controlled trials, in which mean age at event was approximately 70 years, indicate that a 10 mm Hg reduction in systolic BP is associated with a reduction in risk of stroke of approximately one third. Per mm Hg systolic BP reduction, the relative benefits for stroke appear similar between agents, by baseline BP levels, and whether or not individuals have a past history of cardiovascular disease. There is, however, evidence of greater benefit with a larger BP reduction. The epidemiologically expected benefits of BP lowering for stroke risk reduction are broadly consistent across a range of different population subgroups. There are greater benefits from larger BP reductions, and initiating and maintaining BP reduction for stroke prevention is a more important issue than choice of initial agent.

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

PubMed

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

2017-12-01

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

Music-supported therapy for stroke motor recovery: theoretical and practical considerations.

PubMed

Chen, Joyce L

2018-05-08

Music may confer benefits for well-being and health. What is the state of knowledge and evidence for a role of music in supporting the rehabilitation of movements after stroke? In this brief perspective, I provide background context and information about stroke recovery in general, in order to spark reflection and discussion for how we think music may impact motor recovery, given the current clinical milieu. © 2018 New York Academy of Sciences.

[Childhood stroke : What are the special features of childhood stroke?

PubMed

Gerstl, L; Bonfert, M V; Nicolai, T; Dieterich, M; Adamczyk, C; Heinen, F; Olivieri, M; Steinlin, M

2017-12-01

Childhood arterial ischemic stroke differs in essential aspects from adult stroke. It is rare, often relatively unknown among laypersons and physicians and the wide variety of age-specific differential diagnoses (stroke mimics) as well as less established care structures often lead to a considerable delay in the diagnosis of stroke. The possible treatment options in childhood are mostly off-label. Experiences in well-established acute treatment modalities in adult stroke, such as thrombolysis and mechanical thrombectomy are therefore limited in children and only based on case reports and case series. The etiological clarification is time-consuming due to the multitude of risk factors which must be considered. Identifying each child's individual risk profile is mandatory for acute treatment and secondary prevention strategies and has an influence on the individual outcome. In addition to the clinical neurological outcome the residual neurological effects of stroke on cognition and behavior are decisive for the integration of the child into its educational, later professional and social environment.

Smoking and stroke: the more you smoke the more you stroke

PubMed Central

Shah, Reena S; Cole, John W

2010-01-01

Cigarette smoking is a well-established risk factor for all forms of stroke. While both the general public and the global healthcare system are aware of the vascular risks associated with smoking, the prevalence of tobacco use has remained largely unchanged over the last quarter of a century. Approximately one in five US adults are classified as regular smokers, with the initiation of smoking typically occurring during the teenage years. Although the increased risk of stroke associated with smoking is generally acknowledged, it is less well recognized that considerable scientific evidence implicates a strong dose–response relationship between smoking and stroke risk. In this article, we summarize the literature regarding smoking-related stroke risk, the dose–response relationship, and the costs of this detrimental habit to both the individual and society as a whole. PMID:20602553

Blood pressure and stroke: an overview of published reviews.

PubMed

Lawes, Carlene M M; Bennett, Derrick A; Feigin, Valery L; Rodgers, Anthony

2004-03-01

The last few years have seen a considerable increase in the amount of information available concerning blood pressure (BP) and stroke associations. This article provides an overview of published reviews of the effects on stroke seen in trials of BP-lowering drugs and compares these with the results available from cohort studies. We present a review of major overviews of prospective cohort studies and an updated meta-analysis of >40 randomized controlled trials of BP lowering, which included >188 000 participants and approximately 6800 stroke events. Cohort studies now indicate that in the Asia Pacific region as well as in North America and Western Europe, each 10 mm Hg lower systolic BP is associated with a decrease in risk of approximately one third in subjects aged 60 to 79 years. The association is continuous down to levels of at least 115/75 mm Hg and is consistent across sexes, regions, and stroke subtypes and for fatal and nonfatal events. The proportional association is age dependent but is still a strong and positive association in those aged 80 years. Data from randomized controlled trials, in which mean age at event was approximately 70 years, indicate that a 10 mm Hg reduction in systolic BP is associated with a reduction in risk of stroke of approximately one third. Per mm Hg systolic BP reduction, the benefits for stroke appear similar between agents, by baseline BP levels, and whether or not individuals have a past history of cardiovascular disease. There is, however, evidence of greater benefit with a larger BP reduction. The epidemiologically expected benefits of BP lowering for stroke risk reduction are broadly consistent across a range of different population subgroups. There are greater benefits from larger BP reductions, and initiating and maintaining BP reduction for stroke prevention is a more important issue than choice of initial agent.

Randomized trial of therapy with platelet antiaggregants for threatened stroke. 2: Observations on the pathogenesis and natural history of threatened stroke.

PubMed Central

Barnett, H. J.; Gent, M.; Sackett, D. L.; Taylor, D. W.

1980-01-01

Transient cerebral ischemia and stroke may occur despite previous occlusion of the artery supplying the appropriate part of the brain. After occlusion of the internal carotid artery, emboli may pass from the "stump" of the occluded artery to later produce transient cerebral ischemia or a stroke. Transient cerebral ischemia and stroke are due to a variety of conditions, some of which are strongly correlated with platelet thromboembolism, while others have little primary relation to thrombosis. The impact of this on therapeutic considerations is obvious. Thromboembolism related to myxomatous degeneration of the mitral valve (mitral valve prolapse) is a factor to consider in determining the cause of a stroke in a younger person. The prognosis for the different varieties of threatened stroke is incompletely known. When due to arteriosclerosis of the large cerebral arteries, transient cerebral ischemia and minor strokes pose a cumulative threat for a major stroke or death of 13% in the first year, 22% in the second year and 30% in the third year. Images FIG. 1 FIG. 2 FIG. 3 FIG. 4 PMID:6989464

"I had no idea what a complicated business eating is…": a qualitative study of the impact of dysphagia during stroke recovery.

PubMed

Moloney, Jennifer; Walshe, Margaret

2018-06-01

Persons with dysphagia following stroke may experience uncomfortable symptoms such as persistent coughing, choking and poor salivary management. They may also spend long periods of time unable to eat or drink or with restrictions on oral intake. Experiences of dysphagia post-stroke are richly described in unsolicited narratives such as autobiographies on the stroke event, which often include details of the author's journey through their stroke recovery. The aim of this study is to use autobiographical accounts to explore the experiences of those living with dysphagia following stroke. Published autobiographies narrating the author's experiences of living with dysphagia following stroke were sourced. Ten autobiographies were retrieved and the texts were manually inspected. All references to eating, drinking and swallowing were extracted and pooled to form the data set. A qualitative approach using a six-step interpretive phenomenological analysis process was taken to analyze this data set. A wide range of interconnected themes emerged from the data, allowing further synthesis into six overarching super-ordinate themes. These six super-ordinate themes were: "physical consequences of dysphagia"; "process of recovery"; "coping and adjusting"; "changed relationships"; "society" and "control". This study highlights the unique contribution of autobiographical accounts in developing our understanding of living with dysphagia following stroke. The findings emphasize the significant emotional and social impact of dysphagia during the stroke recovery process and add further depth to our understanding of the experience of this clinical group. Implications for Rehabilitation Autobiographical accounts often hold valuable first-hand information on patient perspectives and journeys, which when viewed through the eyes of a qualitative researcher, can add depth to our understanding of particular healthcare experiences. Persons who experience dysphagia as a result of stroke travel a complex rehabilitation journey, involving the interaction of many physical, emotional and social considerations. Healthcare professionals should be aware of not only the physical, but also the significant psychosocial consequences of living with dysphagia following stroke. Further research is required in this field, so that the experiences of these persons can be better understood and findings can be used to contribute to high-quality and evidence-based service delivery.

Reconciling Marriage and Care after Stroke.

PubMed

Anderson, Sharon; Keating, Norah; Wilson, Donna

2017-09-01

Most research on stroke's impact on couples has focused on the transition to caregiving/receiving. Despite considerable evidence that marriage is the primary source of support in the face of chronic conditions, little is known about what happens to marriage in the context of care after stroke. To address this gap, we undertook a qualitative grounded-theory study of 18 couples in which one partner had experienced a stroke. Findings revealed two interrelated themes of the couple processes: working out care, which involved discovering and addressing disruptions in day-to-day activities; and rethinking marriage, which involved determining the meaning of their relationship within the new context of care and disability. Three distinct types of marriages evolved from these processes: reconfirmed around their pre-stroke marriage; recalibrated around care; and a parallel relationship, "his" and "her" marriage. Our findings highlight the need to consider relationship dynamics in addition to knowledge about stroke and care.

Effects of virtual reality training on mobility and physical function in stroke.

PubMed

Malik, Arshad Nawaz; Masood, Tahir

2017-10-01

Stroke is a common disabling condition which declines the functional and mobility level. The purpose of the case series was to determine the effect of virtual reality training on sensorimotor function and mobility level in stroke patients. Ten male (40-60 year) patients of stroke (08 Infarction, 02 Haemorrhagic) were selected from Physiotherapy department of Pakistan Railway Hospital, Rawalpindi. The additional virtual reality training (15-20 minutes) was provided 03 days per week for 06weeks along with task oriented training. All patients were assessed through Fugl-Meyer Assessment-Lower Extremity (FMA-LE) and Timed Get Up and Go Test (TUG) at baseline and after 06 weeks of training. The results showed that there was significant improvement in mobility level of stroke patients. It is concluded that combination of task oriented and virtual reality training considerably improves the physical performance and mobility level in stroke patients.

Choosing a particular oral anticoagulant and dose for stroke prevention in individual patients with non-valvular atrial fibrillation: part 1

PubMed Central

Diener, Hans-Christoph; Aisenberg, James; Ansell, Jack; Atar, Dan; Breithardt, Günter; Eikelboom, John; Ezekowitz, Michael D.; Granger, Christopher B.; Halperin, Jonathan L.; Hohnloser, Stefan H.; Hylek, Elaine M.; Kirchhof, Paulus; Lane, Deirdre A.; Verheugt, Freek W.A.; Veltkamp, Roland; Lip, Gregory Y.H.

2017-01-01

Patients with atrial fibrillation (AF) have a high risk of stroke and mortality, which can be considerably reduced by oral anticoagulants (OAC). Recently, four non-vitamin-K oral anticoagulants (NOACs) were compared with warfarin in large randomized trials for the prevention of stroke and systemic embolism. Today's clinician is faced with the difficult task of selecting a suitable OAC for a patient with a particular clinical profile or a particular pattern of risk factors and concomitant diseases. We reviewed analyses of subgroups of patients from trials of vitamin K antagonists vs. NOACs for stroke prevention in AF with the aim to identify patient groups who might benefit from a particular OAC more than from another. In the first of a two-part review, we discuss the choice of NOAC for stroke prevention in the following subgroups of patients with AF: (i) stable coronary artery disease or peripheral artery disease, including percutaneous coronary intervention with stenting and triple therapy; (ii) cardioversion, ablation and anti-arrhythmic drug therapy; (iii) mechanical valves and rheumatic valve disease, (iv) patients with time in therapeutic range of >70% on warfarin; (v) patients with a single stroke risk factor (CHA2DS2VASc score of 1 in males, 2 in females); and (vi) patients with a single first episode of paroxysmal AF. Although there are no major differences in terms of efficacy and safety between the NOACs for some clinical scenarios, in others we are able to suggest that particular drugs and/or doses be prioritized for anticoagulation. PMID:26848149

[Knowledge of support and aid after first stroke].

PubMed

Schlote, A; Poppendick, U; Möller, C; Wessel, K; Wunderlich, M; Wallesch, C-W

2008-06-01

The literature predicts a considerable demand of support and aid for stroke patients and their caregivers. It is not known to what extent existing resources are used by these groups. The present study aimed at a survey of knowledge of and acquaintance with institutions and organizations offering support after stroke and actual use of these resources. Six and twelve months after stroke, 84 patients and their nearest others were questioned concerning their acquaintance with and use of professional and institutional resources for support and also with respect to social support and self-efficacy. Six and twelve months after stroke, actual use of the various resources for support varied between 0 and 13%. Only part of the patients (11-65%) and relatives (up to 78%) knew about the professional and institutional resource available. Information about resources for support after stroke is unsatisfactory and should be established at a point in the delivery of care chain where all those affected by stroke and their caregivers are accessed.

Measuring stroke patients' exercise preferences using a discrete choice experiment.

PubMed

Geidl, Wolfgang; Knocke, Katja; Schupp, Wilfried; Pfeifer, Klaus

2018-03-30

Physical activity post stroke improves health, yet physical inactivity is highly prevalent. Tailored exercise programs considering physical activity preferences are a promising approach to promote physical activity. Therefore, this study seeks to measure exercise preferences of stroke survivors. Stroke survivors conducted a discrete choice experiment (DCE). DCE was presented in a face-to-face interview where patients had to choose eight times between two different exercise programs. Exercise programs differed by characteristics, with the six attributes under consideration being social situation, location, type of exercise, intensity, frequency, and duration. Utilities of the exercise attributes were estimated with a logit choice model. Stroke survivors (n=103, mean age: 67, SD=13.0; 60% male) show significant differences in the rated utilities of the exercise attributes (P<0.001). Participants had strong preferences for light and moderate intense physical activity and favored shorter exercise sessions. Stroke survivors have remarkable exercise preferences especially for intensity and duration of exercise. Results contribute to the tailoring of physical activity programs after stroke thereby facilitating maintenance of physical activity.

The effect of tobacco control measures during a period of rising cardiovascular disease risk in India: a mathematical model of myocardial infarction and stroke.

PubMed

Basu, Sanjay; Glantz, Stanton; Bitton, Asaf; Millett, Christopher

2013-01-01

We simulated tobacco control and pharmacological strategies for preventing cardiovascular deaths in India, the country that is expected to experience more cardiovascular deaths than any other over the next decade. A microsimulation model was developed to quantify the differential effects of various tobacco control measures and pharmacological therapies on myocardial infarction and stroke deaths stratified by age, gender, and urban/rural status for 2013 to 2022. The model incorporated population-representative data from India on multiple risk factors that affect myocardial infarction and stroke mortality, including hypertension, hyperlipidemia, diabetes, coronary heart disease, and cerebrovascular disease. We also included data from India on cigarette smoking, bidi smoking, chewing tobacco, and secondhand smoke. According to the model's results, smoke-free legislation and tobacco taxation would likely be the most effective strategy among a menu of tobacco control strategies (including, as well, brief cessation advice by health care providers, mass media campaigns, and an advertising ban) for reducing myocardial infarction and stroke deaths over the next decade, while cessation advice would be expected to be the least effective strategy at the population level. In combination, these tobacco control interventions could avert 25% of myocardial infarctions and strokes (95% CI: 17%-34%) if the effects of the interventions are additive. These effects are substantially larger than would be achieved through aspirin, antihypertensive, and statin therapy under most scenarios, because of limited treatment access and adherence; nevertheless, the impacts of tobacco control policies and pharmacological interventions appear to be markedly synergistic, averting up to one-third of deaths from myocardial infarction and stroke among 20- to 79-y-olds over the next 10 y. Pharmacological therapies could also be considerably more potent with further health system improvements. Smoke-free laws and substantially increased tobacco taxation appear to be markedly potent population measures to avert future cardiovascular deaths in India. Despite the rise in co-morbid cardiovascular disease risk factors like hyperlipidemia and hypertension in low- and middle-income countries, tobacco control is likely to remain a highly effective strategy to reduce cardiovascular deaths.

Left Atrial Appendage Exclusion for Atrial Fibrillation

PubMed Central

Syed, Faisal F.; DeSimone, Christopher V.; Friedman, Paul A.; Asirvatham, Samuel J.

2015-01-01

SYNOPSIS Percutaneous left atrial appendage (LAA) closure is increasingly being used as a treatment strategy to prevent stroke in patients with atrial fibrillation (AF) who have contraindications to anticoagulants. A number of approaches and devices have been developed in the last few years, each with their own unique set of advantages and disadvantages. We review the published studies on surgical and percutaneous approaches to LAA closure; focusing on stroke mechanisms in AF, LAA structure and function relevant to stroke prevention, practical differences in procedural approach, and clinical considerations surrounding management. PMID:25443240

Nitric Oxide Donors as Neuroprotective Agents after an Ischemic Stroke-Related Inflammatory Reaction

PubMed Central

Rojas-Mayorquín, Argelia E.; Ortuño-Sahagún, Daniel

2013-01-01

Cerebral ischemia initiates a cascade of detrimental events including glutamate-associated excitotoxicity, intracellular calcium accumulation, formation of Reactive oxygen species (ROS), membrane lipid degradation, and DNA damage, which lead to the disruption of cellular homeostasis and structural damage of ischemic brain tissue. Cerebral ischemia also triggers acute inflammation, which exacerbates primary brain damage. Therefore, reducing oxidative stress (OS) and downregulating the inflammatory response are options that merit consideration as potential therapeutic targets for ischemic stroke. Consequently, agents capable of modulating both elements will constitute promising therapeutic solutions because clinically effective neuroprotectants have not yet been discovered and no specific therapy for stroke is available to date. Because of their ability to modulate both oxidative stress and the inflammatory response, much attention has been focused on the role of nitric oxide donors (NOD) as neuroprotective agents in the pathophysiology of cerebral ischemia-reperfusion injury. Given their short therapeutic window, NOD appears to be appropriate for use during neurosurgical procedures involving transient arterial occlusions, or in very early treatment of acute ischemic stroke, and also possibly as complementary treatment for neurodegenerative diseases such as Parkinson or Alzheimer, where oxidative stress is an important promoter of damage. In the present paper, we focus on the role of NOD as possible neuroprotective therapeutic agents for ischemia/reperfusion treatment. PMID:23691263

Challenges in assessing hospital-level stroke mortality as a quality measure: comparison of ischemic, intracerebral hemorrhage, and total stroke mortality rates.

PubMed

Xian, Ying; Holloway, Robert G; Pan, Wenqin; Peterson, Eric D

2012-06-01

Public reporting efforts currently profile hospitals based on overall stroke mortality rates, yet the "mix" of hemorrhagic and ischemic stroke cases may impact this rate. Using the 2005 to 2006 New York state data, we examined the degree to which hospital stroke mortality rankings varied regarding ischemic versus hemorrhagic versus total stroke. Observed/expected ratio was calculated using the Agency for Healthcare Research and Quality Inpatient Quality Indicator software. The observed/expected ratio and outlier status based on stroke types across hospitals were examined using Pearson correlation coefficients (r) and weighted κ. Overall 30-day stroke mortality rates were 15.2% and varied from 11.3% for ischemic stroke and 37.3% for intracerebral hemorrhage. Hospital risk-adjusted ischemic stroke observed/expected ratio was weakly correlated with its own intracerebral hemorrhage observed/expected ratio (r=0.38). When examining hospital performance group (mortality better, worse, or no different than average), disagreement was observed in 35 of 81 hospitals (κ=0.23). Total stroke mortality observed/expected ratio and rankings were correlated with intracerebral hemorrhage (r=0.61 and κ=0.36) and ischemic stroke (r=0.94 and κ=0.71), but many hospitals still switched classification depending on mortality metrics. However, hospitals treating a higher percent of hemorrhagic stroke did not have a statistically significant higher total stroke mortality rate relative to those treating fewer hemorrhagic strokes. Hospital stroke mortality ratings varied considerably depending on whether ischemic, hemorrhagic, or total stroke mortality rates were used. Public reporting of stroke mortality measures should consider providing risk-adjusted outcome on separate stroke types.

Restriction of therapy mainly explains lower thrombolysis rates in reduced stroke service levels.

PubMed

Gumbinger, Christoph; Reuter, Björn; Hacke, Werner; Sauer, Tamara; Bruder, Ingo; Diehm, Curt; Wiethölter, Horst; Schoser, Karin; Daffertshofer, Michael; Neumaier, Stephan; Drewitz, Elke; Rode, Susanne; Kern, Rolf; Hennerici, Michael G; Stock, Christian; Ringleb, Peter

2016-05-24

To assess the influence of preexisting disabilities, age, and stroke service level on standardized IV thrombolysis (IVT) rates in acute ischemic stroke (AIS). We investigated standardized IVT rates in a retrospective registry-based study in 36,901 patients with AIS from the federal German state Baden-Wuerttemberg over a 5-year period. Patients admitted within 4.5 hours after stroke onset were selected. Factors associated with IVT rates (patient-level factors and stroke service level) were assessed using robust Poisson regression modeling. Interactions between factors were considered to estimate risk-adjusted mortality rates and potential IVT rates by service level (with stroke centers as benchmark). Overall, 10,499 patients (28.5%) received IVT. The IVT rate declined with service level from 44.0% (stroke center) to 13.1% (hospitals without stroke unit [SU]). Especially patients >80 years of age and with preexisting disabilities had a lower chance of being treated with IVT at lower stroke service levels. Interactions between stroke service level and age group, preexisting disabilities, and stroke severity (all p < 0.0001) were observed. High IVT rates seemed not to increase mortality. Estimated potential IVT rates ranged between 41.9% and 44.6% depending on stroke service level. Differences in IVT rates among stroke service levels were mainly explained by differences administering IVT to older patients and patients with preexisting disabilities. This indicates considerable further potential to increase IVT rates. Our findings support guideline recommendations to admit acute stroke patients to SUs. © 2016 American Academy of Neurology.

Health Gain through Screening--Coronary Heart Disease and Stroke: Developing Primary Health Care Services for People with Intellectual Disability.

ERIC Educational Resources Information Center

Wells, M. B.; Turner, S.; Martin, D. M.; Roy, A.

1997-01-01

A study of 120 British adults with intellectual disability found they had higher risk factors of developing coronary heart disease and stroke than the general population. There was a greater incidence of obesity and considerably lower physical activity levels than the general population. Several also had abnormal cholesterol readings. (CR)

Prevalence of Individuals Experiencing the Effects of Stroke in Canada: Trends and Projections.

PubMed

Krueger, Hans; Koot, Jacqueline; Hall, Ruth E; O'Callaghan, Christina; Bayley, Mark; Corbett, Dale

2015-08-01

Previous estimates of the number and prevalence of individuals experiencing the effects of stroke in Canada are out of date and exclude critical population groups. It is essential to have complete data that report on stroke disability for monitoring and planning purposes. The objective was to provide an updated estimate of the number of individuals experiencing the effects of stroke in Canada (and its regions), trending since 2000 and forecasted prevalence to 2038. The prevalence, trends, and projected number of individuals experiencing the effects of stroke were estimated using region-specific survey data and adjusted to account for children aged <12 years and individuals living in homes for the aged. In 2013, we estimate that there were 405 000 individuals experiencing the effects of stroke in Canada, yielding a prevalence of 1.15%. This value is expected to increase to between 654 000 and 726 000 by 2038. Trends in stroke data between 2000 and 2012 suggest a nonsignificant decrease in stroke prevalence, but a substantial and rising increase in the number of individuals experiencing the effects of stroke. Stroke prevalence varied considerably between regions. Previous estimates of stroke prevalence have underestimated the true number of individuals experiencing the effects of stroke in Canada. Furthermore, the projected increases that will result from population growth and demographic changes highlight the importance of maintaining up-to-date estimates. © 2015 American Heart Association, Inc.

Inhibition of VEGF Signaling Reduces Diabetes-Exacerbated Brain Swelling, but Not Infarct Size, in Large Cerebral Infarction in Mice.

PubMed

Kim, Eunhee; Yang, Jiwon; Park, Keun Woo; Cho, Sunghee

2017-12-30

In light of repeated translational failures with preclinical neuroprotection-based strategies, this preclinical study reevaluates brain swelling as an important pathological event in diabetic stroke and investigates underlying mechanism of the comorbidity-enhanced brain edema formation. Type 2 (mild), type 1 (moderate), and mixed type 1/2 (severe) diabetic mice were subjected to transient focal ischemia. Infarct volume, brain swelling, and IgG extravasation were assessed at 3 days post-stroke. Expression of vascular endothelial growth factor (VEGF)-A, endothelial-specific molecule-1 (Esm1), and the VEGF receptor 2 (VEGFR2) was determined in the ischemic brain. Additionally, SU5416, a VEGFR2 inhibitor, was treated in the type 1/2 diabetic mice, and stroke outcomes were determined. All diabetic groups displayed bigger infarct volume and brain swelling compared to nondiabetic mice, and the increased swelling was disproportionately larger relative to infarct enlargement. Diabetic conditions significantly increased VEGF-A, Esm1, and VEGFR2 expressions in the ischemic brain compared to nondiabetic mice. Notably, in diabetic mice, VEGFR2 mRNA levels were positively correlated with brain swelling, but not with infarct volume. Treatment with SU5416 in diabetic mice significantly reduced brain swelling. The study shows that brain swelling is a predominant pathological event in diabetic stroke and that an underlying event for diabetes-enhanced brain swelling includes the activation of VEGF signaling. This study suggests consideration of stroke therapies aiming at primarily reducing brain swelling for subjects with diabetes.

CPAP as treatment of sleep apnea after stroke: A meta-analysis of randomized trials.

PubMed

Brill, Anne-Kathrin; Horvath, Thomas; Seiler, Andrea; Camilo, Millene; Haynes, Alan G; Ott, Sebastian R; Egger, Matthias; Bassetti, Claudio L

2018-04-03

To perform a systematic review and meta-analysis of randomized controlled trials (RCTs) examining the effectiveness of continuous positive airway pressure (CPAP) in stroke patients with sleep disordered breathing (SDB). In a systematic literature search of electronic databases (MEDLINE, Embase, and the Cochrane Library) from 1980 to November 2016, we identified RCTs that assessed CPAP compared to standard care or sham CPAP in adult patients with stroke or TIA with SDB. Mean CPAP use, odds ratios (ORs), and standardized mean differences (SMDs) were calculated. The prespecified outcomes were adherence to CPAP, neurologic improvement, adverse events, new vascular events, and death. Ten RCTs (564 participants) with CPAP as intervention were included. Two studies compared CPAP with sham CPAP; 8 compared CPAP with usual care. Mean CPAP use across the trials was 4.53 hours per night (95% confidence interval [CI] 3.97-5.08). The OR of dropping out with CPAP was 1.83 (95% CI 1.05-3.21, p = 0.033). The combined analysis of the neurofunctional scales (NIH Stroke Scale and Canadian Neurological Scale) showed an overall neurofunctional improvement with CPAP (SMD 0.5406, 95% CI 0.0263-1.0548) but with a considerable heterogeneity ( I 2 = 78.9%, p = 0.0394) across the studies. Long-term survival was improved with CPAP in 1 trial. CPAP use after stroke is acceptable once the treatment is tolerated. The data indicate that CPAP might be beneficial for neurologic recovery, which justifies larger RCTs. © 2018 American Academy of Neurology.

Network dysfunction predicts speech production after left hemisphere stroke.

PubMed

Geranmayeh, Fatemeh; Leech, Robert; Wise, Richard J S

2016-03-09

To investigate the role of multiple distributed brain networks, including the default mode, fronto-temporo-parietal, and cingulo-opercular networks, which mediate domain-general and task-specific processes during speech production after aphasic stroke. We conducted an observational functional MRI study to investigate the effects of a previous left hemisphere stroke on functional connectivity within and between distributed networks as patients described pictures. Study design included various baseline tasks, and we compared results to those of age-matched healthy participants performing the same tasks. We used independent component and psychophysiological interaction analyses. Although activity within individual networks was not predictive of speech production, relative activity between networks was a predictor of both within-scanner and out-of-scanner language performance, over and above that predicted from lesion volume, age, sex, and years of education. Specifically, robust functional imaging predictors were the differential activity between the default mode network and both the left and right fronto-temporo-parietal networks, respectively activated and deactivated during speech. We also observed altered between-network functional connectivity of these networks in patients during speech production. Speech production is dependent on complex interactions among widely distributed brain networks, indicating that residual speech production after stroke depends on more than the restoration of local domain-specific functions. Our understanding of the recovery of function following focal lesions is not adequately captured by consideration of ipsilesional or contralesional brain regions taking over lost domain-specific functions, but is perhaps best considered as the interaction between what remains of domain-specific networks and domain-general systems that regulate behavior. © 2016 American Academy of Neurology.

Network dysfunction predicts speech production after left hemisphere stroke

PubMed Central

Leech, Robert; Wise, Richard J.S.

2016-01-01

Objective: To investigate the role of multiple distributed brain networks, including the default mode, fronto-temporo-parietal, and cingulo-opercular networks, which mediate domain-general and task-specific processes during speech production after aphasic stroke. Methods: We conducted an observational functional MRI study to investigate the effects of a previous left hemisphere stroke on functional connectivity within and between distributed networks as patients described pictures. Study design included various baseline tasks, and we compared results to those of age-matched healthy participants performing the same tasks. We used independent component and psychophysiological interaction analyses. Results: Although activity within individual networks was not predictive of speech production, relative activity between networks was a predictor of both within-scanner and out-of-scanner language performance, over and above that predicted from lesion volume, age, sex, and years of education. Specifically, robust functional imaging predictors were the differential activity between the default mode network and both the left and right fronto-temporo-parietal networks, respectively activated and deactivated during speech. We also observed altered between-network functional connectivity of these networks in patients during speech production. Conclusions: Speech production is dependent on complex interactions among widely distributed brain networks, indicating that residual speech production after stroke depends on more than the restoration of local domain-specific functions. Our understanding of the recovery of function following focal lesions is not adequately captured by consideration of ipsilesional or contralesional brain regions taking over lost domain-specific functions, but is perhaps best considered as the interaction between what remains of domain-specific networks and domain-general systems that regulate behavior. PMID:26962070

Quality of life after ischemic stroke varies in western countries: data from the tinzaparin in Acute Ischaemic Stroke Trial (TAIST).

PubMed

Sprigg, Nikola; Gray, Laura J; Bath, Philip M W; Christensen, Hanne; De Deyn, Peter Paul; Leys, Didier; O'Neill, Desmond; Ringelstein, E Bernd

2012-10-01

Functional outcome after stroke varies significantly between countries. However, whether health-related quality of life (QoL) after stroke also differs between countries is unknown. TAIST was a randomised controlled trial assessing the safety and efficacy of tinzaparin versus aspirin in 1484 patients with acute ischaemic stroke across 11 countries. Countries were grouped into 5 geographic regions: British Isles (Ireland and UK), Franco (Belgium and France), North America (Canada), northwest Europe (Germany and The Netherlands), and Scandinavia (Denmark, Finland, Norway, and Sweden). QoL was measured at 6 months using the Short-Form 36 (SF-36) health survey. The relationship between region and QoL was assessed relative to the British Isles using linear regression adjusted for case mix, service quality variables, and treatment assignment. A total of 1220 survivors were included in this analysis. Significant differences in QoL were identified between countries and regions; northwest Europe rated their QoL highest in terms of physical functioning (20.3; 95% confidence interval [CI] 10.8-29.8), bodily pain (12.3; 95% CI, 2.7-22.0), and vitality (9.0; 95% CI, 1.1-16.9). Franco countries reported the lowest QoL for emotional role (-17.9; 95% CI, -32.6 to -3.3) and mental health (-11.2; 95% CI, -18.2 to -4.3). The British Isles rated QoL lowest for physical and social functioning. Our data indicate that QoL varies considerably among countries and regions, even when adjusted for prognostic case mix and care quality variables. How different case mixes and healthcare systems might contribute to these findings merits further investigation. Copyright © 2012 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Body mass index and cardiovascular disease in the Asia-Pacific Region: an overview of 33 cohorts involving 310 000 participants.

PubMed

Ni Mhurchu, C; Rodgers, A; Pan, W H; Gu, D F; Woodward, M

2004-08-01

Few prospective data from the Asia-Pacific region are available relating body mass index (BMI) to the risks of stroke and ischaemic heart disease (IHD). Our objective was to assess the age-, sex-, and region-specific associations of BMI with cardiovascular disease using individual participant data from prospective studies in the Asia-Pacific region. Studies were identified from literature searches, proceedings of meetings, and personal communication. All studies had at least 5000 person-years of follow-up. Hazard ratios were calculated from Cox models, stratified by sex and cohort, and adjusted for age at risk and smoking. The first 3 years of follow-up were excluded in order to reduce confounding due to disease at baseline. A total of 33 cohort studies, including 310 283 participants, contributed 2 148 354 person-years of follow-up, during which 3332 stroke and 2073 IHD events were observed. There were continuous positive associations between baseline BMI and the risks of ischaemic stroke, haemorrhagic stroke, and IHD, with each 2 kg/m(2) lower BMI associated a 12% (95% CI: 9, 15%) lower risk of ischaemic stroke, 8% (95% CI: 4, 12%) lower risk in haemorrhagic stroke, and 11% (95% CI: 9, 13%) lower risk of IHD. The strengths of all associations were strongly age dependent, and there was no significant difference between Asian and Australasian cohorts. This overview provides the most reliable estimates to date of the associations between BMI and cardiovascular disease in the Asia-Pacific region, and the first direct comparisons within the region. Continuous relationships of approximately equal strength are evident in both Asian and Australasian populations. These results indicate considerable potential for cardiovascular disease reduction with population-wide lowering of BMI.

Early Surgery for Endocarditis Complicated by Preoperative Cerebral Emboli Is Not Associated With Worsened Outcomes

PubMed Central

Sorabella, Robert A.; Han, Sang Myung; Grbic, Mark; Wu, Yeu Sanz; Takyama, Hiroo; Kurlansky, Paul; Borger, Michal A.; Argenziano, Michael; Gordon, Rachel; George, Isaac

2015-01-01

Background Valve surgery for patients presenting with infective endocarditis (IE) complicated by stroke is thought to carry elevated risk of postoperative complications. Our aim is to compare outcomes of IE patients who undergo surgery early after diagnosis of septic cerebral emboli with patients without preoperative emboli. Methods All patients undergoing surgery for left-sided IE between 1996–2013 at our institution were reviewed. Patients undergoing surgery > 14 days after embolic stroke diagnosis (n=11) and those with purely hemorrhagic lesions were excluded from analysis (n=7). In total, 308 were included in the study and stratified according to the presence (STR, n=54) or absence of a preoperative septic cerebral embolus (NoSTR, n=254). Primary outcomes of interest were development of new postoperative stroke and 30-day mortality. Results Mean time to surgical intervention from stroke onset was 6.0 ± 4.1 days. S. aureus (39% STR vs. 21% NoSTR, p = 0.004) and annular abscess at surgery (52% STR vs. 27% NoSTR, p < 0.001) were more prevalent in STR patients. There was no significant difference in 30-day mortality (9.3% STR vs. 7.1% NoSTR, p = 0.57) or rate of new postoperative stroke [5 (9.4%) STR vs. 12 (4.7%) NoSTR, p = 0.19] between groups. Additionally, there was no difference in 10-year survival between groups (log rank p = 0.74). Conclusions Early surgical intervention in patients with IE complicated by preoperative septic cerebral emboli does not lead to significantly worse postoperative outcomes. Early surgery for IE following embolic stroke warrants consideration, particularly in patients with high-risk features such as S. aureus and/or annular abscess. PMID:26116483

Diagnostic testing for coagulopathies in patients with ischemic stroke.

PubMed

Bushnell, C D; Goldstein, L B

2000-12-01

Hypercoagulable states are a recognized, albeit uncommon, etiology of ischemic stroke. It is unclear how often the results of specialized coagulation tests affect management. Using data compiled from a systematic review of available studies, we employed quantitative methodology to assess the diagnostic yield of coagulation tests for identification of coagulopathies in ischemic stroke patients. We performed a MEDLINE search to identify controlled studies published during 1966-1999 that reported the prevalence of deficiencies of protein C, protein S, antithrombin III, plasminogen, activated protein C resistance (APCR)/factor V Leiden mutation (FVL), anticardiolipin antibodies (ACL), or lupus anticoagulant (LA) in patients with ischemic stroke. The cumulative prevalence rates (pretest probabilities) and positive likelihood ratios for all studies and for those including only patients aged

Association of Left Atrial Enlargement with Cortical Infarction in Subjects with Patent Foramen Ovale.

PubMed

Lee, Mi Ji; Park, Sung-Ji; Yoon, Chang Hyo; Hwang, Ji-Won; Ryoo, Sookyung; Kim, Suk Jae; Kim, Gyeong-Moon; Chung, Chin-Sang; Lee, Kwang Ho; Bang, Oh Young

2016-09-01

Left atrial dysfunction has been reported in patients with patent foramen ovale (PFO). Here we investigated the role of left atrial dysfunction in the development of embolic stroke in patients with PFO. We identified consecutive patients with embolic stroke of undetermined sources except for PFO (PFO+ESUS). Healthy subjects with PFO served as controls (PFO+control). A stratified analysis by 10-year age group and an age- and sex- matching analysis were performed to compare echocardiographic markers between groups. In the PFO+ESUS group, infarct patterns of PFO-related stroke were determined (cortical vs. cortico-subcortical) and analyzed in correlation with left atrial function parameters. A total of 118 patients and 231 controls were included. The left atrial volume indices (LAVIs) of the PFO+ESUS patients were higher than those of the PFO+controls in age groups of 40-49, 50-59, and 60-69 years ( P <0.001, P =0.003, and P =0.027, respectively), and in the age- and sex-matched analysis ( P =0.001). In the PFO+ESUS patients, a higher (>28 mL/m 2 ) LAVI was more associated with the cortical infarct pattern ( P =0.043 for an acute infarction and P =0.024 for a chronic infarction, both adjusted for age and shunt amount). The degree of right-to-left shunting was not associated with infarct patterns, but with the posterior location of acute infarcts ( P =0.028). Left atrial enlargement was associated with embolic stroke in subjects with PFO. Left atrial physiology might contribute to the development of PFO-related stroke and need to be taken into consideration for optimal prevention of PFO-related stroke.

Perioperative management of adult patients with a history of stroke or transient ischaemic attack undergoing elective non-cardiac surgery.

PubMed

Mehdi, Zehra; Birns, Jonathan; Partridge, Judith; Bhalla, Ajay; Dhesi, Jugdeep

2016-12-01

It is increasingly common for physicians and anaesthetists to be asked for advice in the medical management of surgical patients who have an incidental history of stroke or transient ischaemic attack (TIA). Advising clinicians requires an understanding of the common predictors, outcomes and management of perioperative stroke. The most important predictor of perioperative stroke is a previous history of stroke, and outcomes associated with such an event are extremely poor. The perioperative management of this patient group needs careful consideration to minimise the thrombotic risk and a comprehensive, individualised approach is crucial. Although there is literature supporting the management of such patients undergoing cardiac surgery, evidence is lacking in the setting of non-cardiac surgical intervention. This article reviews the current evidence and provides a pragmatic interpretation to inform the perioperative management of patients with a history of stroke and/or TIA presenting for elective non-cardiac surgery. © Royal College of Physicians 2016. All rights reserved.

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association.

PubMed

Winstein, Carolee J; Stein, Joel; Arena, Ross; Bates, Barbara; Cherney, Leora R; Cramer, Steven C; Deruyter, Frank; Eng, Janice J; Fisher, Beth; Harvey, Richard L; Lang, Catherine E; MacKay-Lyons, Marilyn; Ottenbacher, Kenneth J; Pugh, Sue; Reeves, Mathew J; Richards, Lorie G; Stiers, William; Zorowitz, Richard D

2016-06-01

The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke. Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee. Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential. As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.). © 2016 American Heart Association, Inc.

Self-perceived psychological stress and ischemic stroke: a case-control study

PubMed Central

Jood, Katarina; Redfors, Petra; Rosengren, Annika; Blomstrand, Christian; Jern, Christina

2009-01-01

Background A growing body of evidence suggests that psychological stress contributes to coronary artery disease. However, associations between stress and stroke are less clear. In this study, we investigated the possible association between ischemic stroke and self-perceived psychological stress, as measured by a single-item questionnaire, previously reported to be associated with myocardial infarction. Methods In the Sahlgrenska Academy Study on Ischemic Stroke (SAHLSIS), 600 consecutive patients with acute ischemic stroke (aged 18 to 69 years) and 600 age-matched and sex-matched population controls were recruited. Ischemic stroke subtype was determined according to Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria. Self-perceived psychological stress preceding stroke was assessed retrospectively using a single-item questionnaire. Results Permanent self-perceived psychological stress during the last year or longer was independently associated with overall ischemic stroke (multivariate adjusted odds ratio (OR) 3.49, 95% confidence interval (CI) 2.06 to 5.93). Analyses by stroke subtype showed that this association was present for large vessel disease (OR 3.91, 95% CI 1.58 to 9.67), small vessel disease (OR 3.20, 95% CI 1.64 to 6.24), and cryptogenic stroke (OR 4.03, 95% CI 2.34 to 6.95), but not for cardioembolic stroke (OR 1.48, 95% CI 0.64 to 3.39). Conclusion In this case-control study, we found an independent association between self-perceived psychological stress and ischemic stroke. A novel finding was that this association differed by ischemic stroke subtype. Our results emphasize the need for further prospective studies addressing the potential role for psychological stress as a risk factor for ischemic stroke. In such studies ischemic stroke subtypes should be taken into consideration. PMID:19796376

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

PubMed

Schubert, Ingrid; Hammer, Antje; Köster, Ingrid

2017-10-01

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

Biotherapies in stroke.

PubMed

Detante, O; Jaillard, A; Moisan, A; Barbieux, M; Favre, I M; Garambois, K; Hommel, M; Remy, C

2014-12-01

Stroke is the second leading cause of death worldwide and the most common cause of severe disability. Neuroprotection and repair mechanisms supporting endogenous brain plasticity are often insufficient to allow complete recovery. While numerous neuroprotective drugs trials have failed to demonstrate benefits for patients, they have provided interesting translational research lessons related to neurorestorative therapy mechanisms in stroke. Stroke damage is not limited to neurons but involve all brain cell type including the extracellular matrix in a "glio-neurovascular niche". Targeting a range of host brain cells, biotherapies such as growth factors and therapeutic cells, currently hold great promise as a regenerative medical strategy for stroke. These techniques can promote both neuroprotection and delayed neural repair through neuro-synaptogenesis, angiogenesis, oligodendrogliogenesis, axonal sprouting and immunomodulatory effects. Their complex mechanisms of action are interdependent and vary according to the particular growth factor or grafted cell type. For example, while "peripheral" stem or stromal cells can provide paracrine trophic support, neural stem/progenitor cells (NSC) or mature neurons can act as more direct neural replacements. With a wide therapeutic time window after stroke, biotherapies could be used to treat many patients. However, guidelines for selecting the optimal time window, and the best delivery routes and doses are still debated and the answers may depend on the chosen product and its expected mechanism including early neuroprotection, delayed neural repair, trophic systemic transient effects or graft survival and integration. Currently, the great variety of growth factors, cell sources and cell therapy products form a therapeutic arsenal that is available for stroke treatment. Their effective clinical use will require prior careful considerations regarding safety (e.g. tumorgenicity, immunogenicity), potential efficacy, cell characterization, delivery route and in vivo biodistribution. Bone marrow-derived cell populations such as mesenchymal stromal/stem cells (MSC) or mononuclear cells (MNC), umbilical cord stem cells and NSC are most investigated notably in clinical trials. Finally, we discuss perspectives concerning potential novel biotherapies such as combinatorial approaches (growth factor combined with cell therapy, in vitro optimization of cell products, or co-transplantation) and the development of biomaterials, which could be used as injectable hydrogel scaffold matrices that could protect a cell graft or selectively deliver drugs and growth factors into the post-stroke cavity at chronic stages. Considering the remaining questions about the best procedure and the safety cautions, we can hope that future translational research about biotherapies will bring more efficient treatments that will decrease post-stroke disability for many patients. Copyright © 2014 Elsevier Masson SAS. All rights reserved.

Toward Personalized Cell Therapies: Autologous Menstrual Blood Cells for Stroke

PubMed Central

Rodrigues, Maria Carolina O.; Glover, Loren E.; Weinbren, Nathan; Rizzi, Jessica A.; Ishikawa, Hiroto; Shinozuka, Kazutaka; Tajiri, Naoki; Kaneko, Yuji; Sanberg, Paul R.; Allickson, Julie G.; Kuzmin-Nichols, Nicole; Garbuzova-Davis, Svitlana; Voltarelli, Julio Cesar; Cruz, Eduardo; Borlongan, Cesar V.

2011-01-01

Cell therapy has been established as an important field of research with considerable progress in the last years. At the same time, the progressive aging of the population has highlighted the importance of discovering therapeutic alternatives for diseases of high incidence and disability, such as stroke. Menstrual blood is a recently discovered source of stem cells with potential relevance for the treatment of stroke. Migration to the infarct site, modulation of the inflammatory reaction, secretion of neurotrophic factors, and possible differentiation warrant these cells as therapeutic tools. We here propose the use of autologous menstrual blood cells in the restorative treatment of the subacute phase of stroke. We highlight the availability, proliferative capacity, pluripotency, and angiogenic features of these cells and explore their mechanistic pathways of repair. Practical aspects of clinical application of menstrual blood cells for stroke will be discussed, from cell harvesting and cryopreservation to administration to the patient. PMID:22162629

Bioethical considerations in translational research: primate stroke.

PubMed

Sughrue, Michael E; Mocco, J; Mack, Willam J; Ducruet, Andrew F; Komotar, Ricardo J; Fischbach, Ruth L; Martin, Thomas E; Connolly, E Sander

2009-05-01

Controversy and activism have long been linked to the subject of primate research. Even in the midst of raging ethical debates surrounding fertility treatments, genetically modified foods and stem-cell research, there has been no reduction in the campaigns of activists worldwide. Playing their trade of intimidation aimed at ending biomedical experimentation in all animals, they have succeeded in creating an environment where research institutions, often painted as guilty until proven innocent, have avoided addressing the issue for fear of becoming targets. One area of intense debate is the use of primates in stroke research. Despite the fact that stroke kills more people each year than AIDS and malaria, and less than 5% of patients are candidates for current therapies, there is significant opposition to primate stroke research. A balanced examination of the ethics of primate stroke research is thus of broad interest to all areas of biomedical research.

Care Received by Elderly US Stroke Survivors may be Underestimated

PubMed Central

Skolarus, Lesli E.; Freedman, Vicki A.; Feng, Chunyang; Wing, Jeffrey J.; Burke, James F.

2016-01-01

Background and Purpose Previous studies exploring stroke-related caregiving focused solely on informal caregiving and a relatively limited set of activities. We sought to determine whether, and at what cost, stroke survivors receive more care than matched controls using an expanded definition of caregiving and inclusion of paid caregivers. Methods Data were drawn from the National Health and Aging Trends Study (NHATS), a nationally representative survey of Medicare beneficiaries. NHATS personnel conducted in-person interviews with respondents or proxies to determine the weekly hours of care received. We compared hours of assistance received between self-reported stroke survivors (N=892) and demographic- and comorbidity-matched non-stroke controls (N=892). The annual cost of stroke caregiving was estimated using reported paid caregiving data and estimates of unpaid caregiving costs. Results Of community dwelling elderly stroke survivors, 51.4% received help from a caregiver. Stroke survivors received an average of 10 hours of additional care per week compared to demographic- and comorbidity-matched controls (22.3 hours vs. 11.8 hours, p<0.01). We estimate that the average annual cost for caregiving for an elderly stroke survivor is approximately $11,300, or about $40 billion annually, for all elderly stroke survivors, of which $5,000 per person, or $18.2 billion annually, is specific to stroke. Conclusions Although stroke survivors are known to require considerable caregiving resources, our findings suggest that prior assessments may underestimate hours of care received and hence costs. PMID:27387990

The Riks-Stroke story: building a sustainable national register for quality assessment of stroke care.

PubMed

Asplund, Kjell; Hulter Åsberg, Kerstin; Appelros, Peter; Bjarne, Daniela; Eriksson, Marie; Johansson, Asa; Jonsson, Fredrik; Norrving, Bo; Stegmayr, Birgitta; Terént, Andreas; Wallin, Sari; Wester, Per-Olov

2011-04-01

Riks-Stroke, the Swedish Stroke Register, is the world's longest-running national stroke quality register (established in 1994) and includes all 76 hospitals in Sweden admitting acute stroke patients. The development and maintenance of this sustainable national register is described. Riks-Stroke includes information on the quality of care during the acute phase, rehabilitation and secondary prevention of stroke, as well as data on community support. Riks-Stroke is unique among stroke quality registers in that patients are followed during the first year after stroke. The data collected describe processes, and medical and patient-reported outcome measurements. The register embraces most of the dimensions of health-care quality (evidence-based, safe, provided in time, distributed fairly and patient oriented). Annually, approximately 25,000 patients are included. In 2009, approximately 320,000 patients had been accumulated (mean age 76-years). The register is estimated to cover 82% of all stroke patients treated in Swedish hospitals. Among critical issues when building a national stroke quality register, the delicate balance between simplicity and comprehensiveness is emphasised. Future developments include direct transfer of data from digital medical records to Riks-Stroke and comprehensive strategies to use the information collected to rapidly implement new evidence-based techniques and to eliminate outdated methods in stroke care. It is possible to establish a sustainable quality register for stroke at the national level covering all hospitals admitting acute stroke patients. Riks-Stroke is fulfilling its main goals to support continuous quality improvement of Swedish stroke services and serve as an instrument for following up national stroke guidelines. © 2010 The Authors. International Journal of Stroke © 2010 World Stroke Organization.

Managing and Rehabilitating the ‘Stroke’ Patient

PubMed Central

Sky, Ruth

1972-01-01

Strokes account for five out of every 1,000 general hospital admissions. Postoperative care can be frustrating, but with judicious use of allied health workers, and careful assessment of the patient's condition, most patients who survive can be rehabilitated to a considerable degree of self-care. The patient's family must be included in the team, and his preferences in activities must be considered. This article describes the results of a study done on 244 patient charts at a convalescent hospital in Toronto. PMID:20468858

The prevalence of stroke and associated disability.

PubMed

O'Mahony, P G; Thomson, R G; Dobson, R; Rodgers, H; James, O F

1999-06-01

There are limited data available on the prevalence of stroke in the United Kingdom. Such data are important for the assessment of the health needs of the population. This study aimed to determine the prevalence of stroke and the prevalence of associated dependence in a district of northern England. This was a two-stage point prevalence study. A valid screening questionnaire was used to identify stroke survivors from an age- and sex-stratified sample of the population aged 45 years and over in a family health services authority district. This was followed by assessment of stroke patients with scales of disability and handicap. The overall prevalence of stroke was found to be 17.5/1000 (95 per cent confidence interval (CI) 17.0, 18.0). The prevalence of stroke-associated dependence was 11.7/1000 (95 per cent CI 11.3, 12.1). Self-reported comorbidity was most commonly due to circulatory and musculoskeletal disorders. The prevalence of stroke in this district is considerably higher than current guidelines and previous results suggest. Nevertheless, the result from this study combined with that from a previous study in another district in the United Kingdom should allow those interested in epidemiologically based health needs assessment to make reasonable estimates of the burden of stroke in their area.

Heart Performance Determination by Visualization in Larval Fishes: Influence of Alternative Models for Heart Shape and Volume

PubMed Central

Perrichon, Prescilla; Grosell, Martin; Burggren, Warren W.

2017-01-01

Understanding cardiac function in developing larval fishes is crucial for assessing their physiological condition and overall health. Cardiac output measurements in transparent fish larvae and other vertebrates have long been made by analyzing videos of the beating heart, and modeling this structure using a conventional simple prolate spheroid shape model. However, the larval fish heart changes shape during early development and subsequent maturation, but no consideration has been made of the effect of different heart geometries on cardiac output estimation. The present study assessed the validity of three different heart models (the “standard” prolate spheroid model as well as a cylinder and cone tip + cylinder model) applied to digital images of complete cardiac cycles in larval mahi-mahi and red drum. The inherent error of each model was determined to allow for more precise calculation of stroke volume and cardiac output. The conventional prolate spheroid and cone tip + cylinder models yielded significantly different stroke volume values at 56 hpf in red drum and from 56 to 104 hpf in mahi. End-diastolic and stroke volumes modeled by just a simple cylinder shape were 30–50% higher compared to the conventional prolate spheroid. However, when these values of stroke volume multiplied by heart rate to calculate cardiac output, no significant differences between models emerged because of considerable variability in heart rate. Essentially, the conventional prolate spheroid shape model provides the simplest measurement with lowest variability of stroke volume and cardiac output. However, assessment of heart function—especially if stroke volume is the focus of the study—should consider larval heart shape, with different models being applied on a species-by-species and developmental stage-by-stage basis for best estimation of cardiac output. PMID:28725199

Rehabilitation Needs of Stroke Survivors After Discharge From Hospital in India.

PubMed

Kamalakannan, Sureshkumar; Gudlavalleti Venkata, Murthy; Prost, Audrey; Natarajan, Subbulakshmy; Pant, Hira; Chitalurri, Naveen; Goenka, Shifalika; Kuper, Hannah

2016-09-01

To assess the rehabilitation needs of stroke survivors in Chennai, India, after discharge from the hospital. Mixed-methods research design. Home-based. Stroke survivors (n=50; mean age ± SD, 58.9±10.5y) and primary caregivers of these stroke survivors (n=50; mean age ± SD, 43.1±11.8y) took part in the quantitative survey. A subsample of stroke survivors (n=12), primary caregivers (n=10), and health care professionals (n=8) took part in the qualitative in-depth interviews. Not applicable. Rehabilitation needs after hospital discharge. About 82% of the needs expressed by stroke survivors and 92% of the needs expressed by caregivers indicated that they had a substantial need for information. The proportion of financial needs reported by the stroke survivors and the caregivers was 70% and 75%, respectively. The qualitative data revealed major gaps in access to stroke rehabilitation services. Service providers identified availability and affordability of services as key problems. Stroke survivors and their caregivers identified lack of information about stroke as major barriers to accessibility of stroke rehabilitation services. Caregivers expressed a tremendous need for support to manage family dynamics. The study highlights a considerable unmet need for poststroke rehabilitation services. Given the lack of rehabilitation resources in India, developing an accessible, innovative, patient-centered, culturally sensitive rehabilitation intervention is of public health importance. It is crucial for low- and middle-income countries like India to develop technology-driven stroke rehabilitation strategies to meet the growing rehabilitation needs of stroke survivors. Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.

Uptake of atrial fibrillation screening aiming at stroke prevention: geo-mapping of target population and non-participation.

PubMed

Engdahl, Johan; Holmén, Anders; Rosenqvist, Mårten; Strömberg, Ulf

2013-08-03

In a screening study for silent atrial fibrillation (AF), which is a frequent source of cardiac emboli with ischemic stroke, the proportion of non-participants was considerable and their clinical profile differed from the participants' profile. We intended to geo-map the target population and non-participation in an attempt to understand factors related to screening uptake and, thereby, obtain useful information needed to intervene for improved uptake. In the municipality of Halmstad, Sweden, all residents born in 1934-1935 were invited to the screening study during April 2010 to February 2012. The total study group included 848 participants and 367 non-participants from 12 parishes. Geo-maps displaying participation, along with target-population-based geo-maps displaying proportion of immigrants and ischemic stroke incidence, were used. Smoothed non-participation ratios (SmNPR) varied from 0.81 to 1.24 across different parishes (SmNRP=1 corresponds to the expected participation based on the total study group). Among high risk individuals, the geographical variation was more pronounced (SmNPR range 0.75-1.51). Two parishes with higher share of immigrants and elevated population-based ischemic stroke incidence showed markedly lower participation, particularly among high-risk individuals. AF screening uptake varied evidently between parishes, particularly among high-risk individuals. Geo-mapping of target population and non-participation yielded useful information needed to intervene for improved screening uptake.

Late onset MELAS with m.3243A > G mutation and its association with aneurysm formation.

PubMed

Zhu, Kun; Li, Shuang; Chen, Huan; Wang, Yao; Yu, Miao; Wang, Hongyan; Zhao, Weijie; Cao, Yunpeng

2017-08-01

We reported a 53-year-old with late-onset mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) accompanied by aneurysm and large vessel dilations. Most studies have focused on microangiopathy causing stroke-like episodes. We report a case to describe large vessel involvement in clinical considerations, and possible mechanisms of aneurysm formation. We recommended regular angiographic examination for patients with MELAS.

[A case of mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episode/Leigh overlap syndrome].

PubMed

Matsui, Jun; Takano, Tomoyuki; Ryujin, Fukiko; Anzai, Yuko; Yoshioka, Seiichiro; Takeuchi, Yoshihiro; Goto, Yuichi

2014-09-01

We experienced a case in which mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes (MELAS) was identified as complications following the onset of Leigh syndrome along with a 10191 T>C mutation of the mitochondrial gene. The case pertains to a 26-year-old woman. The disease appeared when she was 11 years old due to divergent strabismus, at which point a diagnosis of juvenile Leigh syndrome was made. Many infraction images not conforming to the vessel region were observed upon a brain MRI which was performed at 26 years of age, thus leading to her being diagnosed with MELAS as a complication. Upoon bibliographical consideration, it was speculated that the clinical features of MELAS/Leigh overlap syndrome clearly differ from Leigh syndrome in terms of age of onset, symptoms, and prognosis. Pleiotropic genetic factors including heteroplasmy were presumed to be involved in the diverse phenotype of overlap syndrome.

The effect of normobaric oxygen in patients with acute stroke: a systematic review and meta-analysis.

PubMed

Ding, Jiayue; Zhou, Da; Sui, Meng; Meng, Ran; Chandra, Ankush; Han, Jie; Ding, Yuchuan; Ji, Xunming

2018-03-30

Background Normobaric oxygen (NBO) has received considerable attention due to controversial data in brain protection in patients with acute stroke. This study aims to analyze current data of NBO on brain protection as used in the clinic. Methods We searched for and reviewed relevant articles and references from Pubmed, Medline, Embase, Cochrane, and Clincialtrials.gov that were published prior to October 2017. Data from prospective studies were processed using RevMan5.0 software, provided by Cochrane collaboration and transformed using relevant formulas. Results A total of 11 prospective RCT studies including 6366 patients with acute stroke (NBO group, 3207; control group, 3159) were enrolled in this analysis. △NIHSS represented the values of NIHSS at 4, 24 h, or 7 days post-stroke minus baseline NIHSS. Compared to controls, there was a minor trend toward NBO benefits in short-term prognostic indices, as indicated by decreased ΔNIHSS at our defined time points. By contrast, NBO decreased Barthel Index scores between 3 and 7 months, and increased death rates at 3, 6 months, and 1 year, whereas, modified Rankin Scale scores between 3 and 6 months were unchanged. Conclusions The existing trends toward benefits revealed in this meta-analysis help us appreciate the promising value of NBO, although current evidence of NBO on improving clinical outcomes of stroke is insufficient. Well-designed multi-center clinical trials are encouraged and urgently needed to further explore the efficacy of NBO on brain protection.

Drug Delivery to the Ischemic Brain

PubMed Central

Thompson, Brandon J.; Ronaldson, Patrick T.

2014-01-01

Cerebral ischemia occurs when blood flow to the brain is insufficient to meet metabolic demand. This can result from cerebral artery occlusion that interrupts blood flow, limits CNS supply of oxygen and glucose, and causes an infarction/ischemic stroke. Ischemia initiates a cascade of molecular events inneurons and cerebrovascular endothelial cells including energy depletion, dissipation of ion gradients, calcium overload, excitotoxicity, oxidative stress, and accumulation of ions and fluid. Blood-brain barrier (BBB) disruption is associated with cerebral ischemia and leads to vasogenic edema, a primary cause of stroke-associated mortality. To date, only a single drug has received US Food and Drug Administration (FDA) approval for acute ischemic stroke treatment, recombinant tissue plasminogen activator (rt-PA). While rt-PA therapy restores perfusion to ischemic brain, considerable tissue damage occurs when cerebral blood flow is re-established. Therefore, there is a critical need for novel therapeutic approaches that can “rescue” salvageable brain tissue and/or protect BBB integrity during ischemic stroke. One class of drugs that may enable neural cell rescue following cerebral ischemia/reperfusion injury is the HMG-CoA reductase inhibitors (i.e., statins). Understanding potential CNS drug delivery pathways for statins is critical to their utility in ischemic stroke. Here, we review molecular pathways associated with cerebral ischemia and novel approaches for delivering drugs to treat ischemic disease. Specifically, we discuss utility of endogenous BBB drug uptake transporters such as organic anion transporting polypeptides (OATPs/Oatps) and nanotechnology-based carriers for optimization of CNS drug delivery. Overall, this chapter highlights state-of-the-art technologies that may improve pharmacotherapy of cerebral ischemia. PMID:25307217

Poststroke Hemiparesis Impairs the Rate but not Magnitude of Adaptation of Spatial and Temporal Locomotor Features

PubMed Central

Savin, Douglas N.; Tseng, Shih-Chiao; Whitall, Jill; Morton, Susanne M.

2015-01-01

Background Persons with stroke and hemiparesis walk with a characteristic pattern of spatial and temporal asymmetry that is resistant to most traditional interventions. It was recently shown in nondisabled persons that the degree of walking symmetry can be readily altered via locomotor adaptation. However, it is unclear whether stroke-related brain damage affects the ability to adapt spatial or temporal gait symmetry. Objective Determine whether locomotor adaptation to a novel swing phase perturbation is impaired in persons with chronic stroke and hemiparesis. Methods Participants with ischemic stroke (14) and nondisabled controls (12) walked on a treadmill before, during, and after adaptation to a unilateral perturbing weight that resisted forward leg movement. Leg kinematics were measured bilaterally, including step length and single-limb support (SLS) time symmetry, limb angle center of oscillation, and interlimb phasing, and magnitude of “initial” and “late” locomotor adaptation rates were determined. Results All participants had similar magnitudes of adaptation and similar initial adaptation rates both spatially and temporally. All 14 participants with stroke and baseline asymmetry temporarily walked with improved SLS time symmetry after adaptation. However, late adaptation rates poststroke were decreased (took more strides to achieve adaptation) compared with controls. Conclusions Mild to moderate hemiparesis does not interfere with the initial acquisition of novel symmetrical gait patterns in both the spatial and temporal domains, though it does disrupt the rate at which “late” adaptive changes are produced. Impairment of the late, slow phase of learning may be an important rehabilitation consideration in this patient population. PMID:22367915

The Effect of Tobacco Control Measures during a Period of Rising Cardiovascular Disease Risk in India: A Mathematical Model of Myocardial Infarction and Stroke

PubMed Central

Basu, Sanjay; Glantz, Stanton; Bitton, Asaf; Millett, Christopher

2013-01-01

Background We simulated tobacco control and pharmacological strategies for preventing cardiovascular deaths in India, the country that is expected to experience more cardiovascular deaths than any other over the next decade. Methods and Findings A microsimulation model was developed to quantify the differential effects of various tobacco control measures and pharmacological therapies on myocardial infarction and stroke deaths stratified by age, gender, and urban/rural status for 2013 to 2022. The model incorporated population-representative data from India on multiple risk factors that affect myocardial infarction and stroke mortality, including hypertension, hyperlipidemia, diabetes, coronary heart disease, and cerebrovascular disease. We also included data from India on cigarette smoking, bidi smoking, chewing tobacco, and secondhand smoke. According to the model's results, smoke-free legislation and tobacco taxation would likely be the most effective strategy among a menu of tobacco control strategies (including, as well, brief cessation advice by health care providers, mass media campaigns, and an advertising ban) for reducing myocardial infarction and stroke deaths over the next decade, while cessation advice would be expected to be the least effective strategy at the population level. In combination, these tobacco control interventions could avert 25% of myocardial infarctions and strokes (95% CI: 17%–34%) if the effects of the interventions are additive. These effects are substantially larger than would be achieved through aspirin, antihypertensive, and statin therapy under most scenarios, because of limited treatment access and adherence; nevertheless, the impacts of tobacco control policies and pharmacological interventions appear to be markedly synergistic, averting up to one-third of deaths from myocardial infarction and stroke among 20- to 79-y-olds over the next 10 y. Pharmacological therapies could also be considerably more potent with further health system improvements. Conclusions Smoke-free laws and substantially increased tobacco taxation appear to be markedly potent population measures to avert future cardiovascular deaths in India. Despite the rise in co-morbid cardiovascular disease risk factors like hyperlipidemia and hypertension in low- and middle-income countries, tobacco control is likely to remain a highly effective strategy to reduce cardiovascular deaths. Please see later in the article for the Editors' Summary PMID:23874160

A comparative analysis of risk factors for stroke in blacks and whites: The Atherosclerosis Risk in Communities (ARIC) Study

PubMed Central

Huxley, Rachel; Bell, Elizabeth J.; Lutsey, Pamela L.; Bushnell, Cheryl; Shahar, Eyal; Rosamond, Wayne; Gottesman, Rebecca; Folsom, Aaron

2013-01-01

Objective Previous studies have speculated that the higher stroke incidence rate in blacks compared with whites may be due, in part, to stroke risk factors exerting a more adverse effect among blacks than whites. To determine whether such racial differences exist we compared the prospective associations between novel, traditional and emerging stroke risk factors in blacks and whites. Design Baseline characteristics on risk factor levels were obtained on 15,407 participants from the Atherosclerosis Risk in Communities Study. Stroke incidence was ascertained from 1987–2008. Adjusted Cox proportional hazard models were used to compute hazard ratios (HRs) and their 95% confidence intervals (CIs) for stroke in relation to stroke risk factor levels stratified by race. Results During follow-up 988 stroke events occurred: Blacks had higher stroke incident rates compared with whites with the greatest difference in those aged <60 years: 4.34, 3.24, 1.20 and 0.84 per 1,000 person-years, in black men, black women, white men and white women, respectively. Associations between risk factors with incident stroke were similar in blacks and whites excluding diabetes which was more strongly associated with risk of stroke in blacks than in whites: HR 2.54 (95% CI: 2.03–3.18) vs. 1.74 (1.37–2.21), respectively; p for race interaction=0.02. Conclusions At all ages, blacks are at considerably higher risk of incident stroke compared with whites, although the effect is most marked in younger age groups. This is most likely due to blacks having a greater burden of stroke risk factors rather than there being any substantial race differences in the associations between risk factors and stroke outcomes. PMID:24261746

High frequency of intracranial arterial stenosis and cannabis use in ischaemic stroke in the young.

PubMed

Wolff, Valérie; Armspach, Jean-Paul; Beaujeux, Rémy; Manisor, Monica; Rouyer, Olivier; Lauer, Valérie; Meyer, Nicolas; Marescaux, Christian; Geny, Bernard

2014-01-01

Leading aetiologies of ischaemic stroke in young adults are cervico-cerebral arterial dissections and cardio-embolism, but the causes remain undetermined in a considerable proportion of cases. In a few reports, intracranial arterial stenosis has been suggested to be a potential cause of ischaemic stroke in young adults. The aim of our work was to evaluate the frequency, characteristics and risk factors of intracranial arterial stenosis in a prospective series of young ischaemic stroke patients. The study was based on a prospective consecutive hospital-based series of 159 patients aged 18-45 years who were admitted to our unit for an acute ischaemic stroke from October 2005 to December 2010. A structured questionnaire was used in order to assess common vascular risk factors such as hypertension, diabetes, hypercholesterolemia, use of tobacco, alcohol and illicit drugs, migraine, and, in women, oral contraceptive use. A systematic screening was performed, including the following: brain magnetic resonance imaging or, if not feasible, brain computed tomography scan, carotid and vertebral Duplex scanning and trans-cranial Doppler sonography, 3D time-of-flight magnetic resonance cerebral angiography or cerebral computed tomography angiography. Long-duration electrocardiography, trans-thoracic and trans-oesophageal echocardiography were performed and laboratory blood investigations were extensive. Urine samples were screened for cannabinoids, cocaine, amphetamine and methylene-dioxy-methamphetamine. When this initial work-up was inconclusive, trans-femoral intra-arterial selective digital subtraction angiography with reconstructed 3D images was performed. In this series, 49 patients (31%) had intracranial arterial stenosis. Other defined causes were found in 91 patients (57%), including cardio-embolism in 32 (20%), cervical dissection in 23 (14%), extracranial atherosclerosis in 7 (4%), haematological disorders in 7 (4%), small vessel disease in 1, and isolated patent foramen ovale in 21 (13%); in 19 patients (12%), ischaemic stroke was related to an undetermined aetiology. Comparing risk factors between patients with intracranial arterial stenosis and those with other definite causes showed that there were only two significant differences: a lower age and a higher frequency of vasoactive substances (especially cannabis) in patients with intracranial arterial stenosis. All intracranial arterial stenosis in patients who used vasoactive substances were located in several intracranial vessels. Intracranial arterial stenosis may be an important mechanism of stroke in young patients and it should be systematically investigated using vascular imaging. Strong questioning about illicit drug consumption (including cannabis) or vasoactive medication use should also be performed. It should be emphasized for health prevention in young adults that cannabis use might be associated with critical consequences such as stroke. © 2014 S. Karger AG, Basel.

Design of a specialized computer for on-line monitoring of cardiac stroke volume

NASA Technical Reports Server (NTRS)

Webb, J. A., Jr.; Gebben, V. D.

1972-01-01

The design of a specialized analog computer for on-line determination of cardiac stroke volume by means of a modified version of the pressure pulse contour method is presented. The design consists of an analog circuit for computation and a timing circuit for detecting necessary events on the pressure waveform. Readouts of arterial pressures, systolic duration, heart rate, percent change in stroke volume, and percent change in cardiac output are provided for monitoring cardiac patients. Laboratory results showed that computational accuracy was within 3 percent, while animal experiments verified the operational capability of the computer. Patient safety considerations are also discussed.

Medication errors versus time of admission in a subpopulation of stroke patients undergoing inpatient rehabilitation complications and considerations.

PubMed

Pitts, Eric P

2011-01-01

This study looked at the medication ordering error frequency and the length of inpatient hospital stay in a subpopulation of stroke patients (n-60) as a function of time of patient admission to an inpatient rehabilitation hospital service. A total of 60 inpatient rehabilitation patients, 30 arriving before 4 pm, and 30 arriving after 4 pm, with as admitting diagnosis of stroke were randomly selected from a larger sample (N=426). There was a statistically significant increase in medication ordering errors and the number of inpatient rehabilitation hospital days in the group of patients who arrived after 4 pm.

The Quest for Arterial Recanalization in Acute Ischemic Stroke-The Past, Present and the Future

PubMed Central

L.L.Yeo, Leonard; Sharma, Vijay K

2013-01-01

Ischemic stroke is one of the major causes of mortality and long-term disability. In the recent past, only very few treatment options were available and a considerable proportion of stroke survivors remained permanently disabled. However, over the last 2 decades rapid advances in acute stroke care have resulted in a corresponding improvement in mortality rates and functional outcomes. In this review, we describe the evolution of systemic thrombolytic agents and various interventional devices, their current status as well as some of the future prospects. We reviewed literature pertaining to acute ischemic stroke reperfusion treatment. We explored the current accepted treatment strategies to attain cerebral reperfusion via intravenous modalities and compare and contrast them within the boundaries of their clinical trials. Subsequently we reviewed the trials for interventional devices for acute ischemic stroke, categorizing them into thrombectomy devices, aspiration devices, clot disruption devices and thrombus entrapment devices. Finally we surveyed several of the alternative reperfusion strategies available. We also shed some light on the controversies surrounding the current strategies of treatment of acute ischemic stroke. Acute invasive interventional strategies continue to improve along with the noninvasive modalities. Both approaches appear promising. We conducted a comprehensive chronological review of the existing treatments as well as upcoming remedies for acute ischemic stroke. PMID:23864913

Stroke Repair via Biomimicry of the Subventricular Zone

NASA Astrophysics Data System (ADS)

Matta, Rita; Gonzalez, Anjelica L.

2018-03-01

Stroke is among the leading causes of death and disability worldwide, 85% of which are ischemic. Current stroke therapies are limited by a narrow effective therapeutic time and fail to effectively complete the recovery of the damaged area. Magnetic resonance imaging of the subventricular zone (SVZ) following infarct/stroke has allowed visualization of new axonal connections and projections being formed, while new immature neurons migrate from the SVZ to the peri-infarct area. Such studies suggest that the SVZ is a primary source of regenerative cells for the repair and regeneration of stroke-damaged neurons and tissue. Therefore, the development of tissue engineered scaffolds that serve as a bioreplicative SVZ niche would support the survival of multiple cell types that reside in the SVZ. Essential to replication of the human SVZ microenvironment is the establishment of microvasculature that regulates both the healthy and stroke-injured blood brain barrier, which is dysregulated post-stroke. In order to reproduce this niche, understanding how cells interact in this environment is critical, in particular neural stem cells, endothelial cells, pericytes, ependymal cells, and microglia. Remodeling and repair of the matrix-rich SVZ niche by endogenous reparative mechanisms may then support functional recovery when enhanced by an artificial niche that supports the survival and proliferation of migrating vascular and neuronal cells. Critical considerations to mimic this area include an understanding of resident cell types, delivery method, and the use of biocompatible materials. Controlling stem cell survival, differentiation, and migration are key factors to consider when transplanting stem cells. Here, we discuss the role of the SVZ architecture and resident cells in the promotion and enhancement of endogenous repair mechanisms. We elucidate the interplay between the extracellular matrix composition and cell interactions prior to and following stroke. Lastly, we review current cell and neuronal niche biomimetic materials that allow for a tissue- engineered approach in order to promote structural and functional restoration of neural circuitry. By creating an artificial mimetic SVZ, tissue engineers can strive to facilitate tissue regeneration and functional recovery.

Cerebrovascular complications and granuloma formation after wrapping or coating of intracranial aneurysms with cotton gauze and human fibrin adhesives: results from a single-center patient series over a 5-year period.

PubMed

Beitzke, Markus; Leber, Klaus A; Deutschmann, Hannes; Gattringer, Thomas; Poltrum, Birgit; Fazekas, Franz

2013-10-01

Reinforcement of intracranial aneurysms (IAs) by wrapping or coating is a well-established therapeutic approach to those IAs not amenable to any other definitive treatment, but has been associated with complications such as parent artery narrowing, granuloma formation, and ischemic stroke. The goal of this study was to systematically investigate cerebrovascular complications following this procedure. The authors' hospital database was searched for all patients who underwent wrapping or coating of IAs with cotton gauze and human fibrin adhesives between October 2006 and October 2011. The follow-up records of these patients were extracted, including regular clinical visits and vascular imaging. Five hundred sixty-seven patients were treated for IAs over the 5-year period: 303 patients underwent endovascular strategies and 264 underwent craniotomies. Wrapping or coating of IAs was performed in 20 patients (3.5%). Parent artery narrowing occurred in 5 (25%) of the 20 patients and was associated with major ischemic strokes in 4 patients and severe headache in another. Ischemic strokes were associated with parent artery narrowing, which occurred early postoperatively in 2 patients or was a consequence of granuloma formation in 2 patients 1 and 2 months after the procedure, respectively. These data should add to the awareness of significant cerebrovascular complications following wrapping or coating of IAs with cotton gauze and human fibrin adhesives and indicate that major ischemic strokes need to be included in the risk/benefit considerations during decision making for such treatment strategies. Patients who receive IA wrapping should be monitored and followed up closely for arterial narrowing and granuloma formation.

[Consideration of guidelines, recommendations and quality indicators for treatment of stroke in the dataset "Emergency Department" of DIVI].

PubMed

Kulla, M; Friess, M; Schellinger, P D; Harth, A; Busse, O; Walcher, F; Helm, M

2015-12-01

The dataset "Emergency Department" of the German Interdisciplinary Association of Critical Care and Emergency Medicine (DIVI) has been developed during several expert meetings. Its goal is an all-encompassing documentation of the early clinical treatment of patients in emergency departments. Using the example of the index disease acute ischemic stroke (stroke), the aim was to analyze how far this approach has been fulfilled. In this study German, European and US American guidelines were used to analyze the extent of coverage of the datasets on current emergency department guidelines and recommendations from professional societies. In addition, it was examined whether the dataset includes recommended quality indicators (QI) for quality management (QM) and in a third step it was examined to what extent national provisions for billing are included. In each case a differentiation was made whether the respective rationale was primary, i.e. directly apparent or whether it was merely secondarily depicted by expertise. In the evaluation an additional differentiation was made between the level of recommendations and further quality relevant criteria. The modular design of the emergency department dataset comprising 676 data fields is briefly described. A total of 401 individual fields, divided into basic documentation, monitoring and specific neurological documentation of the treatment of stroke patients were considered. For 247 data fields a rationale was found. Partially overlapping, 78.9 % of 214 medical recommendations in 3 guidelines and 85.8 % of the 106 identified quality indicators were primarily covered. Of the 67 requirements for billing of performance of services, 55.5 % are primarily part of the emergency department dataset. Through appropriate expertise and documentation by a board certified neurologist, the results can be improved to almost 100 %. The index disease stroke illustrates that the emergency department dataset of the DIVI covers medical guidelines, especially 100 % of the German guidelines with a grade of recommendation. All necessary information to document the specialized stroke treatment procedure in the German diagnosis-related groups (DRG) system is also covered. The dataset is also suitable as a documentation tool of quality management, for example, to participate in the registry of the German Stroke Society (ADSR). Best results are obtained if the dataset is applied by a physician specialized in the treatment of patients with stroke (e.g. board certified neurologist). Finally the results show that changes in medical guidelines and recommendations for quality management as well as billing-relevant content should be implemented in the development of datasets for documentation to avoid duplicate documentation.

Service provision for stroke: The Greek paradox.

PubMed

Fountouki, Antigoni; Theofanidis, Dimitrios

2017-09-01

Stroke remains a leading cause of mortality, as well as of subsequent serious long-term physical and mental morbidity. This places special demands for updated clinical excellence and optimum organization of stroke care services. Stroke units have been shown to improve patient outcomes. Thus, many western countries have developed and implemented sophisticated stroke facilities and corresponding public awareness strategies. These cannot be easily "translated" in Greece due to special features on the hospital administration system such as a unique rotation system for acute admissions and long-standing austerity. Yet, despite adverse conditions, clinicians within the Greek health care system have been exceeding themselves in their attempt to provide optimum care outcomes. An example of such efforts is the improvisation of stroke bays (SBs) as part of a medical or neurology ward, providing sophisticated treatments. New centralized policy decisions are now needed in order to improve stroke services nationwide. These should be tailored to the country's geography and health care mapping especially as there is already considerable technical knowhow and local efforts in place. A pragmatic solution would be to create a "grid" of services for stroke, by providing a comprehensive stroke centers in each of the two major cities and SBs at a prefectural level. Once these are established, more efforts should be taken to educate the public on stroke recognition and subsequently on facilities available. Copyright © 2017 Society for Vascular Nursing, Inc. Published by Elsevier Inc. All rights reserved.

Adherence to a Healthy Nordic Diet and Risk of Stroke: A Danish Cohort Study.

PubMed

Hansen, Camilla Plambeck; Overvad, Kim; Kyrø, Cecilie; Olsen, Anja; Tjønneland, Anne; Johnsen, Søren Paaske; Jakobsen, Marianne Uhre; Dahm, Christina Catherine

2017-02-01

Specific dietary patterns, including the Mediterranean diet, have been associated with stroke prevention. Our aim was to investigate whether adherence to a healthy Nordic diet, including fish, apples and pears, cabbages, root vegetables, rye bread, and oatmeal, was associated with risk of stroke. Incident cases of stroke among 55 338 men and women from the Danish Diet, Cancer and Health cohort were identified from the Danish National Patient Register and verified by review of records. Cases of ischemic stroke were further subclassified based on etiology according to the TOAST classification system (Trial of Org 10172 in Acute Stroke Treatment). Information on diet was collected at baseline (1993-1997) using a semiquantitative food-frequency questionnaire. Cox proportional hazards models were used to estimate hazards ratios of total stroke and subtypes of ischemic and hemorrhagic stroke. During a median follow-up of 13.5 years, 2283 cases of incident stroke were verified, including 1879 ischemic strokes. Adherence to a healthy Nordic diet, as reflected by a higher Healthy Nordic Food Index score, was associated with a lower risk of stroke. The hazards ratio comparing an index score of 4 to 6 (high adherence) with an index score of 0 to 1 (low adherence) was 0.86 (95% confidence interval 0.76-0.98) for total stroke. Inverse associations were observed for ischemic stroke, including large-artery atherosclerosis. No trend was observed for hemorrhagic stroke; however, a statistically insignificant trend was observed for intracerebral hemorrhage. Our findings suggest that a healthy Nordic diet may be recommended for the prevention of stroke. © 2017 American Heart Association, Inc.

A systematic review and meta-analysis of acute stroke unit care: What’s beyond the statistical significance?

PubMed Central

2013-01-01

Background The benefits of stroke unit care in terms of reducing death, dependency and institutional care were demonstrated in a 2009 Cochrane review carried out by the Stroke Unit Trialists’ Collaboration. Methods As requested by the Belgian health authorities, a systematic review and meta-analysis of the effect of acute stroke units was performed. Clinical trials mentioned in the original Cochrane review were included. In addition, an electronic database search on Medline, Embase, the Cochrane Central Register of Controlled Trials, and Physiotherapy Evidence Database (PEDro) was conducted to identify trials published since 2006. Trials investigating acute stroke units compared to alternative care were eligible for inclusion. Study quality was appraised according to the criteria recommended by Scottish Intercollegiate Guidelines Network (SIGN) and the GRADE system. In the meta-analysis, dichotomous outcomes were estimated by calculating odds ratios (OR) and continuous outcomes were estimated by calculating standardized mean differences. The weight of a study was calculated based on inverse variance. Results Evidence from eight trials comparing acute stroke unit and conventional care (general medical ward) were retained for the main synthesis and analysis. The findings from this study were broadly in line with the original Cochrane review: acute stroke units can improve survival and independency, as well as reduce the chance of hospitalization and the length of inpatient stay. The improvement with stroke unit care on mortality was less conclusive and only reached borderline level of significance (OR 0.84, 95% CI 0.70 to 1.00, P = 0.05). This improvement became statistically non-significant (OR 0.87, 95% CI 0.74 to 1.03, P = 0.12) when data from two unpublished trials (Goteborg-Ostra and Svendborg) were added to the analysis. After further also adding two additional trials (Beijing, Stockholm) with very short observation periods (until discharge), the difference between acute stroke units and general medical wards on death remained statistically non-significant (OR 0.86, 95% CI 0.74 to 1.01, P = 0.06). Furthermore, based on figures reported by the clinical trials included in this study, a slightly higher proportion of patients became dependent after receiving care in stroke units than those treated in general medical wards – although the difference was not statistically significant. This result could have an impact on the future demand for healthcare services for individuals that survive a stroke but became dependent on their care-givers. Conclusions These findings demonstrate that a well-conducted meta-analysis can produce results that can be of value to policymakers but the choice of inclusion/exclusion criteria and outcomes in this context needs careful consideration. The financing of interventions such as stroke units that increase independency and reduce inpatient stays are worthwhile in a context of an ageing population with increasing care needs. One limitation of this study was the selection of trials published in only four languages: English, French, Dutch and German. This choice was pragmatic in the context of this study, where the objective was to support health authorities in their decision processes. PMID:24164771

Lifetime cost of stroke subtypes in Australia: findings from the North East Melbourne Stroke Incidence Study (NEMESIS).

PubMed

Dewey, Helen M; Thrift, Amanda G; Mihalopoulos, Cathy; Carter, Robert; Macdonell, Richard A L; McNeil, John J; Donnan, Geoffrey A

2003-10-01

Little is known about any variations in resource use and costs of care between stroke subtypes, especially nonhospital costs. The purpose of this study was to describe the patterns of resource use and to estimate the first-year and lifetime costs for stroke subtypes. A cost-of-illness model was used to estimate the total first-year costs and lifetime costs of stroke subtypes for all strokes (subarachnoid hemorrhages excluded) that occurred in Australia during 1997. For each subtype, average cost per case during the first year and the present value of average cost per case over a lifetime were calculated. Resource use data obtained in the North East Melbourne Stroke Incidence Study (NEMESIS) were used. The present value of total lifetime costs for all strokes was Aus 1.3 billion dollars (US 985 million dollars). Total lifetime costs were greatest for ischemic stroke (72%; Aus 936.8 million dollars; US 709.7 million dollars), followed by intracerebral hemorrhage (26%; Aus 334.5 million dollars; US 253.4 million dollars) and unclassified stroke (2%; Aus 30 million dollars; US 22.7 million dollars). The average cost per case during the first year was greatest for total anterior circulation infarction (Aus 28 266 dollars). Over a lifetime, the present value of average costs was greatest for intracerebral hemorrhage (Aus 73 542 dollars), followed by total anterior circulation infarction (Aus 53 020 dollars), partial anterior circulation infarction (Aus 50 692 dollars), posterior circulation infarction (Aus 37 270 dollars), lacunar infarction (Aus 34 470 dollars), and unclassified stroke (Aus 12 031 dollars). First-year and lifetime costs vary considerably between stroke subtypes. Variation in average length of total hospital stay is the main explanation for differences in first-year costs.

Public awareness of warning symptoms, risk factors, and treatment of stroke in northwest India.

PubMed

Pandian, Jeyaraj D; Jaison, Ashish; Deepak, Sukhbinder S; Kalra, Guneet; Shamsher, Shivali; Lincoln, Douglas J; Abraham, George

2005-03-01

This study assessed public awareness of warning symptoms, risk factors, and treatment of stroke in Ludhiana, Punjab, North West India. A hospital-based survey was conducted between February 2002 and September 2002 by the Stroke section of Christian Medical College. The study subjects were relatives of patients without history of stroke, attending the outpatient department of the hospital. Trained medical students, interns, and a nurse interviewed subjects using a structured, pretested, open-ended questionnaire. Nine hundred forty-two individuals were interviewed during the study period (56.4% men, mean age 40.1 years, age range 15 to 80 years). Forty-five percent of the subjects did not recognize the brain as the affected organ in stroke. In the multivariate analysis, higher education (P<0.001; odds ratio 2.6; 95%, CI 1.8 to 3.8) and upper socioeconomic status (P<0.005; odds ratio 1.6; CI, 1.1 to 2.2) correlated with a better knowledge of which organ was affected in stroke. Twenty-three percent of the participants did not know a single warning symptom of stroke. Twenty-one percent of the subjects could not identify even a single risk factor for stroke. Seven percent of the study population believed that oil massage would improve stroke victims. A small proportion of subjects believed in witchcraft, faith healing, homeopathic, and ayurvedic treatment (3%). This hospital-based survey reveals a better awareness of stroke warning signs and risk factors. However, knowledge regarding the organ involved, etiology, and treatment of stroke is lacking. Considerable education is needed to increase public awareness in modern concepts of stroke treatment.

Resonance vibrations in intake and exhaust pipes of in-line engines III : the inlet process of a four-stroke-cycle engine

NASA Technical Reports Server (NTRS)

Lutz, O

1940-01-01

Using a previously developed method, the boundary process of four-stroke-cycle engines are set up. The results deviate considerably from those obtained under the assumption that the velocity fluctuation is proportional to the cylinder piston motion. The deviation is less at the position of resonance frequencies. By the method developed, the effect of the resonance vibrations on the volumetric efficiency can be demonstrated.

Stroke from systemic vascular disorders in Saudi children. The devastating role of hypernatremic dehydration.

PubMed

Salih, Mustafa A; Zahraa, Jihad N; Al-Jarallah, Ahmed A; Alorainy, Ibrahim A; Hassan, Hamdy H

2006-03-01

Systemic vascular disorders, leading to childhood stroke, include volume depletion or systemic hypotension and hypernatremic dehydration. We describe 3 cases of stroke following systemic vascular disorders. These were diagnosed during a prospective and retrospective study on childhood stroke, which included 104 patients. Post-gastroenteritis hypernatremic dehydration is an important, potentially preventable, cause of stroke in Saudi children.

Meeting the psychological needs of community-living stroke patients and carers: a study of third sector provision.

PubMed

Morris, Reg

2016-01-01

To elucidate how community stroke staff in a major third sector organisation experienced their role and understood and responded to clients' psychological needs. In stage 1, three focus groups of 28 staff in total were recorded, transcribed and analysed using inductive thematic analysis. Themes were authenticated by new staff groups. In stage 2, these themes informed the construction of a questionnaire delivered through the organisation's intranet by "Survey Monkey". Five themes emerged from the focus groups: background and context; perceptions of clients' psychological issues; approaches to meeting psychological needs; the experience of working with psychological needs and sources of support; aspirations for future development. Four themes were used in constructing the questionnaire. Responses from 144 staff with diverse qualifications and experience were received; over half encountered 16 (of 35) psychological issues at least once per week. Stroke survivors' needs predominated over carers' needs. Skills used to address psychological problems were identified, also training and support needs and future aspirations. Support needs included information, training and access to specialist consultants. Psychological issues were central in the work of third sector community stroke staff; psychological skills were routinely used. Attention to means of supporting and developing these skills is required. Service leaders and commissioners should be aware that third sector community stroke staff frequently deal with a diverse range of psychological issues and perceive psychological care as central. Service leaders should consider providing training in assessment and management of mood and cognition, risk assessment and management and basic counselling. Staff should be provided with access to specialist consultation and better information about psychological aspects of referrals. There is uncertainty about key methods for supporting the delivery of psychological care (supervision, mentoring and peer support) which requires consideration.

Pathogenesis and neuroimaging of cerebral large and small vessel disease in type 2 diabetes: A possible link between cerebral and retinal microvascular abnormalities.

PubMed

Umemura, Toshitaka; Kawamura, Takahiko; Hotta, Nigishi

2017-03-01

Diabetes patients have more than double the risk of ischemic stroke compared with non-diabetic individuals, and its neuroimaging characteristics have important clinical implications. To understand the pathophysiology of ischemic stroke in diabetes, it is important to focus not only on the stroke subtype, but also on the size and location of the occlusive vessels. Specifically, ischemic stroke in diabetes patients might be attributed to both large and small vessels, and intracranial internal carotid artery disease and small infarcts of the posterior circulation often occur. An additional feature is that asymptomatic lacunar infarctions are often seen in the basal ganglia and brain stem on brain magnetic resonance imaging. In particular, cerebral small vessel disease (SVD), including lacunar infarctions, white matter lesions and cerebral microbleeds, has been shown to be associated not only with stroke incidence, but also with the development and progression of dementia and diabetic microangiopathy. However, the pathogenesis of cerebral SVD is not fully understood. In addition, data on the association between neuroimaging findings of the cerebral SVD and diabetes are limited. Recently, the clinical importance of the link between cerebral SVD and retinal microvascular abnormalities has been a topic of considerable interest. Several clinical studies have shown that retinal microvascular abnormalities are closely related to cerebral SVD, suggesting that retinal microvascular abnormalities might be pathophysiologically linked to ischemic cerebral SVD. We review the literature relating to the pathophysiology and neuroimaging of cerebrovascular disease in diabetes, and discuss the problems based on the concept of cerebral large and small vessel disease. © 2016 The Authors. Journal of Diabetes Investigation published by Asian Association for the Study of Diabetes (AASD) and John Wiley & Sons Australia, Ltd.

Individualized model predicts brain current flow during transcranial direct-current stimulation treatment in responsive stroke patient.

PubMed

Datta, Abhishek; Baker, Julie M; Bikson, Marom; Fridriksson, Julius

2011-07-01

Although numerous published reports have demonstrated the beneficial effects of transcranial direct-current stimulation (tDCS) on task performance, fundamental questions remain regarding the optimal electrode configuration on the scalp. Moreover, it is expected that lesioned brain tissue will influence current flow and should therefore be considered (and perhaps leveraged) in the design of individualized tDCS therapies for stroke. The current report demonstrates how different electrode configurations influence the flow of electrical current through brain tissue in a patient who responded positively to a tDCS treatment targeting aphasia. The patient, a 60-year-old man, sustained a left hemisphere ischemic stroke (lesion size = 87.42 mL) 64 months before his participation. In this study, we present results from the first high-resolution (1 mm(3)) model of tDCS in a brain with considerable stroke-related damage; the model was individualized for the patient who received anodal tDCS to his left frontal cortex with the reference cathode electrode placed on his right shoulder. We modeled the resulting brain current flow and also considered three additional reference electrode positions: right mastoid, right orbitofrontal cortex, and a "mirror" configuration with the anode over the undamaged right cortex. Our results demonstrate the profound effect of lesioned tissue on resulting current flow and the ability to modulate current pattern through the brain, including perilesional regions, through electrode montage design. The complexity of brain current flow modulation by detailed normal and pathologic anatomy suggest: (1) That computational models are critical for the rational interpretation and design of individualized tDCS stroke-therapy; and (2) These models must accurately reproduce head anatomy as shown here. Copyright © 2011 Elsevier Inc. All rights reserved.

Blood Biomarkers for the Early Diagnosis of Stroke: The Stroke-Chip Study.

PubMed

Bustamante, Alejandro; López-Cancio, Elena; Pich, Sara; Penalba, Anna; Giralt, Dolors; García-Berrocoso, Teresa; Ferrer-Costa, Carles; Gasull, Teresa; Hernández-Pérez, María; Millan, Mónica; Rubiera, Marta; Cardona, Pedro; Cano, Luis; Quesada, Helena; Terceño, Mikel; Silva, Yolanda; Castellanos, Mar; Garces, Moisés; Reverté, Silvia; Ustrell, Xavier; Marés, Rafael; Baiges, Joan Josep; Serena, Joaquín; Rubio, Francisco; Salas, Eduardo; Dávalos, Antoni; Montaner, Joan

2017-09-01

Stroke diagnosis could be challenging in the acute phase. We aimed to develop a blood-based diagnostic tool to differentiate between real strokes and stroke mimics and between ischemic and hemorrhagic strokes in the hyperacute phase. The Stroke-Chip was a prospective, observational, multicenter study, conducted at 6 Stroke Centers in Catalonia. Consecutive patients with suspected stroke were enrolled within the first 6 hours after symptom onset, and blood samples were drawn immediately after admission. A 21-biomarker panel selected among previous results and from the literature was measured by immunoassays. Outcomes were differentiation between real strokes and stroke mimics and between ischemic and hemorrhagic strokes. Predictive models were developed by combining biomarkers and clinical variables in logistic regression models. Accuracy was evaluated with receiver operating characteristic curves. From August 2012 to December 2013, 1308 patients were included (71.9% ischemic, 14.8% stroke mimics, and 13.3% hemorrhagic). For stroke versus stroke mimics comparison, no biomarker resulted included in the logistic regression model, but it was only integrated by clinical variables, with a predictive accuracy of 80.8%. For ischemic versus hemorrhagic strokes comparison, NT-proBNP (N-Terminal Pro-B-Type Natriuretic Peptide) >4.9 (odds ratio, 2.40; 95% confidence interval, 1.55-3.71; P <0.0001) and endostatin >4.7 (odds ratio, 2.02; 95% confidence interval, 1.19-3.45; P =0.010), together with age, sex, blood pressure, stroke severity, atrial fibrillation, and hypertension, were included in the model. Predictive accuracy was 80.6%. The studied biomarkers were not sufficient for an accurate differential diagnosis of stroke in the hyperacute setting. Additional discovery of new biomarkers and improvement on laboratory techniques seem necessary for achieving a molecular diagnosis of stroke. © 2017 American Heart Association, Inc.

Herbal Medicine in Ischemic Stroke: Challenges and Prospective.

PubMed

Gaire, Bhakta Prasad

2018-04-01

Herbal medicines, mainly of plant source, are invaluable source for the discovery of new therapeutic agents for all sorts of human ailments. The complex pathogenesis of stroke and multifactorial effect of herbal medicine and their active constituents may suggest the promising future of natural medicine for stroke treatment. Anti-oxidant, anti-inflammatory, anti-apoptotic, neuroprotective and vascular protective effect of herbal medicines are believed to be efficacious in stroke treatment. Herbs typically have fewer reported side effects than allopathic medicine, and may be safer to use over longer period of time. Herbal medicines are believed to be more effective for the longstanding health complaints, such as stroke. Several medicinal plants and their active constituents show the promising results in laboratory research. However failure in transformation of laboratory animal research to the clinical trials has created huge challenge for the use of herbal medicine in stroke. Until and unless scientifically comprehensive evidence of the efficacy and safety of herbal medicine in ischemic stroke patients is available, efforts should be made to continue implementing treatment strategies of proven effectiveness. More consideration should be paid to natural compounds that can have extensive therapeutic time windows, perfect pharmacological targets with few side effects. Herbal medicine has excellent prospective for the treatment of ischemic stroke, but a lot of effort should be invested to transform the success of animal research to human use.

Role of rivaroxaban in the management of atrial fibrillation: insights from clinical practice.

PubMed

Vimalesvaran, Kavitha; Dockrill, Seth J; Gorog, Diana A

2018-01-01

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, and it leads to significant morbidity and mortality, predominantly from ischemic stroke. Vitamin K antagonists, mainly warfarin, have been used for decades to prevent ischemic stroke in AF, but their use is limited due to interactions with food and other drugs, as well as the requirement for regular monitoring of the international normalized ratio. Rivaroxaban, a direct factor Xa inhibitor and the most commonly used non-vitamin K oral anticoagulant, avoids many of these challenges and is being prescribed with increasing frequency for stroke prevention in non-valvular AF. Randomized controlled trial (RCT) data from the ROCKET-AF(Rivaroxaban once daily oral direct Factor Xa inhibition compared with vitamin K antagonism for prevention of stroke and embolism trial in atrial fibrillation) trial have shown rivaroxaban to be non-inferior to warfarin in preventing ischemic stroke and systemic embolism and to have comparable overall bleeding rates. Applicability of the RCT data to real-world practice can sometimes be limited by complex clinical scenarios or multiple comorbidities not adequately represented in the trials. Available real-world evidence in non-valvular AF patients with comorbidities - including renal impairment, acute coronary syndrome, diabetes mellitus, malignancy, or old age - supports the use of rivaroxaban as safe and effective in preventing ischemic stroke in these subgroups, though with some important considerations required to reduce bleeding risk. Patient perspectives on rivaroxaban use are also considered. Real-world evidence indicates superior rates of drug adherence with rivaroxaban when compared with vitamin K antagonists and with alternative non-vitamin K oral anticoagulants - perhaps, in part, due to its once-daily dosing regimen. Furthermore, self-reported quality of life scores are highest among patients compliant with rivaroxaban therapy. The generally high levels of patient satisfaction with rivaroxaban therapy contribute to overall favorable clinical outcomes.

Development of a shared decision-making tool to assist patients and clinicians with decisions on oral anticoagulant treatment for atrial fibrillation.

PubMed

Kaiser, Karen; Cheng, Wendy Y; Jensen, Sally; Clayman, Marla L; Thappa, Andrew; Schwiep, Frances; Chawla, Anita; Goldberger, Jeffrey J; Col, Nananda; Schein, Jeff

2015-12-01

Decision aids (DAs) are increasingly used to operationalize shared decision-making (SDM) but their development is not often described. Decisions about oral anticoagulants (OACs) for atrial fibrillation (AF) involve a trade-off between lowering stroke risk and increasing OAC-associated bleeding risk, and consideration of how treatment affects lifestyle. The benefits and risks of OACs hinge upon a patient's risk factors for stroke and bleeding and how they value these outcomes. We present the development of a DA about AF that estimates patients' risks for stroke and bleeding and assesses their preferences for outcomes. Based on a literature review and expert discussions, we identified stroke and major bleeding risk prediction models and embedded them into risk assessment modules. We identified the most important factors in choosing OAC treatment (warfarin used as the default reference OAC) through focus group discussions with AF patients who had used warfarin and clinician interviews. We then designed preference assessment and introductory modules accordingly. We integrated these modules into a prototype AF SDM tool and evaluated its usability through interviews. Our tool included four modules: (1) introduction to AF and OAC treatment risks and benefits; (2) stroke risk assessment; (3) bleeding risk assessment; and (4) preference assessment. Interactive risk calculators estimated patient-specific stroke and bleeding risks; graphics were developed to communicate these risks. After cognitive interviews, the content was improved. The final AF tool calculates patient-specific risks and benefits of OAC treatment and couples these estimates with patient preferences to improve clinical decision-making. The AF SDM tool may help patients choose whether OAC treatment is best for them and represents a patient-centered, integrative approach to educate patients on the benefits and risks of OAC treatment. Future research is needed to evaluate this tool in a real-world setting. The development process presented can be applied to similar SDM tools.

Guidelines for the use of carotid endarterectomy: current recommendations from the Canadian Neurosurgical Society.

PubMed

Findlay, J M; Tucker, W S; Ferguson, G G; Holness, R O; Wallace, M C; Wong, J H

1997-09-15

To develop guidelines on the suitability of patients for carotid endarterectomy (CEA). For atherosclerotic carotid stenosis that has resulted in retinal or cerebral ischemia: antiplatelet drugs or CEA. For asymptomatic carotid stenosis: CEA or no surgery. Risk of stroke and death. Trials comparing CEA with nonsurgical management of carotid stenosis. Greatest weight was given to findings that were highly significant both statistically and clinically. Benefit: reduction in the risk of stroke. Major harms: iatrogenic stroke, cardiac complications and death secondary to surgical manipulations of the artery or the systemic stress of surgery. Costs were not considered. CEA is clearly recommended for patients with surgically accessible internal carotid artery (ICA) stenoses equal to or greater than 70% of the more distal, normal ICA lumen diameter, providing: (1) the stenosis is symptomatic, causing transient ischemic attacks or nondisabling stroke (including retinal infarction); (2) there is no worse distal, ipsilateral, carotid distribution arterial disease; (3) the patient is in stable medical condition; and (4) the rates of major surgical complications (stroke and death) among patients of the treating surgeon are less than 6%. Surgery is not recommended for asymptomatic stenoses of less than 60%. Symptomatic stenoses of less than 70% and asymptomatic stenoses of greater than 60% are uncertain indications. For these indications, consideration should be given to (1) patient presentation, age and medical condition; (2) plaque characteristics such as degree of narrowing, the presence of ulceration and any documented worsening of the plaque over time; (3) other cerebral arterial stenoses or occlusions, or cerebral infarcts identified through neuroimaging; and (4) surgical complication rates at the institution. CEA should not be considered for asymptomatic stenoses unless the combined stroke and death rate among patients of the surgeon is less than 3%. These guidelines generally agree with position statements prepared by other organizations in recent years, and with a January 1995 consensus statement by a group of experts assembled by the American Heart Association.

Correlated observations of three triggered lightning flashes

NASA Technical Reports Server (NTRS)

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

1984-01-01

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

Recovery in treated aphasia in the first year post-stroke.

PubMed

Sarno, M T; Levita, E

1979-01-01

During a one year post-stroke period of observation, the recovery trend in treated aphasic patients was characterized by general progression in communication skill. The most notable improvement occurred on a measure of everyday function with changes worthy of note on tasks of auditory comprehension and spontaneous word production. In the first 6 months post-stroke, the greatest gain occurred in aphasic patients classified as Fluent, and the least gain in Global aphasics. On the auditory comprehension task, however, improvement was noted in all aphasics regardless of type. In contrast, during the latter half of the first year post-stroke, Fluent aphasics showed least and Global aphasics the greatest improvement. In spite of their progress, Global aphasic patients remained considerably more impaired than the other groups. That the Global aphasics remained so impaired was expected, but the extent and temporal characteristics of their progress in communicating was unexpected.

Blood markers of coagulation, fibrinolysis, endothelial dysfunction and inflammation in lacunar stroke versus non-lacunar stroke and non-stroke: systematic review and meta-analysis.

PubMed

Wiseman, Stewart; Marlborough, Fergal; Doubal, Fergus; Webb, David J; Wardlaw, Joanna

2014-01-01

The cause of cerebral small vessel disease is not fully understood, yet it is important, accounting for about 25% of all strokes. It also increases the risk of having another stroke and contributes to about 40% of dementias. Various processes have been implicated, including microatheroma, endothelial dysfunction and inflammation. A previous review investigated endothelial dysfunction in lacunar stroke versus mostly non-stroke controls while another looked at markers of inflammation and endothelial damage in ischaemic stroke in general. We have focused on blood markers between clinically evident lacunar stroke and other subtypes of ischaemic stroke, thereby controlling for stroke in general. We systematically assessed the literature for studies comparing blood markers of coagulation, fibrinolysis, endothelial dysfunction and inflammation in lacunar stroke versus non-stroke controls or other ischaemic stroke subtypes. We assessed the quality of included papers and meta-analysed results. We split the analysis on time of blood draw in relation to the stroke. We identified 1,468 full papers of which 42 were eligible for inclusion, including 4,816 ischaemic strokes, of which 2,196 were lacunar and 2,500 non-stroke controls. Most studies subtyped stroke using TOAST. The definition of lacunar stroke varied between studies. Markers of coagulation/fibrinolysis (tissue plasminogen activator (tPA), plasminogen activator inhibitor (PAI), fibrinogen, D-dimer) were higher in lacunar stroke versus non-stroke although fibrinogen was no different to non-stroke in the acute phase. tPA and PAI were no different between lacunar and non-lacunar stroke. Fibrinogen and D-dimer were significantly lower in lacunar stroke compared to other ischaemic strokes, both acutely and chronically. Markers of endothelial dysfunction (homocysteine, von Willebrand Factor (vWF), E-selectin, P-selectin, intercellular adhesion molecule-1 (ICAM), vascular cellular adhesion molecule-1 (VCAM)) were higher or had insufficient or conflicting data (P-selectin, VCAM) in lacunar stroke versus non-stroke. Compared to other ischaemic stroke subtypes, homocysteine did not differ in lacunar stroke while vWF was significantly lower in lacunar stroke acutely [atherothrombotic standardized mean difference, SMD, -0.34 (-0.61, -0.08); cardioembolic SMD -0.38 (-0.62, -0.14)], with insufficient data chronically. Markers of inflammation (C-reactive protein (CRP), tumour necrosis factor-alpha (TNF-α), interleukin-6 (IL-6)) were higher in lacunar stroke versus non-stroke, although there were no studies measuring TNF-α chronically and the sole study measuring IL-6 chronically showed no difference between lacunar stroke and non-stroke. Compared to other ischaemic stroke subtypes, there was no difference (CRP) or insufficient or conflicting data (TNF-α) to lacunar stroke. IL-6 was significantly lower [atherothrombotic SMD -0.37 (-0.63, -0.10); cardioembolic SMD -0.52 (-0.82, -0.22)] in lacunar stroke acutely, with insufficient data chronically. Lacunar stroke is an important stroke subtype. More studies comparing lacunar stroke to non-lacunar stroke specifically, rather than to non-stroke controls, are needed. Prospective studies with measurements taken well after the acute event are more likely to be helpful in determining pathogenesis. The available data in this review were limited and do not exclude the possibility that peripheral inflammatory processes including endothelial dysfunction are associated with lacunar stroke and cerebral small vessel disease. © 2013 S. Karger AG, Basel

A population-based study of disability and institutionalisation after TIA and stroke: 10-year results of the Oxford Vascular Study

PubMed Central

Luengo-Fernandez, Ramon; Paul, Nicola L.M.; Gray, Alastair M.; Pendlebury, Sarah T.; Bull, Linda M.; Welch, Sarah J.V.; Cuthbertson, Fiona C.; Rothwell, Peter M.

2016-01-01

Background and Purpose Long-term outcome information after TIA and stroke is required to help plan and allocate care services. We evaluated the impact of TIA and stroke on disability and institutionalisation over 5 years using data from a population-based study. Methods Patients from a UK population-based cohort study (Oxford Vascular Study) were recruited from 2002 to 2007, and followed-up to 2012. Patients were followed-up at 1, 6, 12, 24 and 60 months post-event and assessed using the modified Rankin Scale (mRS). A multivariate regression analysis was performed to assess the predictors of disability post-event. Results 748 index stroke and 440 TIA cases were studied. For TIA patients, disability levels increased from 14% (63/440) pre-morbidly to 23% (60/256) at 5 years (p=0.002), with occurrence of subsequent stroke being a major predictor of disability. For stroke survivors, the proportion disabled (mRS>2) increased from 21% (154/748) pre-morbidly to 43% (273/634) at 1-month (p<0.001), with 39% (132/339) of survivors disabled 5 years post-stroke. 5 years post-event, 70% (483/690) of stroke patients and 48% (179/375) of TIA patients were either dead or disabled. The 5-year risk of care home institutionalisation was 11% after TIA and 19% after stroke. The average 5-year cost per institutionalised TIA patient was $99,831 (S.D. 67,020) and $125,359 (S.D. 91,121) for stroke patients. Conclusions Our results show that 70% of stroke patients are either dead or disabled 5 years after the event. There therefore remains considerable scope for improvements in acute treatment and secondary prevention to reduce post-event disability and institutionalisation. PMID:23920019

Prevention of Stroke in Patients With Silent Cerebrovascular Disease: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association.

PubMed

Smith, Eric E; Saposnik, Gustavo; Biessels, Geert Jan; Doubal, Fergus N; Fornage, Myriam; Gorelick, Philip B; Greenberg, Steven M; Higashida, Randall T; Kasner, Scott E; Seshadri, Sudha

2017-02-01

Two decades of epidemiological research shows that silent cerebrovascular disease is common and is associated with future risk for stroke and dementia. It is the most common incidental finding on brain scans. To summarize evidence on the diagnosis and management of silent cerebrovascular disease to prevent stroke, the Stroke Council of the American Heart Association convened a writing committee to evaluate existing evidence, to discuss clinical considerations, and to offer suggestions for future research on stroke prevention in patients with 3 cardinal manifestations of silent cerebrovascular disease: silent brain infarcts, magnetic resonance imaging white matter hyperintensities of presumed vascular origin, and cerebral microbleeds. The writing committee found strong evidence that silent cerebrovascular disease is a common problem of aging and that silent brain infarcts and white matter hyperintensities are associated with future symptomatic stroke risk independently of other vascular risk factors. In patients with cerebral microbleeds, there was evidence of a modestly increased risk of symptomatic intracranial hemorrhage in patients treated with thrombolysis for acute ischemic stroke but little prospective evidence on the risk of symptomatic hemorrhage in patients on anticoagulation. There were no randomized controlled trials targeted specifically to participants with silent cerebrovascular disease to prevent stroke. Primary stroke prevention is indicated in patients with silent brain infarcts, white matter hyperintensities, or microbleeds. Adoption of standard terms and definitions for silent cerebrovascular disease, as provided by prior American Heart Association/American Stroke Association statements and by a consensus group, may facilitate diagnosis and communication of findings from radiologists to clinicians. © 2016 American Heart Association, Inc.

Estimating the long-term costs of ischemic and hemorrhagic stroke for Australia: new evidence derived from the North East Melbourne Stroke Incidence Study (NEMESIS).

PubMed

Cadilhac, Dominique A; Carter, Rob; Thrift, Amanda G; Dewey, Helen M

2009-03-01

Stroke is associated with considerable societal costs. Cost-of-illness studies have been undertaken to estimate lifetime costs; most incorporating data up to 12 months after stroke. Costs of stroke, incorporating data collected up to 12 months, have previously been reported from the North East Melbourne Stroke Incidence Study (NEMESIS). NEMESIS now has patient-level resource use data for 5 years. We aimed to recalculate the long-term resource utilization of first-ever stroke patients and compare these to previous estimates obtained using data collected to 12 months. Population structure, life expectancy, and unit prices within the original cost-of-illness models were updated from 1997 to 2004. New Australian stroke survival and recurrence data up to 10 years were incorporated, as well as cross-sectional resource utilization data at 3, 4, and 5 years from NEMESIS. To enable comparisons, 1997 costs were inflated to 2004 prices and discounting was standardized. In 2004, 27 291 ischemic stroke (IS) and 4291 intracerebral hemorrhagic stroke (ICH) first-ever events were estimated. Average annual resource use after 12 months was AU$6022 for IS and AU$3977 for ICH. This is greater than the 1997 estimates for IS (AU$4848) and less than those for ICH (previously AU$10 692). The recalculated average lifetime costs per first-ever case differed for IS (AU$57 106 versus AU$52 855 [1997]), but differed more for ICH (AU$49 995 versus AU$92 308 [1997]). Basing lifetime cost estimates on short-term data overestimated the costs for ICH and underestimated those for IS. Patterns of resource use varied by stroke subtype and, overall, the societal cost impact was large.

Active drag, useful mechanical power output and hydrodynamic force coefficient in different swimming strokes at maximal velocity.

PubMed

Kolmogorov, S V; Duplishcheva, O A

1992-03-01

By comparing the time of the same distance swum with and without an added resistance, under the assumption of an equal power output in both cases, the drag of 73 top swimmers was estimated. The active drag Fr(a.d.) at maximal swimming velocities varied considerably across strokes and individuals. In the females Fr(a.d.) ranged from 69.78 to 31.16 N in the front-crawl, from 83.04 to 37.78 N in dolphin, from 93.56 to 45.19 N in breaststroke, and from 65.51 to 37.79 N in back-stroke. In the males Fr(a.d.) ranged from 167.11 to 42.23 N in front-crawl, from 156.09 to 46.95 N in dolphin, from 176.87 to 55.61 N in breaststroke, and from 146.28 to 46.36 N in back-stroke. Also, the ratio of Fr(a.d.) to the passive drag Fr(a.d.) as determined for the analogical velocity in a tugging condition (in standard body position-front gliding) shows considerable individual variations. In the female swimmers variations in Fr(a.d.)/Fr(p.d.) ranged from 145.17 to 59.94% in front-crawl, from 192.39 to 85.57% in dolphin, from 298.03 to 124.50% in breaststroke, and from 162.87 to 85.61% in back-stroke. In the male swimmers variations in Fr(a.d.)/Fr(p.d.) ranged from 162.24 to 62.39% in front-crawl, from 191.70 to 70.38% in dolphin, from 295.57 to 102.83% in breaststroke, and from 198.82 to 74.48% in back-stroke. The main reason for such variations is found in the individual features of swimming technique and can be quantitatively estimated with the hydrodynamic force coefficient, which thus provides an adequate index of technique.

Performance Factors Related to the Different Tennis Backhand Groundstrokes: A Review

PubMed Central

Genevois, Cyril; Reid, Machar; Rogowski, Isabelle; Crespo, Miguel

2015-01-01

The backhand is one of the two basic groundstrokes in tennis and can be played both with one or two hands, with topspin or backspin. Despite its variety of derivatives, the scientific literature describing the backhand groundstroke production has not been reviewed as extensively as with the serve and the forehand. The purpose of this article is to review the research describing the mechanics of one and two-handed backhands, with a critical focus on its application to clinicians and coaches. One hundred and thirty four articles satisfied a key word search (tennis, backhand) in relevant databases and manual search, with only 61 of those articles considered directly relevant to our review. The consensus of this research supports major differences between both the one- and two-handed strokes, chiefly about their respective contributions of trunk rotation and the role of the non-dominant upper extremity. Two-handed backhand strokes rely more on trunk rotation for the generation of racquet velocity, while the one-handed backhands utilize segmental rotations of the upper limb to develop comparable racquet speeds. There remains considerable scope for future research to examine expertise, age and/or gender-related kinematic differences to strengthen the practitioner’s understanding of the key mechanical considerations that may shape the development of proficient backhand strokes. Key points One-and two-handed backhands require different motor coordination Two-handed backhand strokes rely more on trunk rotation for racquet velocity generation, whereas one-handed backhand strokes rely more on segmental rotations of the upper limb Players using a two-handed backhand should learn early a slice one-handed backhand because of the different co-ordination pattern involved Equipment scaling is a great tool for coaches to learn early proper one-handed backhand strokes Future research related to the interaction between backhand technique, gender and skill level is needed PMID:25729308

Trying to understand routine stroke outcome data: the need for adequate casemix adjustment and some practical considerations.

PubMed

Weir, N U; Signorini, D F; Dennis, M S; Murdoch, P S

2000-07-01

To determine how far the difference in published stroke case fatality between the Western General Hospital (WGH), Edinburgh and the Falkirk and District Royal Infirmary (FDRI) for the period 1990-93 can be explained by adjusting more fully for casemix. The cases were ascertained and followed prospectively at the WGH and retrospectively at the FDRI; casemix correction was performed using a validated logistic regression model. The WGH is a teaching hospital and the FDRI a district general hospital. Four hundred and thirty seven patients with a verified acute stroke at the WGH; 471 patients assigned a cerebrovascular disease discharge diagnostic code at the FDRI. Thirty day case fatality. About half of the difference in the two hospitals' published stroke case fatality could be accounted for by variation in measured casemix. The residual difference in adjusted case fatality might have been due to differences in the structure of stroke care or simply to remaining differences in casemix. Full investigation of the cause was prevented by the destruction of the deceased patients records. Comparisons of routinely collected stroke outcomes will remain difficult to interpret unless casemix is properly accounted for and deceased patients' records stored for several years.

Considerations for the Optimization of Induced White Matter Injury Preclinical Models

PubMed Central

Ahmad, Abdullah Shafique; Satriotomo, Irawan; Fazal, Jawad; Nadeau, Stephen E.; Doré, Sylvain

2015-01-01

White matter (WM) injury in relation to acute neurologic conditions, especially stroke, has remained obscure until recently. Current advances in imaging technologies in the field of stroke have confirmed that WM injury plays an important role in the prognosis of stroke and suggest that WM protection is essential for functional recovery and post-stroke rehabilitation. However, due to the lack of a reproducible animal model of WM injury, the pathophysiology and mechanisms of this injury are not well studied. Moreover, producing selective WM injury in animals, especially in rodents, has proven to be challenging. Problems associated with inducing selective WM ischemic injury in the rodent derive from differences in the architecture of the brain, most particularly, the ratio of WM to gray matter in rodents compared to humans, the agents used to induce the injury, and the location of the injury. Aging, gender differences, and comorbidities further add to this complexity. This review provides a brief account of the techniques commonly used to induce general WM injury in animal models (stroke and non-stroke related) and highlights relevance, optimization issues, and translational potentials associated with this particular form of injury. PMID:26322013

The pathophysiology of post-stroke aphasia: A network approach.

PubMed

Thiel, Alexander; Zumbansen, Anna

2016-06-13

Post-stroke aphasia syndromes as a clinical entity arise from the disruption of brain networks specialized in language production and comprehension due to permanent focal ischemia. This approach to post-stroke aphasia is based on two pathophysiological concepts: 1) Understanding language processing in terms of distributed networks rather than language centers and 2) understanding the molecular pathophysiology of ischemic brain injury as a dynamic process beyond the direct destruction of network centers and their connections. While considerable progress has been made in the past 10 years to develop such models on a systems as well as a molecular level, the influence of these approaches on understanding and treating clinical aphasia syndromes has been limited. In this article, we review current pathophysiological concepts of ischemic brain injury, their relationship to altered information processing in language networks after ischemic stroke and how these mechanisms may be influenced therapeutically to improve treatment of post-stroke aphasia. Understanding the pathophysiological mechanism of post-stroke aphasia on a neurophysiological systems level as well as on the molecular level becomes more and more important for aphasia treatment, as the field moves from standardized therapies towards more targeted individualized treatment strategies comprising behavioural therapies as well as non-invasive brain stimulation (NIBS).

Methodology for a Community Based Stroke Preparedness Intervention: The ASPIRE Study

PubMed Central

Boden-Albala, Bernadette; Edwards, Dorothy F.; Clair, Shauna St; Wing, Jeffrey J; Fernandez, Stephen; Gibbons, Chris; Hsia, Amie W.; Morgenstern, Lewis B.; Kidwell, Chelsea S.

2014-01-01

Background and Purpose Acute stroke education has focused on stroke symptom recognition. Lack of education about stroke preparedness and appropriate actions may prevent people from seeking immediate care. Few interventions have rigorously evaluated preparedness strategies in multiethnic community settings. Methods The Acute Stroke Program of Interventions Addressing Racial and Ethnic Disparities (ASPIRE) project is a multi-level program utilizing a community engaged approach to stroke preparedness targeted to underserved black communities in the District of Columbia (DC). This intervention aimed to decrease acute stroke presentation times and increase intravenous tissue plasminogen activator (IV tPA) utilization for acute ischemic stroke. Results Phase 1 included: 1) enhancement of EMS focus on acute stroke; 2) hospital collaborations to implement and/or enrich acute stroke protocols and transition DC hospitals toward Primary Stroke Center certification; and 3) pre-intervention acute stroke patient data collection in all 7 acute care DC hospitals. A community advisory committee, focus groups, and surveys identified perceptions of barriers to emergency stroke care. Phase 2 included a pilot intervention and subsequent citywide intervention rollout. A total of 531 community interventions were conducted with over 10,256 participants reached; 3289 intervention evaluations were performed, and 19,000 preparedness bracelets and 14,000 stroke warning magnets were distributed. Phase 3 included an evaluation of EMS and hospital processes for acute stroke care and a yearlong post-intervention acute stroke data collection period to assess changes in IV tPA utilization. Conclusions We report the methods, feasibility, and pre-intervention data collection efforts of the ASPIRE intervention. PMID:24876243

Early Diagnosis of Pneumonia in Severe Stroke: Clinical Features and the Diagnostic Role of C-Reactive Protein.

PubMed

Warusevitane, Anushka; Karunatilake, Dumin; Sim, Julius; Smith, Craig; Roffe, Christine

2016-01-01

Accurate diagnosis of pneumonia complicating severe stroke is challenging due to difficulties in physical examination, altered immune responses and delayed manifestations of radiological changes. The aims of this study were to describe early clinical features and to examine C-reactive protein (CRP) as a diagnostic marker of post-stroke pneumonia. Patients who required nasogastric feeding and had no evidence of pneumonia within 7 days of stroke onset were included in the study and followed-up for 21 days with a daily clinical examination. Pneumonia was diagnosed using modified British Thoracic Society criteria. 60 patients were recruited (mean age 77 years, mean National Institutes of Health Stroke Scale Score 19.47). Forty-four episodes of pneumonia were identified. Common manifestations on the day of the diagnosis were new onset crackles (43/44, 98%), tachypnoea>25/min (42/44, 95%), and oxygen saturation <90% (41/44, 93%). Cough, purulent sputum, and pyrexia >38°C were observed in 27 (61%), 25 (57%) and 15 (34%) episodes respectively. Leucocytosis (WBC>11,000/ml) and raised CRP (>10 mg/l) were observed in 38 (86%) and 43 (97%) cases of pneumonia respectively. The area under the ROC curve for CRP was 0.827 (95% CI 0.720, 0.933). The diagnostic cut-off for CRP with an acceptable sensitivity (>0.8) was 25.60 mg/L (Youden index (J) 0.515; sensitivity 0.848; specificity 0.667). A cut-off of 64.65 mg/L had the highest diagnostic accuracy (J 0.562; sensitivity 0.636; specificity 0.926). Patients with severe stroke frequently do not manifest key diagnostic features of pneumonia such as pyrexia, cough and purulent sputum early in their illness. The most common signs in this group are new-onset crackles, tachypnoea and hypoxia. Our results suggest that a CRP >25 mg/L should prompt investigations for pneumonia while values >65 mg/L have the highest diagnostic accuracy to justify consideration of this threshold as a diagnostic marker of post-stroke pneumonia.

Current understanding of the relationship between cervical manipulation and stroke: what does it mean for the chiropractic profession?

PubMed Central

2010-01-01

The understanding of the relationship between cervical manipulative therapy (CMT) and vertebral artery dissection and stroke (VADS) has evolved considerably over the years. In the beginning the relationship was seen as simple cause-effect, in which CMT was seen to cause VADS in certain susceptible individuals. This was perceived as extremely rare by chiropractic physicians, but as far more common by neurologists and others. Recent evidence has clarified the relationship considerably, and suggests that the relationship is not causal, but that patients with VADS often have initial symptoms which cause them to seek care from a chiropractic physician and have a stroke some time after, independent of the chiropractic visit. This new understanding has shifted the focus for the chiropractic physician from one of attempting to "screen" for "risk of complication to manipulation" to one of recognizing the patient who may be having VADS so that early diagnosis and intervention can be pursued. In addition, this new understanding presents the chiropractic profession with an opportunity to change the conversation about CMT and VADS by taking a proactive, public health approach to this uncommon but potentially devastating disorder. PMID:20682039

Mitochondrial Encephalomyopathy With Lactic Acidosis and Stroke-Like Episodes—MELAS Syndrome

PubMed Central

Henry, Caitlin; Patel, Neema; Shaffer, William; Murphy, Lillian; Park, Joe

2017-01-01

Background: Mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes (MELAS) syndrome is a rare inherited disorder that results in waxing and waning nervous system and muscle dysfunction. MELAS syndrome may overlap with other neurologic disorders but shows distinctive imaging features. Case Report: We present the case of a 28-year-old female with atypical stroke-like symptoms, a strong family history of stroke-like symptoms, and a relapsing-remitting course for several years. We discuss the imaging features distinctive to the case, the mechanism of the disease, typical presentation, imaging diagnosis, and disease management. Conclusion: This case is a classic example of the relapse-remitting MELAS syndrome progression with episodic clinical flares and fluctuating patterns of stroke-like lesions on imaging. MELAS is an important diagnostic consideration when neuroimaging reveals a pattern of disappearing and relapsing cortical brain lesions that may occur in different areas of the brain and are not necessarily limited to discrete vascular territories. Future studies should investigate disease mechanisms at the cellular level and the value of advanced magnetic resonance imaging techniques for a targeted approach to therapy. PMID:29026367

Mitochondrial Encephalomyopathy With Lactic Acidosis and Stroke-Like Episodes-MELAS Syndrome.

PubMed

Henry, Caitlin; Patel, Neema; Shaffer, William; Murphy, Lillian; Park, Joe; Spieler, Bradley

2017-01-01

Mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes (MELAS) syndrome is a rare inherited disorder that results in waxing and waning nervous system and muscle dysfunction. MELAS syndrome may overlap with other neurologic disorders but shows distinctive imaging features. We present the case of a 28-year-old female with atypical stroke-like symptoms, a strong family history of stroke-like symptoms, and a relapsing-remitting course for several years. We discuss the imaging features distinctive to the case, the mechanism of the disease, typical presentation, imaging diagnosis, and disease management. This case is a classic example of the relapse-remitting MELAS syndrome progression with episodic clinical flares and fluctuating patterns of stroke-like lesions on imaging. MELAS is an important diagnostic consideration when neuroimaging reveals a pattern of disappearing and relapsing cortical brain lesions that may occur in different areas of the brain and are not necessarily limited to discrete vascular territories. Future studies should investigate disease mechanisms at the cellular level and the value of advanced magnetic resonance imaging techniques for a targeted approach to therapy.

Impact of light rail transit on traffic-related pollution and stroke mortality.

PubMed

Park, Eun Sug; Sener, Ipek Nese

2017-09-01

This paper evaluates the changes in vehicle exhaust and stroke mortality for the general public residing in the surrounding area of the light rail transit (LRT) in Houston, Texas, after its opening. The number of daily deaths due to stroke for 2002-2005 from the surrounding area of the original LRT line (exposure group) and the control groups was analyzed using an interrupted time-series analysis. Ambient concentrations of acetylene before and after the opening of LRT were also compared. A statistically significant reduction in the average concentration of acetylene was observed for the exposure sites whereas the reduction was negligible at the control site. Poisson regression models applied to the stroke mortality data indicated a significant reduction in daily stroke mortality after the opening of LRT for the exposure group, while there was either an increase or a considerably smaller reduction for the control groups. The findings support the idea that LRT systems provide health benefits for the general public and that the reduction in motor-vehicle-related air pollution may have contributed to these health benefits.

Do lacunar strokes benefit from thrombolysis? Evidence from the Registry of the Canadian Stroke Network.

PubMed

Shobha, Nandavar; Fang, Jiming; Hill, Michael D

2013-10-01

Lacunar infarcts constitute up to 25% of all ischaemic strokes. As acute intracranial vascular imaging has become widely available with computed tomographic angiography, thrombolysis of lacunar strokes has become contentious because an intracranial vascular lesion cannot be visualized. We studied the effect of thrombolysis on lacunar strokes compared to other clinical ischaemic stroke sub-types. Ischaemic stroke patients from phase 3 of the Registry of the Canadian Stroke Network data (July 2003-March 2008) were included. Lacunar stroke was defined as a lacunar syndrome supported by computed tomography brain showing a subcortical hypodense lesion with a diameter <20 mm. Clinical syndromes were used to define other stroke sub-types. The outcomes were mortality at 90 days, modified Rankin Scale score 0-2 at discharge, occurrence of intracranial haemorrhage as a complication of stroke in-hospital, and discharge disposition to home. A total of 11,503 patients of ischaemic stroke were included from the Registry of the Canadian Stroke Network 3 between July 2003 and March 2008. Lacunar strokes formed 19.1% of the total strokes. The total number of patients who received tissue plasminogen activator was 1630 (14.2%). A significant association was found between tissue plasminogen activator treatment and outcomes after controlling Oxfordshire Community Stroke Project types--for modified Rankin Scale at discharge and discharge to home, but not for mortality. A thrombolysis-by-Oxfordshire Community Stroke Project stroke sub-type interaction was observed due to lack of benefit among the posterior circulation stroke sub-types. Patients with lacunar strokes, partial anterior circulation stroke, and total anterior circulation strokes all benefited approximately equally from thrombolysis. Thrombolysis is associated with clinically improved outcome among patients with lacunar stroke syndromes. © 2012 The Authors. International Journal of Stroke © 2012 World Stroke Organization.

Shaping innovations in long-term care for stroke survivors with multimorbidity through stakeholder engagement.

PubMed

Sadler, Euan; Porat, Talya; Marshall, Iain; Hoang, Uy; Curcin, Vasa; Wolfe, Charles D A; McKevitt, Christopher

2017-01-01

Stroke, like many long-term conditions, tends to be managed in isolation of its associated risk factors and multimorbidity. With increasing access to clinical and research data there is the potential to combine data from a variety of sources to inform interventions to improve healthcare. A 'Learning Health System' (LHS) is an innovative model of care which transforms integrated data into knowledge to improve healthcare. The objective of this study is to develop a process of engaging stakeholders in the use of clinical and research data to co-produce potential solutions, informed by a LHS, to improve long-term care for stroke survivors with multimorbidity. We used a stakeholder engagement study design informed by co-production principles to engage stakeholders, including service users, carers, general practitioners and other health and social care professionals, service managers, commissioners of services, policy makers, third sector representatives and researchers. Over a 10 month period we used a range of methods including stakeholder group meetings, focus groups, nominal group techniques (priority setting and consensus building) and interviews. Qualitative data were recorded, transcribed and analysed thematically. 37 participants took part in the study. The concept of how data might drive intervention development was difficult to convey and understand. The engagement process led to four priority areas for needs for data and information being identified by stakeholders: 1) improving continuity of care; 2) improving management of mental health consequences; 3) better access to health and social care; and 4) targeting multiple risk factors. These priorities informed preliminary design interventions. The final choice of intervention was agreed by consensus, informed by consideration of the gap in evidence and local service provision, and availability of robust data. This shaped a co-produced decision support tool to improve secondary prevention after stroke for further development. Stakeholder engagement to identify data-driven solutions is feasible but requires resources. While a number of potential interventions were identified, the final choice rested not just on stakeholder priorities but also on data availability. Further work is required to evaluate the impact and implementation of data-driven interventions for long-term stroke survivors.

Shaping innovations in long-term care for stroke survivors with multimorbidity through stakeholder engagement

PubMed Central

Porat, Talya; Marshall, Iain; Hoang, Uy; Curcin, Vasa; Wolfe, Charles D. A.; McKevitt, Christopher

2017-01-01

Background Stroke, like many long-term conditions, tends to be managed in isolation of its associated risk factors and multimorbidity. With increasing access to clinical and research data there is the potential to combine data from a variety of sources to inform interventions to improve healthcare. A ‘Learning Health System’ (LHS) is an innovative model of care which transforms integrated data into knowledge to improve healthcare. The objective of this study is to develop a process of engaging stakeholders in the use of clinical and research data to co-produce potential solutions, informed by a LHS, to improve long-term care for stroke survivors with multimorbidity. Methods We used a stakeholder engagement study design informed by co-production principles to engage stakeholders, including service users, carers, general practitioners and other health and social care professionals, service managers, commissioners of services, policy makers, third sector representatives and researchers. Over a 10 month period we used a range of methods including stakeholder group meetings, focus groups, nominal group techniques (priority setting and consensus building) and interviews. Qualitative data were recorded, transcribed and analysed thematically. Results 37 participants took part in the study. The concept of how data might drive intervention development was difficult to convey and understand. The engagement process led to four priority areas for needs for data and information being identified by stakeholders: 1) improving continuity of care; 2) improving management of mental health consequences; 3) better access to health and social care; and 4) targeting multiple risk factors. These priorities informed preliminary design interventions. The final choice of intervention was agreed by consensus, informed by consideration of the gap in evidence and local service provision, and availability of robust data. This shaped a co-produced decision support tool to improve secondary prevention after stroke for further development. Conclusions Stakeholder engagement to identify data-driven solutions is feasible but requires resources. While a number of potential interventions were identified, the final choice rested not just on stakeholder priorities but also on data availability. Further work is required to evaluate the impact and implementation of data-driven interventions for long-term stroke survivors. PMID:28475606

Design Considerations of Polishing Lap for Computer-Controlled Cylindrical Polishing Process

NASA Technical Reports Server (NTRS)

Khan, Gufran S.; Gubarev, Mikhail; Arnold, William; Ramsey, Brian D.

2009-01-01

This paper establishes a relationship between the polishing process parameters and the generation of mid spatial-frequency error. The consideration of the polishing lap design to optimize the process in order to keep residual errors to a minimum and optimization of the process (speeds, stroke, etc.) and to keep the residual mid spatial-frequency error to a minimum, is also presented.

The FAST-ED App: A Smartphone Platform for the Field Triage of Patients With Stroke.

PubMed

Nogueira, Raul G; Silva, Gisele S; Lima, Fabricio O; Yeh, Yu-Chih; Fleming, Carol; Branco, Daniel; Yancey, Arthur H; Ratcliff, Jonathan J; Wages, Robert Keith; Doss, Earnest; Bouslama, Mehdi; Grossberg, Jonathan A; Haussen, Diogo C; Sakano, Teppei; Frankel, Michael R

2017-05-01

The Emergency Medical Services field triage to stroke centers has gained considerable complexity with the recent demonstration of clinical benefit of endovascular treatment for acute ischemic stroke. We sought to describe a new smartphone freeware application designed to assist Emergency Medical Services professionals with the field assessment and destination triage of patients with acute ischemic stroke. Review of the application's platform and its development as well as the different variables, assessments, algorithms, and assumptions involved. The FAST-ED (Field Assessment Stroke Triage for Emergency Destination) application is based on a built-in automated decision-making algorithm that relies on (1) a brief series of questions assessing patient's age, anticoagulant usage, time last known normal, motor weakness, gaze deviation, aphasia, and hemineglect; (2) a database of all regional stroke centers according to their capability to provide endovascular treatment; and (3) Global Positioning System technology with real-time traffic information to compute the patient's eligibility for intravenous tissue-type plasminogen activator or endovascular treatment as well as the distances/transportation times to the different neighboring stroke centers in order to assist Emergency Medical Services professionals with the decision about the most suitable destination for any given patient with acute ischemic stroke. The FAST-ED smartphone application has great potential to improve the triage of patients with acute ischemic stroke, as it seems capable to optimize resources, reduce hospital arrivals times, and maximize the use of both intravenous tissue-type plasminogen activator and endovascular treatment ultimately leading to better clinical outcomes. Future field studies are needed to properly evaluate the impact of this tool in stroke outcomes and resource utilization. © 2017 American Heart Association, Inc.

The unfortunate generation: stroke survivors in Riga, Latvia.

PubMed

McKevitt, Christopher; Luse, Agita; Wolfe, Charles

2003-05-01

The poor health status of citizens in post-Soviet states has been reported but few studies have investigated the illness experiences of people in those countries. This paper reports findings from an interview study conducted with stroke patients in Riga, Latvia, who were part of a cohort recruited over 1 year for a European study comparing the provision of care, outcomes and resource use. The interview study aimed to elicit stroke patients' own perceptions of the impact of stroke 1 year after the event. Adopting a phenomenological perspective we illustrate how the particular social setting shapes stroke as an illness, its influences on access to health care and on consideration of the impact of stroke. We argue that for stroke survivors and their relatives in post-Soviet Latvia this disorder acquires a meaning that transcends the individual biography and signifies an upheaval of social life in general. The meanings attributed to stroke by interviewees are developed in the context of the momentous recent historical events which participants lived through. In this sense, stroke has become an idiom of a disruption in social biography rather than individual biography alone. Most participants were pensioners and their main concern was their own poverty. Some complained of their inability to meet their basic needs, much less pay for on-going medication and therapy. Only one person was 'severely disabled', using a standard neurological definition, but about half of those interviewed regarded the stroke as a sign foretelling their own death. Although this generation had expected to be cared for in their older age under the Soviet regime, the much longed for Latvian independence was seen to have brought unexpected hardships for those who were old and sick.

The costs of stroke in Spain by aetiology: the CONOCES study protocol.

PubMed

Mar, J; Álvarez-Sabín, J; Oliva, J; Becerra, V; Casado, M Á; Yébenes, M; González-Rojas, N; Arenillas, J F; Martínez-Zabaleta, M T; Rebollo, M; Lago, A; Segura, T; Castillo, J; Gállego, J; Jiménez-Martínez, C; López-Gastón, J I; Moniche, F; Casado-Naranjo, I; López-Fernández, J C; González-Rodríguez, C; Escribano, B; Masjuan, J

2013-01-01

Patients with stroke associated with non-valvular atrial fibrillation (NVAF) are a specific group, and their disease has a considerable social and economic impact. The primary objective of the CONOCES study, the protocol of which is presented here, is to compare the costs of stroke in NVAF patients to those of patients without NVAF in Spanish stroke units from a societal perspective. CONOCES is an epidemiological, observational, naturalistic, prospective, multicentre study of the cost of the illness in a sample of patients who have suffered a stroke and were admitted to a Spanish stroke unit. During a 12-month follow-up period, we record sociodemographic and clinical variables, score on the NIH stroke scale, level of disability, degree of functional dependency according to the modified Rankin scale, and use of healthcare resources (hospitalisation at the time of the first episode, readmissions, outpatient rehabilitation, orthotic and/or prosthetic material, medication for secondary prevention, medical check-ups, nursing care and formal social care services). Estimated monthly income, lost work productivity and health-related quality of life measured with the generic EQ-5D questionnaire are also recorded. We also administer a direct interview to the caregiver to determine loss of productivity, informal care, and caregiver burden. The CONOCES study will provide more in-depth information about the economic and clinical impact of stroke according to whether or not it is associated with NVAF. Copyright © 2012 Sociedad Española de Neurología. Published by Elsevier Espana. All rights reserved.

Determinants of quality of life in stroke survivors and their informal caregivers.

PubMed

Jönsson, Ann-Cathrin; Lindgren, Ingrid; Hallström, Björn; Norrving, Bo; Lindgren, Arne

2005-04-01

We examined longitudinal changes of quality of life (QOL) covering physical and mental factors in an unselected group of stroke patients and their informal caregivers. Our hypothesis was that informal caregivers would have better QOL than patients at both follow-ups, and that changes, if any, would be related to the patients' status. QOL of 304 consecutive stroke patients and their 234 informal caregivers from the population-based Lund Stroke Register was assessed 4 months after stroke onset with the Short Form 36 (SF-36) questionnaire. SF-36 was repeated for both groups after 16 months together with Mini Mental State Examination (MMSE) and Geriatric Depression Scale (GDS-20) for patients. The patients' mean QOL scores improved between 4 and 16 months after stroke in the socio-emotional and mental SF-36 domains and decreased in the domain physical function. Multivariate analyses showed that the patients' most important determinants of QOL after 16 months were GDS-20 score, functional status, age, and gender. Informal caregivers had better QOL than patients except for the domain role emotional and the mental component summary. The caregivers' most important determinants of QOL were their own age and the patients' functional status. Our study highlights depressive symptoms in determining QOL of stroke patients. Despite self-perceived deterioration in physical function over time, several other components of QOL improved, suggesting internal adaptation to changes in their life situations. Informal caregivers of stroke patients may be under considerable strain as suggested by their lower emotional-mental scores.

Diabetes mellitus and stroke: A clinical update

PubMed Central

Tun, Nyo Nyo; Arunagirinathan, Ganesan; Munshi, Sunil K; Pappachan, Joseph M

2017-01-01

Cardiovascular disease including stroke is a major complication that tremendously increases the morbidity and mortality in patients with diabetes mellitus (DM). DM poses about four times higher risk for stroke. Cardiometabolic risk factors including obesity, hypertension, and dyslipidaemia often co-exist in patients with DM that add on to stroke risk. Because of the strong association between DM and other stroke risk factors, physicians and diabetologists managing patients should have thorough understanding of these risk factors and management. This review is an evidence-based approach to the epidemiological aspects, pathophysiology, diagnostic work up and management algorithms for patients with diabetes and stroke. PMID:28694925

Factors associated with community reintegration in the first year after stroke: a qualitative meta-synthesis.

PubMed

Walsh, Mary E; Galvin, Rose; Loughnane, Cliona; Macey, Chris; Horgan, N Frances

2015-01-01

Although acute stroke care has improved survival, many individuals report dissatisfaction with community reintegration after stroke. The aim of this qualitative meta-synthesis was to examine the barriers and facilitators of community reintegration in the first year after stroke from the perspective of people with stroke. A systematic literature search was conducted. Papers that used qualitative methods to explore the experiences of individuals with stroke around community reintegration in the first year after stroke were included. Two reviewers independently assessed the methodological quality of papers. Themes, concepts and interpretations were extracted from each study, compared and meta-synthesised. From the 18 included qualitative studies four themes related to community reintegration in the first year after stroke were identified: (i) the primary effects of stroke, (ii) personal factors, (iii) social factors and (iv) relationships with professionals. This review suggests that an individual's perseverance, adaptability and ability to overcome emotional challenges can facilitate reintegration into the community despite persisting effects of their stroke. Appropriate support from family, friends, the broader community and healthcare professionals is important. Therapeutic activities should relate to meaningful activities and should be tailored to the individual stroke survivor. Stroke survivors feel that rehabilitation in familiar environments and therapeutic activities that reflect real-life could help their community re-integration. In addition to the physical sequelae of stroke, emotional consequences of stroke should be addressed during rehabilitation. Healthcare professionals can provide clear and locally relevant advice to facilitate aspects of community reintegration, including the return to driving and work.

Outperforming hummingbirds' load-lifting capability with a lightweight hummingbird-like flapping-wing mechanism.

PubMed

Leys, Frederik; Reynaerts, Dominiek; Vandepitte, Dirk

2016-08-15

The stroke-cam flapping mechanism presented in this paper closely mimics the wing motion of a hovering Rufous hummingbird. It is the only lightweight hummingbird-sized flapping mechanism which generates a harmonic wing stroke with both a high flapping frequency and a large stroke amplitude. Experiments on a lightweight prototype of this stroke-cam mechanism on a 50 mm-long wing demonstrate that a harmonic stroke motion is generated with a peak-to-peak stroke amplitude of 175° at a flapping frequency of 40 Hz. It generated a mass lifting capability of 5.1 g, which is largely sufficient to lift the prototype's mass of 3.39 g and larger than the mass-lifting capability of a Rufous hummingbird. The motor mass of a hummingbird-like robot which drives the stroke-cam mechanism is considerably larger (about five times) than the muscle mass of a hummingbird with comparable load-lifting capability. This paper presents a flapping wing nano aerial vehicle which is designed to possess the same lift- and thrust-generating principles of the Rufous hummingbird. The application is indoor flight. We give an overview of the wing kinematics and some specifications which should be met to develop an artificial wing, and also describe the applications of these in the mechanism which has been developed in this work. © 2016. Published by The Company of Biologists Ltd.

Outperforming hummingbirds’ load-lifting capability with a lightweight hummingbird-like flapping-wing mechanism

PubMed Central

Reynaerts, Dominiek; Vandepitte, Dirk

2016-01-01

ABSTRACT The stroke-cam flapping mechanism presented in this paper closely mimics the wing motion of a hovering Rufous hummingbird. It is the only lightweight hummingbird-sized flapping mechanism which generates a harmonic wing stroke with both a high flapping frequency and a large stroke amplitude. Experiments on a lightweight prototype of this stroke-cam mechanism on a 50 mm-long wing demonstrate that a harmonic stroke motion is generated with a peak-to-peak stroke amplitude of 175° at a flapping frequency of 40 Hz. It generated a mass lifting capability of 5.1 g, which is largely sufficient to lift the prototype's mass of 3.39 g and larger than the mass-lifting capability of a Rufous hummingbird. The motor mass of a hummingbird-like robot which drives the stroke-cam mechanism is considerably larger (about five times) than the muscle mass of a hummingbird with comparable load-lifting capability. This paper presents a flapping wing nano aerial vehicle which is designed to possess the same lift- and thrust-generating principles of the Rufous hummingbird. The application is indoor flight. We give an overview of the wing kinematics and some specifications which should be met to develop an artificial wing, and also describe the applications of these in the mechanism which has been developed in this work. PMID:27444790

Slowdown in the decline of stroke mortality in the United States, 1978-1986.

PubMed

Cooper, R; Sempos, C; Hsieh, S C; Kovar, M G

1990-09-01

The gradual decline in stroke mortality rates observed in the United States since 1900 accelerated markedly around 1973 for whites and around 1968 for blacks. During the next decade stroke mortality rates decreased by almost 50% so that the United States now experiences one of the lowest stroke mortality rates in the world. Beginning in 1979, however the annual rate of decline in stroke mortality began to slow considerably. Comparing the period 1979-1986 with the previous decade, a 57% slowing in the absolute rate of decline (as estimated by the slope of the linear portion of the mortality curve) was observed for white men; the corresponding slowdowns in the rate of decline were 58% for white women, 44% for black men, and 62% for black women. If the decline during the 1980s had continued at the rate observed for the period 1968/73-1978, there would have been 131,000 fewer stroke deaths during the period 1979-1986, 28,000 fewer in 1986 alone. This slowdown in the rate of decline in stroke mortality is occurring while mortality rates for both coronary heart disease and all causes are leveling off. The reasons for this change in the mortality trend remain unknown, and corresponding trends in the treatment and control of hypertension do not provide an entirely satisfactory explanation.

Evaluation of heat engine for hybrid vehicle application

NASA Technical Reports Server (NTRS)

Schneider, H. W.

1984-01-01

The status of ongoing heat-engine developments, including spark-ignition, compression-ignition, internal-combustion, and external-combustion engines is presented. The potential of engine concepts under consideration for hybrid vehicle use is evaluated, using self-imposed criteria for selection. The deficiencies of the engines currently being evaluated in hybrid vehicles are discussed. Focus is on recent research with two-stroke, rotary, and free-piston engines. It is concluded that these engine concepts have the most promising potential for future application in hybrid vehicles. Recommendations are made for analysis and experimentation to evaluate stop-start and transient emission behavior of recommended engine concepts.

Nutrition and Lifestyle Intervention on Mood and Neurological Disorders

PubMed Central

Null, Gary; Pennesi, Luanne; Feldman, Martin

2016-01-01

This group study explored how an intervention of diet and lifestyle, including a vegan diet, fruit and vegetable juicing, nutritional supplements, regular exercise, and destressing techniques, would affect 27 subjects with anxiety, depression, poor memory, dementia, Alzheimer’s disease, Parkinson’s disease, history of stroke, or multiple sclerosis. Several subjects had overlapping conditions. Videotaped testimonials were obtained describing subjective results. Testimonials stated multiple benefits across all conditions addressed by the study, with subjects often reporting substantial benefits. These results demonstrate that an intervention of diet, juicing, supplements, exercise, and lifestyle may provide considerable benefits for all conditions addressed. PMID:26976087

The impact of Magnetic Resonance Imaging (MRI) on ischemic stroke detection and incidence: minimal impact within a population-based study.

PubMed

Kleindorfer, Dawn; Khoury, Jane; Alwell, Kathleen; Moomaw, Charles J; Woo, Daniel; Flaherty, Matthew L; Adeoye, Opeolu; Ferioli, Simona; Khatri, Pooja; Kissela, Brett M

2015-09-25

There are several situations in which magnetic resonance imaging (MRI) might impact whether an cerebrovascular event is considered a new stroke. These include clinically non-focal events with positive imaging for acute cerebral infarction, and worsening of older symptoms without evidence of new infarction on MRI. We sought to investigate the impact of MRI on stroke detection and stroke incidence, by describing agreement between a strictly clinical definition of stroke and a definition based on physician opinion, including MRI imaging findings. All hospitalized strokes that occurred in five Ohio and Northern Kentucky counties (population 1.3 million) in the calendar year of 2005 were identified using ICD-9 discharge codes 430-436. The two definitions used were: "clinical case definition" which included sudden onset focal neurologic symptoms referable to a vascular territory for >24 h, compared to the "best clinical judgment of the physician definition", which considers all relevant information, including neuroimaging findings. The 95% confidence intervals (CI) for the incidence rates were calculated assuming a Poisson distribution. Rates were standardized to the 2000 U.S. population, adjusting for age, race, and sex, and included all age groups. There were 2403 ischemic stroke events in 2269 patients; 1556 (64%) had MRI performed. Of the events, 2049 (83%) were cases by both definitions, 185 (7.7%) met the clinical case definition but were non-cases in the physician's opinion and 169 (7.0%) were non-cases by clinical definition but were cases in the physician's opinion. There was no significant difference in the incidence rates of first-ever or total ischemic strokes generated by the two different definitions, or when only those with MRI imaging were included. We found that MRI findings do not appear to substantially change stroke incidence estimates, as the strictly clinical definition of stroke did not significantly differ from a definition that included imaging findings. Including MRI in the case definition "rules out" almost the same number of strokes as it "rules in".

Routine echocardiography in the management of stroke and transient ischaemic attack: a systematic review and economic evaluation.

PubMed

Holmes, Michael; Rathbone, John; Littlewood, Chris; Rawdin, Andrew; Stevenson, Matt; Stevens, John; Archer, Rachel; Evans, Pippa; Wang, Jenny

2014-03-01

Identification of the underlying cause of stroke and transient ischaemic attack (TIA) is important so that preventative therapy can be used to reduce the risk of recurrence. Transthoracic echocardiography (TTE) and transoesophageal echocardiography (TOE) are diagnostic tools used to identify those cardiac sources of stroke that may respond to treatment. (1) Undertake systematic reviews to determine (a) the prevalence of cardiac sources of stroke and TIA and (b) the diagnostic accuracy of echocardiography; (2) undertake a survey to ascertain which guidelines and management strategies are used by UK stroke centres; and (3) evaluate the cost-effectiveness of the addition of TTE to the routine assessment of patients who have had a first-episode diagnosed stroke or TIA in the UK. Bibliographic databases including MEDLINE, EMBASE, the Cumulative Index to Nursing and Allied Health Literature, PsycINFO and the NHS Economic Evaluation Database were searched from inception to December 2010 (prevalence) or September 2011 (diagnostic accuracy). Bibliographies of related papers were screened and experts were contacted to identify additional published and unpublished references. The systematic reviews were undertaken according to the general principles recommended in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A decision-analytic model was developed to estimate the costs and quality-adjusted life-years accrued by each potential echocardiography strategy in the management of stroke and TIA for patients aged 45, 55 and 65 years. The model took a lifetime horizon and a NHS perspective. Costs and health benefits were discounted at an annual rate of 3.5%. Evidence to enable modelling was found for left atrial thrombus only. The cost-effectiveness of echocardiography is therefore based on all stroke patients being tested but only those with a left atrial thrombus receiving the benefits and harms of treatment. To describe current NHS stroke management practice we provided a questionnaire to the lead clinician of all stroke units in the UK. The searches identified 17,278 citations for the systematic review of the prevalence of potential cardiac sources of stroke and TIA, of which 65 studies were included. Patent foramen ovale was the most frequently reported pathology, followed by atrial septal aneurysm and mitral valve prolapse, with prevalence ranging from 0.25% to 73%, from 0.4% to 28% and from 0% to 31.6% respectively. For the systematic review of the diagnostic accuracy of echocardiography, 16,504 citations were identified, of which 51 studies were included. The pooled sensitivity to detect left atrial thrombus in three studies using transthoracic echocardiography in second harmonic imaging mode (TTEh) was 0.79 [95% credible interval (CrI) 0.47 to 0.94], with a pooled specificity of 1.00 (95% CrI 0.99 to 1.00) compared with TOE. Differences in the diagnostic accuracy of tests occurred mostly in their sensitivity to detect cardiac sources of stroke. No adverse events data were reported. Our principal economic finding is that TTEh is a cost-effective use of NHS resources compared with TOE when clinicians deem it the most appropriate test. The survey showed that the decision-making process for the management of stroke and TIA is very complex and varies considerably by site. It is clear that to accurately describe current management practice a very sophisticated questionnaire would be required. The prevalence review highlights the difficulties that clinicians face when identifying the cause of cardioembolic stroke (the limitations of the tests, the confounding comorbidities and the inherent mobility of blood clots). The diagnostic accuracy review was limited by the small number of studies reporting data or because studies included too few participants with a cardiac pathology, leaving a large degree of uncertainty about the underlying diagnostic accuracy. The economic model has limitations because of the limited data available for important parameters such as the efficacy of treatment in reducing stroke recurrence. The economic analysis indicates that, in those cases in which TTEh is deemed the most appropriate test, it is a cost-effective use of NHS resources. However, this analysis has highlighted a lack of evidence in several areas and the results of the economic evaluation should therefore be treated with caution. There is a need for further evaluation of current echocardiography technologies, the causal associations between potential risk factors and stroke and whether or not anticoagulation therapies prevent recurrent stroke. Studies attempting to establish the prevalence of cardiac sources of stroke should identify all potential risk factors, rule out those that are not relevant and grade the findings according to risk. Research is also needed to reduce the uncertainty around the estimates of the sensitivity and specificity of TTEh and TOE, singly and in combination, in detecting treatable cardiac abnormalities compared with the 'gold standard' in each pathology. The study is registered as PROSPERO no. CRD42011001353. The National Institute for Health Research Health Technology Assessment programme.

Content validation of the international classification of functioning, disability and health core set for stroke from gender perspective using a qualitative approach.

PubMed

Glässel, A; Coenen, M; Kollerits, B; Cieza, A

2014-06-01

The extended ICF Core Set for stroke is an application of the International Classification of Functioning, Disability and Health (ICF) of the World Health Organisation (WHO) with the purpose to represent the typical spectrum of functioning of persons with stroke. The objective of the study is to add evidence to the content validity of the extended ICF Core Set for stroke from persons after stroke taking into account gender perspective. A qualitative study design was conducted by using individual interviews with women and men after stroke in an in- and outpatient rehabilitation setting. The sampling followed the maximum variation strategy. Sample size was determined by saturation. Concepts from qualitative data analysis were linked to ICF categories and compared to the extended ICF Core Set for stroke. Twelve women and 12 men participated in 24 individual interviews. In total, 143 out of 166 ICF categories included in the extended ICF Core Set for stroke were confirmed (women: N.=13; men: N.=17; both genders: N.=113). Thirty-eight additional categories that are not yet included in the extended ICF Core Set for stroke were raised by women and men. This study confirms that the experience of functioning and disability after stroke shows communalities and differences for women and men. The validity of the extended ICF Core Set for stroke could be mostly confirmed, since it does not only include those areas of functioning and disability relevant to both genders but also those exclusively relevant to either women or men. Further research is needed on ICF categories not yet included in the extended ICF Core Set for stroke.

Determinants of Length of Stay in Stroke Patients: A Geriatric Rehabilitation Unit Experience

ERIC Educational Resources Information Center

Atalay, Ayce; Turhan, Nur

2009-01-01

The objective was to identify the predictors of length of stay--the impact of age, comorbidity, and stroke subtype--on the outcome of geriatric stroke patients. One hundred and seventy stroke patients (129 first-ever ischemic, 25 hemorrhagic, and 16 ischemic second strokes) were included in the study. The Oxfordshire Community Stroke Project…

Assistive technologies after stroke: self-management or fending for yourself? A focus group study

PubMed Central

2013-01-01

Background Assistive Technologies, defined as “electrical or mechanical devices designed to help people recover movement” have demonstrated clinical benefits in upper-limb stroke rehabilitation. Stroke services are becoming community-based and more reliant on self-management approaches. Assistive technologies could become important tools within self-management, however, in practice, few people currently use assistive technologies. This study investigated patients’, family caregivers and health professionals’ experiences and perceptions of stroke upper-limb rehabilitation and assistive technology use and identified the barriers and facilitators to their use in supporting stroke self-management. Methods A three-day exhibition of assistive technologies was attended by 204 patients, family caregivers/friends and health professionals. Four focus groups were conducted with people purposively sampled from exhibition attendees. They included i) people with stroke who had used assistive technologies (n = 5), ii) people with stroke who had not used assistive technologies (n = 6), iii) family caregivers (n = 5) and iv) health professionals (n = 6). The audio-taped focus groups were facilitated by a moderator and observer. All participants were asked to discuss experiences, strengths, weaknesses, barriers and facilitators to using assistive technologies. Following transcription, data were analysed using thematic analysis. Results All respondents thought assistive technologies had the potential to support self-management but that this opportunity was currently unrealised. All respondents considered assistive technologies could provide a home-based solution to the need for high intensity upper-limb rehabilitation. All stakeholders also reported significant barriers to assistive technology use, related to i) device design ii) access to assistive technology information and iii) access to assistive technology provision. The lack of and need for a coordinated system for assistive technology provision was apparent. A circular limitation of lack of evidence in clinical settings, lack of funded provision, lack of health professional knowledge about assistive technologies and confidence in prescribing them leading to lack of assistive technology service provision meant that often patients either received no assistive technologies or they and/or their family caregivers liaised directly with manufacturers without any independent expert advice. Conclusions Considerable systemic barriers to realising the potential of assistive technologies in upper-limb stroke rehabilitation were reported. Attention needs to be paid to increasing evidence of assistive technology effectiveness and develop clinical service provision. Device manufacturers, researchers, health professionals, service funders and people with stroke and family caregivers need to work creatively and collaboratively to develop new funding models, improve device design and increase knowledge and training in assistive technology use. PMID:23968362

Interaction of Lightning Electromagnetic Pulse with the Ionosphere as Inferred from Wideband Measurements and Modeling

NASA Astrophysics Data System (ADS)

Somu, Vijaya Bhaskar

Apparent ionospheric reflection heights estimated using the zero-to-zero and peak-to-peak methods to measure skywave delay relative to the groundwave were compared for 108 first and 124 subsequent strokes observed at LOG in 2009. For either metric there was a considerable decrease in average re ection height for subsequent strokes relative to first strokes. Median uncertainties in daytime re ection heights did not exceed 0.7 km. The standard errors in mean re ection heights were less than 3% of the mean value. Apparent changes in re ection height (estimated using the peak-to-peak method) within individual ashes for 54 daytime and 11 nighttime events at distances ranging from 50 km to 330 km were compared. For daytime conditions, the majority of the ashes showed a monotonic decrease in re ection height. For nighttime ashes, the monotonic decrease was found to be considerably less frequent. The apparent ionospheric re ection height tends to increase with return-stroke peak current. In order to increase the sample size for nighttime conditions, additional data for 43 nighttime flashes observed at LOG in 2014 were analyzed. The "fast-break-point" method of measuring skywave delay (McDonald et al., 1979) was additionally used. The 2014 results for return strokes are generally consistent with the 2009 results. The 2014 data were also used for estimating ionospheric re ection heights for elevated sources (6 CIDs and 3 PB pulses) using the double-skywave feature. The results were compared with re ection heights estimated for corresponding return strokes (if any), and fairly good agreement was generally found. It has been shown, using two different FDTD simulation codes, that the observed differences in re ection height cannot be explained by the difference in the frequency content of first and subsequent return-stroke currents. FDTD simulations showed that within 200 km the re ection heights estimated using the peak-to-peak method are close to the hOE parameter of the ionospheric profile for both daytime and nighttime conditions and for both first and second skywaves. The TL model was used to estimate the radial extent of elves produced by the interaction of LEMP with the ionosphere as a function of return-stroke peak current. For a peak current of 100 kA and the speed equal to one-half of the speed of light, the expected radius of elves is 157 km. Skywaves associated with 24 return strokes in 6 lightning ashes triggered at CB in 2015 and recorded at LOG (at a distance of 45 km from CB) were not found for any of the strokes recorded. In contrast, natural-lightning strokes do produce skywaves at comparable distances. One possible reason is the difference in the higher-frequency content (field waveforms for triggered lightning are more narrow than for natural lightning).

Barriers and facilitators to staying in work after stroke: insight from an online forum.

PubMed

Balasooriya-Smeekens, Chantal; Bateman, Andrew; Mant, Jonathan; De Simoni, Anna

2016-04-06

To explore barriers and facilitators to staying in work following stroke. Qualitative analysis of posts regarding staying in work following stroke using the archives of an online forum for stroke survivors. 60 stroke survivors (29 male, 23 female, 8 not stated; mean age at stroke 44 years) who have returned to work, identified using terms 'return to work' and 'back at work'. Posts from UK stroke survivors and family members on Talkstroke, the forum of the Stroke Association, between 2004 and 2011. Stroke and transient ischaemic attack (TIA) survivors reported residual impairments that for many had impact on work. Most impairments were 'invisible', including fatigue, problems with concentration, memory and personality changes. Participants described positive (eg, back at work being better than expected) and negative work experiences, including being at risk of losing the job because of stroke-related impairments. Barriers to successfully staying in work included lack of understanding of stroke--in particular invisible impairments--of survivors, employers and general practitioners (GPs), and lack of support in terms of formal adjustments, and 'feeling supported'. Stroke survivors described how they developed their own coping strategies, and how workplace and employer helped them to stay in work. Despite having been able to return to work after a stroke, people may still experience difficulties in staying in work and risking losing their job. There is a need to improve awareness, in particular of invisible stroke-related impairments, among stroke survivors, work personnel and clinicians. This might be achieved through improved assessments of residual impairments in the workplace and in general practice. Future studies should investigate the effect of unrecognised fatigue and invisible impairments on staying in work following stroke, and explore the potential role for primary care in supporting stroke survivors who have returned to employment. 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/

Rehabilitation for post-stroke cognitive impairment: an overview of recommendations arising from systematic reviews of current evidence.

PubMed

Gillespie, David C; Bowen, Audrey; Chung, Charlie S; Cockburn, Janet; Knapp, Peter; Pollock, Alex

2015-02-01

Although cognitive impairments are common following stroke, there is considerable uncertainty about the types of interventions that can reduce activity restrictions and improve quality of life. Indeed, a recent project to identify priorities for research into life after stroke determined that the top priority for patients, carers and health professionals was how to improve cognitive impairments. To provide an overview of the evidence for the effectiveness of cognitive rehabilitation for patients with stroke and to determine the main gaps in the current evidence base. Evidence was synthesised for the six Cochrane reviews relating to rehabilitation for post-stroke cognitive impairment and any subsequently published randomized controlled trials to February 2012. Data arising from 44 trials involving over 1500 patients was identified. Though there was support for the effectiveness of cognitive rehabilitation for some cognitive impairments, significant gaps were found in the current evidence base. All of the Cochrane reviews identified major limitations within the evidence they identified. There is currently insufficient research evidence, or evidence of insufficient quality, to support clear recommendations for clinical practice. Recommendations are made as to the research required to strengthen the evidence base, and so facilitate the delivery of effective interventions to individuals with cognitive impairment after stroke. © The Author(s) 2014.

Piloting a Sex-Specific, Technology-Enhanced, Active Learning Intervention for Stroke Prevention in Women.

PubMed

Dirickson, Amanda; Stutzman, Sonja E; Alberts, Mark J; Novakovic, Roberta L; Stowe, Ann M; Beal, Claudia C; Goldberg, Mark P; Olson, DaiWai M

2017-12-01

Recent studies reveal deficiencies in stroke awareness and knowledge of risk factors among women. Existing stroke education interventions may not address common and sex-specific risk factors in the population with the highest stroke-related rate of mortality. This pilot study assessed the efficacy of a technology-enhanced, sex-specific educational program ("SISTERS") for women's knowledge of stroke. This was an experimental pretest-posttest design. The sample consisted of 150 women (mean age, 55 years) with at least 1 stroke risk factor. Participants were randomized to either the intervention (n = 75) or control (n = 75) group. Data were collected at baseline and at a 2-week posttest. There was no statistically significant difference in mean knowledge score (P = .67), mean confidence score (P = .77), or mean accuracy score (P = .75) between the intervention and control groups at posttest. Regression analysis revealed that older age was associated with lower knowledge scores (P < .001) and lower confidence scores (P < .001). After controlling for age, the SISTERS program was associated with a statistically significant difference in knowledge (P < .001) and confidence (P < .001). Although no change occurred overall, after controlling for age, there was a statistically significant benefit. Older women may have less comfort with technology and require consideration for cognitive differences.

Where are aphasia theory and management “headed”?

PubMed Central

Tippett, Donna C.; Hillis, Argye E.

2017-01-01

The sequelae of post-stroke aphasia are considerable, necessitating an understanding of the functional neuroanatomy of language, cognitive processes underlying various language tasks, and the mechanisms of recovery after stroke. This knowledge is vital in providing optimal care of individuals with aphasia and counseling to their families and caregivers. The standard of care in the rehabilitation of aphasia dictates that treatment be evidence-based and person-centered. Promising techniques, such as cortical stimulation as an adjunct to behavioral therapy, are just beginning to be explored. These topics are discussed in this review. PMID:28713549

Where are aphasia theory and management "headed"?

PubMed

Tippett, Donna C; Hillis, Argye E

2017-01-01

The sequelae of post-stroke aphasia are considerable, necessitating an understanding of the functional neuroanatomy of language, cognitive processes underlying various language tasks, and the mechanisms of recovery after stroke. This knowledge is vital in providing optimal care of individuals with aphasia and counseling to their families and caregivers. The standard of care in the rehabilitation of aphasia dictates that treatment be evidence-based and person-centered. Promising techniques, such as cortical stimulation as an adjunct to behavioral therapy, are just beginning to be explored. These topics are discussed in this review.

Adult-onset of mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes (MELAS) syndrome with hypothyroidism and psychiatric disorders.

PubMed

Ge, Yu-Xing; Shang, Bo; Chen, Wen-Zhen; Lu, You; Wang, Jue

2017-03-01

Mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes (MELAS) is a clinical syndrome associated with mitochondrial disorders (MIDs). This report illustrates a case of MELAS syndrome with hypothyroidism and psychiatric disorders, which is different from the common clinical manifestations of MELAS syndrome, such as exercise intolerance, migraine-like headaches, hearing loss and seizures etc. There are considerable interests in the possibility that mitochondrial dysfunction may play a role in the pathogenesis of endocrine dysfunctions and psychiatric disorders in MELAS syndrome.

Design and implementation of observational studies to measure disease burden with a focus on stroke.

PubMed

Howard, George; Howard, Virginia J

2018-02-01

Observational epidemiological studies have the dual goals of measuring disease burden and assessing the association between exposures and outcomes. This report focuses on the first of these goals and provides an overview of design considerations of commonly used approaches, specifically community surveillance studies, cross-sectional studies, and longitudinal cohort studies. Each of these designs has strengths and weaknesses, with no study design being superior in all cases. Rather, these designs are complementary to achieve a better understanding of the burden of stroke.

Behavior Correlates of Post-Stroke Disability Using Data Mining and Infographics.

PubMed

Yoon, Sunmoo; Gutierrez, Jose

Disability is a potential risk for stroke survivors. This study aims to identify disability risk factors associated with stroke and their relative importance and relationships from a national behavioral risk factor dataset. Data of post-stroke individuals in the U.S (n=19,603) including 397 variables were extracted from a publically available national dataset and analyzed. Data mining algorithms including C4.5 and linear regression with M5s methods were applied to build association models for post-stroke disability using Weka software. The relative importance and relationship of 70 variables associated with disability were presented in infographics for clinicians to understand easily. Fifty-five percent of post-stroke patients experience disability. Exercise, employment and satisfaction of life were relatively important factors associated with disability among stroke patients. Modifiable behavior factors strongly associated with disability include exercise (OR: 0.46, P<0.01) and good rest (OR 0.37, P<0.01). Data mining is promising to discover factors associated with post-stroke disability from a large population dataset. The findings can be potentially valuable for establishing the priorities for clinicians and researchers and for stroke patient education. The methods may generalize to other health conditions.

Behavior Correlates of Post-Stroke Disability Using Data Mining and Infographics

PubMed Central

Yoon, Sunmoo; Gutierrez, Jose

2015-01-01

Purpose Disability is a potential risk for stroke survivors. This study aims to identify disability risk factors associated with stroke and their relative importance and relationships from a national behavioral risk factor dataset. Methods Data of post-stroke individuals in the U.S (n=19,603) including 397 variables were extracted from a publically available national dataset and analyzed. Data mining algorithms including C4.5 and linear regression with M5s methods were applied to build association models for post-stroke disability using Weka software. The relative importance and relationship of 70 variables associated with disability were presented in infographics for clinicians to understand easily. Results Fifty-five percent of post-stroke patients experience disability. Exercise, employment and satisfaction of life were relatively important factors associated with disability among stroke patients. Modifiable behavior factors strongly associated with disability include exercise (OR: 0.46, P<0.01) and good rest (OR 0.37, P<0.01). Conclusions Data mining is promising to discover factors associated with post-stroke disability from a large population dataset. The findings can be potentially valuable for establishing the priorities for clinicians and researchers and for stroke patient education. The methods may generalize to other health conditions. PMID:26835413

Connector Mechanism Has Smaller Stroke

NASA Technical Reports Server (NTRS)

Milam, M. Bruce

1992-01-01

System for connecting electrical and/or fluid lines includes mechanism reducing length of stroke necessary to make or break connections. Feature enables connection and disconnection in confined space, and compensates for misalignment between connectors. Connector in active member moves upward at twice the speed of downward stroke of passive member. Stroke amplified within connector system. Applications include connections between modular electronic units, coupled vehicles, and hydraulic systems.

Prevalence, incidence, and factors associated with pre-stroke and post-stroke dementia: a systematic review and meta-analysis.

PubMed

Pendlebury, Sarah T; Rothwell, Peter M

2009-11-01

Reliable data on the prevalence and predictors of post-stroke dementia are needed to inform patients and carers, plan services and clinical trials, ascertain the overall burden of stroke, and understand its causes. However, published data on the prevalence and risk factors for pre-stroke and post-stroke dementia are conflicting. We undertook this systematic review to assess the heterogeneity in the reported rates and to identify risk factors for pre-stroke and post-stroke dementia. Studies published between 1950 and May 1, 2009, were identified from bibliographic databases, reference lists, and journal contents pages. Studies were included if they were on patients with symptomatic stroke, were published in English, reported on a series of consecutive eligible patients or volunteers in prospective cohort studies, included all stroke or all ischaemic stroke, measured dementia by standard criteria, and followed up patients for at least 3 months after stroke. Pooled rates of dementia were stratified by study setting, inclusion or exclusion of pre-stroke dementia, and by first, any, or recurrent stroke. Pooled odds ratios were calculated for factors associated with pre-stroke and post-stroke dementia. We identified 22 hospital-based and eight population-based eligible cohorts (7511 patients) described in 73 papers. The pooled prevalence of pre-stroke dementia was higher (14.4%, 95% CI 12.0-16.8) in hospital-based studies than in population-based studies (9.1%, 6.9-11.3). Although post-stroke (

Improvement in symptoms of the syndrome of mitochondrial encephalopathy, lactic acidosis, and stroke-like symptoms (MELAS) following treatment with sympathomimetic amines--possible implications for improving fecundity in women of advanced reproductive age.

PubMed

Potestio, C P; Check, J H; Mitchell-Williams, J

2014-01-01

To evaluate the efficacy of sympathomimetic amine therapy on a mitochondrial abnormality known as the mitochondrial encephalopathy lactic acidosis and stroke-like symptoms syndrome (MELAS syndrome). Dextroamphetamine sulfate 15 mg extended release capsule was prescribed to a woman with a 25 year history of MELAS syndrome refractory to most other therapies. Within one month of therapy the woman noticed considerable improvement in her chronic fatigue, pain, and edema. The MELAS syndrome is thus another condition to add to the list of various chronic refractory disorders that improve considerably after dextroamphetamine therapy. This is the first mitochondrial disorder shown to improve with sympathomimetic amines which could suggest that dextroamphetamine could prove useful in decreasing the risk of aneuploidy in women of advanced reproductive age.

Postoperative stroke after hemiarthroplasty for femoral neck fracture: a report of 2 cases and review of literature.

PubMed

Ding, David Yi; Christoforou, Dimitrios; Turner, Garth; Tejwani, Nirmal C

2014-06-01

Femoral neck fractures in the elderly comprise a significant number of orthopedic surgical cases at a major trauma center. These patients are immediately incapacitated, and surgical fixation can help increase mobility, restore independence, and reduce morbidity and mortality. However, operative treatment carries its own inherent risks including infections, deep vein thromboses, and intraoperative cardiovascular collapse. Cerebrovascular stroke is a relatively uncommon occurrence after hip fractures. We present 2 cases with unusual postoperative medical complication after cemented hip hemiarthroplasty for femoral neck fracture that will serve to illustrate an infrequent but very serious complication. Case 1 was a 73-year-old man with a Garden IV femoral neck fracture who underwent a right hip unipolar cemented hemiarthroplasty under general anesthesia. After uneventful surgery, he developed neurological deficits, and a postoperative noncontrast head computed tomography showed a right medial thalamic infarct. Case 2 was an 82-year-old man with a Garden IV femoral neck fracture who underwent a right hip unipolar cemented hemiarthroplasty under general anesthesia. After uneventful surgery, the patient became hemodynamically unstable. A postoperative noncontrast head computed tomography showed a large evolving left middle cerebral artery stroke. General anesthesia in the setting of decreased cardiac function (decreased ejection fraction and output) carries the risk for ischemic injury to the brain from decreased cerebral perfusion. Risk factors including advanced age, history of coronary artery disease, atherosclerotic disease, and atrial fibrillation increase the risk for perioperative stroke. Furthermore, it is known that during the cementing of implants, microemboli can be released, which must be considered in patients with preoperative heart disease. As a result, consideration of using a noncemented implant or cementing without pressurizing in this clinical scenario should be an important aspect of the preoperative plan in an at-risk patient. Further studies are needed that can elucidate a causal relationship.

The Yin and Yang of innate immunity in stroke.

PubMed

Xu, Xiaomeng; Jiang, Yongjun

2014-01-01

Immune system plays an elementary role in the pathophysiological progress of ischemic stroke. It consists of innate and adaptive immune system. Activated within minutes after ischemic onset, innate immunity is responsible for the elimination of necrotic cells and tissue repair, while it is critically involved in the initiation and amplification of poststroke inflammation that amplifies ischemic damage to the brain tissue. Innate immune response requires days to be fully developed, providing a considerable time window for therapeutic intervention, suggesting prospect of novel immunomodulatory therapies against poststroke inflammation-induced brain injury. However, obstacles still exist and a comprehensive understanding of ischemic stroke and innate immune reaction is essential. In this review, we highlighted the current experimental and clinical data depicting the innate immune response following ischemic stroke, mainly focusing on the recognition of damage-associated molecular patterns, activation and recruitment of innate immune cells, and involvement of various cytokines. In addition, clinical trials targeting innate immunity were also documented regardless of the outcome, stressing the requirements for further investigation.

Basic Land Drills for Swimming Stroke Acquisition

ERIC Educational Resources Information Center

Zhang, Peng

2014-01-01

Teaching swimming strokes can be a challenging task in physical education. The purpose of the article is to introduce 12 on land drills that can be utilized to facilitate the learning of swimming strokes, including elementary back stroke, sidestroke, front crawl, back stroke, breaststroke, and butterfly. Each drill consists of four components…

Fall-related experiences of stroke survivors: a meta-ethnography.

PubMed

Walsh, Mary; Galvin, Rose; Horgan, N Frances

2017-04-01

Health professionals view falls after stroke as common adverse events with both physical and psychological consequences. Stroke survivors' experiences are less well understood. The aim of this systematic review was to explore the perception of falls-risk within the stroke recovery experience from the perspective of people with stroke. A systematic literature search was conducted. Papers that used qualitative methods to explore the experiences of individuals with stroke around falls, falls-risk and fear of falling were included. Two reviewers independently assessed the methodological quality of papers. Meta-ethnography was conducted. Concepts from each study were translated into each other to form theories that were combined through a "lines-of-argument" synthesis. Four themes emerged from the six included qualitative studies: (i) Fall circumstances, (ii) perception of fall consequences, (iii) barriers to community participation and (iv) coping strategies. The synthesis revealed that stroke survivors' perceived consequences of falls exist on a continuum. Cognitive and emotional adjustment may be required in the successful adoption of coping strategies to overcome fall-related barriers to participation. Stroke survivors' fall-related experiences appear to exist within the context of activity and community participation. Further research is warranted due to the small number of substantive studies available for synthesis. Implications for Rehabilitation Health care professionals should recognize that cognitive and emotional adjustment may berequired for stroke survivors to accept strategies for overcoming falls-risk, including dependenceon carers and assistive devices. Several factors in addition to physical interventions may be needed to minimize falls-risk whileincreasing activity participation. These factors could include increasing public awareness about the effects of stroke and falls-risk,and ensuring access to psychological services for stroke survivors. Rehabilitation professionals should reflect on whether they perceive there to be an appropriatelevel of fear of falling post-stroke. They should understand that stroke survivors might not conceptualize falls-risk in this way.

Guidelines for the Primary Prevention of Stroke

PubMed Central

Meschia, James F.; Bushnell, Cheryl; Boden-Albala, Bernadette; Braun, Lynne T.; Bravata, Dawn M.; Chaturvedi, Seemant; Creager, Mark A.; Eckel, Robert H.; Elkind, Mitchell S.V.; Fornage, Myriam; Goldstein, Larry B.; Greenberg, Steven M.; Horvath, Susanna E.; Iadecola, Costantino; Jauch, Edward C.; Moore, Wesley S.; Wilson, John A.

2016-01-01

The aim of this updated statement is to provide comprehensive and timely evidence-based recommendations on the prevention of stroke among individuals who have not previously experienced a stroke or transient ischemic attack. Evidence-based recommendations are included for the control of risk factors, interventional approaches to atherosclerotic disease of the cervicocephalic circulation, and antithrombotic treatments for preventing thrombotic and thromboembolic stroke. Further recommendations are provided for genetic and pharmacogenetic testing and for the prevention of stroke in a variety of other specific circumstances, including sickle cell disease and patent foramen ovale. PMID:25355838

Barriers and facilitators to staying in work after stroke: insight from an online forum

PubMed Central

Balasooriya-Smeekens, Chantal; Bateman, Andrew; Mant, Jonathan; De Simoni, Anna

2016-01-01

Objective To explore barriers and facilitators to staying in work following stroke. Design Qualitative analysis of posts regarding staying in work following stroke using the archives of an online forum for stroke survivors. Participants 60 stroke survivors (29 male, 23 female, 8 not stated; mean age at stroke 44 years) who have returned to work, identified using terms ‘return to work’ and ‘back at work’. Setting Posts from UK stroke survivors and family members on Talkstroke, the forum of the Stroke Association, between 2004 and 2011. Results Stroke and transient ischaemic attack (TIA) survivors reported residual impairments that for many had impact on work. Most impairments were ‘invisible’, including fatigue, problems with concentration, memory and personality changes. Participants described positive (eg, back at work being better than expected) and negative work experiences, including being at risk of losing the job because of stroke-related impairments. Barriers to successfully staying in work included lack of understanding of stroke—in particular invisible impairments—of survivors, employers and general practitioners (GPs), and lack of support in terms of formal adjustments, and ‘feeling supported’. Stroke survivors described how they developed their own coping strategies, and how workplace and employer helped them to stay in work. Conclusions Despite having been able to return to work after a stroke, people may still experience difficulties in staying in work and risking losing their job. There is a need to improve awareness, in particular of invisible stroke-related impairments, among stroke survivors, work personnel and clinicians. This might be achieved through improved assessments of residual impairments in the workplace and in general practice. Future studies should investigate the effect of unrecognised fatigue and invisible impairments on staying in work following stroke, and explore the potential role for primary care in supporting stroke survivors who have returned to employment. PMID:27053267

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.

Variation in the magnitude of black-white differences in stroke mortality by community occupational structure.

PubMed Central

Casper, M; Wing, S; Strogatz, D

1991-01-01

STUDY OBJECTIVE--The aim was to examine the patterns of black-white differences in stroke mortality across communities with varying levels of occupational structure in the southern region of the United States DESIGN--Annual age adjusted race-sex specific rates for stroke mortality were calculated for the years 1979-1981 and related to socioeconomic conditions. SETTING--The study involved 211 state economic areas comprising the southern region of the USA. STUDY POPULATION--Data on stroke mortality for black and white men and women between the ages of 35 and 74 years living in the study area were acquired from the National Center for Health Statistics. MEASUREMENTS AND MAIN RESULTS--Occupational structure was measured as the proportion of white collar workers in each state economic area, and is an indicator of the employment opportunities and related social and economic resources of a community. Stratified analyses and linear regression modelling indicate that communities of lower occupational structure have (a) higher levels of stroke mortality for all four race-sex groups (p less than 0.05) and (b) larger racial inequalities in stroke mortality (p less than 0.01). For men and women, the excess stroke mortality among blacks compared to whites is larger in communities of lower occupational structure. CONCLUSIONS--Consideration of occupational structure and related patterns of economic development is crucial for understanding the distribution of stroke mortality within and between racial groups, as well as for planning effective public health interventions. The larger racial inequalities in communities of lower occupational structure in the south suggest that aspects of the black experience which are conducive to high rates of stroke mortality are exacerbated in those communities. Public health interventions to reduce the racial and social inequalities in stroke mortality should recognise the social context within which nutritional, occupational, medical care, and environmental determinants of stroke are distributed. PMID:1795152

Characteristics of spinal cord stroke in clinical neurology.

PubMed

Romi, Fredrik; Naess, Halvor

2011-01-01

Spinal cord stroke accounts for about 0.3% of all strokes in our department. Thirty-two patients (15 males, 17 females; mean age 63.3 years) treated in the period 1995-2010 were included. Patients underwent thorough investigation including the use of different stroke scales (National Institute of Health Stroke Scale, Barthel Index and modified Rankin Scale). Twenty-eight patients had infarctions, 3 had hemorrhages, and 1 had arterio-venous fistula. Twenty-eight spinal cord strokes were spontaneous, 2 were secondary to aorta aneurysms, and 2 post surgery. Biphasic ictus was seen in 17% of all spontaneous infarctions. Younger age, male gender, hypertension, diabetes mellitus, and higher blood glucose on admission regardless of diabetes mellitus, were risk factors associated with more severe spinal cord stroke. Treatment and prevention of these risk factors should be essential in spinal cord stroke. We recommend a clinical classification into upper (cervical) and lower (thoracic or medullary conus) spinal cord strokes. Patients with upper strokes in this study had more severe strokes initially, but they had a better prognosis. Therefore it is important to identify this patient group.Acute sensory spinal cord deficit symptoms, common initial symptoms in biphasic spinal cord strokes, should be considered as possible spinal cord stroke, especially when preceded by radiating pain between the shoulders. Copyright © 2011 S. Karger AG, Basel.

Society of Vascular and Interventional Neurology (SVIN) Stroke Interventional Laboratory Consensus (SILC) Criteria: A 7M Management Approach to Developing a Stroke Interventional Laboratory in the Era of Stroke Thrombectomy for Large Vessel Occlusions

PubMed Central

Shams, Tanzila; Zaidat, Osama; Yavagal, Dileep; Xavier, Andrew; Jovin, Tudor; Janardhan, Vallabh

2016-01-01

Brain attack care is rapidly evolving with cutting-edge stroke interventions similar to the growth of heart attack care with cardiac interventions in the last two decades. As the field of stroke intervention is growing exponentially globally, there is clearly an unmet need to standardize stroke interventional laboratories for safe, effective, and timely stroke care. Towards this goal, the Society of Vascular and Interventional Neurology (SVIN) Writing Committee has developed the Stroke Interventional Laboratory Consensus (SILC) criteria using a 7M management approach for the development and standardization of each stroke interventional laboratory within stroke centers. The SILC criteria include: (1) manpower: personnel including roles of medical and administrative directors, attending physicians, fellows, physician extenders, and all the key stakeholders in the stroke chain of survival; (2) machines: resources needed in terms of physical facilities, and angiography equipment; (3) materials: medical device inventory, medications, and angiography supplies; (4) methods: standardized protocols for stroke workflow optimization; (5) metrics (volume): existing credentialing criteria for facilities and stroke interventionalists; (6) metrics (quality): benchmarks for quality assurance; (7) metrics (safety): radiation and procedural safety practices. PMID:27610118

Predictors of stroke in patients with impaired glucose tolerance: results from the Nateglinide and Valsartan in Impaired Glucose Tolerance Outcomes Research trial.

PubMed

Preiss, David; Giles, Thomas D; Thomas, Laine E; Sun, Jie-Lena; Haffner, Steven M; Holman, Rury R; Standl, Eberhard; Mazzone, Theodore; Rutten, Guy E; Tognoni, Gianni; Chiang, Fu-Tien; McMurray, John J V; Califf, Robert M

2013-09-01

Risk factors for stroke are well-established in general populations but sparsely studied in individuals with impaired glucose tolerance. We identified predictors of stroke among participants with impaired glucose tolerance in the Nateglinide and Valsartan in Impaired Glucose Tolerance Outcomes Research (NAVIGATOR) trial. Cox proportional-hazard regression models were constructed using baseline variables, including the 2 medications studied, valsartan and nateglinide. Among 9306 participants, 237 experienced a stroke over 6.4 years. Predictors of stroke included classical risk factors such as existing cerebrovascular and coronary heart disease, higher pulse pressure, higher low-density lipoprotein cholesterol, older age, and atrial fibrillation. Other factors, including previous venous thromboembolism, higher waist circumference, lower estimated glomerular filtration rate, lower heart rate, and lower body mass index, provided additional important predictive information, yielding a C-index of 0.72. Glycemic measures were not predictive of stroke. Variables associated with stroke were similar in participants with no prior history of cerebrovascular disease at baseline. The most powerful predictors of stroke in patients with impaired glucose tolerance included a combination of established risk factors and novel variables, such as previous venous thromboembolism and elevated waist circumference, allowing moderately effective identification of high-risk individuals.

Rehabilitation and education are underutilized for mild stroke and TIA sufferers.

PubMed

Faux, Steven G; Arora, Pooja; Shiner, Christine T; Thompson-Butel, Angelica G; Klein, Linda A

2018-06-01

Transient ischemic attack (TIA) and mild stroke represent a large proportion of cerebrovascular events, at high risk of being followed by recurrent, serious events. The importance of early education addressing risk management, secondary prevention and lifestyle modifications is the centerpiece of further stroke prevention. However, delivering education and rehabilitation to this population can be complex and challenging. Via synthesis of a narrative review and clinical experience, we explore the unique and inherent complexities of rehabilitation management and education provision for patients following mild stroke and TIA. A considerable proportion of TIA/mild stroke survivors have ongoing rehabilitation needs that are poorly addressed. The need for rehabilitation in these patients is often overlooked, and available assessment tools lack the sensitivity to identify common subtle impairments in cognition, mood, language and fatigue. Active and accessible education interventions need to be initiated early after the event, and integrated with ongoing rehabilitation management. Priority areas in need of future development in this field are highlighted and discussed. Implications for rehabilitation Survivors of mild stroke and TIA have ongoing unmet rehabilitation needs and require a unique approach to rehabilitation and education. Rehabilitation needs are difficult to assess and poorly addressed in this cohort, where available assessment tools lack the sensitivity required to identify subtle impairments. Education needs to be initiated early after the event and involve active engagement of the patient in order to improve stroke knowledge, mood and motivate adherence to lifestyle modifications and secondary prevention. Rehabilitation physicians are currently an underutilized resource, who should be more involved in the management of all patients following TIA or mild stroke.

Stroke prevention in atrial fibrillation--an Asian stroke perspective.

PubMed

Tse, Hung-Fat; Wang, Yong-Jun; Ahmed Ai-Abdullah, Moheeb; Pizarro-Borromeo, Annette B; Chiang, Chern-En; Krittayaphong, Rungroj; Singh, Balbir; Vora, Amit; Wang, Chun-Xue; Zubaid, Mohammad; Clemens, Andreas; Lim, Paul; Hu, Dayi

2013-07-01

Despite relatively lower prevalence of atrial fibrillation (AF) in Asians (~1%) than in Caucasians (~2%), Asia has a much higher overall disease burden because of its proportionally larger aged population. For example, on the basis of reported age-adjusted prevalence rates and projected population figures in China, there will be an estimated 5.2 million men and 3.1 million women with AF older than 60 years by year 2050. Stroke is a disabling complication of AF that is of increasing cause for concern in Asians patients. Implementing consensus expert recommendations for managing stroke risk in patients with AF can considerably reduce stroke rates. However, caution is necessary when aligning management of Asian patients with AF to that of their Caucasian counterparts. Current international guidelines and risk stratification tools for AF management are based on findings in predominantly Caucasian populations and may therefore have limited relevance, in certain respects, to Asian patients. Oral anticoagulants play an important role in preventing AF-related stroke. The vitamin K antagonist warfarin is recommended for reducing the risk of stroke and thromboembolism in high-risk patients with nonvalvular AF; however, warfarin interacts with many drugs and food ingredients, which may pose significant challenges in administration and monitoring among Asian patients. Further research is needed to inform specific guidance on the implications of different stroke and bleeding profiles in Asians vs Caucasians. Moreover, there is scope to improve physician perceptions and patient knowledge, as well as considering alternative new oral anticoagulants, for example, direct thrombin inhibitors or factor Xa inhibitors. Copyright © 2013 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

Screening methods for post-stroke visual impairment: a systematic review.

PubMed

Hanna, Kerry Louise; Hepworth, Lauren Rachel; Rowe, Fiona

2017-12-01

To provide a systematic overview of the various tools available to screen for post-stroke visual impairment. A review of the literature was conducted including randomised controlled trials, controlled trials, cohort studies, observational studies, systematic reviews and retrospective medical note reviews. All languages were included and translation was obtained. Participants included adults ≥18 years old diagnosed with a visual impairment as a direct cause of a stroke. We searched a broad range of scholarly online resources and hand-searched articles registers of published, unpublished and on-going trials. Search terms included a variety of MESH terms and alternatives in relation to stroke and visual conditions. Study selection was performed by two authors independently. The quality of the evidence and risk of bias were assessed using the STROBE, GRACE and PRISMA statements. A total of 25 articles (n = 2924) were included in this review. Articles appraised reported on tools screening solely for visual impairments or for general post-stroke disabilities inclusive of vision. The majority of identified tools screen for visual perception including visual neglect (VN), with few screening for visual acuity (VA), visual field (VF) loss or ocular motility (OM) defects. Six articles reported on nine screening tools which combined visual screening assessment alongside screening for general stroke disabilities. Of these, three included screening for VA; three screened for VF loss; three screened for OM defects and all screened for VN. Two tools screened for all visual impairments. A further 19 articles were found which reported on individual vision screening tests in stroke populations; two for VF loss; 11 for VN and six for other visual perceptual defects. Most tools cannot accurately account for those with aphasia or communicative deficits, which are common problems following a stroke. There is currently no standardised visual screening tool which can accurately assess all potential post-stroke visual impairments. The current tools screen for only a number of potential stroke-related impairments, which means many visual defects may be missed. The sensitivity of those which screen for all impairments is significantly lowered when patients are unable to report their visual symptoms. Future research is required to develop a tool capable of assessing stroke patients which encompasses all potential visual deficits and can also be easily performed by both the patients and administered by health care professionals in order to ensure all stroke survivors with visual impairment are accurately identified and managed. Implications for Rehabilitation Over 65% of stroke survivors will suffer from a visual impairment, whereas 45% of stroke units do not assess vision. Visual impairment significantly reduces the quality of life, such as being unable to return to work, driving and depression. This review outlines the available screening methods to accurately identify stroke survivors with visual impairments. Identifying visual impairment after stroke can aid general rehabilitation and thus, improve the quality of life for these patients.

Variability in Criteria for Emergency Medical Services Routing of Acute Stroke Patients to Designated Stroke Center Hospitals.

PubMed

Dimitrov, Nikolay; Koenig, William; Bosson, Nichole; Song, Sarah; Saver, Jeffrey L; Mack, William J; Sanossian, Nerses

2015-09-01

Comprehensive stroke systems of care include routing to the nearest designated stroke center hospital, bypassing non-designated hospitals. Routing protocols are implemented at the state or county level and vary in qualification criteria and determination of destination hospital. We surveyed all counties in the state of California for presence and characteristics of their prehospital stroke routing protocols. Each county's local emergency medical services agency (LEMSA) was queried for the presence of a stroke routing protocol. We reviewed these protocols for method of stroke identification and criteria for patient transport to a stroke center. Thirty-three LEMSAs serve 58 counties in California with populations ranging from 1,175 to nearly 10 million. Fifteen LEMSAs (45%) had stroke routing protocols, covering 23 counties (40%) and 68% of the state population. Counties with protocols had higher population density (1,500 vs. 140 persons per square mile). In the six counties without designated stroke centers, patients meeting criteria were transported out of county. Stroke identification in the field was achieved using the Cincinnati Prehospital Stroke Screen in 72%, Los Angeles Prehospital Stroke Screen in 7% and a county-specific protocol in 22%. California EMS prehospital acute stroke routing protocols cover 68% of the state population and vary in characteristics including activation by symptom onset time and destination facility features, reflecting matching of system design to local geographic resources.

The effect of the inspiratory muscle training on functional ability in stroke patients.

PubMed

Jung, Nam-Jin; Na, Sang-Su; Kim, Seung-Kyu; Hwangbo, Gak

2017-11-01

[Purpose] This study was to find out an inspiratory muscle training (IMT) program therapeutic effects on stroke patients' functional ability. [Subjects and Methods] Twenty stroke patients were assigned to one of two groups: inspiratory muscle training (n=10), and control (n=10), randomization. The inspiratory muscle training participants undertook an exercise program for 30 minute per times, 5 times a week for 6 weeks. The investigator measured the patients' trunk impairment scale (TIS) and 6 minute walking test (6MW) for functional ability before and after IMT. [Results] The TIS appeared some significant differences in both groups before and after the training. The 6MW test showed some significant differences in the inspiratory muscle training group, but didn't show any significant difference in the control group. And the differences in both groups after depending the inspiratory muscle training were significantly found in the tests of TIS and 6MW test [Conclusion] The results showed that the inspiratory muscle training in stroke patients are correlated with the trunk stability and locomotion ability, suggesting that physical therapist must take into consideration the inspiratory muscle training, as well as functional training to improve physical function in stroke patients.

Heat stroke leading to acute liver injury & failure: A case series from the Acute Liver Failure Study Group.

PubMed

Davis, Brian C; Tillman, Holly; Chung, Raymond T; Stravitz, Richard T; Reddy, Rajender; Fontana, Robert J; McGuire, Brendan; Davern, Timothy; Lee, William M

2017-04-01

In the United States, nearly 1000 annual cases of heat stroke are reported but the frequency and outcome of severe liver injury in such patients is not well described. The aim of this study was to describe cases of acute liver injury (ALI) or failure (ALF) caused by heat stroke in a large ALF registry. Amongst 2675 consecutive subjects enrolled in a prospective observational cohort of patients with ALI or ALF between January 1998 and April 2015, there were eight subjects with heat stroke. Five patients had ALF and three had ALI. Seven patients developed acute kidney injury, all eight had lactic acidosis and rhabdomyolysis. Six patients underwent cooling treatments, three received N-acetyl cysteine (NAC), three required mechanical ventilation, three required renal replacement therapy, two received vasopressors, one underwent liver transplantation, and two patients died-both within 48 hours of presentation. All cases occurred between May and August, mainly in healthy young men because of excessive exertion. Management of ALI and ALF secondary to heat stroke should focus on cooling protocols and supportive care, with consideration of liver transplantation in refractory patients. © 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Applying principles from the game theory to acute stroke care: Learning from the prisoner's dilemma, stag-hunt, and other strategies.

PubMed

Saposnik, Gustavo; Johnston, S Claiborne

2016-04-01

Acute stroke care represents a challenge for decision makers. Decisions based on erroneous assessments may generate false expectations of patients and their family members, and potentially inappropriate medical advice. Game theory is the analysis of interactions between individuals to study how conflict and cooperation affect our decisions. We reviewed principles of game theory that could be applied to medical decisions under uncertainty. Medical decisions in acute stroke care are usually made under constrains: short period of time, with imperfect clinical information, limit understanding about patients and families' values and beliefs. Game theory brings some strategies to help us manage complex medical situations under uncertainty. For example, it offers a different perspective by encouraging the consideration of different alternatives through the understanding of patients' preferences and the careful evaluation of cognitive distortions when applying 'real-world' data. The stag-hunt game teaches us the importance of trust to strength cooperation for a successful patient-physician interaction that is beyond a good or poor clinical outcome. The application of game theory to stroke care may improve our understanding of complex medical situations and help clinicians make practical decisions under uncertainty. © 2016 World Stroke Organization.

Are rehabilitation and/or care co-ordination interventions delivered in the community effective in reducing depression, facilitating participation and improving quality of life after stroke?

PubMed

Graven, Christine; Brock, Kim; Hill, Keith; Joubert, Lynette

2011-01-01

To conduct a systematic review to explore the effectiveness of community-based rehabilitation interventions delivered by allied health professionals and/or nursing staff in reducing depression, facilitating participation and improving health-related quality of life (HRQoL) post-inpatient stroke rehabilitation. A search was conducted in the databases of MEDLINE, PEDro, CINAHL and the Cochrane Library. Publications were classified into categories based on the type of the interventions. Best evidence synthesis and meta-analysis were utilised to determine the level of evidence. Fifty-four studies were included in the review, and divided into nine broad intervention categories. Meta-analysis demonstrated significant reduction in depression with exercise interventions (n = 137; effect estimate SMD: -2.03, 95%CI: -3.22, -0.85). Community-based interventions targeting participation and leisure domains showed moderate evidence for improvement in global participation measures and HRQoL. Comprehensive rehabilitation demonstrated limited evidence for depression and participation, and strong evidence for HRQoL. There is limited to moderate evidence supporting some rehabilitation interventions in affecting the outcomes of depression, participation and HRQoL post-stroke. Heterogeneity of the studies made evidence synthesis difficult. Further consideration needs to be given to the type and timing of outcome measures selected to represent the domains of participation and HRQoL.

Sustained administration of corticosterone at stress-like levels after stroke suppressed glial reactivity at sites of thalamic secondary neurodegeneration.

PubMed

Zalewska, Katarzyna; Pietrogrande, Giovanni; Ong, Lin Kooi; Abdolhoseini, Mahmoud; Kluge, Murielle; Johnson, Sarah J; Walker, Frederick R; Nilsson, Michael

2018-03-01

Secondary neurodegeneration (SND) is an insidious and progressive condition involving the death of neurons in regions of the brain that were connected to but undamaged by the initial stroke. Our group have published compelling evidence that exposure to psychological stress can significantly exacerbate the severity SND, a finding that has considerable clinical implications given that stroke-survivors often report experiencing high and unremitting levels of psychological stress. It may be possible to use one or more targeted pharmacological approaches to limit the negative effects of stress on the recovery process but in order to move forward with this approach the most critical stress signals have to be identified. Accordingly, in the current study we have directed our attention to examining the potential effects of corticosterone, delivered orally at stress-like levels. Our interest is to determine how similar the effects of corticosterone are to stress on repair and remodelling that is known to occur after stroke. The study involved 4 groups, sham and stroke, either administered corticosterone or normal drinking water. The functional impact was assessed using the cylinder task for paw asymmetry, grid walk for sensorimotor function, inverted grid for muscle strength and coordination and open field for anxiety-like behaviour. Biochemically and histologically, we considered disturbances in main cellular elements of the neurovascular unit, including microglia, astrocytes, neurons and blood vessels using both immunohistochemistry and western blotting. In short, we identified that corticosterone delivery after stroke results in significant suppression of key microglial and astroglial markers. No changes were observed on the vasculature and in neuronal specific markers. No changes were identified for sensorimotor function or anxiety-like behaviour. We did, however, observe a significant change in motor function as assessed using the inverted grid walk test. Collectively, these results suggest that pharmacologically targeting corticosterone levels in the future may be warranted but that such an approach is unlikely to limit all the negative effects associated with exposure to chronic stress. Copyright © 2017 Elsevier Inc. All rights reserved.

Eye-Tracking Provides a Sensitive Measure of Exploration Deficits After Acute Right MCA Stroke

PubMed Central

Delazer, Margarete; Sojer, Martin; Ellmerer, Philipp; Boehme, Christian; Benke, Thomas

2018-01-01

The eye-tracking study aimed at assessing spatial biases in visual exploration in patients after acute right MCA (middle cerebral artery) stroke. Patients affected by unilateral neglect show less functional recovery and experience severe difficulties in everyday life. Thus, accurate diagnosis is essential, and specific treatment is required. Early assessment is of high importance as rehabilitative interventions are more effective when applied soon after stroke. Previous research has shown that deficits may be overlooked when classical paper-and-pencil tasks are used for diagnosis. Conversely, eye-tracking allows direct monitoring of visual exploration patterns. We hypothesized that the analysis of eye-tracking provides more sensitive measures for spatial exploration deficits after right middle cerebral artery stroke. Twenty-two patients with right MCA stroke (median 5 days after stroke) and 28 healthy controls were included. Lesions were confirmed by MRI/CCT. Groups performed comparably in the Mini–Mental State Examination (patients and controls median 29) and in a screening of executive functions. Eleven patients scored at ceiling in neglect screening tasks, 11 showed minimal to severe signs of unilateral visual neglect. An overlap plot based on MRI and CCT imaging showed lesions in the temporo–parieto–frontal cortex, basal ganglia, and adjacent white matter tracts. Visual exploration was evaluated in two eye-tracking tasks, one assessing free visual exploration of photographs, the other visual search using symbols and letters. An index of fixation asymmetries proved to be a sensitive measure of spatial exploration deficits. Both patient groups showed a marked exploration bias to the right when looking at complex photographs. A single case analysis confirmed that also most of those patients who showed no neglect in screening tasks performed outside the range of controls in free exploration. The analysis of patients’ scoring at ceiling in neglect screening tasks is of special interest, as possible deficits may be overlooked and thus remain untreated. Our findings are in line with other studies suggesting considerable limitations of laboratory screening procedures to fully appreciate the occurrence of neglect symptoms. Future investigations are needed to explore the predictive value of the eye-tracking index and its validity in everyday situations.

Development of a tool to improve the quality of decision making in atrial fibrillation

PubMed Central

2011-01-01

Background Decision-making about appropriate therapy to reduce the stroke risk associated with non-valvular atrial fibrillation (NVAF) involves the consideration of trade-offs among the benefits, risks, and inconveniences of different treatment options. The objective of this paper is to describe the development of a decision support tool for NVAF based on the provision of individualized risk estimates for stroke and bleeding and on preparing patients to communicate with their physicians about their values and potential treatment options. Methods We developed a tool based on the principles of the International Patient Decision Aids Standards. The tool focuses on the patient-physician dyad as the decision-making unit and emphasizes improving the interaction between the two. It is built on the recognition that the application of patient values to a specific treatment decision is complex and that the final treatment choice is best made through a process of patient-clinician communication. Results The tool provides education incorporating patients ' illness perceptions to explain the relationship between NVAF and stroke, and then presents individualized risk estimates, derived using separate risk calculators for stroke and bleeding over a clinically meaningful time period (5 years) associated with no treatment, aspirin, and warfarin. Sequelae of both stroke and bleeding outcomes are also described. Patients are encouraged to verbalize how they value the incremental risks and benefits associated with each option and write down specific concerns to address with their physician. A physician prompt to encourage patients to discuss their opinions is included as part of the decision support tool. In pilot testing with 11 participants (mean age 78 ± 9 years, 64% with ≤ high-school education), 8 (72%) rated ease of completion as "very easy," and 9 (81%) rated amount of information as "just right." Conclusions The risks and benefits of different treatment options for reduction of stroke in NVAF vary widely according to patients' comorbidities. This tool facilitates the provision of individualized outcome data and encourages patients to communicate with their physicians about these risks and benefits. Future studies will examine whether use of the tool is associated with improved quality of decision making. PMID:21977943

Reducing robotic guidance during robot-assisted gait training improves gait function: a case report on a stroke survivor.

PubMed

Krishnan, Chandramouli; Kotsapouikis, Despina; Dhaher, Yasin Y; Rymer, William Z

2013-06-01

To test the feasibility of patient-cooperative robotic gait training for improving locomotor function of a chronic stroke survivor with severe lower-extremity motor impairments. Single-subject crossover design. Performed in a controlled laboratory setting. A 62-year-old man with right temporal lobe ischemic stroke was recruited for this study. The baseline lower-extremity Fugl-Meyer score of the subject was 10 on a scale of 34, which represented severe impairment in the paretic leg. However, the subject had a good ambulation level (community walker with the aid of a stick cane and ankle-foot orthosis) and showed no signs of sensory or cognitive impairments. The subject underwent 12 sessions (3 times per week for 4wk) of conventional robotic training with the Lokomat, where the robot provided full assistance to leg movements while walking, followed by 12 sessions (3 times per week for 4wk) of patient-cooperative robotic control training, where the robot provided minimal guidance to leg movements during walking. Clinical outcomes were evaluated before the start of the intervention, immediately after 4 weeks of conventional robotic training, and immediately after 4 weeks of cooperative control robotic training. These included: (1) self-selected and fast walking speed, (2) 6-minute walk test, (3) Timed Up & Go test, and (4) lower-extremity Fugl-Meyer score. Results showed that clinical outcomes changed minimally after full guidance robotic training, but improved considerably after 4 weeks of reduced guidance robotic training. The findings from this case study suggest that cooperative control robotic training is superior to conventional robotic training and is a feasible option to restoring locomotor function in ambulatory stroke survivors with severe motor impairments. A larger trial is needed to verify the efficacy of this advanced robotic control strategy in facilitating gait recovery after stroke. Copyright © 2013 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.

The Kinematics of Trunk and Upper Extremities in One-Handed and Two-Handed Backhand Stroke

PubMed Central

Stępień, Adam; Bober, Tadeusz; Zawadzki, Jerzy

2011-01-01

The aim of this study was to present kinematics of trunk and upper extremities in tennis players who perform one-handed and two-handed backhand strokes. The study aimed to address the question of whether one of those techniques has some important advantage over the other. If so, what makes it superior? The study included 10 tennis coaches with average coaching experience of 9 years. The coaches were asked to hit 15 one-handed and two-handed backhands. The tests were carried out in a laboratory. A sponge ball was used in order to protect the measurement equipment. Video motion analysis was carried out using BTS SMART system; images were recorded with 6 cameras with a rate of 120 frames per second. The analysis of both backhand strokes focused on the second phase of the stroke (acceleration). The use of an eight-element model of human body for description of upper body motion in both techniques revealed kinematic differences in how both backhands are performed. The two-handed backhand was performed in closed kinetic chain with 8 degrees of freedom, whereas the one-handed backhand involved an open kinetic chain with 7 degrees of freedom. Higher rigidity of upper extremities which are connected with trunk in the two-handed backhand, contributes to an elevated trunk effect in this stroke. This is confirmed by higher component velocities for racket handle, which result from trunk rotation in the two-handed backhand and a negative separation angle in the two-handed backhand at the moment of contact of the racket with the ball. The study does not provide a clear-cut answer to the question of advantages of one technique over the other; however, it reveals dissimilar patterns of driving the racket in both techniques, which suggests the need for extending the analysis of techniques of both backhands with additional kinematics of tennis racket in consideration of measurements of ball velocities. PMID:23486650

Five-day course of paired associative stimulation fails to improve motor function in stroke patients.

PubMed

Tarri, Mohamed; Brimhat, Nabila; Gasq, David; Lepage, Benoît; Loubinoux, Isabelle; De Boissezon, Xavier; Marque, Philippe; Castel-Lacanal, Evelyne

2018-03-01

Non-invasive brain stimulation has been studied as a therapeutic adjunct for upper-limb recovery in patients with stroke. One type of stimulation, paired associative stimulation (PAS), has effects on plasticity in both patients and healthy participants. Lasting several hours, these effects are reversible and topographically specific. The goal was to investigate the presence of a lasting increase in motor cortex plasticity for extensor wrist muscles - extensor carpi radialis (ECR) - and an improvement in upper-limb function after 5 days of daily PAS in patients at the subacute post-stroke stage. A total of 24 patients (mean [SD] age 50.1 [12.1] years, weeks since stroke 10.1 [5.3]) were included in a double-blind, placebo-controlled trial and randomly assigned to the PAS or sham group (n=13 and n=11). For the PAS group, patients underwent a 5-day course of electrical peripheral stimulation combined with magnetic cortical stimulation applied to the ECR muscle in a single daily session at 0.1Hz for 30min; patients with sham treatment received minimal cortical stimulation. Both patient groups underwent 2 hr of conventional physiotherapy. Variations in the motor evoked potential (MEP) surface area of the ECR muscle and Fugl-Meyer Assessment-Upper-Limb motor scores were analysed up to day 12. The 2 groups did not differ in electrophysiological or motor parameters. Repeated PAS sessions seemed to affect only patients with low initial cortical excitability. We found considerable variability in PAS effects between patients and across the sessions. We failed to induce a lasting effect with PAS in the present study. PAS does not seem to be the main method for post-stroke brain stimulation. Perhaps recruitment of patients could be more selective, possibly targeting those with a wide altered ipsilesional corticomotor pathway. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

5-year survival and rehospitalization due to stroke recurrence among patients with hemorrhagic or ischemic strokes in Singapore.

PubMed

Sun, Yan; Lee, Sze Haur; Heng, Bee Hoon; Chin, Vivien S

2013-10-03

Stroke is the 4th leading cause of death and 1st leading cause of disability in Singapore. However the information on long-term post stroke outcomes for Singaporean patients was limited. This study aimed to investigate the post stroke outcomes of 5-year survival and rehospitalization due to stroke recurrence for hemorrhagic and ischemic stroke patients in Singapore. The outcomes were stratified by age, ethnic group, gender and stroke types. The causes of death and stroke recurrence were also explored in the study. A multi-site retrospective cohort study. Patients admitted for stroke at any of the three hospitals in the National Healthcare Group of Singapore were included in the study. All study patients were followed up to 5 years. Kaplan-Meier was applied to study the time to first event, death or rehospitalization due to stroke recurrence. Cox proportional hazard model was applied to study the time to death with adjustment for stroke type, age, sex, ethnic group, and admission year. Cumulative incidence model with competing risk was applied for comparing the risks of rehospitalization due to stroke recurrence with death as the competing risk. Totally 12,559 stroke patients were included in the study. Among them, 59.3% survived for 5 years; 18.4% were rehospitalized due to stroke recurrence in 5 years. The risk of stroke recurrence and mortality increased with age in all stroke types. Gender, ethnic group and admitting year were not significantly associated with the risk of mortality or stroke recurrence in hemorrhagic stroke. Male or Malay patient had higher risk of stroke recurrence and mortality in ischemic stroke. Hemorrhagic stroke had higher early mortality while ischemic stroke had higher recurrence and late mortality. The top cause of death among died stroke patients was cerebrovascular diseases, followed by pneumonia and ischemic heart diseases. The recurrent stroke was most likely to be the same type as the initial stroke among rehospitalized stroke patients. Five year post-stroke survival and rehospitalization due to stroke recurrence as well as their associations with patient demographics were studied for different stroke types in Singapore. Specific preventive strategies are needed to target the high risk groups to improve their long-term outcomes after acute stroke.

Efficacy of antiplatelet therapy in secondary prevention following lacunar stroke: pooled analysis of randomized trials.

PubMed

Kwok, Chun Shing; Shoamanesh, Ashkan; Copley, Hannah Charlotte; Myint, Phyo Kyaw; Loke, Yoon K; Benavente, Oscar R

2015-04-01

Lacunar stroke accounts for ≈25% of ischemic stroke, but optimal antiplatelet regimen to prevent stroke recurrence remains unclear. We aimed to evaluate the efficacy of antiplatelet agents in secondary stroke prevention after a lacunar stroke. We searched MEDLINE, Embase, and the Cochrane library for randomized controlled trials that reported risk of recurrent stroke or death with antiplatelet therapy in patients with lacunar stroke. We used random effects meta-analysis and evaluated heterogeneity with I(2). We included 17 trials with 42,234 participants (mean age 64.4 years, 65% male) and follow up ranging from 4 weeks to 3.5 years. Compared with placebo, any single antiplatelet agent was associated with a significant reduction in recurrence of any stroke (risk ratio [RR] 0.77, 0.62-0.97, 2 studies) and ischemic stroke (RR 0.48, 0.30-0.78, 2 studies), but not for the composite outcome of any stroke, myocardial infarction, or death (RR 0.89, 0.75-1.05, 2 studies). When other antiplatelet agents (ticlodipine, cilostazol, and dipyridamole) were compared with aspirin, there was no consistent reduction in stroke recurrence (RR 0.91, 0.75-1.10, 3 studies). Dual antiplatelet therapy did not confer clear benefit over monotherapy (any stroke RR 0.83, 0.68-1.00, 3 studies; ischemic stroke RR 0.80, 0.62-1.02, 3 studies; composite outcome RR 0.90, 0.80-1.02, 3 studies). Our results suggest that any of the single antiplatelet agents compared with placebo in the included trials is adequate for secondary stroke prevention after lacunar stroke. Dual antiplatelet therapy should not be used for long-term stroke prevention in this stroke subtype. © 2015 American Heart Association, Inc.

Diagnostic approach and management strategy of childhood stroke.

PubMed

Salih, Mustafa A; Abdel-Gader, Abdel-Galil M

2006-03-01

Prompt recognition and early intervention, with pertinent management and medication, may reduce subsequent neurologic deficits in stroke, which constitutes a devastating event in children. This is due to the tasking and demanding consequences including death or residual neurological deficits, which may last for many decades, in over 60% of survivors. Evidence-based treatment for children with stroke is still lacking, reflecting scarcity in baseline epidemiological data on pediatric stroke, the multitude of underlying risk factors, and the ethical and practical challenges incurred in conducting clinical trials. Based on the experience we gained from a combined prospective and retrospective study on childhood stroke (covering 10 years and 7 months and involving a cohort of 104 Saudi children), a diagnostic algorithm, which outlines the approach to a child with suspected stroke/cerebrovascular lesion, was designed. This algorithm might also be of use for managing other children with stroke from the Arabian Peninsula and Middle Eastern Region with similar demographic, socioeconomic, and ethnic backgrounds. Underlying risk factors, which need special attention, include thrombophilia and hypercoagulable states and sickle cell disease (SCD), which contrary to previous studies from Saudi Arabia, were found to constitute a common risk factor with severe manifestations. Other risk factors include infections (especially neurobrucellosis), cardiac diseases, and hypernatremic dehydration. Recognition of an identifiable syndrome or inherited metabolic cause may unravel an underlying cerebrovascular disease. This is particularly important in this region, given the large pool of autosomal recessive diseases and the high rate of consanguinity. In the evaluation of a suspected case of stroke, important imaging modalities include cranial CT, MRI (including diffusion-weighted images), magnetic resonance angiography (MRA), magnetic resonance venography (MRV) and conventional angiography. Transcranial Doppler sonography of the intracranial vessels and Duplex scan of the neck are valuable modalities for detecting large vessel vasculopathy, which occur in SCD, moyamoya syndrome, arterial dissection, and stenosis. Antithrombotic drugs are increasingly being used in the acute phase of childhood ischemic stroke. These include unfractionated heparin, low-molecular-weight heparins, aspirin or warfarin, or both. Specialized stroke care and follow-up are needed for children with stroke, as well as their families.

Advancing stroke genomic research in the age of Trans-Omics big data science: Emerging priorities and opportunities.

PubMed

Owolabi, Mayowa; Peprah, Emmanuel; Xu, Huichun; Akinyemi, Rufus; Tiwari, Hemant K; Irvin, Marguerite R; Wahab, Kolawole Wasiu; Arnett, Donna K; Ovbiagele, Bruce

2017-11-15

We systematically reviewed the genetic variants associated with stroke in genome-wide association studies (GWAS) and examined the emerging priorities and opportunities for rapidly advancing stroke research in the era of Trans-Omics science. Using the PRISMA guideline, we searched PubMed and NHGRI- EBI GWAS catalog for stroke studies from 2007 till May 2017. We included 31 studies. The major challenge is that the few validated variants could not account for the full genetic risk of stroke and have not been translated for clinical use. None of the studies included continental Africans. Genomic study of stroke among Africans presents a unique opportunity for the discovery, validation, functional annotation, Trans-Omics study and translation of genomic determinants of stroke with implications for global populations. This is because all humans originated from Africa, a continent with a unique genomic architecture and a distinctive epidemiology of stroke; as well as substantially higher heritability and resolution of fine mapping of stroke genes. Understanding the genomic determinants of stroke and the corresponding molecular mechanisms will revolutionize the development of a new set of precise biomarkers for stroke prediction, diagnosis and prognostic estimates as well as personalized interventions for reducing the global burden of stroke. Copyright © 2017 Elsevier B.V. All rights reserved.

Stroke rehabilitation

PubMed Central

Bindawas, Saad M.; Vennu, Vishal S.

2016-01-01

Stroke is a major cause of death and other complications worldwide. In Saudi Arabia, stroke has become an emerging health issue leading to disability and death. However, stroke care including rehabilitation services, in Saudi Arabia lags behind developed countries. Stroke rehabilitation is an essential recovery option after stroke and should start as early as possible to avoid potential complications. The growing evidence on stroke rehabilitation effectiveness in different health care settings and outcome measures used widely are reviewed in this call to action paper. PMID:27744457

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

PubMed

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

2017-11-01

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

Cost-Effectiveness of Endovascular Stroke Therapy: A Patient Subgroup Analysis From a US Healthcare Perspective.

PubMed

Kunz, Wolfgang G; Hunink, M G Myriam; Sommer, Wieland H; Beyer, Sebastian E; Meinel, Felix G; Dorn, Franziska; Wirth, Stefan; Reiser, Maximilian F; Ertl-Wagner, Birgit; Thierfelder, Kolja M

2016-11-01

Endovascular therapy in addition to standard care (EVT+SC) has been demonstrated to be more effective than SC in acute ischemic large vessel occlusion stroke. Our aim was to determine the cost-effectiveness of EVT+SC depending on patients' initial National Institutes of Health Stroke Scale (NIHSS) score, time from symptom onset, Alberta Stroke Program Early CT Score (ASPECTS), and occlusion location. A decision model based on Markov simulations estimated lifetime costs and quality-adjusted life years (QALYs) associated with both strategies applied in a US setting. Model input parameters were obtained from the literature, including recently pooled outcome data of 5 randomized controlled trials (ESCAPE [Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke], EXTEND-IA [Extending the Time for Thrombolysis in Emergency Neurological Deficits-Intra-Arterial], MR CLEAN [Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands], REVASCAT [Randomized Trial of Revascularization With Solitaire FR Device Versus Best Medical Therapy in the Treatment of Acute Stroke Due to Anterior Circulation Large Vessel Occlusion Presenting Within 8 Hours of Symptom Onset], and SWIFT PRIME [Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment]). Probabilistic sensitivity analysis was performed to estimate uncertainty of the model results. Net monetary benefits, incremental costs, incremental effectiveness, and incremental cost-effectiveness ratios were derived from the probabilistic sensitivity analysis. The willingness-to-pay was set to $50 000/QALY. Overall, EVT+SC was cost-effective compared with SC (incremental cost: $4938, incremental effectiveness: 1.59 QALYs, and incremental cost-effectiveness ratio: $3110/QALY) in 100% of simulations. In all patient subgroups, EVT+SC led to gained QALYs (range: 0.47-2.12), and mean incremental cost-effectiveness ratios were considered cost-effective. However, subgroups with ASPECTS ≤5 or with M2 occlusions showed considerably higher incremental cost-effectiveness ratios ($14 273/QALY and $28 812/QALY, respectively) and only reached suboptimal acceptability in the probabilistic sensitivity analysis (75.5% and 59.4%, respectively). All other subgroups had acceptability rates of 90% to 100%. EVT+SC is cost-effective in most subgroups. In patients with ASPECTS ≤5 or with M2 occlusions, cost-effectiveness remains uncertain based on current data. © 2016 American Heart Association, Inc.

Antiplatelet Agents for the Secondary Prevention of Ischemic Stroke or Transient Ischemic Attack: A Network Meta-Analysis.

PubMed

Wang, Wen; Zhang, Lu; Liu, Weiming; Zhu, Qin; Lan, Qing; Zhao, Jizong

2016-05-01

Stroke can cause high morbidity and mortality, and ischemic stroke (IS) and transient ischemic attack (TIA) patients have a high stroke recurrence rate. Antiplatelet agents are the standard therapy for these patients, but it is often difficult for clinicians to select the best therapy from among the multiple treatment options. We therefore performed a network meta-analysis to estimate the efficacy of antiplatelet agents for secondary prevention of recurrent stroke. We systematically searched 3 databases (PubMed, Embase, and Cochrane) for relevant studies published through August 2015. The primary end points of this meta-analysis were overall stroke, hemorrhagic stroke, and fatal stroke. A total of 30 trials were included in our network meta-analysis and abstracted data. Among the therapies evaluated in the included trials, the estimates for overall stroke and hemorrhagic stroke for cilostazol (Cilo) were significantly better than those for aspirin (odds ratio [OR] = .64, 95% credibility interval [CrI], .45-.91; OR = .23, 95% CrI, .08-.58). The estimate for fatal stroke was highest for Cilo plus aspirin combination therapy, followed by Cilo therapy. The results of our meta-analysis indicate that Cilo significantly improves overall stroke and hemorrhagic stroke in IS or TIA patients and reduces fatal stroke, but with low statistical significance. Our results also show that Cilo was significantly more efficient than other therapies in Asian patients; therefore, future trials should focus on Cilo treatment for secondary prevention of recurrent stroke in non-Asian patients. Copyright © 2016 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Elevated body temperature in ischemic stroke associated with neurological improvement.

PubMed

Khanevski, A N; Naess, H; Thomassen, L; Waje-Andreassen, U; Nacu, A; Kvistad, C E

2017-11-01

Some studies suggest that high body temperature within the first few hours of ischemic stroke onset is associated with improved outcome. We hypothesized an association between high body temperature on admission and detectable improvement within 6-9 hours of stroke onset. Consecutive ischemic stroke patients with NIHSS scores obtained within 3 hours and in the interval 6-9 hours after stroke onset were included. Body temperature was measured on admission. A total of 315 patients with ischemic stroke were included. Median NIHSS score on admission was 6. Linear regression showed that NIHSS score 6-9 hours after stroke onset was inversely associated with body temperature on admission after adjusting for confounders including NIHSS score <3 hours after stroke onset (P<.001). The same result was found in patients with proximal middle cerebral occlusion on admission. We found an inverse association between admission body temperature and neurological improvement within few hours after admission. This finding may be limited to patients with documented proximal middle cerebral artery occlusion on admission and suggests a beneficial effect of higher body temperature on clot lysis within the first three hours. © 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Pediatric stroke and transcranial direct current stimulation: methods for rational individualized dose optimization

PubMed Central

Gillick, Bernadette T.; Kirton, Adam; Carmel, Jason B.; Minhas, Preet; Bikson, Marom

2014-01-01

Background: Transcranial direct current stimulation (tDCS) has been investigated mainly in adults and doses may not be appropriate in pediatric applications. In perinatal stroke where potential applications are promising, rational adaptation of dosage for children remains under investigation. Objective: Construct child-specific tDCS dosing parameters through case study within a perinatal stroke tDCS safety and feasibility trial. Methods: 10-year-old subject with a diagnosis of presumed perinatal ischemic stroke and hemiparesis was identified. T1 magnetic resonance imaging (MRI) scans used to derive computerized model for current flow and electrode positions. Workflow using modeling results and consideration of dosage in previous clinical trials was incorporated. Prior ad hoc adult montages vs. de novo optimized montages provided distinct risk benefit analysis. Approximating adult dose required consideration of changes in both peak brain current flow and distribution which further tradeoff between maximizing efficacy and adding safety factors. Electrode size, position, current intensity, compliance voltage, and duration were controlled independently in this process. Results: Brain electric fields modeled and compared to values previously predicted models (Datta et al., 2011; Minhas et al., 2012). Approximating conservative brain current flow patterns and intensities used in previous adult trials for comparable indications, the optimal current intensity established was 0.7 mA for 10 min with a tDCS C3/C4 montage. Specifically 0.7 mA produced comparable peak brain current intensity of an average adult receiving 1.0 mA. Electrode size of 5 × 7 cm2 with 1.0 mA and low-voltage tDCS was employed to maximize tolerability. Safety and feasibility confirmed with subject tolerating the session well and no serious adverse events. Conclusion: Rational approaches to dose customization, with steps informed by computational modeling, may improve guidance for pediatric stroke tDCS trials. PMID:25285077

Anesthetic variation and potential impact of anesthetics used during endovascular management of acute ischemic stroke.

PubMed

Sivasankar, Chitra; Stiefel, Michael; Miano, Todd A; Kositratna, Guy; Yandrawatthana, Sukanya; Hurst, Robert; Kofke, W Andrew

2016-11-01

Many authors have reported that general anesthesia (GA), as a generic and uncharacterized therapy, is contraindicated for patients undergoing endovascular management of acute ischemic stroke (EMAIS). The recent American Heart Association update cautiously suggests that it might be reasonable to favor conscious sedation over GA during EMAIS. We are concerned that such recommendations will result in patients undergoing endovascular treatment without consideration of the effects of specific anesthetic agents and anesthetic dose, and without appropriate critical consideration of the individual patient's issues. We hypothesized that significant variation in anesthetic practice comprises GA, and that outcome differences among types of GA would arise. With IRB approval, we examined the records of patients who underwent anterior circulation EMAIS at the University of Pennsylvania from 2010 to 2015. Patients were managed by different anesthesiologists with no specific protocol. We analyzed American Society of Anesthesiologists status, NIH Stroke Scale, type of stroke, procedure, different types of anesthetic, blood pressure control, and outcome metrics. Modified Rankin Scale (mRS) scores were determined from medical records. GA was used in 91% of patients. Several types of GA were employed: intravenous, volatile, and intravenous/volatile combined. mRS scores ≤2 at discharge were observed in 42.8% of patients receiving volatile anesthesia and were better in patients receiving only volatile agents after induction of anesthesia (p<0.05). Our data support the notion that anesthetic techniques and associated physiology used in EMAIS are not homogeneous, making any statements about the effects of generic GA in stroke ambiguous. Moreover, our data suggest that the type of GA may affect the outcome after EMAIS. 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/.

Dental Management of a Pediatric Patient with Moyamoya Syndrome: A Rare Clinical Entity.

PubMed

Ko, Brittany L; Unkel, John H

2018-01-01

Moyamoya disease (MMD) is a rare cerebrovascular disorder involving progressive constriction of the internal carotid artery and its branches. The disease has a particularly aggressive course in very young patients, and early surgical intervention is often necessary to prevent permanent neurological damage. MMD patients have an increased risk of stroke development, which may be provoked by pain or anxiety. Currently, no reports of pediatric patients with MMD exist in the dental literature. The purpose of this paper was to discuss the dental management of a two-year-old with moyamoya disease who presented with early childhood caries and dental fear, offering recommendations for dental providers with emphasis on stroke prevention, collaboration with the medical team, anesthesia considerations for patients with increased stroke risk, and the challenges to maintain the oral health of a patient undergoing complex medical treatment.

Association of MTHFR C677T Genotype With Ischemic Stroke Is Confined to Cerebral Small Vessel Disease Subtype

PubMed Central

Traylor, Matthew; Adib-Samii, Poneh; Thijs, Vincent; Sudlow, Cathie; Rothwell, Peter M.; Boncoraglio, Giorgio; Dichgans, Martin; Meschia, James; Maguire, Jane; Levi, Christopher; Rost, Natalia S.; Rosand, Jonathan; Hassan, Ahamad; Bevan, Steve; Markus, Hugh S.

2016-01-01

Background and Purpose— Elevated plasma homocysteine levels are associated with stroke. However, this might be a reflection of bias or confounding because trials have failed to demonstrate an effect from homocysteine lowering in stroke patients, although a possible benefit has been suggested in lacunar stroke. Genetic studies could potentially overcome these issues because genetic variants are inherited randomly and are fixed at conception. Therefore, we tested the homocysteine levels–associated genetic variant MTHFR C677T for association with magnetic resonance imaging–confirmed lacunar stroke and compared this with associations with large artery and cardioembolic stroke subtypes. Methods— We included 1359 magnetic resonance imaging–confirmed lacunar stroke cases, 1824 large artery stroke cases, 1970 cardioembolic stroke cases, and 14 448 controls, all of European ancestry. Furthermore, we studied 3670 ischemic stroke patients in whom white matter hyperintensities volume was measured. We tested MTHFR C677T for association with stroke subtypes and white matter hyperintensities volume. Because of the established association of homocysteine with hypertension, we additionally stratified for hypertension status. Results— MTHFR C677T was associated with lacunar stroke (P=0.0003) and white matter hyperintensity volume (P=0.04), but not with the other stroke subtypes. Stratifying the lacunar stroke cases for hypertension status confirmed this association in hypertensive individuals (P=0.0002), but not in normotensive individuals (P=0.30). Conclusions— MTHFR C677T was associated with magnetic resonance imaging–confirmed lacunar stroke, but not large artery or cardioembolic stroke. The association may act through increased susceptibility to, or interaction with, high blood pressure. This heterogeneity of association might explain the lack of effect of lowering homocysteine in secondary prevention trials which included all strokes. PMID:26839351

Projected Numbers of Ischemic Strokes Recorded in the Austrian Stroke-Unit Registry from 2012 to 2075.

PubMed

Hitzl, Wolfgang; Trinka, Eugen; Seyfang, Leonard; Mutzenbach, Sebastian; Stadler, Katharina; Pikija, Slaven; Killer, Monika; Broussalis, Erasmia

2016-10-01

This study analyzed the number of patients with ischemic strokes recorded in the Austrian Stroke-Unit Registry with the aim of projecting this number from 2012 to 2075 and to highlight that the Austrian health system will face a dramatic increase in older patients within the next few decades. Current demographic information was obtained from EUROSTAT, and information on age- and sex-stratified 1-year incidence rates of ischemic stroke were obtained from the Austrian Stroke-Unit Registry. Sensitivity analysis was performed by analyzing the projections based on predicted ageing, main, and growth population scenarios, and with stratification by age and gender. The total number of ischemic strokes recorded in the Austrian Stroke-Unit Registry was 8,690 in 2012 and is expected to increase to 15,826, 15,626, or 18,134 in 2075 according to the ageing, main, and growth scenarios, respectively. The corresponding numbers of patients are projected to increase or decrease within different age strata as follows (100%=number of registered ischemic strokes in 2012): 0-40 years, 100%/99% (males/females); 40-50 years, 83%/83%; 50-60 years, 98%/97%; 60-70 years, 126%/119%; 70-80 years, 159%/139%; 80-90 years, 307%/199%; and 90+ years, 894%/413%. The ageing population in Austria will result in the number of patients increasing considerably from 2012 to 2075, to 182%, 180%, or 208% (relative to 100% in 2012) according to the ageing, main, and growth scenarios, respectively; the corresponding value among those aged 80+ years is 315%, 290%, or 347%. These figures demonstrated the importance of improving primary preventive measures. The results of this study should provide a basis for discussions among health-care professionals and economists to face the future large financial burden of ischemic stroke on the Austrian health system.

Factors associated with hospital arrival time after the onset of stroke symptoms: A cross-sectional study at two teaching hospitals in Harare, Zimbabwe.

PubMed

Seremwe, Farayi; Kaseke, Farayi; Chikwanha, Theodora M; Chikwasha, Vasco

2017-06-01

Late presentation to hospital after onset of stroke affects management and outcomes of the patients. This study aimed to determine the factors associated with time taken to present to hospital after the onset of acute stroke symptoms. A descriptive cross sectional study was conducted at two teaching hospitals in Zimbabwe. Participants included patients admitted with stroke and their relatives. A self-administered questionnaire was used to collect information on history of stroke occurrence and time taken to present to hospital. Data was analysed for means, frequencies, percentages and Odds ratios. Less than half (33%) of the participants were able to recognize symptoms of stroke. Not having money to pay for hospital bills was a predictor of late hospital presentation (OR =6.64; 95% CI, (2.05-21.53); p=0.002). The other factors, though not statistically significant included not perceiving stroke as a serious illness (OR = 2.43; 95% CI (0.78-5.51); p=0.083) and unavailability of transport (OR=2.33; 95% CI (0.71-7.56); p=0.161). Predictors for early presentation included receiving knowledge about stroke from the community (OR=0.46; 95% CI (0.15-1.39); p=0.170); seeking help at the hospital (OR=0.50; 95% CI (0.18-1.37); p=0.177) and having a stroke while at the workplace (OR =0.46; 95% CI (0.08-2.72); p=0.389). Regarding stroke as an emergency that does not require prerequisite payment for services at hospitals and improved community awareness on stroke may improve time taken to present to hospital after the onset of stroke symptoms.

Predictors and Outcomes of Dysphagia Screening After Acute Ischemic Stroke.

PubMed

Joundi, Raed A; Martino, Rosemary; Saposnik, Gustavo; Giannakeas, Vasily; Fang, Jiming; Kapral, Moira K

2017-04-01

Guidelines advocate screening all acute stroke patients for dysphagia. However, limited data are available regarding how many and which patients are screened and how failing a swallowing screen affects patient outcomes. We sought to evaluate predictors of receiving dysphagia screening after acute ischemic stroke and outcomes after failing a screening test. We used the Ontario Stroke Registry from April 1, 2010, to March 31, 2013, to identify patients hospitalized with acute ischemic stroke and determine predictors of documented dysphagia screening and outcomes after failing the screening test, including pneumonia, disability, and death. Among 7171 patients, 6677 patients were eligible to receive dysphagia screening within 72 hours, yet 1280 (19.2%) patients did not undergo documented screening. Patients with mild strokes were significantly less likely than those with more severe strokes to have documented screening (adjusted odds ratio, 0.51; 95% confidence interval [CI], 0.41-0.64). Failing dysphagia screening was associated with poor outcomes, including pneumonia (adjusted odds ratio, 4.71; 95% CI, 3.43-6.47), severe disability (adjusted odds ratio, 5.19; 95% CI, 4.48-6.02), discharge to long-term care (adjusted odds ratio, 2.79; 95% CI, 2.11-3.79), and 1-year mortality (adjusted hazard ratio, 2.42; 95% CI, 2.09-2.80). Associations were maintained in patients with mild strokes. One in 5 patients with acute ischemic stroke did not have documented dysphagia screening, and patients with mild strokes were substantially less likely to have documented screening. Failing dysphagia screening was associated with poor outcomes, including in patients with mild strokes, highlighting the importance of dysphagia screening for all patients with acute ischemic stroke. © 2017 American Heart Association, Inc.

Barriers and facilitators associated with return to work after stroke: a qualitative meta-synthesis.

PubMed

Brannigan, Colm; Galvin, Rose; Walsh, Mary E; Loughnane, Cliona; Morrissey, Emma-Jane; Macey, Chris; Delargy, Mark; Horgan, N Frances

2017-02-01

To enhance the employment outcomes of individuals who experience a stroke, it is essential to understand the factors that determine successful return to work. The aim of this systematic review was to examine barriers to and facilitators of return to work after stroke from the perspective of people with stroke through the process of a qualitative meta-synthesis. A systematic literature search was conducted. Studies that employed qualitative methods to explore the experiences of individuals with stroke around return to work after stroke were included. The methodological quality of the studies was assessed by two independent reviewers. Overarching themes, concepts and interpretations were extracted from each individual study, compared and meta-synthesized. Fifteen studies were included and the overall methodological quality of the studies was good. Four broad themes emerged as factors associated with return to work after stroke. These included (i) the nature of the effects of stroke, (ii) the preparatory environment, (iii) personal coping strategies and internal challenges and (iv) the meaning of work. Return to work after stroke is a complex process which can be facilitated or impeded by organizational, social or personal factors, as well as accessibility to appropriate services. Implications for Rehabilitation Following a period of dedicated inpatient rehabilitation, there is a need to integrate community-support services to optimize return to work among stroke survivors. A dedicated community stroke support liaison officer may help to facilitate the transition between the hospital and the community and workplace environment. Education provided by healthcare professionals is necessary in the community and the workplace to ensure that family, friends and employers are aware of the impairments, activity limitations and participation restrictions of the stroke survivor.

Mortality rates for stroke in England from 1979 to 2004: trends, diagnostic precision, and artifacts.

PubMed

Goldacre, Michael J; Duncan, Marie; Griffith, Myfanwy; Rothwell, Peter M

2008-08-01

Stroke mortality appears to be declining more rapidly in the UK than in many other Western countries. To understand this apparent decline better, we studied trends in mortality in the UK using more detailed data than are routinely available. Analysis of datasets that include both the underlying cause and all other mentioned causes of death (together, termed "all mentions"): the Oxford Record Linkage Study from 1979 to 2004 and English national data from 1996 to 2004. Mortality rates based on underlying cause and based on all mentions showed similar downward trends. Mortality based on underlying cause alone misses about one quarter of all stroke-related deaths. Changes during the period in the national rules for selecting the underlying cause of death had a significant but fairly small effect on the trend. Overall, mortality fell by an average annual rate of 2.3% (95% confidence interval 2.1% to 2.5%) for stroke excluding subarachnoid hemorrhage; and by 2.1% (1.7% to 2.6%) per annum for subarachnoid hemorrhage. Coding of stroke as hemorrhagic, occlusive, or unspecified varied substantially across the study period. As a result, rates for hemorrhagic and occlusive stroke, affected by artifact, seemed to fall substantially in the first part of the study period and then leveled off. Studies of stroke mortality should include all mentions as well as the certified underlying cause, otherwise the burden of stroke will be underestimated. Studies of stroke mortality that include strokes specified as hemorrhagic or occlusive, without also considering stroke overall, are likely to be misleading. Stroke mortality in the Oxford region halved between 1979 and 2004.

Life Satisfaction and Risk of Chronic Diseases in the European Prospective Investigation into Cancer and Nutrition (EPIC)-Germany Study

PubMed Central

Feller, Silke; Teucher, Birgit; Kaaks, Rudolf; Boeing, Heiner; Vigl, Matthaeus

2013-01-01

Objective The aim of the study was to examine the prospective association between life satisfaction and risk of type 2 diabetes mellitus, myocardial infarction, stroke, and cancer. Previous studies suggested that psychosocial factors may affect the development of chronic diseases but the impact of positive attitudes, in particular life satisfaction, is yet to be determined. Methods The analysis included 50,358 participants of the European Prospective Investigation into Cancer and Nutrition (EPIC)-Germany study in Potsdam and Heidelberg. Life satisfaction was assessed in a baseline interview and incident cases of chronic diseases were identified and verified during follow-up. Hazard ratios were calculated using Cox proportional hazards regression models that were systematically multivariable-adjusted for established risk factors and prevalent diseases. Results During an average of 8 years of follow-up 2,293 cases of cancer, 1,840 cases of type 2 diabetes mellitus, 440 cases of stroke, and 562 cases of myocardial infarction were observed. Women who were unsatisfied with life at baseline showed in all models a significantly increased risk of cancer (HR: 1.45; 95% CI: 1.18-1.78) and stroke (HR: 1.69; 95% CI: 1.05-2.73) as well as an increased risk of type 2 diabetes mellitus by trend across categories (p-trend=0.04) compared to women very satisfied with life. In men, a relationship between life satisfaction and stroke was found but did not persist after consideration of lifestyle factors and prevalent diseases. No significant association was observed between life satisfaction and risk of myocardial infarction. Conclusions The results of this study suggest that reduced life satisfaction is related to the development of chronic diseases—particularly in women and partly mediated by established risk factors. PMID:23977388

Impact of a Computerized Antithrombotic Risk Assessment Tool on the Prescription of Thromboprophylaxis in Atrial Fibrillation: Hospital Setting.

PubMed

Pandya, E; Masood, N; Wang, Y; Krass, I; Bajorek, B

2018-01-01

The computerized antithrombotic risk assessment tool (CARAT) is an online decision-support algorithm that facilitates a systematic review of a patient's stroke risk, bleeding risk, and pertinent medication safety considerations, to generate an individualized treatment recommendation. The CARAT was prospectively applied across 2 hospitals in the greater Sydney area. Its impact on antithrombotics utilization for thromboprophylaxis in patients with nonvalvular atrial fibrillation was evaluated. Factors influencing prescribers' treatment selection were identified. The CARAT recommended a change in baseline therapy for 51.8% of patients. Among anticoagulant-eligible patients (ie, where the risk of stroke outweighed the risk of bleeding) using "nil therapy" or antiplatelet therapy at baseline, the CARAT recommended an upgrade to warfarin in 60 (30.8%) patients. For those in whom the bleeding risk outweighed the stroke risk, the CARAT recommended a downgrade from warfarin to safer alternatives (eg, aspirin) in 37 (19%) patients. Among the "most eligible" (ie, high stroke risk, low bleeding risk, no contraindications; n = 75), the CARAT recommended warfarin for all cases. Discharge therapy observed a marginal increase in anticoagulation prescription in eligible patients (n = 116; 57.8% vs 64.7%, P = .35) compared to baseline. Predictors of warfarin use (vs antiplatelets) included congestive cardiac failure, diabetes mellitus, and polypharmacy. The CARAT was able to optimize the selection of therapy, increasing anticoagulant use among eligible patients. With the increasing complexity of decision-making, such tools may be useful adjuncts in therapy selection in atrial fibrillation. Future studies should explore the utility of such tools in selecting therapies from within an expanded treatment armamentarium comprising the non-vitamin K antagonist oral anticoagulants.

Quantifying links between stroke and risk factors: a study on individual health risk appraisal of stroke in a community of Chongqing.

PubMed

Wu, Yazhou; Zhang, Ling; Yuan, Xiaoyan; Wu, Yamin; Yi, Dong

2011-04-01

The objective of this study is to investigate the risk factors of stroke in a community in Chongqing by setting quantitative criteria for determining the risk factors of stroke. Thus, high-risk individuals can be identified and laid a foundation for predicting individual risk of stroke. 1,034 cases with 1:2 matched controls (2,068) were chosen from five communities in Chongqing including Shapingba, Xiaolongkan, Tianxingqiao, Yubei Road and Ciqikou. Participants were interviewed with a uniform questionnaire. The risk factors of stroke and the odds ratios of risk factors were analyzed with a logistic regression model, and risk exposure factors of different levels were converted into risk scores using statistical models. For men, ten risk factors including hypertension (5.728), family history of stroke (4.599), and coronary heart disease (5.404), among others, were entered into the main effect model. For women, 11 risk factors included hypertension (5.270), family history of stroke (4.866), hyperlipidemia (4.346), among others. The related risk scores were added to obtain a combined risk score to predict the individual's risk of stoke in the future. An individual health risk appraisal model of stroke, which was applicable to individuals of different gender, age, health behavior, disease and family history, was established. In conclusion, personal diseases including hypertension, diabetes mellitus, etc., were very important to the prevalence of stoke. The prevalence of stroke can be effectively reduced by changing unhealthy lifestyles and curing the positive individual disease. The study lays a foundation for health education to persuade people to change their unhealthy lifestyles or behaviors, and could be used in community health services.

Cerebellar stroke presenting with isolated dizziness: Brain MRI in 136 patients.

PubMed

Perloff, Michael D; Patel, Nimesh S; Kase, Carlos S; Oza, Anuja U; Voetsch, Barbara; Romero, Jose R

2017-11-01

To evaluate occurrence of cerebellar stroke in Emergency Department (ED) presentations of isolated dizziness (dizziness with a normal exam and negative neurological review of systems). A 5-year retrospective study of ED patients presenting with a chief complaint of "dizziness or vertigo", without other symptoms or signs in narrative history or on exam to suggest a central nervous system lesion, and work-up included a brain MRI within 48h. Patients with symptoms commonly peripheral in etiology (nystagmus, tinnitus, gait instability, etc.) were included in the study. Patient demographics, stroke risk factors, and gait assessments were recorded. One hundred and thirty-six patients, who had a brain MRI for isolated dizziness, were included. There was a low correlation of gait assessment between ED physician and Neurologist (49 patients, Spearman's correlation r 2 =0.17). Based on MRI DWI sequence, 3.7% (5/136 patients) had acute cerebellar strokes, limited to or including, the medial posterior inferior cerebellar artery vascular territory. In the 5 cerebellar stroke patients, mean age, body mass index (BMI), hemoglobin A1c, gender distribution, and prevalence of hypertension were similar to the non-cerebellar stroke patient group. Mean LDL/HDL ratio was 3.63±0.80 and smoking prevalence was 80% in the cerebellar stroke group compared to 2.43±0.79 and 22% (respectively, p values<0.01) in the non-cerebellar stroke group. Though there was preselection bias for stroke risk factors, our study suggests an important proportion of cerebellar stroke among ED patients with isolated dizziness, considering how common this complaint is. Copyright © 2017 Elsevier Inc. All rights reserved.

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

PubMed

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

2011-09-01

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

Risk factors, quality of care and prognosis in South Asian, East Asian and White patients with stroke.

PubMed

Khan, Nadia A; Quan, Hude; Hill, Michael D; Pilote, Louise; McAlister, Finlay A; Palepu, Anita; Shah, Baiju R; Zhou, Limei; Zhen, Hong; Kapral, Moira K

2013-07-05

Stroke has emerged as a significant and escalating health problem for Asian populations. We compared risk factors, quality of care and risk of death or recurrent stroke in South Asian, East Asian and White patients with acute ischemic and hemorrhagic stroke. Retrospective analysis was performed on consecutive patients with ischemic stroke or intracerebral hemorrhage admitted to 12 stroke centers in Ontario, Canada (July 2003-March 2008) and included in the Registry of the Canadian Stroke Network database. The database was linked to population-based administrative databases to determine one-year risk of death or recurrent stroke. The study included 253 South Asian, 513 East Asian and 8231 White patients. East Asian patients were more likely to present with intracerebral hemorrhage (30%) compared to South Asian (17%) or White patients (15%) (p<0.001). Time from stroke to hospital arrival was similarly poor with delays >2 hours for more than two thirds of patients in all ethnic groups. Processes of stroke care, including thrombolysis, diagnostic imaging, antithrombotic medications, and rehabilitation services were similar among ethnic groups. Risk of death or recurrent stroke at one year after ischemic stroke was similar for patients who were White (27.6%), East Asian (24.7%, aHR 0.97, 95% CI 0.78-1.21 vs. White), or South Asian (21.9%, aHR 0.91, 95% CI 0.67-1.24 vs. White). Although risk of death or recurrent stroke at one year after intracerebral hemorrhage was higher in East Asian (35.5%) and White patients (47.9%) compared to South Asian patients (30.2%) (p=0.002), these differences disappeared after adjustment for age, sex, stroke severity and comorbid conditions (aHR 0.89 [0.67-1.19] for East Asian vs White and 0.99 [0.54-1.81] for South Asian vs. White). After stratification by stroke type, stroke care and outcomes are similar across ethnic groups in Ontario. Enhanced health promotion is needed to reduce delays to hospital for all ethnic groups.

Risk factors, quality of care and prognosis in South Asian, East Asian and White patients with stroke

PubMed Central

2013-01-01

Background Stroke has emerged as a significant and escalating health problem for Asian populations. We compared risk factors, quality of care and risk of death or recurrent stroke in South Asian, East Asian and White patients with acute ischemic and hemorrhagic stroke. Methods Retrospective analysis was performed on consecutive patients with ischemic stroke or intracerebral hemorrhage admitted to 12 stroke centers in Ontario, Canada (July 2003-March 2008) and included in the Registry of the Canadian Stroke Network database. The database was linked to population-based administrative databases to determine one-year risk of death or recurrent stroke. Results The study included 253 South Asian, 513 East Asian and 8231 White patients. East Asian patients were more likely to present with intracerebral hemorrhage (30%) compared to South Asian (17%) or White patients (15%) (p<0.001). Time from stroke to hospital arrival was similarly poor with delays >2 hours for more than two thirds of patients in all ethnic groups. Processes of stroke care, including thrombolysis, diagnostic imaging, antithrombotic medications, and rehabilitation services were similar among ethnic groups. Risk of death or recurrent stroke at one year after ischemic stroke was similar for patients who were White (27.6%), East Asian (24.7%, aHR 0.97, 95% CI 0.78-1.21 vs. White), or South Asian (21.9%, aHR 0.91, 95% CI 0.67-1.24 vs. White). Although risk of death or recurrent stroke at one year after intracerebral hemorrhage was higher in East Asian (35.5%) and White patients (47.9%) compared to South Asian patients (30.2%) (p=0.002), these differences disappeared after adjustment for age, sex, stroke severity and comorbid conditions (aHR 0.89 [0.67-1.19] for East Asian vs White and 0.99 [0.54-1.81] for South Asian vs. White). Conclusion After stratification by stroke type, stroke care and outcomes are similar across ethnic groups in Ontario. Enhanced health promotion is needed to reduce delays to hospital for all ethnic groups. PMID:23829874

Acute Neurological Issues in Pregnancy and the Peripartum

PubMed Central

Hosley, Catherine M.; McCullough, Louise D.

2011-01-01

Acute neurological diseases requiring hospitalization are relatively rare in women of childbearing age. However, during pregnancy and the postpartum period, several diseases increase in prevalence. Some are unique to the pregnant/postpartum state including preeclampsia and delivery-associated neuropathies. Others, although indirectly related to pregnancy, such as cerebral venous thrombosis, ischemic stroke, and intracerebral hemorrhage, increase in frequency and carry considerable risk of morbidity and mortality. In addition, treatment options are often limited. This review discusses the diseases more commonly seen during pregnancy and the postpartum period, with a focus on emergent neurological diseases and their management. Interventional therapies will also be discussed. PMID:23983844

Psychosocial experiences and needs of Australian caregivers of people with stroke: prognosis messages, caregiver resilience, and relationships.

PubMed

El Masry, Yasmeen; Mullan, Barbara; Hackett, Maree

2013-01-01

Despite stroke being the most common form of cerebrovascular disease, there has been relatively little attention paid to the psychosocial experiences and needs of Australian caregivers of people who have had a stroke. Twenty Australian informal caregivers and 10 stroke survivors participated in individual semi-structured qualitative interviews covering all aspects of caregiving, including stroke survivors' views on their caregiver's experiences. The 5 interrelated topics most discussed were changes in relationships and support services, including being told to expect a poor outcome; caregiver attributes and coping strategies; stroke survivor limitations; external employment and financial stressors; and unexpected positive changes in relationships and priorities. Caring for a stroke survivor involves a complex interaction of these factors that appear to be moderated by the quality of the pre-existing stroke survivor-caregiver relationship and the poststroke coping strategies used. Particular attention should be paid to how prognosis is conveyed and whether appropriate outpatient services are available. Clinicians should also consider discussing appropriate caregiver coping strategies and the quality of the relationship between the stroke survivor and caregiver.

Dysphagia in the elderly: management and nutritional considerations

PubMed Central

Sura, Livia; Madhavan, Aarthi; Carnaby, Giselle; Crary, Michael A

2012-01-01

Dysphagia is a prevalent difficulty among aging adults. Though increasing age facilitates subtle physiologic changes in swallow function, age-related diseases are significant factors in the presence and severity of dysphagia. Among elderly diseases and health complications, stroke and dementia reflect high rates of dysphagia. In both conditions, dysphagia is associated with nutritional deficits and increased risk of pneumonia. Recent efforts have suggested that elderly community dwellers are also at risk for dysphagia and associated deficits in nutritional status and increased pneumonia risk. Swallowing rehabilitation is an effective approach to increase safe oral intake in these populations and recent research has demonstrated extended benefits related to improved nutritional status and reduced pneumonia rates. In this manuscript, we review data describing age related changes in swallowing and discuss the relationship of dysphagia in patients following stroke, those with dementia, and in community dwelling elderly. Subsequently, we review basic approaches to dysphagia intervention including both compensatory and rehabilitative approaches. We conclude with a discussion on the positive impact of swallowing rehabilitation on malnutrition and pneumonia in elderly who either present with dysphagia or are at risk for dysphagia. PMID:22956864

Evaluation of actuators for the SDOF and MDOF active microgravity isolation systems

NASA Technical Reports Server (NTRS)

1993-01-01

The University of Virginia examined the design of actuators for both single-degree-of-freedom (SDOF) and multiple-degree-of-freedom (MDOF) active microgravity isolation systems. For SDOF systems, two actuators were considered: a special large gap magnetic actuator and a large stroke Lorentz actuator. The magnetic actuator was viewed to be of greater difficulty than the Lorentz actuator with little compelling technical advantage and was dropped from consideration. A Lorentz actuator was designed and built for the SDOF test rig using magnetic circuit and finite element analysis. The design and some experimental results are discussed. The University also examined the design of actuators for MDOF isolation systems. This includes design of an integrated 1 cm gap 6-DOF noncontacting magnetic suspension system and of a 'coarse' follower which permits the practical extension of magnetic suspension to large strokes. The proposed 'coarse' actuator was a closed kinematic chain manipulator known as a Stewart Platform. The integration of the two isolation systems together, the isolation tasks assigned to each, and possible control architectures were also explored. The results of this research are examined.

A stepwise approach to stroke surveillance in Brazil: the EMMA (Estudo de Mortalidade e Morbidade do Acidente Vascular Cerebral) study.

PubMed

Goulart, Alessandra C; Bustos, Iara R; Abe, Ivana M; Pereira, Alexandre C; Fedeli, Ligia M; Benseñor, Isabela M; Lotufo, Paulo A

2010-08-01

Stroke mortality rates in Brazil are the highest in the Americas. Deaths from cerebrovascular disease surpass coronary heart disease. To verify stroke mortality rates and morbidity in an area of São Paulo, Brazil, using the World Health Organization Stepwise Approach to Stroke Surveillance. We used the World Health Organization Stepwise Approach to Stroke Surveillance structure of stroke surveillance. The hospital-based data comprised fatal and nonfatal stroke (Step 1). We gathered stroke-related mortality data in the community using World Health Organization questionnaires (Step 2). The questionnaire determining stroke prevalence was activated door to door in a family-health-programme neighbourhood (Step 3). A total of 682 patients 18 years and above, including 472 incident cases, presented with cerebrovascular disease and were enrolled in Step 1 during April-May 2009. Cerebral infarction (84.3%) and first-ever stroke (85.2%) were the most frequent. In Step 2, 256 deaths from stroke were identified during 2006-2007. Forty-four per cent of deaths were classified as unspecified stroke, 1/3 as ischaemic stroke, and 1/4 due to haemorrhagic subtype. In Step 3, 577 subjects over 35 years old were evaluated at home, and 244 cases of stroke survival were diagnosed via a questionnaire, validated by a board-certified neurologist. The population demographic characteristics were similar in the three steps, except in terms of age and gender. By including data from all settings, World Health Organization stroke surveillance can provide data to help plan future resources that meet the needs of the public-health system.

Kids Identifying and Defeating Stroke (KIDS): development and implementation of a multiethnic health education intervention to increase stroke awareness among middle school students and their parents.

PubMed

Mullen Conley, Kathleen; Juhl Majersik, Jennifer; Gonzales, Nicole R; Maddox, Katherine E; Pary, Jennifer K; Brown, Devin L; Moyé, Lemuel A; Espinosa, Nina; Grotta, James C; Morgenstern, Lewis B

2010-01-01

The Kids Identifying and Defeating Stroke (KIDS) project is a 3-year prospective, randomized, controlled, multiethnic school-based intervention study. Project goals include increasing knowledge of stroke signs and treatment and intention to immediately call 911 among Mexican American (MA) and non-Hispanic White (NHW) middle school students and their parents. This article describes the design, implementation, and interim evaluation of this theory-based intervention. Intervention students received a culturally appropriate stroke education program divided into four 50-minute classes each year during the sixth, seventh, and eighth grades. Each class session also included a homework assignment that involved the students' parents or other adult partners. Interim-test results indicate that this educational intervention was successful in improving students' stroke symptom and treatment knowledge and intent to call 911 upon witnessing a stroke compared with controls. The authors conclude that this school-based educational intervention to reduce delay time to hospital arrival for stroke shows early promise.

Paediatric stroke: pressing issues and promising directions.

PubMed

Kirton, Adam; deVeber, Gabrielle

2015-01-01

Stroke occurs across the lifespan with unique issues in the fetus, neonate, and child. The past decade has seen substantial advances in paediatric stroke research and clinical care, but many unanswered questions and controversies remain. The pathobiology of perinatal stroke needs to be better understood if prevention strategies are to be realised. Similarly, enhanced understanding of the mechanisms underlying childhood stroke, including cerebral arteriopathies, could inform the development of mechanism-specific treatments. Emerging clinical trials, including studies of neonatal sinovenous thrombosis and childhood arterial stroke, offer the hope of evidence-based treatment options in the near future. Early recognition of stroke in children is a key educational target for both the public and health-care professionals, and has translational potential to advance the application of neuroprotective, thrombolytic, and antithrombotic interventions and rehabilitation strategies to the earliest possible timepoints after stroke onset, improving outcomes and quality of life for affected children and their families. Copyright © 2015 Elsevier Ltd. All rights reserved.

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

PubMed

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

2015-01-01

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

Suicidal ideation at 1-year post-stroke: A nationwide survey in China.

PubMed

Yang, Yang; Shi, Yu-Zhi; Zhang, Ning; Wang, Shuo; Ungvari, Gabor S; Ng, Chee H; Wang, Yi-Long; Zhao, Xing-Quan; Wang, Yong-Jun; Wang, Chun-Xue; Xiang, Yu-Tao

Few studies on suicidal ideation have been conducted in post-stroke patients in China. This national study examined suicidal ideation at 1-year post-stroke and explored its demographic and clinical correlates. A total of 1418 patients with ischemic stroke were included in 56 hospitals nationwide. Demographic, clinical characteristics and neuro-imaging information were collected with standardized instruments, including assessment of stroke severity, depression, cognitive impairment, stroke recurrence, physical disability and insomnia. Suicidal ideation was measured using item 3 of the Hamilton Rating Scale for Depression. The frequency of suicidal ideation in this study was 6.6%. Multivariate analyses revealed that disability (OR=2.07, 95% CI=1.09-3.05), stroke recurrence (OR=4.13, 95% CI=1.74-9.77) and insomnia early (OR=1.87, 95% CI=1.03-3.39), middle (OR=2.66, 95% CI=1.46-4.85) and late (OR=2.35, 95% CI=1.31-4.19) at the 1-year follow-up and post-stroke depression (OR=2.16, 95% CI=1.23-3.82) were significantly associated with post-stroke suicidal ideation. Post-stroke depression, disability, insomnia and stroke recurrence are possible risk factors of suicidal ideation that warrant attention in clinical practice. Copyright © 2016 Elsevier Inc. All rights reserved.

Risk of Ischemic Stroke and Transient Ischemic Attack Is Increased up to 90 Days after Non-Carotid and Non-Cardiac Surgery.

PubMed

Grau, Armin J; Eicke, Martin; Burmeister, Christoph; Hardt, Roland; Schmitt, Eberhard; Dienlin, Sieghard

2017-01-01

The risk of stroke after cardiac and carotid surgery is well established. In contrast, stroke risk in association with non-cardiac and non-carotid surgery and its time course are insufficiently known. We investigated the prevalence of recent and planned surgery among patients with stroke and transient ischemic attack (TIA), time dependency of stroke risk, stroke etiology, and interruption of antithrombotic medication in association with surgery. Data on type and date of surgery and similar interventions within the last year or planned for the next 2 weeks were anonymously collected together with demographic data, vascular risk factors, stroke severity, handicap before stroke and stroke etiology within a state-wide, mandatory, hospital-based acute stroke care quality monitoring project (Rhineland-Palatinate, Germany) for 1 year (2010). Non-carotid and non-cardiothoracic surgery was reported as performed within 1 year before the index event or as planned for the next 2 weeks thereafter in 532 out of 12,120 patients with ischemic stroke/TIA (4.4%). Compared to 91-365 days before stroke/TIA as reference period, risk of cerebral ischemia (per day analysis) was increased for surgery within 61-90 days before ischemia (rate ratio 2.0, 95% CI 1.5-2.8) and continuously increased along shorter intervals between stroke and surgery (31-60 days: rate ratio 3.6, 95% CI 2.9-4.5; 15-30 days: rate ratio 8.2, 95% CI 6.7-10.1; 8-14 days: rate ratio 13.2, 95% CI 10.3-16.8; 4-7 days: rate ratio 16.5, 95% CI 12.2-22.1) peaking at an interval of 1-3 days before ischemia (rate ratio 34.0, 95% CI 26.9-42.8). On the day of surgery, rate ratio was 14.8 (95% CI 7.8-27.9) and for planned surgery it was 2.7 (95% CI 1.8-4.0). Results were similar for first-ever and for recurrent ischemic stroke. Perioperative stroke/TIA was positively associated with atrial fibrillation and cardioembolic stroke etiology, higher mortality, more severe neurological deficits at discharge, and longer hospital stay; and it was inversely associated with microangiopathic etiology and discharge at home. In 34.5% of patients with recent/planned surgery, prior antithrombotic or anticoagulant medication had been interrupted. Recent or planned surgery imposes a considerable short-term stroke risk particularly by cardioembolism with cessation of medication as an important contributor. Stroke after surgery is associated with poor outcome and high mortality. Better strategies to reduce the burden of perioperative stroke are urgently required. © 2017 S. Karger AG, Basel.

The Effects of Delirium Prevention Guidelines on Elderly Stroke Patients.

PubMed

Song, Jihye; Lee, Minkyung; Jung, Dukyoo

2017-07-01

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

Uncovering the Rosetta Stone: Report from the First Annual Conference on Key Elements in Translating Stroke Therapeutics from Pre-Clinical to Clinical.

PubMed

Bix, Gregory J; Fraser, Justin F; Mack, William J; Carmichael, S Thomas; Perez-Pinzon, Miguel; Offner, Halina; Sansing, Lauren; Bosetti, Francesca; Ayata, Cenk; Pennypacker, Keith R

2018-06-01

The first annual Stroke Translational Research Advancement Workshop (STRAW), entitled "Uncovering the Rosetta Stone: Key Elements in Translating Stroke Therapeutics from Pre-Clinical to Clinical" was held at the University of Kentucky on October 4-5, 2017. This workshop was organized by the Center for Advanced Translational Stroke Science. The workshop consisted of 2 days of activities. These included three presentations establishing the areas of research in stroke therapeutics, discussing the routes for translation from bench to bedside, and identifying successes and failures in the field. On day 2, grant funding opportunities and goals for the National Institute for Neurological Diseases and Stroke were presented. In addition, the meeting also included break-out sessions designed to connect researchers in areas of stroke, and to foster potential collaborations. Finally, the meeting concluded with an open discussion among attendees led by a panel of experts.

Targeting the brain: considerations in 332 consecutive patients treated by deep brain stimulation (DBS) for severe neurological diseases.

PubMed

Franzini, Angelo; Cordella, Roberto; Messina, Giuseppe; Marras, Carlo Efisio; Romito, Luigi Michele; Albanese, Alberto; Rizzi, Michele; Nardocci, Nardo; Zorzi, Giovanna; Zekaj, Edvin; Villani, Flavio; Leone, Massimo; Gambini, Orsola; Broggi, Giovanni

2012-12-01

Deep brain stimulation (DBS) extends the treatment of some severe neurological diseases beyond pharmacological and conservative therapy. Our experience extends the field of DBS beyond the treatment of Parkinson disease and dystonia, including several other diseases such as cluster headache and disruptive behavior. Since 1993, at the Istituto Nazionale Neurologico "Carlo Besta" in Milan, 580 deep brain electrodes were implanted in 332 patients. The DBS targets include Stn, GPi, Voa, Vop, Vim, CM-pf, pHyp, cZi, Nacc, IC, PPN, and Brodmann areas 24 and 25. Three hundred patients are still available for follow-up and therapeutic considerations. DBS gave a new therapeutic chance to these patients affected by severe neurological diseases and in some cases controlled life-threatening pathological conditions, which would otherwise result in the death of the patient such as in status dystonicus, status epilepticus and post-stroke hemiballismus. The balance of DBS in severe neurological disease is strongly positive even if further investigations and studies are needed to search for new applications and refine the selection criteria for the actual indications.

[Relationship between patent foramen ovale and cryptogenic stroke in a retrospective hospital-based study].

PubMed

Böjti, Péter; Bartha, Noémi Eszter; May, Zsolt; Bereczki, Dániel; Fülöp, Szilvia; Szakács, Zoltán; Szilágyi, Géza

2018-05-30

After routine workup, 23-25% of ischemic strokes etiology remains unknown, i.e. cryptogenic. However, according to international results pathogenic patent foramen ovale (PFO) reveals in 25% of these cases. Aim of our retrospective study to prove the substantial etiological role of PFO-related stroke (PFO-RS) in cryptogenic strokes (CS), and to identify age related differences in stroke etiology. All new ischemic strokes of 2014-2015 were classified by ASCOD (Atherosclerosis, Small-vessel disease, Cardiac pathology, Other, Dissection) phenotyping. CS was defined when the etiology was unknown. With the help of special ultrasound techniques and RoPE (Risk of Paradoxical Embolism) score the portion of PFO-RS were determined in the examined CS population. Moreover, etiological distribution and differences between age groups (<40, 40-60, >60 years) were described. During the examined period, 8.12% of 985 new ischemic strokes were categorized as CS. 41.38% of examined CS were found to be PFO-related. PFO-RS were considerably more frequent in the younger age groups than in the older age groups. The probability of appearance of PFO-RS were significantly higher in younger age than in case of age independency. Our results verify the substantial etiological role of PFO-RS in CS, and confirm the essential role of contrast enhanced functional transcranial Doppler in the routine diagnostic workup. Age related differences in stroke etiology were found to be statistically significant (p=0.000, df=14), in which small-vessel disease, cardiac pathology, dissection, other pathologies, CS and PFO-RS were contributed significantly. Based on our results, till in young age rare etiologies are typical, while in older age classical etiologies are mainly characteristic.

Diagnostic performance of bone metabolic indexes for the detection of stroke.

PubMed

Tan, Li Ming; Wang, Lu; Chen, Juan-Juan; Li, Hua; Luo, Wen-Bo

2017-01-01

To explore the diagnostic performance of 25-hydroxyvitamin D (25(OH)D), parathyroid hormone (PTH), bone alkaline phosphatase (BALP), and osteocalcin (OC) in predicting stroke.  Methods: This retrospective survey was conducted in The Second Affiliated Hospital to Nanchang University, Nanchang, Jiangxi Province, China. involved 121 cerebral infarction patients and 103 cerebral hemorrhage patients as the experimental groups, 100 volunteers as the healthy control group and 80 brain trauma patients as the disease control group. The 25(OH)D, PTH, BALP, and OC levels of all participants were measured by electrochemiluminescence immunoassay.  Results: The serum concentration of 25(OH)D in stroke patients was appreciably lower than that of the control groups (p less than 0.05), and subsequently, the deficiency level of 25(OH)D in the stroke population was considerably higher than that of the control groups (p less than 0.05). The serum concentrations of PTH and OC in stroke patients exceeded those found in the control groups (p less than 0.05), and the abnormal level in the stroke patients was also higher than that of the control. Compared with the control group, BALP concentrations in cerebral infarction patients were increased significantly. Additionally, abnormal levels of BALP in stroke patients were found to be higher than those in the control groups. However, concentrations and abnormal levels of BALP in cerebral hemorrhage patients were not found to be significantly different than those found in cerebral infarction and the control groups, There were no substantial differences between the 2 control groups. Conclusion: Lack of 25(OH)D and excessive PTH, BALP, and OC could indicate a high risk of stroke.

The Virtual Brain: Modeling Biological Correlates of Recovery after Chronic Stroke

PubMed Central

Falcon, Maria Inez; Riley, Jeffrey D.; Jirsa, Viktor; McIntosh, Anthony R.; Shereen, Ahmed D.; Chen, E. Elinor; Solodkin, Ana

2015-01-01

There currently remains considerable variability in stroke survivor recovery. To address this, developing individualized treatment has become an important goal in stroke treatment. As a first step, it is necessary to determine brain dynamics associated with stroke and recovery. While recent methods have made strides in this direction, we still lack physiological biomarkers. The Virtual Brain (TVB) is a novel application for modeling brain dynamics that simulates an individual’s brain activity by integrating their own neuroimaging data with local biophysical models. Here, we give a detailed description of the TVB modeling process and explore model parameters associated with stroke. In order to establish a parallel between this new type of modeling and those currently in use, in this work we establish an association between a specific TVB parameter (long-range coupling) that increases after stroke with metrics derived from graph analysis. We used TVB to simulate the individual BOLD signals for 20 patients with stroke and 10 healthy controls. We performed graph analysis on their structural connectivity matrices calculating degree centrality, betweenness centrality, and global efficiency. Linear regression analysis demonstrated that long-range coupling is negatively correlated with global efficiency (P = 0.038), but is not correlated with degree centrality or betweenness centrality. Our results suggest that the larger influence of local dynamics seen through the long-range coupling parameter is closely associated with a decreased efficiency of the system. We thus propose that the increase in the long-range parameter in TVB (indicating a bias toward local over global dynamics) is deleterious because it reduces communication as suggested by the decrease in efficiency. The new model platform TVB hence provides a novel perspective to understanding biophysical parameters responsible for global brain dynamics after stroke, allowing the design of focused therapeutic interventions. PMID:26579071

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

PubMed

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

2013-08-01

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

Hospitalized Infection as a Trigger for Acute Ischemic Stroke: The Atherosclerosis Risk in Communities Study.

PubMed

Cowan, Logan T; Alonso, Alvaro; Pankow, James S; Folsom, Aaron R; Rosamond, Wayne D; Gottesman, Rebecca F; Lakshminarayan, Kamakshi

2016-06-01

Acute triggers for ischemic stroke, which may include infection, are understudied, as is whether background cardiovascular disease (CVD) risk modifies such triggering. We hypothesized that infection increases acute stroke risk, especially among those with low CVD risk. Hospitalized strokes and infections were identified in the Atherosclerosis Risk in Communities (ARIC) cohort. A case-crossover design and conditional logistic regression were used to compare hospitalized infections among patients with stroke (14, 30, 42, and 90 days before stroke) with corresponding control periods 1 year and 2 years before stroke. Background CVD risk was assessed at both visit 1 and the visit most proximal to stroke, with risk dichotomized at the median. A total of 1008 adjudicated incident ischemic strokes were included. Compared with control periods, hospitalized infection was more common within 2 weeks before stroke (14-day odds ratio [OR], 7.7; 95% CI, 2.1-27.3); the strength of association declined with increasing time in the exposure window before stroke (30-day OR, 5.7 [95% CI, 2.3-14.3]; 42-day OR, 4.5 [95% CI, 2.0-10.2]; and 90-day OR, 3.6 [95% CI, 2.1-6.5]). Stroke risk was higher among those with low compared with high CVD risk, with this interaction reaching statistical significance for some exposure periods. These results support the hypothesis that hospitalized infection is a trigger of ischemic stroke and may explain some cryptogenic strokes. Infection control efforts may prevent strokes. CVD preventive therapies may prevent strokes if used in the peri-infection period, but clinical trials are needed. © 2016 American Heart Association, Inc.

Trends in risk factors, patterns and causes in hospitalized strokes over 25 years: The Lausanne Stroke Registry.

PubMed

Carrera, Emmanuel; Maeder-Ingvar, Malin; Rossetti, Andrea O; Devuyst, Gérald; Bogousslavsky, Julien

2007-01-01

The Lausanne Stroke Registry includes, from 1979, all patients admitted to the department of Neurology of the Lausanne University Hospital with the diagnosis of first clinical stroke. Using the Lausanne Stroke Registry, we aimed to determine trends in risk factors, causes, localization and inhospital mortality over 25 years in hospitalized stroke patients. We assessed temporal trends in stroke patients characteristics through the following consecutive periods: 1979-1987, 1988-1995 and 1996-2003. Age-adjusted cardiovascular risk factors, etiologies, stroke localizations and mortality were compared between the three periods. Overall, 5,759 patients were included. Age was significantly different among the analyzed periods (p < 0.001), showing an increment in older patients throughout time. After adjustment for age, hypercholesterolemia increased (p < 0.001), as opposed to cigarette smoking (p < 0.001), hypertension (p < 0.001) and diabetes and hyperglycemia (p < 0.001). In patients with ischemic strokes, there were significant changes in the distribution of causes with an increase in cardioembolic strokes (p < 0.001), and in the localization of strokes with an increase in entire middle cerebral artery (MCA) and posterior circulation strokes together with a decrease in superficial middle cerebral artery stroke (p < 0.001). In patients with hemorrhagic strokes, the thalamic localizations increased, whereas the proportion of striatocapsular hemorrhage decreased (p = 0.022). Except in the older patient group, the mortality rate decreased. This study shows major trends in the characteristics of stroke patients admitted to a department of neurology over a 25-year time span, which may result from referral biases, development of acute stroke management and possibly from the evolution of cerebrovascular risk factors.

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.

The mediating effect of psychological distress on functional dependence in stroke patients.

PubMed

Huang, Hui-Chuan; Huang, Li-Kai; Hu, Chaur-Jong; Chang, Chien-Hung; Lee, Hsin-Chien; Chi, Nai-Fang; Shyu, Meei-Ling; Chang, Hsiu-Ju

2014-12-01

To explore varied forms of psychological distress and to determine the mediating influence of psychological distress on functional outcomes in stroke patients. Previous studies attest to the influence of depression on poststroke functional recovery. While there is evidence for neuropathological deficits that occur after stroke to be associated with psychological distress, few studies have explored the effect of various types of psychological distress on functional recovery. A cross-sectional study was used. Data were collected from 178 first-time stroke patients. Study variables included demographic and disease characteristics (stroke location and stroke syndrome classification), psychological distress (the Chinese language version of the Emotional and Social Dysfunction Questionnaire) and functional outcome (Barthel index). Regression and mediation models were used to evaluate the effect of psychological distress on functional outcome. Results revealed that stroke patients experience various forms of mild psychological distress, including anger, helplessness, emotional dyscontrol, indifference, inertia and euphoria, after stroke. Regression and mediation analyses further confirmed that various forms of psychological distress significantly mediated the effect of severe stroke syndromes on functional dependence. The various forms of psychological distress after stroke might play a mediating role in functional recovery and explain how stroke severity affects functional dependence. By understanding the nature of various forms of psychological distress, healthcare professionals should adopt appropriate assessment instruments and design effective interventions to help improve mental and physical function of stroke patients. © 2014 John Wiley & Sons Ltd.

Assimilation of Web-Based Urgent Stroke Evaluation: A Qualitative Study of Two Networks

PubMed Central

Mathiassen, Lars; Switzer, Jeffrey A; Adams, Robert J

2014-01-01

Background Stroke is a leading cause of death and serious, long-term disability across the world. Urgent stroke care treatment is time-sensitive and requires a stroke-trained neurologist for clinical diagnosis. Rural areas, where neurologists and stroke specialists are lacking, have a high incidence of stroke-related death and disability. By virtually connecting emergency department physicians in rural hospitals to regional medical centers for consultations, specialized Web-based stroke evaluation systems (telestroke) have helped address the challenge of urgent stroke care in underserved communities. However, many rural hospitals that have deployed telestroke have not fully assimilated this technology. Objective The objective of this study was to explore potential sources of variations in the utilization of a Web-based telestroke system for urgent stroke evaluation and propose a telestroke assimilation model to improve stroke care performance. Methods An exploratory, qualitative case study of two telestroke networks, each comprising an academic stroke center (hub) and connected rural hospitals (spokes), was conducted. Data were collected from 50 semistructured interviews with 40 stakeholders, telestroke usage logs from 32 spokes, site visits, published papers, and reports. Results The two networks used identical technology (called Remote Evaluation of Acute isCHemic stroke, REACH) and were of similar size and complexity, but showed large variations in telestroke assimilation across spokes. Several observed hub- and spoke-related characteristics can explain these variations. The hub-related characteristics included telestroke institutionalization into stroke care, resources for the telestroke program, ongoing support for stroke readiness of spokes, telestroke performance monitoring, and continuous telestroke process improvement. The spoke-related characteristics included managerial telestroke championship, stroke center certification, dedicated telestroke coordinator, stroke committee of key stakeholders, local neurological expertise, and continuous telestroke process improvement. Conclusions Rural hospitals can improve their stroke readiness with use of telestroke systems. However, they need to integrate the technology into their stroke delivery processes. A telestroke assimilation model may improve stroke care performance. PMID:25601232

Botanical phenolics and brain health

PubMed Central

Sun, Albert Y.; Wang, Qun; Simonyi, Agnes; Sun, Grace Y.

2009-01-01

The high demand for molecular oxygen, the enrichment of polyunsaturated fatty acids in membrane phospholipids and the relatively low abundance of antioxidant defense enzymes are factors rendering cells in the central nervous system (CNS) particularly vulnerable to oxidative stress. Excess production of reactive oxygen species (ROS) in the brain has been implicated as a common underlying factor for the etiology of a number of neurodegenerative diseases, including Alzheimer's disease (AD), Parkinson's disease (PD), and stroke. While ROS are generated by enzymatic and non-enzymatic reactions in the mitochondria and cytoplasm under normal conditions, excessive production under pathological conditions is associated with activation of Ca2+-dependent enzymes including proteases, phospholipases, nucleases, and alterations of signaling pathways which subsequently lead to mitochondrial dysfunction, release of inflammatory factors and apoptosis. In recent years, there is considerable interest to investigate anti-oxidative and anti-inflammatory effects of phenolic compounds from different botanical sources. In this review, we describe oxidative mechanisms associated with AD, PD, and stroke, and evaluate neuroprotective effects of phenolic compounds, such as resveratrol from grape and red wine, curcumin from turmeric, apocynin from Picrorhiza kurroa, and epi-gallocatechin from green tea. The main goal is to provide a better understanding of the mode of action of these compounds and assess their use as therapeutics to ameliorate age-related neurodegenerative diseases. PMID:19191039

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

PubMed

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

2017-04-01

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

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.

The incidence of ischemic stroke in chronic heart failure: a meta-analysis.

PubMed

Witt, Brandi J; Gami, Apoor S; Ballman, Karla V; Brown, Robert D; Meverden, Ryan A; Jacobsen, Stephen J; Roger, Véronique L

2007-08-01

There is marked variability in the reported stroke rates among persons with heart failure (HF). We performed a meta-analysis to provide summary estimates of the stroke rate in HF and to explain heterogeneity in the existing literature. We will summarize the ischemic stroke rate at various time points during follow-up among adults with chronic heart failure. A systematic review of the electronic literature in Medline and PubMed as well as hand searching of the reference lists of identified articles and of the meeting abstracts for the 1995-2004 American College of Cardiology and American Heart Association scientific sessions was performed to identify qualifying studies. Articles were included if they included a population with chronic HF and reported the number (or percent) of persons with HF who experienced an ischemic stroke during follow-up. Studies were excluded if the study population included > or = 50% of persons with acute (postmyocardial infarction) HF, or if > or = 50% of the study population required artificial support with a ventricular assist device or parenteral inotropic medications. Case reports, case series, and nonoriginal research articles were not included. Determination of study eligibility and data extraction were conducted by 2 independent reviewers using standardized forms. Results are reported as stroke rate per 1000 cases of HF, with 95% Poisson confidence intervals. Pooled estimates of the stroke rate were calculated with fixed and random effects models. Heterogeneity was explored according to a priori specified subgroup analyses. Overall, 26 studies met inclusion criteria. Eighteen of every 1000 persons suffered a stroke during the first year after the diagnosis of HF. The stroke rate increased to a maximum of 47.4 per 1000 at 5 years. Studies with fewer women, those conducted in 1990 or earlier, and cohort studies reported higher stroke rates than studies with more women, those conducted after 1990, and clinical trials. Stroke is an important complication among persons with HF. Variability among reported stroke rates can be explained in part by differences in study design, patient population, and HF standards of care at the time of the study. Despite the heterogeneity in reported stroke rates, this meta-analysis shows that stroke prevention in HF represents an opportunity to prevent morbidity and save many lives in this highly fatal disease.

Neurology Concepts: Young Women and Ischemic Stroke-Evaluation and Management in the Emergency Department.

PubMed

Chang, Bernard P; Wira, Charles; Miller, Joseph; Akhter, Murtaza; Barth, Bradley E; Willey, Joshua; Nentwich, Lauren; Madsen, Tracy

2018-01-01

Ischemic stroke is a leading cause of morbidity and mortality worldwide. While the incidence of ischemic stroke is highest in older populations, incidence of ischemic stroke in adults has been rising particularly rapidly among young (e.g., premenopausal) women. The evaluation and timely diagnosis of ischemic stroke in young women presents a challenging situation in the emergency department, due to a range of sex-specific risk factors and to broad differentials. The goals of this concepts paper are to summarize existing knowledge regarding the evaluation and management of young women with ischemic stroke in the acute setting. A panel of six board-certified emergency physicians, one with fellowship training in stroke and one with training in sex- and sex-based medicine, along with one vascular neurologist were coauthors involved in the paper. Each author used various search strategies (e.g., PubMed, PsycINFO, and Google Scholar) for primary research and reviewed articles related to their section. The references were reviewed and evaluated for relevancy and included based on review by the lead authors. Estimates on the incidence of ischemic stroke in premenopausal women range from 3.65 to 8.9 per 100,000 in the United States. Several risk factors for ischemic stroke exist for young women including oral contraceptive (OCP) use and migraine with aura. Pregnancy and the postpartum period (up to 12 weeks) is also an important transient state during which risks for both ischemic stroke and cerebral hemorrhage are elevated, accounting for 18% of strokes in women under 35. Current evidence regarding the management of acute ischemic stroke in young women is also summarized including use of thrombolytic agents (e.g., tissue plasminogen activator) in both pregnant and nonpregnant individuals. Unique challenges exist in the evaluation and diagnosis of ischemic stroke in young women. There are still many opportunities for future research aimed at improving detection and treatment of this population. © 2017 by the Society for Academic Emergency Medicine.

Patient knowledge on stroke risk factors, symptoms and treatment options.

PubMed

Faiz, Kashif Waqar; Sundseth, Antje; Thommessen, Bente; Rønning, Ole Morten

2018-01-01

Public campaigns focus primarily on stroke symptom and risk factor knowledge, but patients who correctly recognize stroke symptoms do not necessarily know the reason for urgent hospitalization. The aim of this study was to explore knowledge on stroke risk factors, symptoms and treatment options among acute stroke and transient ischemic attack patients. This prospective study included patients admitted to the stroke unit at the Department of Neurology, Akershus University Hospital, Norway. Patients with previous cerebrovascular disease, patients receiving thrombolytic treatment and patients who were not able to answer the questions in the questionnaire were excluded. Patients were asked two closed-ended questions: "Do you believe that stroke is a serious disorder?" and "Do you believe that time is of importance for stroke treatment?". In addition, patients were asked three open-ended questions where they were asked to list as many stroke risk factors, stroke symptoms and stroke treatment options as they could. A total of 173 patients were included, of whom 158 (91.3%) confirmed that they regarded stroke as a serious disorder and 148 patients (85.5%) considered time being of importance. In all, 102 patients (59.0%) could not name any treatment option. Forty-one patients (23.7%) named one or more adequate treatment options, and they were younger ( p <0.001) and had higher educational level ( p <0.001), but had a nonsignificant shorter prehospital delay time ( p =0.292). The level of stroke treatment knowledge in stroke patients seems to be poor. Public campaigns should probably also focus on information on treatment options, which may contribute to reduce prehospital delay and onset-to-treatment-time.

Countries with women inequalities have higher stroke mortality.

PubMed

Kim, Young Dae; Jung, Yo Han; Caso, Valeria; Bushnell, Cheryl D; Saposnik, Gustavo

2017-10-01

Background Stroke outcomes can differ by women's legal or socioeconomic status. Aim We investigated whether differences in women's rights or gender inequalities were associated with stroke mortality at the country-level. Methods We used age-standardized stroke mortality data from 2008 obtained from the World Health Organization. We compared female-to-male stroke mortality ratio and stroke mortality rates in women and men between countries according to 50 indices of women's rights from Women, Business and the Law 2016 and Gender Inequality Index from the Human Development Report by the United Nations Development Programme. We also compared stroke mortality rate and income at the country-level. Results In our study, 176 countries with data available on stroke mortality rate in 2008 and indices of women's rights were included. There were 46 (26.1%) countries where stroke mortality in women was higher than stroke mortality in men. Among them, 29 (63%) countries were located in Sub-Saharan African region. After adjusting by country income level, higher female-to-male stroke mortality ratio was associated with 14 indices of women's rights, including differences in getting a job or opening a bank account, existence of domestic violence legislation, and inequalities in ownership right to property. Moreover, there was a higher female-to-male stroke mortality ratio among countries with higher Gender Inequality Index (r = 0.397, p < 0.001). Gender Inequality Index was more likely to be associated with stroke mortality rate in women than that in men (p < 0.001). Conclusions Our study suggested that the gender inequality status is associated with women's stroke outcomes.

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

PubMed

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

2017-05-01

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

Two-stroke engine diagnostics and design

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

Not Available

1992-01-01

This paper focuses on research and development efforts on two-stroke cycle engines for automotive applications. Partial contents include: Velocity Field Characteristics in Motored Two-Stroke Ported Engines; Flow Vector Measurements at the Scavenging Ports in a Fired Two-Stroke Engine; A Study on Exhaust Dynamic Effect of Two-Stroke Motorcycle Petrol Engine; Characterization of Ignition and Parametric Study of a Two-Stroke-Cycle Direct-Injected Gasoline Engine; LDV Measurements of Intake Port Flow in a Two-Stroke Engine with and without Combustion; Appraisal of Regenerative Blowers for Scavenging of Small 2T S.I. Powerplants; and Development Experience of a Poppet-Valved Two-Stroke Flagship Engine.

The Vocational Rehabilitation of Stroke Victims: Description and Prediction

ERIC Educational Resources Information Center

Lugar, Owen; Kelz, James

1971-01-01

The purpose of the study was to predict the outcome of a stroke victim's vocational rehabilitation through the use of demographic and medical data. Characteristics of stroke clients were used to develop an eight-factor stroke rating scale. Recommendations for further refinement of the scale were included. (Author)

Sight Impairment registration due to stroke-A small yet significant rise?

PubMed

Bunce, Catey; Zekite, Antra; Wormald, Richard; Rowe, Fiona

2017-12-01

In the United Kingdom, when an individual's sight falls to and remains at a certain threshold, they may be offered registration as sight impaired. Recent analysis of causes of registrable sight impairment in England/Wales indicated that visual impairment due to stroke had increased as a proportionate cause of sight loss. We aim to assess whether there is evidence of an increase in incidence of certification for sight impairment due to stroke in England/Wales between 2008 and 2014. The number of certifications with a main cause of sight impairment being stroke was obtained from the Certifications Office London. Directly standardized rates per 100,000 were computed with 95% confidence intervals and examined. Poisson regression was used to assess evidence of trend over time. In the year ending 31st March 2008, 992 people were newly certified with stroke with an estimated DSR of 2.1 (2.0 to 2.2) per 100,000 persons at risk. In the year ending March 31st 2014, there were 1310 certifications with a DSR of 2.5 (2.4 to 2.7). Figures were higher for men than women. Poisson regression indicated an estimated incidence rate ratio of 1.03 per year with 95% confidence intervals of 1.028 to 1.051, P  < .001. These data suggest a small but statistically significant increase in the incidence of certifiable visual impairment due to stroke between 2008 and 2014. Figures are, however, considerably lower than estimated, perhaps suggesting that more should be done to address the visual needs of those who have suffered stroke.

Heat-Related Illnesses

MedlinePlus Videos and Cool Tools

... for signs of heat stroke or exhaustion. Heat Stroke and Exhaustion Symptoms of early heat exhaustion symptoms ... heavy sweating; nausea; and giddiness. Symptoms of heat stroke (late stage of heat illness) include flushed, hot, ...

Economic burden of informal care attributable to stroke among those aged 65 years or older in China.

PubMed

Joo, Heesoo; Liang, Di

2017-02-01

Stroke is a leading cause of disability in China, frequently resulting in the need for informal care. No information, however, is available on costs of informal care associated with stroke, required to understand the true cost of stroke in China. Using the 2011 China Health and Retirement Longitudinal Study, we identified 4447 respondents aged ≥65 years suitable for analyses, including 184 stroke survivors. We estimated the economic burden of informal care associated with stroke using a two-part model. The monthly number of hours of informal caregiving associated with stroke was 29.2 h/stroke survivor, and the average annual cost of informal care associated with stroke was 10,612 RMB per stroke survivor. The findings stress the necessity of proper interventions to prevent stroke and will be useful for estimating the economic burden of stroke.

A Review of Stroke Research in Malaysia from 2000 - 2014.

PubMed

Cheah, W K; Hor, C P; Zariah, A A; Looi, I

2016-06-01

Over 100 articles related to stroke were found in a search through a database dedicated to indexing all literature with original data involving the Malaysian population between years 2000 and 2014. Stroke is emerging as a major public health problem. The development of the National Stroke Registry in the year 2009 aims to coordinate and improve stroke care, as well as to generate more data on various aspects of stroke in the country. Studies on predictors of survival after strokes have shown potential to improve the overall management of stroke, both during acute event and long term care. Stroke units were shown to be effective locally in stroke outcomes and prevention of stroke-related complications. The limited data looking at direct cost of stroke management suggests that the health economic burden in stroke management may be even higher. Innovative rehabilitation programmes including braincomputer interface technology were studied with encouraging results. Studies in traditional complementary medicine for strokes such as acupuncture, Urut Melayu and herbal medicine were still limited.

Strokes with minor symptoms: an exploratory analysis of the National Institute of Neurological Disorders and Stroke recombinant tissue plasminogen activator trials.

PubMed

Khatri, Pooja; Kleindorfer, Dawn O; Yeatts, Sharon D; Saver, Jeffrey L; Levine, Steven R; Lyden, Patrick D; Moomaw, Charles J; Palesch, Yuko Y; Jauch, Edward C; Broderick, Joseph P

2010-11-01

The pivotal National Institute of Neurological Disorders and Stroke recombinant tissue plasminogen activator trials excluded patients with ischemic stroke with specific minor presentations or rapidly improving symptoms. The recombinant tissue plasminogen activator product label notes that its use for minor neurological deficit or rapidly improving stroke symptoms has not been evaluated. As a result, patients with low National Institutes of Health Stroke Scale scores are not commonly treated in clinical practice. We sought to further characterize the patients with minor stroke who were included in the National Institute of Neurological Disorders and Stroke trials. Minor strokes were defined as National Institutes of Health Stroke Scale score ≤ 5 at baseline for this retrospective analysis, because this subgroup is most commonly excluded from treatment in clinical practice and trials. Clinical stroke syndromes were defined based on prespecified National Institutes of Health Stroke Scale item score clusters. Clinical outcomes were reviewed generally and within these cluster subgroups. Only 58 cases had National Institutes of Health Stroke Scale scores of 0 to 5 in the National Institute of Neurological Disorders and Stroke trials (42 recombinant tissue plasminogen activator and 16 placebo), and 2971 patients were excluded from the trials due to "rapidly improving" or "minor symptoms" as the primary reason. No patients were enrolled with isolated motor symptoms, isolated facial droop, isolated ataxia, dysarthria, isolated sensory symptoms, or with only symptoms/signs not captured by the National Institutes of Health Stroke Scale score (ie, National Institutes of Health Stroke Scale=0). There were ≤ 3 patients with each of the other isolated deficits enrolled in the trial. The National Institute of Neurological Disorders and Stroke trials excluded a substantial number of strokes with minor presentations, those that were included were small in number, and conclusions about outcomes based on specific syndromes cannot be drawn. Further prospective, systematic study of this subgroup is needed.

Fragmentation of care and the use of head computed tomography in patients with ischemic stroke.

PubMed

Bekelis, Kimon; Roberts, David W; Zhou, Weiping; Skinner, Jonathan S

2014-05-01

Computed tomographic (CT) scans are central diagnostic tests for ischemic stroke. Their inefficient use is a negative quality measure tracked by the Centers for Medicare and Medicaid Services. We performed a retrospective analysis of Medicare fee-for-service claims data for adults admitted for ischemic stroke from 2008 to 2009, with 1-year follow-up. The outcome measures were risk-adjusted rates of high-intensity CT use (≥4 head CT scans) and risk- and price-adjusted Medicare expenditures in the year after admission. The average number of head CT scans in the year after admission, for the 327 521 study patients, was 1.94, whereas 11.9% had ≥4. Risk-adjusted rates of high-intensity CT use ranged from 4.6% (Napa, CA) to 20.0% (East Long Island, NY). These rates were 2.6% higher for blacks than for whites (95% confidence interval, 2.1%-3.1%), with considerable regional variation. Higher fragmentation of care (number of different doctors seen) was associated with high-intensity CT use. Patients living in the top quintile regions of fragmentation experienced a 5.9% higher rate of high-intensity CT use, with the lowest quintile as reference; the corresponding odds ratio was 1.77 (95% confidence interval, 1.71-1.83). Similarly, 1-year risk- and price-adjusted expenditures exhibited considerable regional variation, ranging from $31 175 (Salem, MA) to $61 895 (McAllen, TX). Regional rates of high-intensity CT scans were positively associated with 1-year expenditures (r=0.56; P<0.01). Rates of high-intensity CT use for patients with ischemic stroke reflect wide practice patterns across regions and races. Medicare expenditures parallel these disparities. Fragmentation of care is associated with high-intensity CT use. © 2014 American Heart Association, Inc.

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.

Trends in Ten-Year Survival of Stroke Patients Hospitalized between 1980 and 2000: The Minnesota Stroke Survey

PubMed Central

Lakshminarayan, Kamakshi; Berger, Alan K; Fuller, Candace C.; Jacobs, David R.; Anderson, David C.; Steffen, Lyn M; Sillah, Arthur; Luepker, Russell V.

2014-01-01

Background & Purpose We report on trends in post-stroke survival, both in the early period after stroke and over the long-term. We examine these trends by stroke sub-type. Methods The Minnesota Stroke Survey (MSS) is a study of all hospitalized acute stroke patients aged 30–74 years in the Minneapolis-St. Paul metropolis. Validated stroke events were sampled for survey years 1980, 1985, 1990, 1995 and 2000 and subtyped as ischemic or hemorrhagic by neuroimaging for survey years 1990, 1995 and 2000. Survival was obtained by linkage to vital statistics data through the year 2010. Results There were 3773 acute stroke events. Age-adjusted 10-year survival improved from 1980 to 2000 (men 29.5% to 46.5%, p < 0.0001; women 32.6% to 50.5%, p < 0.0001). Ten-year ischemic stroke survival (n = 1667) improved from 1990 to 2000 (men 35.3% to 50%, p = 0.0001; women 38% to 55.3%, p < 0.0001). Ten-year hemorrhagic stroke survival showed a trend toward improvement but this (n = 489) did not reach statistical significance, perhaps because of their smaller number (men 29.7% to 45.8%, p=0.06; women 39.2% to 49.6%, p=0.2). Markers of stroke severity including unconsciousness or major neurological deficits at admission declined from 1980 to 2000 while neuroimaging use increased. Conclusions These post-stroke survival trends are likely due to multiple factors including more sensitive case ascertainment shifting the case-mix toward less severe strokes, improved stroke care and risk factor management, and overall improvements in population health and longevity. PMID:25028450

Juvenile Churg-Strauss Syndrome as an Etiology of Myocarditis and Ischemic Stroke in Adolescents; a Case Report

PubMed Central

Moradinejad, Mohammad-Hassan; Rezaei, Amir; Ziaee, Vahid

2011-01-01

Background Churg-Strauss syndrome (CSS), a systemic vasculitis accompanied by asthma and eosinophilia, almost invariably affects the lung and is frequently associated with cutaneous involvement. It rarely has cardiac involvement. We report an unusual case of CSS with myocardial involvement and stroke. Case Presentation A 16-year old female suffered of allergic asthma for 4 years. She was under treatment with oral prednisolone and seretide inhalation. After CSS diagnosis, she developed paroxysmal atrial tachycardia. Serum levels of Troponin I and Troponin T were increased indicating massive myocardial damage probably due to myocarditis. After 5 months she developed acute hemiparesis without any evidence of ischemic or hemorrhagic event. She was treated with IVIg, intravenous pulses of methylprednisone and cyclophosphamide for each complication. Conclusion Myocarditis and stroke may also complicate CSS which should be taken in consideration for better management. PMID:23056844

Burden of stroke in Egypt: current status and opportunities.

PubMed

Abd-Allah, Foad; Moustafa, Ramez Reda

2014-12-01

Middle East and North Africa (MENA) countries have a diversity of populations with similar life style, dietary habits, and vascular risk factors that may influence stroke risk, prevalence, types, and disease burden. Egypt is the most populated nation in the Middle East with an estimated 85.5 million people. In Egypt, according to recent estimates, the overall prevalence rate of stroke is high with a crude prevalence rate of 963/100,000 inhabitants. In spite of disease burden, yet there is a huge evidence practice gap. The recommended treatments for ischemic stroke that are guideline include systematic supportive care in a stroke unit or stroke center is still deficient. In addition, the frequency of thrombolysis in Egypt is very low for many reasons; the major one is that the health insurance system is not covering thrombolysis therapy in nonprivate sectors so patients must cover the costs using their own personal savings; otherwise, they will not receive treatment. Another important factor is the pronounced delay in prehospital and in hospital management of acute stroke. Improvement of stroke care in Egypt should be achieved through multi and interdisciplinary approach including public awareness, physicians' education, and synergistic approach to stroke care with Emergency Medical System. © 2014 World Stroke Organization.

Implementation of evidence-based stroke care: enablers, barriers, and the role of facilitators

PubMed Central

Purvis, Tara; Moss, Karen; Denisenko, Sonia; Bladin, Chris; Cadilhac, Dominique A

2014-01-01

A stroke care strategy was developed in 2007 to improve stroke services in Victoria, Australia. Eight stroke network facilitators (SNFs) were appointed in selected hospitals to enable the establishment of stroke units, develop thrombolysis services, and implement protocols. We aimed to explain the main issues being faced by clinicians in providing evidence-based stroke care, and to determine if the appointment of an SNF was perceived as an acceptable strategy to improve stroke care. Face-to-face semistructured interviews were used in a qualitative research design. Interview transcripts were verified by respondents prior to coding. Two researchers conducted thematic analysis of major themes and subthemes. Overall, 84 hospital staff participated in 33 interviews during 2008. The common factors found to impact on stroke care included staff and equipment availability, location of care, inconsistent use of clinical pathways, and professional beliefs. Other barriers included limited access to specialist clinicians and workload demands. The establishment of dedicated stroke units was considered essential to improve the quality of care. The SNF role was valued for identifying gaps in care and providing capacity to change clinical processes. This is the first large, qualitative multicenter study to describe issues associated with delivering high-quality stroke care and the potential benefits of SNFs to facilitate these improvements. PMID:25246799

A systematic review of perceived barriers and motivators to physical activity after stroke.

PubMed

Nicholson, Sarah; Sniehotta, Falko F; van Wijck, Frederike; Greig, Carolyn A; Johnston, Marie; McMurdo, Marion E T; Dennis, Martin; Mead, Gillian E

2013-07-01

Physical fitness is impaired after stroke, may contribute to disability, yet is amenable to improvement through regular physical activity. To facilitate uptake and maintenance of physical activity, it is essential to understand stroke survivors' perceived barriers and motivators. Therefore, we undertook a systematic review of perceived barriers and motivators to physical activity after stroke. Electronic searches of EMBASE, Medline, CINAHL, and PsychInfo were performed. We included peer-reviewed journal articles, in English, between 1 January 1966 and 30 August 2010 reporting stroke survivors' perceived barriers and motivators to physical activity. Searches identified 73,807 citations of which 57 full articles were retrieved. Six articles were included, providing data on 174 stroke survivors (range 10 to 83 per article). Two reported barriers and motivators, two reported only motivators, and two reported only barriers. Five were qualitative articles and one was quantitative. The most commonly reported barriers were lack of motivation, environmental factors (e.g. transport), health concerns, and stroke impairments. The most commonly reported motivators were social support and the need to be able to perform daily tasks. This review has furthered our understanding of the perceived barriers and motivators to physical activity after a stroke. This review will enable the development of tailored interventions to target barriers, while building upon perceived motivators to increase and maintain stroke survivors' physical activity. © 2012 The Authors. International Journal of Stroke © 2012 World Stroke Organization.

Dietary potassium intake and risk of stroke: a dose-response meta-analysis of prospective studies.

PubMed

Larsson, Susanna C; Orsini, Nicola; Wolk, Alicja

2011-10-01

Potassium intake has been inconsistently associated with risk of stroke. Our aim was to conduct a meta-analysis of prospective studies to assess the relation between potassium intake and stroke risk. Pertinent studies were identified by a search of PubMed from January 1966 through March 2011 and by reviewing the reference lists of retrieved articles. We included prospective studies that reported relative risks with 95% CIs of stroke for ≥3 categories of potassium intake or for potassium intake analyzed as a continuous variable. Study-specific results were pooled using a random-effects model. Ten independent prospective studies, with a total of 8695 stroke cases and 268 276 participants, were included in the meta-analysis. We observed a statistically significant inverse association between potassium intake and risk of stroke. For every 1000-mg/day increase in potassium intake, the risk of stroke decreased by 11% (pooled relative risk, 0.89; 95% CI, 0.83 to 0.97). In the 5 studies that reported results for stroke subtypes, the pooled relative risks were 0.89 (95% CI, 0.81 to 0.97) for ischemic stroke, 0.95 (95% CI, 0.83 to 1.09) for intracerebral hemorrhage, and 1.08 (95% CI, 0.92 to 1.27) for subarachnoid hemorrhage. Dietary potassium intake is inversely associated with risk of stroke, in particular ischemic stroke.

Life after Stroke in an Urban Minority Population: A Photovoice Project.

PubMed

Balakrishnan, Revathi; Kaplan, Benjamin; Negron, Rennie; Fei, Kezhen; Goldfinger, Judith Z; Horowitz, Carol R

2017-03-11

Stroke is a leading cause of disability in the United States and disproportionately affects minority populations. We sought to explore the quality of life in urban, minority stroke survivors through their own photos and narratives. Using the Photovoice method, seventeen stroke survivors were instructed to take pictures reflecting their experience living with and recovering from stroke. Key photographs were discussed in detail; participants brainstormed ways to improve their lives and presented their work in clinical and community sites. Group discussions were recorded, transcribed, and coded transcripts were reviewed with written narratives to identify themes. Participants conveyed recovery from stroke in three stages: learning to navigate the initial physical and emotional impact of the stroke; coping with newfound physical and emotional barriers; and long-term adaptation to physical impairment and/or chronic disease. Participants navigated this stage-based model to varying degrees of success and identified barriers and facilitators to this process. Barriers included limited access for disabled and limited healthy food choices unique to the urban setting; facilitators included presence of social support and community engagement. Using Photovoice, diverse stroke survivors were able to identify common challenges in adapting to life after stroke and important factors for recovery of quality of life.

Secondary stroke prevention: from guidelines to clinical practice.

PubMed

Graham, Glenn D

2008-10-01

Stroke remains a leading cause of mortality and is associated with substantial morbidity in the United States. The majority of strokes are of ischemic origin, with an atherothrombotic trigger, and the clinical manifestation of atherothrombosis depends on the affected vascular site. The systemic nature of atherosclerosis means that stroke patients are at increased risk of ischemic events in several vascular beds, including cerebral, coronary and peripheral sites. Because stroke patients are at heightened risk of more ischemic events, secondary prevention is an important therapeutic goal. Recently, the American Heart Association and its division, the American Stroke Association, released new evidence-based guidelines for secondary stroke prevention in patients with ischemic stroke or transient ischemic attack. The new guidelines emphasize an individualized, patient-oriented approach to treatment based on clinical evidence. Evidence-based recommendations are set forth for the management of risk factors, including hypertension, dyslipidemia and diabetes, through lifestyle modifications and pharmacological interventions. The purpose of this paper is to review the topic of stroke prevention in light of current guidelines and clinical implementation patterns for primary care physicians, and to discuss new and emerging clinical evidence, with a focus on antiplatelet treatment.

Stroke Epidemiology and Risk Factor Management.

PubMed

Guzik, Amy; Bushnell, Cheryl

2017-02-01

Death from stroke has decreased over the past decade, with stroke now the fifth leading cause of death in the United States. In addition, the incidence of new and recurrent stroke is declining, likely because of the increased use of specific prevention medications, such as statins and antihypertensives. Despite these positive trends in incidence and mortality, many strokes remain preventable. The major modifiable risk factors are hypertension, diabetes mellitus, tobacco smoking, and hyperlipidemia, as well as lifestyle factors, such as obesity, poor diet/nutrition, and physical inactivity. This article reviews the current recommendations for the management of each of these modifiable risk factors. It has been documented that some blood pressure medications may increase variability of blood pressure and ultimately increase the risk for stroke. Stroke prevention typically includes antiplatelet therapy (unless an indication for anticoagulation exists), so the most recent evidence supporting use of these drugs is reviewed. In addition, emerging risk factors, such as obstructive sleep apnea, electronic cigarettes, and elevated lipoprotein (a), are discussed. Overall, secondary stroke prevention includes a multifactorial approach. This article incorporates evidence from guidelines and published studies and uses an illustrative case study throughout the article to provide examples of secondary prevention management of stroke risk factors.

What is the evidence for using family based interventions to prevent stroke recurrence?

PubMed

Lawrence, Maggie; McVey, Caroline; Kerr, Susan

Stroke has a devastating impact on individuals and families. Risk factors for recurrence include lifestyle behaviours such as smoking, excessive alcohol consumption, an unhealthy diet and physical inactivity. This article describes a programme of research that aims to gather and synthesise the evidence required to inform the development and evaluation of a family centred, behavioural intervention designed to address lifestyle risk factors for recurrent stroke. We present an overview of the research undertaken to develop the evidence base. This included a survey of stroke nurse practice, a focus group study with people who had had a stroke as well as their family members, and a systematic review of the efficacy of lifestyle interventions.

Third European Stroke Science Workshop.

PubMed

Dichgans, Martin; Planas, Anna M; Biessels, Geert Jan; van der Worp, Bart; Sudlow, Cathie; Norrving, Bo; Lees, Kennedy; Mattle, Heinrich P

2016-07-01

Lake Eibsee, Garmisch-Partenkirchen, November 19 to 21, 2015: The European Stroke Organization convened >120 stroke experts from 27 countries to discuss latest results and hot topics in clinical, translational, and basic stroke research. Since its inception in 2011, the European Stroke Science Workshop has become a cornerstone of European Stroke Organization's academic activities and major highlight for researchers in the field. Participants include stroke researchers at all career stages who convene for plenary lectures and discussions, thus facilitating crosstalk among researchers from different fields. As in previous years, the workshop was organized into 7 scientific sessions each focusing on a major research topic. All sessions started with a keynote lecture that provided an overview on current developments and set the scene for the following presentations. The latter were short focused talks on a timely topic and included the most recent findings, including unpublished data. A new element at this year's meeting was a hot topic session in which speakers had to present a provocative concept or update sharply within 5 minutes. In the following, we summarize the key contents of the meeting. The program is provided in the online-only Data Supplement. © 2016 American Heart Association, Inc.

Mapping patients' experiences after stroke onto a patient-focused intervention framework.

PubMed

Donnellan, C; Martins, A; Conlon, A; Coughlan, T; O'Neill, D; Collins, D R

2013-03-01

Stroke patients' involvement in the rehabilitation process including decision making has made significant advances clinically over the past two decades. However, development of patient-focused interventions in stroke rehabilitation is a relatively under developed area of research. The aim of this study was to interpret the explanations that patients gave of their experience after stroke and how these may validate an already established patient-focused intervention framework - the Quest for quality and improved performance (QQUIP) (2006) that includes seven quality improvement goals. A random purposive sample of eight stroke patients was interviewed between 3 and 6 months following discharge. Patients' reports of their experience after stroke were obtained using in-dept semi-structured interviews and analysed using Qualitative Content Analysis. Explanations given by patients included both positive and negative reports of the stroke experience. Regardless of consequences as a result of physical, psychological and social impairments, there were other life style disruptions that were reported by all patients such as taking new medication and adverse effects of these, experiencing increasing fatigue, difficulties with social activities and situations and having to make changes in health behaviours and lifestyle. Some of the core themes that emerged reflected the aims of QQUIP improvement goals that include improving health literacy, clinical decision-making, self-care, patient safety, access to health advice, care experience and service development. Further recommendations based on the findings from this study would be to consider using the QQUIP framework for developing intervention studies in stroke rehabilitation care that are person-centred. This framework provides a template that is equipped to address some of the main concerns that people have following the experience of stroke and also focuses on improving quality of care.

The network of Shanghai Stroke Service System (4S): A public health-care web-based database using automatic extraction of electronic medical records.

PubMed

Dong, Yi; Fang, Kun; Wang, Xin; Chen, Shengdi; Liu, Xueyuan; Zhao, Yuwu; Guan, Yangtai; Cai, Dingfang; Li, Gang; Liu, Jianmin; Liu, Jianren; Zhuang, Jianhua; Wang, Panshi; Chen, Xin; Shen, Haipeng; Wang, David Z; Xian, Ying; Feng, Wuwei; Campbell, Bruce Cv; Parsons, Mark; Dong, Qiang

2018-07-01

Background Several stroke outcome and quality control projects have demonstrated the success in stroke care quality improvement through structured process. However, Chinese health-care systems are challenged with its overwhelming numbers of patients, limited resources, and large regional disparities. Aim To improve quality of stroke care to address regional disparities through process improvement. Method and design The Shanghai Stroke Service System (4S) is established as a regional network for stroke care quality improvement in the Shanghai metropolitan area. The 4S registry uses a web-based database that automatically extracts data from structured electronic medical records. Site-specific education and training program will be designed and administrated according to their baseline characteristics. Both acute reperfusion therapies including thrombectomy and thrombolysis in the acute phase and subsequent care were measured and monitored with feedback. Primary outcome is to evaluate the differences in quality metrics between baseline characteristics (including rate of thrombolysis in acute stroke and key performance indicators in secondary prevention) and post-intervention. Conclusions The 4S system is a regional stroke network that monitors the ongoing stroke care quality in Shanghai. This project will provide the opportunity to evaluate the spectrum of acute stroke care and design quality improvement processes for better stroke care. A regional stroke network model for quality improvement will be explored and might be expanded to other large cities in China. Clinical Trial Registration-URL http://www.clinicaltrials.gov . Unique identifier: NCT02735226.

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.

Disparities in Stroke Incidence Contributing to Disparities in Stroke Mortality

PubMed Central

Howard, Virginia J.; Kleindorfer, Dawn O.; Judd, Suzanne E.; McClure, Leslie A.; Safford, Monika M.; Rhodes, J. David; Cushman, Mary; Moy, Claudia S.; Soliman, Elsayed Z.; Kissela, Brett M.; Howard, George

2013-01-01

Objective While black-white and regional disparities in U.S. stroke mortality rates are well documented, the contribution of disparities in stroke incidence is unknown. We provide national estimates of stroke incidence by race and region, contrasting these to publicly available stroke mortality data. Methods This analysis included 27,744 men and women without prevalent stroke (40.4% black), aged ≥45 years from the REasons for Geographic And Racial Differences in Stroke (REGARDS) national cohort study, enrolled 2003–2007. Incident stroke was defined as first occurrence of stroke over 4.4 years of follow-up. Age-sex–adjusted stroke mortality rates were calculated using data from the Centers for Disease Control and Prevention (CDC) Wide-Ranging Online Data for Epidemiological Research (WONDER) System. Results There were 460 incident strokes over 113,469 person-years of follow-up. Relative to the rest of the United States, incidence rate ratios (IRRs) of stroke in the southeastern stroke belt and stroke buckle were 1.06 (95% confidence interval [CI], 0.87–1.29) and 1.19 (95% CI, 0.96–1.47), respectively. The age-sex–adjusted black/white IRRblack was 1.51 (95% CI, 1.26–1.81), but for ages 45–54 years the IRRblack was 4.02 (95% CI, 1.23–13.11) while for ages 85+ it was 0.86 (95% CI, 0.33–2.20). Generally, the IRRsblack were less than the mortality rate ratios (MRRs) across age groups; however, only in ages 55–64 years and 65–74 years did the 95% CIs of IRRsblack not include the MRRblack. The MRRs for regions were within 95% CIs for IRRs. Interpretation National patterns of black-white and regional differences in stroke incidence are similar to those for stroke mortality; however, the magnitude of differences in incidence appear smaller. PMID:21416498

[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.

Bleeding complications after endovascular therapy of cerebral arteriovenous malformations.

PubMed

Heidenreich, J O; Hartlieb, S; Stendel, R; Pietilä, T A; Schlattmann, P; Wolf, K-J; Schilling, A M

2006-02-01

Intracerebral hemorrhages after embolization of arteriovenous malformations (AVMs) are the most dreaded complications of this well-established therapy. Apart from the known risk factors, our center noticed a high incidence of complications during postinterventional monitoring in medical intensive care units (ICUs) and stroke units. We report 125 consecutive interventions performed on 66 patients by using flow-dependent microcatheters and n-butyl cyanoacrylate as the embolic agent. Postinterventional intensive care monitoring was performed in an interdisciplinary operative ICU, a stroke unit, or a medical ICU. Patients were compared with regard to bleeding complications, AVM morphology, embolization result, postinterventional monitoring, and demographic factors. Intracerebral hemorrhages occurred in 7 patients. Significant differences in outcome were found between 66 patients monitored in the interdisciplinary operative ICU from medical ICU or stroke unit. This was also true when adjusted for age and extent of AVM reduction by using exact logistic regression. A partial AVM reduction of >60% was a considerable risk factor for hemorrhage (odds ratio [OR] = 18.8; 95% confidence interval [CI] [1.341, not available]. Age was also an essential risk factor. An age difference of 10 years leads to an OR of 2.545 (95% CI [1.56, 7.35]). A considerable AVM reduction in one session appears to increase the risk of hemorrhage technically. This suggests a distribution of the interventions in many partial steps.

Kids Identifying and Defeating Stroke (KIDS): Development and Implementation of a Multi-Ethnic Health Education Intervention to Increase Stroke Awareness Among Middle School Students and Their Parents

PubMed Central

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

2009-01-01

The KIDS (Kids Identifying and Defeating Stroke) Program is a three-year prospective, randomized, controlled, multiethnic school-based intervention study. Program goals include increasing knowledge of stroke signs and treatment and intention to immediately call 911 among Mexican American (MA) and non-Hispanic white (NHW) middle school students and their parents. This article describes the design, implementation and interim evaluation of this theory-based intervention. Intervention students received a culturally appropriate stroke education program divided into four 50-minute classes each year during the 6th, 7th, and 8th grades. Each class session also included a homework assignment that involved the students’ parents or other adult partners. Interim-test results indicate that this educational intervention was successful in improving students’ stroke symptom and treatment knowledge and intent to call 911 upon witnessing a stroke compared with controls (p<0.001). We conclude that this school-based educational intervention to reduce delay time to hospital arrival for stroke shows early promise. PMID:18332150

Vinpocetine for acute ischaemic stroke.

PubMed

Bereczki, D; Fekete, I

2008-01-23

Vasoactive and neuroprotective drugs such as vinpocetine are used to treat stroke in some countries. To assess the effect of vinpocetine in acute ischaemic stroke. We searched the Cochrane Stroke Group Trials Register (last searched February 2007), MEDLINE (1966 to February 2007) and Scopus (1960 to February 2007). We also searched the Internet Stroke Center Stroke Trials Registry, Google Scholar, the science-specific search engine Scirus and Wanfang Data, the leading information provider in China. We contacted researchers in the field and four pharmaceutical companies that manufacture vinpocetine. Searches were complete to February 2007. Unconfounded randomised trials of vinpocetine compared with placebo, or any other reference treatment, in people with acute ischaemic stroke. We included trials if treatment started no later than 14 days after stroke onset. Two review authors independently applied the inclusion criteria. One review author extracted the data, which was then checked by the second review author. We assessed trial quality. The primary outcome measure was death or dependency. We included two trials, involving a total of 70 participants. Data for 63 participants were reported in the two trials combined. The rate of death or dependency did not differ between the treatment and placebo groups at one and three months. The 95% confidence intervals for the outcome measures were wide and included the possibility of both significant benefit and significant harm. No adverse effects were reported. There is not enough evidence to evaluate the effect of vinpocetine on survival or dependency in patients with acute ischaemic stroke.

Barriers to medication adherence for the secondary prevention of stroke: a qualitative interview study in primary care.

PubMed

Jamison, James; Graffy, Jonathan; Mullis, Ricky; Mant, Jonathan; Sutton, Stephen

2016-08-01

Medications are highly effective at reducing risk of recurrent stroke, but success is influenced by adherence to treatment. Among survivors of stroke and transient ischaemic attack (TIA), adherence to medication is known to be suboptimal. To identify and report barriers to medication adherence for the secondary prevention of stroke/TIA. A qualitative interview study was conducted within general practice surgeries in the East of England, UK. Patients were approached by letter and invited to take part in a qualitative research study. Semi-structured interviews were undertaken with survivors of stroke, caregivers, and GPs to explore their perspectives and views around secondary prevention and perceived barriers to medication adherence. Key themes were identified using a grounded theory approach. Verbatim quotes describing the themes are presented here. In total, 28 survivors of stroke, including 14 accompanying caregivers and five GPs, were interviewed. Two key themes were identified. Patient level barriers included ability to self-care, the importance people attach to a stroke event, and knowledge of stroke and medication. Medication level barriers included beliefs about medication and beliefs about how pills work, medication routines, changing medications, and regimen complexity and burden of treatment. Patients who have had a stroke are faced with multiple barriers to taking secondary prevention medications in UK general practice. This research suggests that a collaborative approach between caregivers, survivors, and healthcare professionals is needed to address these barriers and facilitate medication-taking behaviour. © British Journal of General Practice 2016.

Effective Education Materials to Advance Stroke Awareness Without Teacher Participation in Junior High School Students.

PubMed

Ohyama, Satoshi; Yokota, Chiaki; Miyashita, Fumio; Amano, Tatsuo; Inoue, Yasuteru; Shigehatake, Yuya; Sakamoto, Yuki; Toyoda, Kazunori; Minematsu, Kazuo

2015-11-01

Youth stroke education is promising for the spread of stroke awareness. The aim of this study was to examine whether our stroke awareness teaching materials without teacher's participation can increase student awareness to act fast on suspected stroke signs. We used the face, arm, speech, and time (FAST) mnemonic derived from the Cincinnati Prehospital Stroke Scale. Seventy-three students of the second grade and 72 students of the third grade (age range, 13-15 years) in a junior high school were enrolled in the study. The students were divided into 2 groups: students who received a teacher's lesson (group I) and those who did not receive a teacher's lesson (group II). Students in group II watched an animated cartoon and read a Manga comic in class. All students took the educational aids home, including the Manga comic and magnetic posters printed with the FAST message. Questionnaires on stroke knowledge were examined at baseline and immediately and 3 months after receiving the intervention. At 3 months after the intervention, a significant improvement in understanding the FAST message was confirmed in both the groups (group I, 85%; group II, 94%). Significant increases in the knowledge of risk factors were not observed in each group. Our education materials include a Manga comic, an animated cartoon, and a magnetic poster, without an accompanying teacher's lesson can increase stroke awareness, including the FAST message, in junior high school students. Copyright © 2015 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Education-related differences in case fatality among elderly with stroke.

PubMed

Löfmark, Ulrika; Hammarström, Anne

2008-01-01

There is strong evidence for the existence of a socioeconomic gradient in stroke incidence and mortality, but there seem to be contradictory findings concerning an association between socioeconomic status and case fatality after stroke. Moreover, there is still a lack of studies that include men and women as well as people over 75 years. Our aim was to investigate whether there were education-related differences in 28-day case fatality after stroke in different age groups. All patients who were diagnosed with a cerebral infarction at the Umeå University Hospital during a 2-year period were included in this study. In total, 610 stroke patients (331 men, 279 women) aged 20-85 were hospitalized, of whom 77% were first-ever strokes. Overall, there were few education-related differences between the patients in different age groups (20-74 and 75-85 years). The 28-day case fatality after stroke was shown to be associated with a low educational level in patients above 75 years, also after controlling for sex, risk factors and acute stroke care measures. In this population-based study on patients with cerebral infarction, we found an education-related difference in 28-day case fatality in patients aged 75-85 years. The socioeconomic gradient persisted when we adjusted for risk factors and acute care variables. There is a need for more community-based stroke studies including all ages, with good case ascertainment. (c) 2008 S. Karger AG, Basel.

Association between Embolic Stroke Patterns, ESUS Etiology, and New Diagnosis of Atrial Fibrillation: A Secondary Data Analysis of the Find-AF Trial

PubMed Central

Schregel, Katharina; Karch, André; Weber-Krueger, Mark; Stahrenberg, Raoul; Gröschel, Klaus; Knauth, Michael; Psychogios, Marios-Nikos; Wachter, Rolf; Liman, Jan

2017-01-01

Background. Atrial fibrillation (AF) is an important cause of embolic stroke of undetermined source (ESUS). Imaging-patterns like multiple infarcts, simultaneous involvement of different circulations, infarcts of different ages, and isolated cortical infarcts are likely to indicate cardioembolic stroke. The aim of our study was to evaluate the association between embolic stroke patterns, ESUS, and the new diagnosis of AF. Methods. Stroke etiology and imaging characteristics from patients included in the Find-AF study were obtained. Embolic stroke patterns in CT- or MR-imaging were correlated with the diagnosis of ESUS as well as the short- (on baseline ECG and during 7-day Holter) and long-term (12-month follow-up) diagnosis of AF. Results. From 281 patients included in the Find-AF study, 127 (45.2%) patients with ischemic lesions detected in CT or MRI were included. 26 (20.5%) of these patients had ESUS. At least one embolic stroke pattern was detected in 67 (52.7%) patients. Embolic stroke patterns were not associated with ESUS (OR 1.57, 0.65–3.79, p = 0.317), the short-term (OR 0.64, 0.26–1.58, p = 0.327) or long-term diagnosis of AF (OR 0.72, 0.31–1.68, p = 0.448). Conclusions. This secondary data analysis of the Find-AF study could not provide evidence for an association between embolic stroke patterns, ESUS, and the new diagnosis of AF. PMID:28536667

Association between Embolic Stroke Patterns, ESUS Etiology, and New Diagnosis of Atrial Fibrillation: A Secondary Data Analysis of the Find-AF Trial.

PubMed

Maier, Ilko L; Schregel, Katharina; Karch, André; Weber-Krueger, Mark; Mikolajczyk, Rafael T; Stahrenberg, Raoul; Gröschel, Klaus; Bähr, Mathias; Knauth, Michael; Psychogios, Marios-Nikos; Wachter, Rolf; Liman, Jan

2017-01-01

Background . Atrial fibrillation (AF) is an important cause of embolic stroke of undetermined source (ESUS). Imaging-patterns like multiple infarcts, simultaneous involvement of different circulations, infarcts of different ages, and isolated cortical infarcts are likely to indicate cardioembolic stroke. The aim of our study was to evaluate the association between embolic stroke patterns, ESUS, and the new diagnosis of AF. Methods . Stroke etiology and imaging characteristics from patients included in the Find-AF study were obtained. Embolic stroke patterns in CT- or MR-imaging were correlated with the diagnosis of ESUS as well as the short- (on baseline ECG and during 7-day Holter) and long-term (12-month follow-up) diagnosis of AF. Results . From 281 patients included in the Find-AF study, 127 (45.2%) patients with ischemic lesions detected in CT or MRI were included. 26 (20.5%) of these patients had ESUS. At least one embolic stroke pattern was detected in 67 (52.7%) patients. Embolic stroke patterns were not associated with ESUS (OR 1.57, 0.65-3.79, p = 0.317), the short-term (OR 0.64, 0.26-1.58, p = 0.327) or long-term diagnosis of AF (OR 0.72, 0.31-1.68, p = 0.448). Conclusions . This secondary data analysis of the Find-AF study could not provide evidence for an association between embolic stroke patterns, ESUS, and the new diagnosis of AF.

Heart rate as a predictor of stroke in high-risk, hypertensive patients with previous stroke or transient ischemic attack.

PubMed

Sandset, Else Charlotte; Berge, Eivind; Kjeldsen, Sverre E; Julius, Stevo; Holzhauer, Björn; Krarup, Lars-Henrik; Hua, Tsushung A

2014-01-01

Risk factors for first stroke are well established, but less is known about risk factors for recurrent stroke. In the present analysis, we aimed to assess the effect of heart rate and other possible predictors of stroke in a hypertensive population with previous stroke or transient ischemic attack (TIA). The Valsartan Antihypertensive Long-Term Use Evaluation trial was a multicentre, double-masked, randomized controlled, parallel group trial comparing the effects of an angiotensin receptor blocker (valsartan) and a calcium channel blocker (amlodipine) in patients with hypertension and high cardiovascular risk. We used Cox proportional hazard models to investigate the effect of baseline variables on the risk of stroke. Quadratic terms of the continuous variables were entered in the models to test for linearity. Of 15,245 patients included in the trial, 3014 had a previous stroke or TIA at baseline and were included in the present analysis. Stroke recurrence occurred in 239 patients (7.9%) during a median of 4.5 years of follow-up. Resting heart rate (per 10 beats per minute; hazard ratio [HR], 2.78; 95% confidence interval [CI], 1.18-6.58) and diabetes mellitus at baseline (HR, 1.47; 95% CI, 1.03-2.10) were significantly associated with an increased risk of stroke recurrence in the multivariable analysis. In high-risk, hypertensive patients with previous stroke or TIA, resting heart rate was the strongest predictor of recurrent stroke. Copyright © 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Multivitamin use and risk of stroke mortality: the Japan collaborative cohort study.

PubMed

Dong, Jia-Yi; Iso, Hiroyasu; Kitamura, Akihiko; Tamakoshi, Akiko

2015-05-01

An effect of multivitamin supplement on stroke risk is uncertain. We aimed to examine the association between multivitamin use and risk of death from stroke and its subtypes. A total of 72 180 Japanese men and women free from cardiovascular diseases and cancers at baseline in 1988 to 1990 were followed up until December 31, 2009. Lifestyles including multivitamin use were collected using self-administered questionnaires. Cox proportional hazards regression models were used to estimate hazard ratios (HRs) of total stroke and its subtypes in relation to multivitamin use. During a median follow-up of 19.1 years, we identified 2087 deaths from stroke, including 1148 ischemic strokes and 877 hemorrhagic strokes. After adjustment for potential confounders, multivitamin use was associated with lower but borderline significant risk of death from total stroke (HR, 0.87; 95% confidence interval, 0.76-1.01), primarily ischemic stroke (HR, 0.80; 95% confidence interval, 0.63-1.01), but not hemorrhagic stroke (HR, 0.96; 95% confidence interval, 0.78-1.18). In a subgroup analysis, there was a significant association between multivitamin use and lower risk of mortality from total stroke among people with fruit and vegetable intake <3 times/d (HR, 0.80; 95% confidence interval, 0.65-0.98). That association seemed to be more evident among regular users than casual users. Similar results were found for ischemic stroke. Multivitamin use, particularly frequent use, was associated with reduced risk of total and ischemic stroke mortality among Japanese people with lower intake of fruits and vegetables. © 2015 American Heart Association, Inc.

Antihypertensive treatment and stroke prevention: are angiotensin receptor blockers superior to other antihypertensive agents?

PubMed

Armario, Pedro; de la Sierra, Alejandro

2009-06-01

Stroke remains a common vascular event with high mortality and morbidity. After heart disease, stroke is the second leading cause of death worldwide in adult persons. Silent or subclinical stroke is likely to occur with even greater frequency than clinical stroke and increases the risk of subsequent cerebrovascular events. Hypertension is by far the single most important controllable risk factor for stroke. The relationship between blood pressure (BP) and stroke mortality is strong, linear, and continuous in subjects with levels of BP higher than 115/75 mm Hg. Blood pressure reduction by antihypertensive treatment is clearly efficacious in the prevention of stroke (both primary and secondary). Although meta-analyses suggest that BP reduction, per se, is the most important determinant for stroke risk reduction, the question is if specific classes of antihypertensive drugs offer special protection against stroke is still controversial. Some studies have suggested that angiotensin receptors blockers (ARBs) appear to offer additional protection against stroke. This has been hypothesized in studies in hypertensives, such as LIFE and SCOPE, and especially in the only comparative trial focused on secondary stroke prevention. In the MOSES trial, the comparison of eprosartan versus nitrendipine in patients with a previous stroke resulted, despite a similar BP reduction, in a significant reduction in the primary composite endpoint of total mortality plus cardiovascular and cerebrovascular events, including recurrent events. These results may suggest a blood pressure-independent effect of ARBs, which can be mediated through several mechanisms, including their ability to counteract other markers of target organ damage, but also through a direct neuroprotective effect.

Stroke awareness among inpatient nursing staff at an academic medical center

PubMed Central

Adelman, Eric E.; Meurer, William J.; Nance, Dorinda K.; Kocan, Mary Jo; Maddox, Kate E.; Morgenstern, Lewis B.; Skolarus, Lesli E.

2015-01-01

Background and Purpose Since 10% of strokes occur in hospitalized patients, we sought to evaluate stroke knowledge and predictors of stroke knowledge among inpatient and emergency department nursing staff. Methods Nursing staff completed an on-line stroke survey. The survey queried outcome expectations (the importance of rapid stroke identification), self-efficacy in recognizing stroke, and stroke knowledge (name three stroke warning signs/symptoms). Adequate stroke knowledge was defined as the ability to name two or more stroke warning signs. Logistic regression was used to identify the association between stroke symptom knowledge and staff characteristics (education, clinical experience, and nursing unit), stroke self-efficacy, and outcome expectations. Results A total of 875 respondents (84% response rate) completed the survey and most of the respondents were nurses. More than 85% of respondents correctly reported 2 or more stroke warning signs or symptoms. Greater self-efficacy in identifying stroke symptoms (OR 1.13, 95% CI 1.01–1.27) and higher ratings for the importance of rapid identification of stroke symptoms (OR 1.23, 95% CI 1.002–1.51) were associated with stroke knowledge. Clinical experience, educational experience, nursing unit, and personal knowledge of a stroke patient were not associated with stroke knowledge. Conclusions Stroke outcome expectations and self-efficacy are associated with stroke knowledge and should be included in nursing education about stroke. PMID:24135928

Abnormal P-Wave Axis and Ischemic Stroke: The ARIC Study (Atherosclerosis Risk In Communities).

PubMed

Maheshwari, Ankit; Norby, Faye L; Soliman, Elsayed Z; Koene, Ryan J; Rooney, Mary R; O'Neal, Wesley T; Alonso, Alvaro; Chen, Lin Y

2017-08-01

Abnormal P-wave axis (aPWA) has been linked to incident atrial fibrillation and mortality; however, the relationship between aPWA and stroke has not been reported. We hypothesized that aPWA is associated with ischemic stroke independent of atrial fibrillation and other stroke risk factors and tested our hypothesis in the ARIC study (Atherosclerosis Risk In Communities), a community-based prospective cohort study. We included 15 102 participants (aged 54.2±5.7 years; 55.2% women; 26.5% blacks) who attended the baseline examination (1987-1989) and without prevalent stroke. We defined aPWA as any value outside 0 to 75° using 12-lead ECGs obtained during study visits. Each case of incident ischemic stroke was classified in accordance with criteria from the National Survey of Stroke by a computer algorithm and adjudicated by physician review. Multivariable Cox regression was used to estimate hazard ratios and 95% confidence intervals for the association of aPWA with stroke. During a mean follow-up of 20.2 years, there were 657 incident ischemic stroke cases. aPWA was independently associated with a 1.50-fold (95% confidence interval, 1.22-1.85) increased risk of ischemic stroke in the multivariable model that included atrial fibrillation. When subtyped, aPWA was associated with a 2.04-fold (95% confidence interval, 1.42-2.95) increased risk of cardioembolic stroke and a 1.32-fold (95% confidence interval, 1.03-1.71) increased risk of thrombotic stroke. aPWA is independently associated with ischemic stroke. This association seems to be stronger for cardioembolic strokes. Collectively, our findings suggest that alterations in atrial electric activation may predispose to cardiac thromboembolism independent of atrial fibrillation. © 2017 American Heart Association, Inc.

Feasibility and Diagnostic Value of Cardiovascular Magnetic Resonance Imaging After Acute Ischemic Stroke of Undetermined Origin.

PubMed

Haeusler, Karl Georg; Wollboldt, Christian; Bentheim, Laura Zu; Herm, Juliane; Jäger, Sebastian; Kunze, Claudia; Eberle, Holger-Carsten; Deluigi, Claudia Christina; Bruder, Oliver; Malsch, Carolin; Heuschmann, Peter U; Endres, Matthias; Audebert, Heinrich J; Morguet, Andreas J; Jensen, Christoph; Fiebach, Jochen B

2017-05-01

Etiology of acute ischemic stroke remains undetermined (cryptogenic) in about 25% of patients after state-of-the-art diagnostic work-up. One-hundred and three patients with magnetic resonance imaging (MRI)-proven acute ischemic stroke of undetermined origin were prospectively enrolled and underwent 3-T cardiac MRI and magnetic resonance angiography of the aortic arch in addition to state-of-the-art diagnostic work-up, including transesophageal echocardiography (TEE). We analyzed the feasibility, diagnostic accuracy, and added value of cardiovascular MRI (cvMRI) compared with TEE for detecting sources of stroke. Overall, 102 (99.0%) ischemic stroke patients (median 63 years [interquartile range, 53-72], 24% female, median NIHSS (National Institutes of Health Stroke Scale) score on admission 2 [interquartile range, 1-4]) underwent cvMRI and TEE in hospital; 89 (86.4%) patients completed the cvMRI examination. In 93 cryptogenic stroke patients, a high-risk embolic source was found in 9 (8.7%) patients by cvMRI and in 11 (11.8%) patients by echocardiography, respectively. cvMRI and echocardiography findings were consistent in 80 (86.0%) patients, resulting in a degree of agreement of κ=0.24. In 82 patients with cryptogenic stroke according to routine work-up, including TEE, cvMRI identified stroke etiology in additional 5 (6.1%) patients. Late gadolinium enhancement consistent with previous myocardial infarction was found in 13 (14.6%) out of 89 stroke patients completing cvMRI. Only 2 of these 13 patients had known coronary artery disease. Our study demonstrated that cvMRI was feasible in the vast majority of included patients with acute ischemic stroke. The diagnostic information of cvMRI seems to be complementary to TEE but is not replacing echocardiography after acute ischemic stroke. URL: http://www.clinicaltrials.gov. Unique identifier: NCT01917955. © 2017 American Heart Association, Inc.

Anesthesia Technique and Outcomes of Mechanical Thrombectomy in Patients With Acute Ischemic Stroke.

PubMed

Bekelis, Kimon; Missios, Symeon; MacKenzie, Todd A; Tjoumakaris, Stavropoula; Jabbour, Pascal

2017-02-01

The impact of anesthesia technique on the outcomes of mechanical thrombectomy for acute ischemic stroke remains an issue of debate. We investigated the association of general anesthesia with outcomes in patients undergoing mechanical thrombectomy for ischemic stroke. We performed a cohort study involving patients undergoing mechanical thrombectomy for ischemic stroke from 2009 to 2013, who were registered in the New York Statewide Planning and Research Cooperative System database. An instrumental variable (hospital rate of general anesthesia) analysis was used to simulate the effects of randomization and investigate the association of anesthesia technique with case-fatality and length of stay. Among 1174 patients, 441 (37.6%) underwent general anesthesia and 733 (62.4%) underwent conscious sedation. Using an instrumental variable analysis, we identified that general anesthesia was associated with a 6.4% increased case-fatality (95% confidence interval, 1.9%-11.0%) and 8.4 days longer length of stay (95% confidence interval, 2.9-14.0) in comparison to conscious sedation. This corresponded to 15 patients needing to be treated with conscious sedation to prevent 1 death. Our results were robust in sensitivity analysis with mixed effects regression and propensity score-adjusted regression models. Using a comprehensive all-payer cohort of acute ischemic stroke patients undergoing mechanical thrombectomy in New York State, we identified an association of general anesthesia with increased case-fatality and length of stay. These considerations should be taken into account when standardizing acute stroke care. © 2017 American Heart Association, Inc.

A pilot study of rivastigmine in the treatment of delirium after stroke: A safe alternative

PubMed Central

Oldenbeuving, Annemarie W; de Kort, Paul LM; Jansen, Ben PW; Kappelle, L Jaap; Roks, Gerwin

2008-01-01

Background Delirium is a common disorder in the early phase of stroke. Given the presumed cholinergic deficiency in delirium, we tested treatment with the acetylcholinesterase inhibitor rivastigmine. Methods This pilot study was performed within an epidemiological study. In 527 consecutive stroke patients presence of delirium was assessed during the first week with the confusion assessment method. Severity was scored with the delirium rating scale (DRS). Sixty-two patients developed a delirium in the acute phase of stroke. Only patients with a severe and persistent delirium (defined as a DRS of 12 or more for more than 24 hours) were enrolled in the present study. In total 26 fulfilled these criteria of whom 17 were treated with orally administered rivastigmine with a total dose between 3 and 12 mg a day. Eight patients could not be treated because of dysphagia and one because of early discharge. Results No major side effects were recorded. In 16 patients there was a considerable decrease in severity of delirium. The mean DRS declined from 14.8 on day one to 8.5 after therapy and 5.6 after tapering. The mean duration of delirium was 6.7 days (range; 2–17). Conclusion Rivastigmine is safe in stroke patients with delirium even after rapid titration. In the majority of patients the delirium improved after treatment. A randomized controlled trial is needed to establish the usefulness of rivastigmine in delirium after stroke. Trial registration Nederlands Trial Register NTR1395 PMID:18803862

Phenotypic variability in patients with ADA2 deficiency due to identical homozygous R169Q mutations.

PubMed

Van Montfrans, Joris M; Hartman, Esther A R; Braun, Kees P J; Hennekam, Eric A M; Hak, Elisabeth A; Nederkoorn, Paul J; Westendorp, Willeke F; Bredius, Robbert G M; Kollen, Wouter J W; Schölvinck, Elisabeth H; Legger, G Elizabeth; Meyts, Isabelle; Liston, Adrian; Lichtenbelt, Klaske D; Giltay, Jacques C; Van Haaften, Gijs; De Vries Simons, Gaby M; Leavis, Helen; Sanders, Cornelis J G; Bierings, Marc B; Nierkens, Stefan; Van Gijn, Marielle E

2016-05-01

To determine the genotype-phenotype association in patients with adenosine deaminase-2 (ADA2) deficiency due to identical homozygous R169Q mutations inCECR1 METHODS: We present a case series of nine ADA2-deficient patients with an identical homozygous R169Q mutation. Clinical and diagnostic data were collected and available MRI studies were reviewed. We performed genealogy and haplotype analyses and measured serum ADA2 activity. ADA2 activity values were correlated to clinical symptoms. Age of presentation differed widely between the nine presented patients (range: 0 months to 8 years). The main clinical manifestations were (hepato)splenomegaly (8/9), skin involvement (8/9) and neurological involvement (8/9, of whom 6 encountered stroke). Considerable variation was seen in type, frequency and intensity of other symptoms, which included aplastic anaemia, acute myeloid leukaemia and cutaneous ulcers. Common laboratory abnormalities included cytopenias and hypogammaglobulinaemia. ADA2 enzyme activity in patients was significantly decreased compared with healthy controls. ADA2 activity levels tended to be lower in patients with stroke compared with patients without stroke. Genealogical studies did not identify a common ancestor; however, based on allele frequency, a North-West European founder effect can be noted. Three patients underwent haematopoietic cell transplantation, after which ADA2 activity was restored and clinical symptoms resolved. This case series revealed large phenotypic variability in patients with ADA2 deficiency though they were homozygous for the same R169Q mutation inCECR1 Disease modifiers, including epigenetic and environmental factors, thus seem important in determining the phenotype. Furthermore, haematopoietic cell transplantation appears promising for those patients with a severe clinical phenotype. © The Author 2016. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Primary care interventions and current service innovations in modifying long-term outcomes after stroke: a protocol for a scoping review

PubMed Central

Pindus, Dominika M; Lim, Lisa; Rundell, A Viona; Hobbs, Victoria; Aziz, Noorazah Abd; Mullis, Ricky; Mant, Jonathan

2016-01-01

Introduction Interventions delivered by primary and/or community care have the potential to reach the majority of stroke survivors and carers and offer ongoing support. However, an integrative account emerging from the reviews of interventions addressing specific long-term outcomes after stroke is lacking. The aims of the proposed scoping review are to provide an overview of: (1) primary care and community healthcare interventions by generalist healthcare professionals to stroke survivors and/or their informal carers to address long-term outcomes after stroke, (2) the scope and characteristics of interventions which were successful in addressing long-term outcomes, and (3) developments in current clinical practice. Methods and analysis Studies that focused on adult community dwelling stroke survivors and informal carers were included. Academic electronic databases will be searched to identify reviews of randomised controlled trials (RCTs) and controlled trials, trials from the past 5 years; reviews of observational studies. Practice exemplars from grey literature will be identified through advanced Google search. Reports, guidelines and other documents of major health organisations, clinical professional bodies, and stroke charities in the UK and internationally will be included. Two reviewers will independently screen titles, abstracts and full texts for inclusion of published literature. One reviewer will screen search results from the grey literature and identify relevant documents for inclusion. Data synthesis will include analysis of the number, type of studies, year and country of publication, a summary of intervention components/service or practice, outcomes addressed, main results (an indicator of effectiveness) and a description of included interventions. Ethics and dissemination The review will help identify components of care and care pathways for primary care services for stroke. By comparing the results with stroke survivors' and carers' needs identified in the literature, the review will highlight potential gaps in research and practice relevant to long-term care after stroke. PMID:27798023

A practical approach to acute hemiparesis in children.

PubMed

Bhate, Sanjay; Ganesan, Vijeya

2015-08-01

Acute hemiparesis in children is a common clinical syndrome presenting to a variety of care settings. The recognition and the differential diagnosis is challenging, particularly in young children. Arterial ischaemic stroke (AIS) is the primary diagnosis to be considered as this requires emergency investigations and management; however, there are several conditions collectively described as 'stroke mimics' that need consideration. Accurate diagnosis is essential for appropriate management. Clinical data combined with neuroimaging are important for accurate diagnosis and management. This review and the accompanying illustrative case vignettes suggest a practical approach to differential diagnosis and management of children presenting with acute hemiparesis. © 2015 Mac Keith Press.

No correlation between stroke specialty and rate of shoulder pain in NCAA men swimmers

PubMed Central

Wymore, Lucas; Reeve, Robert E.; Chaput, Christopher D.

2012-01-01

Purpose: To established an association between shoulder pain and the stroke specialization among NCAA men swimmers. Materials and Methods: All members of the top 25 NCAA men's swim teams were invited to complete the survey. Eleven teams with a total of 187 participants completed the study survey. The teams were mailed surveys that included multiple choice questions regarding their primary stroke and their incidence of shoulder pain. Additionally, the survey included questions about risk factors including distance trained, type of equipment, weight training, and stretching. Results: The analysis showed that there was no significant difference in the rates of shoulder pain among the four strokes and individual medley specialists. The other risk factors did not show a significant correlation with shoulder pain. Conclusions: This study found no significant correlation between stroke specialty and shoulder pain in male collegiate swimmers. Level of Evidence: Level 3. Clinical Relevance: Descriptive epidemiology study. PMID:23204760

Stroke Outreach in an Inner City Market: A Platform for Identifying African American Males for Stroke Prevention Interventions.

PubMed

Sharrief, Anjail Zarinah; Johnson, Brenda; Urrutia, Victor Cruz

2015-01-01

There are significant racial disparities in stroke incidence and mortality. Health fairs and outreach programs can be used to increase stroke literacy, but they often fail to reach those at highest risk, including African American males. We conducted a stroke outreach and screening program at an inner city market in order to attract a high-risk group for a stroke education intervention. A modified Framingham risk tool was used to estimate stroke risk and a 10-item quiz was developed to assess stroke literacy among 80 participants. We report results of the demographic and stroke risk analyses and stroke knowledge assessment. The program attracted a majority male (70%) and African American (95%) group of participants. Self-reported hypertension (57.5%), tobacco use (40%), and diabetes (23.8%) were prevalent. Knowledge of stroke warning signs, risk factors, and appropriate action to take for stroke symptoms was not poor when compared to the literature. Stroke outreach and screening in an inner city public market may be an effective way to target a high-risk population for stroke prevention interventions. Stroke risk among participants was high despite adequate stroke knowledge.

Stroke mimic diagnoses presenting to a hyperacute stroke unit.

PubMed

Dawson, Ang; Cloud, Geoffrey C; Pereira, Anthony C; Moynihan, Barry J

2016-10-01

Stroke services have been centralised in several countries in recent years. Diagnosing acute stroke is challenging and a high proportion of patients admitted to stroke units are diagnosed as a non-stroke condition (stroke mimics). This study aims to describe the stroke mimic patient group, including their impact on stroke services. We analysed routine clinical data from 2,305 consecutive admissions to a stroke unit at St George's Hospital, London. Mimic groupings were derived from 335 individual codes into 17 groupings. From 2,305 admissions, 555 stroke mimic diagnoses were identified (24.2%) and 72% of stroke mimics had at least one stroke risk factor. Common mimic diagnoses were headache, seizure and syncope. Medically unexplained symptoms and decompensation of underlying conditions were also common. Median length of stay was 1 day; a diagnosis of dementia (p=0.028) or needing MRI (p=0.006) was associated with a longer stay. Despite emergency department assessment by specialist clinicians and computed tomography brain, one in four suspected stroke patients admitted to hospital had a non-stroke diagnosis. Stroke mimics represent a heterogeneous patient group with significant impacts on stroke services. Co-location of stroke and acute neurology services may offer advantages where service reorganisation is being considered. © Royal College of Physicians 2016. All rights reserved.

40 CFR 90.104 - Compliance with emission standards.

Code of Federal Regulations, 2011 CFR

2011-07-01

... Volume Engine Families Engine class Two-stroke engines 1 HC+NOX CO Four-stroke engines HC+NOX CO Engines...). Class IV 1.1 1.1 1.5 1.1 Class V 1.1 1.1 1.5 1.1 1 Two-stroke technologies to which these assigned deterioration factors apply include conventional two-strokes, compression wave designs, and stratified...

40 CFR 90.104 - Compliance with emission standards.

Code of Federal Regulations, 2013 CFR

2013-07-01

... Volume Engine Families Engine class Two-stroke engines 1 HC+NOX CO Four-stroke engines HC+NOX CO Engines...). Class IV 1.1 1.1 1.5 1.1 Class V 1.1 1.1 1.5 1.1 1 Two-stroke technologies to which these assigned deterioration factors apply include conventional two-strokes, compression wave designs, and stratified...

40 CFR 90.104 - Compliance with emission standards.

Code of Federal Regulations, 2012 CFR

2012-07-01

... Volume Engine Families Engine class Two-stroke engines 1 HC+NOX CO Four-stroke engines HC+NOX CO Engines...). Class IV 1.1 1.1 1.5 1.1 Class V 1.1 1.1 1.5 1.1 1 Two-stroke technologies to which these assigned deterioration factors apply include conventional two-strokes, compression wave designs, and stratified...

40 CFR 90.104 - Compliance with emission standards.

Code of Federal Regulations, 2014 CFR

2014-07-01

... Volume Engine Families Engine class Two-stroke engines 1 HC+NOX CO Four-stroke engines HC+NOX CO Engines...). Class IV 1.1 1.1 1.5 1.1 Class V 1.1 1.1 1.5 1.1 1 Two-stroke technologies to which these assigned deterioration factors apply include conventional two-strokes, compression wave designs, and stratified...

40 CFR 90.104 - Compliance with emission standards.

Code of Federal Regulations, 2010 CFR

2010-07-01

... Volume Engine Families Engine class Two-stroke engines 1 HC+NOX CO Four-stroke engines HC+NOX CO Engines...). Class IV 1.1 1.1 1.5 1.1 Class V 1.1 1.1 1.5 1.1 1 Two-stroke technologies to which these assigned deterioration factors apply include conventional two-strokes, compression wave designs, and stratified...

Gaps in care for patients with memory deficits after stroke: views of healthcare providers.

PubMed

Tang, Eugene Yee Hing; Price, Christopher; Stephan, Blossom Christa Maree; Robinson, Louise; Exley, Catherine

2017-09-08

Stroke is a common cause of physical disability but is also strongly associated with cognitive impairment and a risk for future dementia. Despite national clinical guidelines, the service provided for stroke survivors with cognitive and memory difficulties varies across localities. This study critically evaluated the views of healthcare professionals about barriers and facilitators to their care. Seventeen semi-structured individual interviews were conducted by a single interviewer with both primary and secondary care clinicians in regular contact with stroke-survivors. This included stroke medicine specialists, specialist nurses, physiotherapists, occupational therapists, general practitioners and primary care nurses. Topics included individual experiences of the current care offered to patients with cognitive impairment, assessment processes and inter-professional communication. Interviews were audio recorded and transcribed verbatim. Transcripts were thematically analysed and themes grouped into broad categories to facilitate interpretation. Data analysis identified four key themes as barriers to optimal care for stroke-survivors with memory difficulties: 1) Less focus on memory and cognition in post-stroke care; 2) Difficulties bringing up memory and cognitive problems post-stroke; 3) Lack of clarity in current services; and, 4) Assumptions made by healthcare professionals introducing gaps in care. Facilitators included stronger links between primary and secondary care in addition to information provision at all stages of care. The care provided by stroke services is dominated by physical impairments. Clinicians are unsure who should take responsibility for follow-up of patients with cognitive problems. This is made even more difficult by the lack of experience in assessment and stigma surrounding potential diagnoses associated with these deficits. Service development should focus on increased cohesiveness between hospital and community care to create a clear care pathway for post-stroke cognitive impairment.

Education, Socioeconomic Status, and Intelligence in Childhood and Stroke Risk in Later Life: A Meta-analysis.

PubMed

McHutchison, Caroline A; Backhouse, Ellen V; Cvoro, Vera; Shenkin, Susan D; Wardlaw, Joanna M

2017-07-01

Stroke is the second most common cause of death, and a common cause of dependency and dementia. Adult vascular risk factors and socioeconomic status (SES) are associated with increased risk, but less is known about early life risk factors, such as education, childhood SES, or intelligence (IQ). We comprehensively searched Medline, PsycINFO, and EMBASE from inception to November 2015. We included all studies reporting data on >50 strokes examining childhood/premorbid IQ, SES, and education. Two reviewers independently screened full texts and extracted and cross-checked data, including available risk factor adjustments. We meta-analyzed stroke risk using hazard ratios (HR), odds ratios (OR), and mean differences (MD). We tested effects of study and participant characteristics in sensitivity analyses and meta-regression, and assessed heterogeneity and publication bias. We identified 90 studies examining stroke risk and education (79), SES (10), or IQ (nine) including approximately 164,683 stroke and over 5 million stroke-free participants. Stroke risk increased with lower education (OR = 1.35, 95% CI = 1.24, 1.48), SES (OR = 1.28, 95% CI = 1.12, 1.46), and IQ (HR = 1.17, 95% CI = 1.00, 1.37) in studies reporting point estimates, with similar associations for MD. We found minimal publication bias. Between-study heterogeneity was partly explained by participant age and case ascertainment method. Education, childhood SES, and intelligence have modest but important associations with lifetime stroke, and hence dementia, risks. Future studies distinguishing between the individual and combined effects of education, childhood SES and intelligence are needed to determine the independent contribution of each factor to stroke risk. See video abstract at, http://links.lww.com/EDE/B210.

Atrial fibrillation detected by continuous electrocardiographic monitoring using implantable loop recorder to prevent stroke in individuals at risk (the LOOP study): Rationale and design of a large randomized controlled trial.

PubMed

Diederichsen, Søren Zöga; Haugan, Ketil Jørgen; Køber, Lars; Højberg, Søren; Brandes, Axel; Kronborg, Christian; Graff, Claus; Holst, Anders Gaarsdal; Nielsen, Jonas Bille; Krieger, Derk; Svendsen, Jesper Hastrup

2017-05-01

Atrial fibrillation (AF) increases the rate of stroke 5-fold, and AF-related strokes have a poorer prognosis compared with non-AF-related strokes. Atrial fibrillation and stroke constitute an intensifying challenge, and health care organizations are calling for awareness on the topic. Previous studies have demonstrated that AF is often asymptomatic and consequently undiagnosed. The implantable loop recorder (ILR) allows for continuous, long-term electrocardiographic monitoring with daily transmission of arrhythmia information, potentially leading to improvement in AF detection and stroke prevention. The LOOP study is an investigator-initiated, randomized controlled trial with 6,000 participants randomized 3:1 to a control group or to receive an ILR with continuous electrocardiographic monitoring. Participants are identified from Danish registries and are eligible for inclusion if 70years or older and previously diagnosed as having at least one of the following conditions: hypertension, diabetes mellitus, heart failure, or previous stroke. Exclusion criteria include history of AF and current oral anticoagulation treatment. When an AF episode lasting ≥6minutes is detected, oral anticoagulation will be initiated according to guidelines. Expected follow-up is 4years. The primary end point is time to stroke or systemic embolism, whereas secondary end points include time to AF diagnosis and death. The LOOP study will evaluate health benefits and cost-effectiveness of ILR as a screening tool for AF to prevent stroke in patients at risk. Secondary objectives include identification of risk factors for the development of AF and characterization of arrhythmias in the population. The trial holds the potential to influence the future of stroke prevention. Copyright © 2017 Elsevier Inc. All rights reserved.

Nonvitamin-K-antagonist oral anticoagulants versus warfarin in patients with atrial fibrillation and previous stroke or transient ischemic attack: An updated systematic review and meta-analysis of randomized controlled trials.

PubMed

Ntaios, George; Papavasileiou, Vasileios; Diener, Hans-Chris; Makaritsis, Konstantinos; Michel, Patrik

2017-08-01

Background In a previous systematic review and meta-analysis, we assessed the efficacy and safety of nonvitamin-K antagonist oral anticoagulants versus warfarin in patients with atrial fibrillation and stroke or transient ischemic attack. Since then, new information became available. Aim The aim of the present work was to update the results of the previous systematic review and meta-analysis. Methods We searched PubMed until 24 August 2016 for randomized controlled trials using the following search items: "atrial fibrillation" and "anticoagulation" and "warfarin" and "previous stroke or transient ischemic attack." Eligible studies had to be phase III trials in patients with atrial fibrillation comparing warfarin with nonvitamin-K antagonist oral anticoagulants currently on the market or with the intention to be brought to the market in North America or Europe. The outcomes assessed in the efficacy analysis included stroke or systemic embolism, stroke, ischemic or unknown stroke, disabling or fatal stroke, hemorrhagic stroke, cardiovascular death, death from any cause, and myocardial infarction. The outcomes assessed in the safety analysis included major bleeding, intracranial bleeding, and major gastrointestinal bleeding. We performed fixed effects analyses on intention-to-treat basis. Results Among 183 potentially eligible articles, four were included in the meta-analysis. In 20,500 patients, compared to warfarin, nonvitamin-K antagonist oral anticoagulants were associated with a significant reduction of stroke/systemic embolism (relative risk reduction: 13.7%, absolute risk reduction: 0.78%, number needed to treat to prevent one event: 127), hemorrhagic stroke (relative risk reduction: 50.0%, absolute risk reduction: 0.63%, number needed to treat: 157), any stroke (relative risk reduction: 13.1%, absolute risk reduction: 0.7%, number needed to treat: 142), and intracranial hemorrhage (relative risk reduction: 46.1%, absolute risk reduction: 0.88%, number needed to treat: 113) over 1.8-2.8 years. Conclusions This updated meta-analysis in 20,500 atrial fibrillation patients with previous stroke or transient ischemic attack shows that compared to warfarin non-vitamin-K antagonist oral anticoagulants are associated with a significant reduction of stroke, stroke or systemic embolism, hemorrhagic stroke, and intracranial bleeding.

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.

[Functional neuroimaging of the brain structures associated with language in healthy individuals and patients with post-stroke aphasia].

PubMed

Alferova, V V; Mayorova, L A; Ivanova, E G; Guekht, A B; Shklovskij, V M

2017-01-01

The introduction of non-invasive functional neuroimaging techniques such as functional magnetic resonance imaging (fMRI), in the practice of scientific and clinical research can increase our knowledge about the organization of cognitive processes, including language, in normal and reorganization of these cognitive functions in post-stroke aphasia. The article discusses the results of fMRI studies of functional organization of the cortex of a healthy adult's brain in the processing of various voice information as well as the main types of speech reorganization after post-stroke aphasia in different stroke periods. The concepts of 'effective' and 'ineffective' brain plasticity in post-stroke aphasia were considered. It was concluded that there was an urgent need for further comprehensive studies, including neuropsychological testing and several complementary methods of functional neuroimaging, to develop a phased treatment plan and neurorehabilitation of patients with post-stroke aphasia.

Emergency medical service in the stroke chain of survival.

PubMed

Chenaitia, Hichem; Lefevre, Oriane; Ho, Vanessa; Squarcioni, Christian; Pradel, Vincent; Fournier, Marc; Toesca, Richard; Michelet, Pierre; Auffray, Jean Pierre

2013-02-01

The Emergency Medical Services (EMS) play a primordial role in the early management of adults with acute ischaemic stroke (AIS). The aim of this study was to evaluate the role and effectiveness of the EMS in the stroke chain of survival in Marseille. A retrospective observational study was conducted in patients treated for AIS or transient ischaemic attack in three emergency departments and at the Marseille stroke centre over a period of 12 months. In 2009, of 1034 patients ultimately presenting a diagnosis of AIS or transient ischaemic attack, 74% benefited from EMS activation. Dispatchers correctly diagnosed 57% of stroke patients. The symptoms most frequently reported included limb weakness, speech problems and facial paresis. Elements resulting in misdiagnosis by dispatchers were general discomfort, chest pain, dyspnoea, fall or vertigo. Stroke patients not diagnosed by emergency medical dispatchers but calling within 3 h of symptom onset accounted for 20% of cases. Our study demonstrates that public intervention programmes must stress the urgency of recognizing stroke symptoms and the importance of calling EMS through free telephone numbers. Further efforts are necessary to disseminate guidelines for healthcare providers concerning stroke recognition and the new therapeutic possibilities in order to increase the likelihood of acute stroke patients presenting to a stroke team early enough to be eligible for acute treatment. In addition, EMS dispatchers should receive further training about atypical stroke symptoms, and 'Face Arm Speech Test' tests must be included in the routine questionnaires used in emergency medical calls concerning elderly persons.

In-hospital risk prediction for post-stroke depression: development and validation of the Post-stroke Depression Prediction Scale.

PubMed

de Man-van Ginkel, Janneke M; Hafsteinsdóttir, Thóra B; Lindeman, Eline; Ettema, Roelof G A; Grobbee, Diederick E; Schuurmans, Marieke J

2013-09-01

The timely detection of post-stroke depression is complicated by a decreasing length of hospital stay. Therefore, the Post-stroke Depression Prediction Scale was developed and validated. The Post-stroke Depression Prediction Scale is a clinical prediction model for the early identification of stroke patients at increased risk for post-stroke depression. The study included 410 consecutive stroke patients who were able to communicate adequately. Predictors were collected within the first week after stroke. Between 6 to 8 weeks after stroke, major depressive disorder was diagnosed using the Composite International Diagnostic Interview. Multivariable logistic regression models were fitted. A bootstrap-backward selection process resulted in a reduced model. Performance of the model was expressed by discrimination, calibration, and accuracy. The model included a medical history of depression or other psychiatric disorders, hypertension, angina pectoris, and the Barthel Index item dressing. The model had acceptable discrimination, based on an area under the receiver operating characteristic curve of 0.78 (0.72-0.85), and calibration (P value of the U-statistic, 0.96). Transforming the model to an easy-to-use risk-assessment table, the lowest risk category (sum score, <-10) showed a 2% risk of depression, which increased to 82% in the highest category (sum score, >21). The clinical prediction model enables clinicians to estimate the degree of the depression risk for an individual patient within the first week after stroke.

Issues post-stroke for Muslim people in maintaining the practice of salat (prayer): A qualitative study.

PubMed

Mohamed, Che Rabiaah; Nelson, Katherine; Wood, Pamela; Moss, Cheryle

2015-01-01

Muslims throughout the world perform salat (prayer) five times a day; salat involves a person reciting the Holy Qur'an while being in several positions. There are several steps that should be carried out before prayer, including wudhu (ablution) and covering one's awrah (body). To identify educational needs for stroke patients and their caregivers in Malaysia. Another purpose is to report on the needs identified by stroke patients and their families related to salat. Descriptive qualitative study. Phase 1 involved semi-structured interviews with stroke patients (n = 5), family caregivers (n = 5) and health professionals (n = 12) in Kelantan Malaysia. Phase 2 involved presenting the findings from Phase 1 to the health professionals with the aim of establishing priorities and processes to develop education strategies for stroke patients and their families. Preparing for and performing salat was challenging for both patient and family carers to do following a stroke. Themes identified were prayer and the meaning of the stroke events for participants, difficulties praying post-stroke, prayer as part of rehabilitation therapy. Providing culturally safe care should include how nurses assess and support patients and their caregivers post stroke to meet their prayer needs. Nurses have a role in discussing with stroke patients and their families how in addition to its spiritual and customary benefits, prayer and for Muslims reciting the Holy Qur'an can have cognitive and rehabilitation benefits, as well as being a source of psychological support for stroke patients.

Diabetes is an Independent Risk Factor for Stroke Recurrence in Stroke Patients: A Meta-analysis.

PubMed

Shou, Juan; Zhou, Li; Zhu, Shanzhu; Zhang, Xiangjie

2015-09-01

This study aimed to assess the association between diabetes and risk of stroke recurrence (especially ischemic stroke recurrence) and to evaluate whether diabetes was an independent predictor for stroke recurrence in stroke patients with diabetes. The relevant studies were identified through searching databases of PubMed, EMBASE, and Cochrane library. Adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) were pooled to evaluate the association between diabetes and risk of stroke recurrence. Funnel plot and Egger's regression tests were used to assess publication bias. All statistical analyses were conducted in Stata 12.0. Eighteen studies containing totally 43,899 participants were included in the meta-analysis. The results showed that stroke recurrence risk of all stroke patients with diabetes was significantly higher than those without diabetes (HR, 1.45; 95% CI, 1.32-1.59), similar results were achieved in ischemic stroke patients (HR, 1.44; 95% CI, 1.28-1.61), and there were no regional differences (Europe: HR, 1.28; 95% CI, 1.13-1.44; USA: HR, 1.89; 95% CI, 1.53-2.33; Asia: HR, 1.57, 95% CI, 1.28-1.92, respectively) and age differences (mean age <70 years: HR, 1.58; 95% CI, 1.34-1.86; mean age ≥70 years: HR, 1.27; 95% CI, 1.11-1.45, respectively). The heterogeneity of all included studies was not statistically significant, and no publication bias was observed. This meta-analysis shows that diabetes is an independent risk factor for stroke recurrence in stroke patients. Copyright © 2015. Published by Elsevier Inc.

Incidence of constipation in stroke patients

PubMed Central

Li, Jianxiang; Yuan, Mengguo; Liu, Yunfang; Zhao, Yang; Wang, Jingqing; Guo, Weifeng

2017-01-01

Abstract There is growing awareness of a link between the gut and cardiovascular disease. Constipation is common among individuals who have had a stroke, and it negatively affects social functioning and quality of life. However, no systematic study on the incidence of constipation in stroke patients has been reported. We selected studies included in Medline, Embase, Cochrane database, and Web of Science. Studies were included if they reported the incidence in stroke patients. Two authors selected the studies, extracted the data independently, and assessed these. Subgroup analyses were conducted according to the stroke subtype and stage of stroke. After detailed evaluations, 8 studies (n  =  1385 participants) were found that contained data that were suitable for meta-analytic synthesis. A forest plot showed that the incidence of constipation was 48% (95% confidence interval [CI]  =  33%–63%). In the analysis of the type of stroke subgroup, the incidence of constipation in patients who had had a hemorrhagic stroke (66% [95% CI  =  40–91%]) was higher than that in patients who had experienced an ischemic stroke (51% [95% CI  =  27%–75%]). The incidence in the acute stage (45% [95% CI  =  36%–54%]) was lower than that in the rehabilitation stage (48% [95% CI  =  23%–73%]). Constipation after a stroke event occurs frequently. This finding may raise awareness about bowel complications to allow correct evaluation and proper management. PMID:28640117

Sex Differences in Stroke Therapies

PubMed Central

Sohrabji, Farida; Park, Min Jung; Mahnke, Amanda H

2016-01-01

Stroke is the 5th leading cause of death and acquired disability in aged populations. Women are disproportionally affected by stroke, having a higher incidence and worse outcomes than men. Numerous preclinical studies have discovered novel therapies for the treatment of stroke, but almost all of these were found to be unsuccessful in clinical trials. Despite known sex differences in occurrence and severity of stroke, few therapeutics, both preclinically and clinically, take into account possible sex differences in treatment. Reanalysis of data from the only currently FDA-approved stroke therapy, tPA, has shown to not only improve stroke outcomes for both sexes, but to also show sexual dimorphism by more robust improvement in stroke outcome in females. Experimental evidence supports the inclusion of sex as a variable in the study of a number of novel stroke drugs and therapies, including preclinical studies of anti-inflammatory drugs (minocycline), stimulators of cell survival (IGF-1), and inhibitors of cell death pathways (pharmacological inhibition of PARP-1, NO production, and caspase activation), as well as in current clinical trials of stem cell therapy and cortical stimulation. Overall, study design and analyses in clinical trials, as well as in preclinical studies, must include both sexes equally, consider possible sex differences in the analyses, and report the differences/similarities in more systemized/structured way to translate promising therapies to both sexes and increase stroke recovery. PMID:27870437

A Delphi study and ranking exercise to support commissioning services: future delivery of Thrombectomy services in England.

PubMed

Halvorsrud, Kristoffer; Flynn, Darren; Ford, Gary A; McMeekin, Peter; Bhalla, Ajay; Balami, Joyce; Craig, Dawn; White, Phil

2018-02-22

Intra-arterial thrombectomy is the gold standard treatment for large artery occlusive stroke. However, the evidence of its benefits is almost entirely based on trials delivered by experienced neurointerventionists working in established teams in neuroscience centres. Those responsible for the design and prospective reconfiguration of services need access to a comprehensive and complementary array of information on which to base their decisions. This will help to ensure the demonstrated effects from trials may be realised in practice and account for regional/local variations in resources and skill-sets. One approach to elucidate the implementation preferences and considerations of key experts is a Delphi survey. In order to support commissioning decisions, we aimed using an electronic Delphi survey to establish consensus on the options for future organisation of thrombectomy services among physicians with clinical experience in managing large artery occlusive stroke. A Delphi survey was developed with 12 options for future organisation of thrombectomy services in England. A purposive sampling strategy established an expert panel of stroke physicians from the British Association of Stroke Physicians (BASP) Clinical Standards and/or Executive Membership that deliver 24/7 intravenous thrombolysis. Options with aggregate scores falling within the lowest quartile were removed from the subsequent Delphi round. Options reaching consensus following the two Delphi rounds were then ranked in a final exercise by both the wider BASP membership and the British Society of Neuroradiologists (BSNR). Eleven stroke physicians from BASP completed the initial two Delphi rounds. Three options achieved consensus, with subsequently wider BASP (97%, n = 43) and BSNR members (86%, n = 21) assigning the highest approval rankings in the final exercise for transferring large artery occlusive stroke patients to nearest neuroscience centre for thrombectomy based on local CT/CT Angiography. The initial Delphi rounds ensured optimal reduction of options by an expert panel of stroke physicians, while subsequent ranking exercises allowed remaining options to be ranked by a wider group of experts within stroke to reach consensus. The preferred implementation option for thrombectomy is investigating suspected acute stroke patients by CT/CT Angiography and secondary transfer of large artery occlusive stroke patients to the nearest neuroscience (thrombectomy) centre.

Global Burden of Stroke.

PubMed

Feigin, Valery L; Norrving, Bo; Mensah, George A

2017-02-03

On the basis of the GBD (Global Burden of Disease) 2013 Study, this article provides an overview of the global, regional, and country-specific burden of stroke by sex and age groups, including trends in stroke burden from 1990 to 2013, and outlines recommended measures to reduce stroke burden. It shows that although stroke incidence, prevalence, mortality, and disability-adjusted life-years rates tend to decline from 1990 to 2013, the overall stroke burden in terms of absolute number of people affected by, or who remained disabled from, stroke has increased across the globe in both men and women of all ages. This provides a strong argument that "business as usual" for primary stroke prevention is not sufficiently effective. Although prevention of stroke is a complex medical and political issue, there is strong evidence that substantial prevention of stroke is feasible in practice. The need to scale-up the primary prevention actions is urgent. © 2017 American Heart Association, Inc.

Coronary heart disease risk in patients with stroke or transient ischemic attack and no known coronary heart disease: findings from the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) trial.

PubMed

Amarenco, Pierre; Goldstein, Larry B; Sillesen, Henrik; Benavente, Oscar; Zweifler, Richard M; Callahan, Alfred; Hennerici, Michael G; Zivin, Justin A; Welch, K Michael A

2010-03-01

Noncoronary forms of atherosclerosis (including transient ischemic attacks or stroke of carotid origin or >50% stenosis of the carotid artery) are associated with a 10-year vascular risk of >20% and are considered as a coronary heart disease (CHD) -risk equivalent from the standpoint of lipid management. The Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) trial included patients with stroke or transient ischemic attack and no known CHD regardless of the presence of carotid atherosclerosis. We evaluated the risk of developing clinically recognized CHD in SPARCL patients. A total of 4731 patients (mean age, 63 years) was randomized to 80 mg/day atorvastatin placebo. The rates of major coronary event, any CHD event, and any revascularization procedure were evaluated. After 4.9 years of follow-up, the risks of a major coronary event and of any CHD end point in the placebo group were 5.1% and 8.6%, respectively. The rate of outcome of stroke decreased over time, whereas the major coronary event rate was stable. Relative to those having a large vessel-related stroke at baseline, those having a transient ischemic attack, hemorrhagic stroke, small vessel stroke, or a stroke of unknown cause had similar absolute rates for a first major coronary event and for any CHD event; transient ischemic attack, small vessel, and unknown cause groups had lower absolute revascularization procedure rates. Major coronary event, any CHD event, and any revascularization procedure rates were similarly reduced in all baseline stroke subtypes in the atorvastatin arm compared with placebo with no heterogeneity between groups. CHD risk can be substantially reduced by atorvastatin therapy in patients with recent stroke or transient ischemic attack regardless of stroke subtype.

Functional and motor outcome 5 years after stroke is equivalent to outcome at 2 months: follow-up of the collaborative evaluation of rehabilitation in stroke across Europe.

PubMed

Meyer, Sarah; Verheyden, Geert; Brinkmann, Nadine; Dejaeger, Eddy; De Weerdt, Willy; Feys, Hilde; Gantenbein, Andreas R; Jenni, Walter; Laenen, Annouschka; Lincoln, Nadina; Putman, Koen; Schuback, Birgit; Schupp, Wilfried; Thijs, Vincent; De Wit, Liesbet

2015-06-01

Recovery of patients within the first 6 months after stroke is well documented, but there has been little research on long-term recovery. The aim of this study was to analyze functional and motor recovery between admission to rehabilitation centres and 5 years after stroke. This follow-up of the Collaborative Evaluation of Rehabilitation in Stroke Across Europe study, included patients from 4 European rehabilitation centres. Patients were assessed on admission, at 2 and 6 months, and 5 years after stroke, using the Barthel Index, Rivermead Motor Assessment Gross Function, Leg and Trunk function, and Arm function. Linear mixed models were used, corrected for baseline characteristics. To account for the drop-out during follow-up, the analysis is likelihood-based (assumption of missingness at random). A total of 532 patients were included in this study, of which 238 were followed up at 5 years post stroke. Mean age at stroke onset was 69 (±10 SD) years, 53% were men, 84% had ischemic strokes, and 53% had left-sided motor impairment. Linear mixed model analysis revealed a significant deterioration for all 4 outcomes between 6 months and 5 years (P<0.0001). Scores at 2 months were not statistically significant different from scores at 5 years after stroke. Higher age (P<0.0001) and increasing stroke severity on admission (P<0.0001) negatively affected long-term functional and motor recovery. Five-year follow-up revealed deterioration in functional and motor outcome, with a return to the level measured at 2 months. Increasing age and increasing stroke severity negatively affected recovery up to 5 years after stroke. © 2015 American Heart Association, Inc.

Relation of Candidate Genes that Encode for Endothelial Function to Migraine and Stroke: The Stroke Prevention in Young Women Study

PubMed Central

MacClellan, Leah R.; Howard, Timothy D.; Cole, John W.; Stine, O. Colin; Giles, Wayne H.; O’Connell, Jeffery R.; Wozniak, Marcella A.; Stern, Barney J.; Mitchell, Braxton D.; Kittner, Steven J.

2009-01-01

Background and Purpose Migraine with aura is a risk factor for ischemic stroke but the mechanism by which these disorders are associated remains unclear. Both disorders exhibit familial clustering, which may imply a genetic influence on migraine and stroke risk. Genes encoding for endothelial function are promising candidate genes for migraine and stroke susceptibility because of the importance of endothelial function in regulating vascular tone and cerebral blood flow. Methods Using data from the Stroke Prevention in Young Women (SPYW) study, a population-based case-control study including 297 women aged 15–49 years with ischemic stroke and 422 women without stroke, we evaluated whether polymorphisms in genes regulating endothelial function, including endothelin-1 (EDN), endothelin receptor type B (EDNRB), and nitric oxide synthase-3 (NOS3), confer susceptibility to migraine and stroke. Results EDN SNPs rs1800542 and rs10478723 were associated with increased stroke susceptibility in Caucasians, (OR = 2.1 (95% CI, 1.1 to 4.2) and OR = 2.2 (95% CI, 1.1 to 4.4); p = 0.02 and 0.02, respectively) as were EDNRB SNPs rs4885493 and rs10507875, (OR = 1.7 (95% CI, 1.1 to 2.7) and OR = 2.4 (95% CI, 1.4 to 4.3); p = 0.01 and 0.002, respectively). Only one of the tested SNPs (NOS3 - rs3918166) was associated with both migraine and stroke. Conclusions In our study population, variants in EDN and EDNRB were associated with stroke susceptibility in Caucasian but not in African-American women. We found no evidence that these genes mediate the association between migraine and stroke. PMID:19661472

Estimates of stroke incidence and case fatality in Zabrze, 2005-2006.

PubMed

Wawrzyńczyk, Maciej; Pierzchała, Krystyna; Braczkowska, Bogumiła; Mańka-Gaca, Iwona; Kumor, Klaudiusz; Borowski, Daniel; Grodzicka-Zawisza, Lucyna; Zejda, Jan

2011-01-01

Epidemiological rates for stroke obtained in the United States and Western Europe indicate a decrease in incidence and case fatality. Data published for Poland, as for other Central-Eastern European countries, reported unfavourable results, but this was based on data from the 1990s. The authors evaluated current stroke rates in a population study of the southern Poland city of Zabrze. A retrospective registry of all stroke cases treated in Zabrze, southern Poland, in 2005-2006, was established, based on data from the National Health Fund. Cases were identified by verifying patient files. Epidemiological rates were calculated and standardized to the European population in both groups: all stroke patients, including recurrent (all strokes, AS), and patients with first-ever stroke (FES) in their history. We registered 731 strokes, including 572 FES cases (78.3%) and 159 recurrent strokes (21.7%). There were 385 strokes in men (52.7%), and 346 in women (47.2%); 88.6% were ischaemic strokes (IS), and 11.4% were intra-ce-rebral haemorrhages (ICH). The standardized incidence rate for AS patients was 167/100 000 (211 for men, 130 for women), and in the FES group 131/100 000 (161 for men, 104 for women). Twenty-eight day case fatality for the AS group was 18.3% (15.4% for IS, 41% for ICH), and 16.6% for FES (13.4% for IS, 40.9% for ICH). Incidence rates in this southern Poland city are comparable to those reported previously for Poland. Early case fatality decreased, compared to previous data, probably as a result of improved management of acute stroke and hospitalizing all stroke patients.

Influence of stroke subtype on quality of care in the Get With The Guidelines-Stroke Program.

PubMed

Smith, E E; Liang, L; Hernandez, A; Reeves, M J; Cannon, C P; Fonarow, G C; Schwamm, L H

2009-09-01

Little is known about in-hospital care for hemorrhagic stroke. We examined quality of care in intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) admissions in the national Get With The Guidelines-Stroke (GWTG-Stroke) database, and compared them to ischemic stroke (IS) or TIA admissions. Between April 1, 2003, and December 30, 2007, 905 hospitals contributed 479,284 consecutive stroke and TIA admissions. The proportions receiving each quality of care measure were calculated by dividing the total number of patients receiving the intervention by the total number of patients eligible for the intervention, excluding ineligible patients or those with contraindications to treatment. Logistic regression models were used to determine associations between measure compliance and stroke subtype, controlling for patient and hospital characteristics. Stroke subtypes were 61.7% IS, 23.8% TIA, 11.1% ICH, and 3.5% SAH. Performance on care measures was generally lower in ICH and SAH compared to IS/TIA, including guideline-recommended measures for deep venous thrombosis (DVT) prevention (for ICH) and smoking cessation (for SAH) (multivariable-adjusted p < 0.001 for all comparisons). Exceptions were that ICH patients were more likely than IS/TIA to have door-to-CT times <25 minutes (multivariable-adjusted p < 0.001) and to undergo dysphagia screening (multivariable-adjusted p < 0.001). Time spent in the GWTG-Stroke program was associated with improvements in many measures of care for ICH and SAH patients, including DVT prevention and smoking cessation therapy (multivariable-adjusted p < 0.001). Many hospital-based acute care and prevention measures are underutilized in intracerebral hemorrhage and subarachnoid hemorrhage compared to ischemic stroke /TIA. Duration of Get With The Guidelines-Stroke participation is associated with improving quality of care for hemorrhagic stroke.

Translating G-CSF as an Adjunct Therapy to Stem Cell Transplantation for Stroke.

PubMed

Peña, Ike dela; Borlongan, Cesar V

2015-12-01

Among recently investigated stroke therapies, stem cell treatment holds great promise by virtue of their putative ability to replace lost cells, promote endogenous neurogenesis,and produce behavioral and functional improvement through their "bystander effects." Translating stem cell in the clinic, however, presents a number of technical difficulties. A strategy suggested to enhance therapeutic utility of stem cells is combination therapy, i.e., co-transplantation of stem cells or adjunct treatment with pharmacological agents and substrates,which is assumed to produce more profound therapeutic benefits by circumventing limitations of individual treatments and facilitating complementary brain repair processes. We previously demonstrated enhanced functional effects of cotreatment with granulocyte-colony stimulating factor (GCSF)and human umbilical cord blood cell (hUCB) transplantation in animal models of traumatic brain injury (TBI). Here,we suggest that the aforementioned combination therapy may also produce synergistic effects in stroke. Accordingly, G-CSF treatment may reduce expression of pro-inflammatory cytokines and enhance neurogenesis rendering a receptive microenvironment for hUCB engraftment. Adjunct treatment of GCSF with hUCB may facilitate stemness maintenance and guide neural lineage commitment of hUCB cells. Moreover, regenerative mechanisms afforded by G-CSF-mobilized endogenous stem cells, secretion of growth factors by hUCB grafts and G-CSF-recruited endothelial progenitor cells(EPCs), as well as the potential graft–host integration that may promote synaptic circuitry re-establishment could altogether produce more pronounced functional improvement in stroked rats subjected to a combination G-CSF treatment and hUCB transplantation. Nevertheless, differences in pathology and repair processes underlying TBI and stroke deserve consideration when testing the effects of combinatorial G-CSF and hUCB cell transplantation for stroke treatment. Further studies are also required to determine the safety and efficacy of this intervention in both preclinical and clinical stroke studies.

Reasoning about truth-telling in end-of-life care of patients with acute stroke.

PubMed

Rejnö, Åsa; Silfverberg, Gunilla; Ternestedt, Britt-Marie

2017-02-01

Ethical problems are a universal phenomenon but rarely researched concerning patients dying from acute stroke. These patients often have a reduced consciousness from stroke onset and thereby lack ability to convey their needs and could be described as 'incompetent' decision makers regarding their own care. The aim of the study was to deepen the understanding of stroke team members' reasoning about truth-telling in end-of-life care due to acute stroke. Qualitative study based on individual interviews utilizing combined deductive and inductive content analysis. Participants and research context: A total of 15 stroke team members working in stroke units of two associated county hospitals in western Sweden participated. Ethical considerations: The study was approved by the Regional Ethics Review Board, Gothenburg, Sweden. The main findings were the team members' dynamic movement between the categories 'Truth above all' and 'Hide truth to protect'. Honesty was highly valued and considered as a reason for always telling the truth, with the argument of truth as common morality. However, the carers also argued for hiding the truth for different reasons such as not adding extra burden in the sorrow, awaiting a timely moment and not being a messenger of bad news. Withholding truth could both be seen as a way of protecting themselves from difficult conversations and to protect others. The results indicate that there are various barriers for truthfulness. Interpreted from a virtue of ethics perspective, withholding of truth might also be seen as an expression of sound judgement to put the patient's best interest first. The carers may need support in the form of supervision to be given space to reflect on their experience and thereby promote ethically justified care. Here, the multi-professional team can be of great value and contribute through inter-professional sharing of knowledge.

Perceptions of physical activity and walking in an early stage after stroke or acquired brain injury.

PubMed

Törnbom, Karin; Sunnerhagen, Katharina S; Danielsson, Anna

2017-01-01

Physical activity has been established as being highly beneficial for health after stroke. There are considerable global efforts to find rehabilitation programs that encourage increased physical activity for persons with stroke. However, many persons with stroke or acquired brain injury do not reach recommended levels of physical activity and increased knowledge about why is needed. We aimed to explore views and experiences of physical activity and walking among persons with stroke or acquired brain injury. A qualitative study was conducted, among persons with stroke (n = 8) or acquired brain injury (n = 2) from a rehabilitation unit at Sahlgrenska University Hospital in Sweden. Semi-structured in-depth interviews were held about perceptions and experiences of walking and physical activity in general. Data were analyzed using qualitative content analysis, with categories that were determined inductively. Physical activity in general and walking ability more specifically were considered very important by the participants. However, physical activity was, regardless of exercising habits pre-injury, associated with different kinds of negative feelings and experiences. Commonly reported internal barriers in the current study were; fatigue, fear of falling or getting hurt in traffic, lack of motivation and depression. Reported external barriers were mostly related to walking, for example; bad weather, uneven ground, lack of company or noisy or too busy surroundings. Persons with stroke or acquired brain injury found it difficult to engage in and sustain an eligible level of physical activity. Understanding individual concerns about motivators and barriers surrounding physical activity may facilitate the work of forming tailor-made rehabilitation for these groups, so that the levels of physical activity and walking can increase.

Chronic sensory stroke with and without central pain is associated with bilaterally distributed sensory abnormalities as detected by quantitative sensory testing.

PubMed

Krause, Thomas; Asseyer, Susanna; Geisler, Frederik; Fiebach, Jochen B; Oeltjenbruns, Jochen; Kopf, Andreas; Villringer, Kersten; Villringer, Arno; Jungehulsing, Gerhard J

2016-01-01

Approximately 20% of patients suffering from stroke with pure or predominant sensory symptoms (referred to as sensory stroke patients) develop central poststroke pain (CPSP). It is largely unknown what distinguishes these patients from those who remain pain free. Using quantitative sensory testing (QST), we analyzed the somatosensory profiles of 50 patients with chronic sensory stroke, of which 25 suffered from CPSP. As compared with reference data from healthy controls, patients with CPSP showed alterations of thermal and mechanical thresholds on the body area contralateral to their stroke (P < 0.01). Patients with sensory stroke but without CPSP (non-pain sensory stroke [NPSS] patients) exhibited similar albeit less pronounced contralesional changes. Paradoxical heat sensation (PHS) and dynamic mechanical allodynia (DMA) showed higher values in CPSP, and an elevated cold detection threshold (CDT) was seen more often in CPSP than in patients with NPSS (P < 0.05). In patients with CPSP, changes in CDT, PHS, dynamic mechanical allodynia, and temporal pain summation (wind-up ratio) each correlated with the presence of pain (P < 0.05). On the homologous ipsilesional body area, both patient groups showed additional significant abnormalities as compared with the reference data, which strongly resembled the contralesional changes. In summary, our analysis reveals that CPSP is associated with impaired temperature perception and positive sensory signs, but differences between patients with CPSP and NPSS are subtle. Both patients with CPSP and NPSS show considerable QST changes on the ipsilesional body side. These results are in part paralleled by recent findings of bilaterally spread cortical atrophy in CPSP and might reflect chronic maladaptive cortical plasticity, particularly in patients with CPSP.

Reliability of center of pressure measures within and between sessions in individuals post-stroke and healthy controls.

PubMed

Gray, Vicki L; Ivanova, Tanya D; Garland, S Jayne

2014-01-01

Knowing the reliability of the center of pressure (COP) is important for interpreting balance deficits post-stroke, especially when the balance deficits can necessitate the use of short duration trials. The novel aspect of this reliability study was to examine the center of pressure measures using two adjacent force platforms between and within sessions in stroke and controls. After stroke, it is important to understand the contribution of the paretic and non-paretic leg to the motor control of standing balance. Because there is a considerable body of knowledge on COP reliability on a single platform, we chose to examine reliability using two adjacent platforms which has not been examined previously in stroke. Twenty participants post-stroke and 22 controls performed an arm raise, load drop and quiet stance balance task while standing on two adjacent force platforms, on two separate days. Intraclass correlations coefficient (ICC2,1) and percentage standard error of measurement (SEM%) were calculated for COP velocity, ellipse area, anterior-posterior (AP) displacement, and medial-lateral (ML) displacement. Between sessions, COP velocity was the most reliable with high ICCs and low SEM% across groups and tasks and ellipse area was less reliable with low ICCs across groups and tasks. COP measures were less reliable during the arm raise than load drop post-stroke. Within session reliability was high for COP velocity and ML displacement requiring no more than six trials across tasks. The COP velocity was the most reliable measure with high ICCs between sessions and the high reliability was achieved with fewer trials in both groups in a single session. Copyright © 2014 Elsevier B.V. All rights reserved.

The Effects of Stroke Type, Locus, and Extent on Long-Term Outcome of Gait Rehabilitation: The LEAPS Experience.

PubMed

Nadeau, Stephen E; Dobkin, Bruce; Wu, Samuel S; Pei, Qinglin; Duncan, Pamela W

2016-08-01

Background Paresis in stroke is largely a result of damage to descending corticospinal and corticobulbar pathways. Recovery of paresis predominantly reflects the impact on the neural consequences of this white matter lesion by reactive neuroplasticity (mechanisms involved in spontaneous recovery) and experience-dependent neuroplasticity, driven by therapy and daily experience. However, both theoretical considerations and empirical data suggest that type of stroke (large vessel distribution/lacunar infarction, hemorrhage), locus and extent of infarction (basal ganglia, right-hemisphere cerebral cortex), and the presence of leukoaraiosis or prior stroke might influence long-term recovery of walking ability. In this secondary analysis based on the 408 participants in the Locomotor Experience Applied Post-Stroke (LEAPS) study database, we seek to address these possibilities. Methods Lesion type, locus, and extent were characterized by the 2 neurologists in the LEAPS trial on the basis of clinical computed tomography and magnetic resonance imaging scans. A series of regression models was used to test our hypotheses regarding the effects of lesion type, locus, extent, and laterality on 2- to 12-month change in gait speed, controlling for baseline gait speed, age, and Berg Balance Scale score. Results Gait speed change at 1 year was significantly reduced in participants with basal ganglia involvement and prior stroke. There was a trend toward reduction of gait speed change in participants with lacunar infarctions. The presence of right-hemisphere cortical involvement had no significant impact on outcome. Conclusions Type, locus, and extent of lesion, and the loss of substrate for neuroplastic effect as a result of prior stroke may affect long-term outcome of rehabilitation of hemiparetic gait. © The Author(s) 2015.

Direct thrombin and factor Xa inhibition for stroke prevention in patients with atrial fibrillation.

PubMed

Galanis, Taki; Merli, Geno J

2013-02-01

Nonvalvular atrial fibrillation (AF) is the most common clinically significant cardiac arrhythmia occurring in patients in the United States. The primary clinical consequence of AF is an increase in the risk and severity of strokes. Treatment guidelines recommend anticoagulation therapy for most patients with AF. One risk-stratification scheme, the CHADS2 index, is simple and widely used to determine the management of patients with AF in regard to stroke prevention. However, new schemes, such as CHA2DS2-VASc, further refine risk stratification to identify patients who would obtain a net clinical benefit from a particular management strategy, thus improving the quality of management. For patients with AF for whom oral anticoagulation (OAC) is advisable, vitamin K antagonist (VKA) therapy is well established and effective. However, OAC with VKAs presents challenges to prescribers and patients in maintaining therapeutic efficacy. Novel OACs may offer alternatives to VKAs. Dabigatran etexilate, a direct thrombin inhibitor, was approved by the US Food and Drug Administration (FDA) in 2010 for reducing the risk of stroke and systemic embolism in patients with nonvalvular AF. The activated factor X (factor Xa) inhibitor rivaroxaban was recently approved by the FDA both for prophylaxis of deep vein thrombosis, which may lead to pulmonary embolism in patients undergoing knee or hip arthroplasty, and for reducing the risk of stroke and systemic embolism in patients with nonvalvular AF. Apixaban, another factor Xa inhibitor, was recently shown to be effective for stroke prevention in patients with nonvalvular AF. This article reviews clinical considerations regarding new agents that may offer alternatives to VKA therapy for the prevention of stroke in patients with AF.

Statins: pros and cons.

PubMed

Pinal-Fernandez, Iago; Casal-Dominguez, Maria; Mammen, Andrew L

2018-05-23

Statins inhibit the critical step of cholesterol synthesis in which 3-hydroxy-3-methylglutaryl coenzyme A (HMGC) is transformed to mevalonate by the enzyme HMGC reductase. By doing so, they have a potent lipid-lowering effect that reduces cardiovascular risk and decreases mortality. Since the mevalonate pathway also influences endothelial function, the inflammatory response, and coagulation, the effects of statins reach well beyond their cholesterol lowering properties. As with all drugs, statins may have adverse effects; these include musculoskeletal symptoms, increased risk of diabetes, and higher rates of hemorrhagic stroke. However, the frequency of adverse effects is extremely low and, in selected patient populations, the benefits of statins considerably outweigh the potential risks. Published by Elsevier España, S.L.U.

Transcranial Magnetic and Direct Current Stimulation in Children.

PubMed

Hameed, Mustafa Q; Dhamne, Sameer C; Gersner, Roman; Kaye, Harper L; Oberman, Lindsay M; Pascual-Leone, Alvaro; Rotenberg, Alexander

2017-02-01

Promising results in adult neurologic and psychiatric disorders are driving active research into transcranial brain stimulation techniques, particularly transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS), in childhood and adolescent syndromes. TMS has realistic utility as an experimental tool tested in a range of pediatric neuropathologies such as perinatal stroke, depression, Tourette syndrome, and autism spectrum disorder (ASD). tDCS has also been tested as a treatment for a number of pediatric neurologic conditions, including ASD, attention-deficit/hyperactivity disorder, epilepsy, and cerebral palsy. Here, we complement recent reviews with an update of published TMS and tDCS results in children, and discuss developmental neuroscience considerations that should inform pediatric transcranial stimulation.

Transcranial Magnetic and Direct Current Stimulation in Children

PubMed Central

Hameed, Mustafa Q.; Dhamne, Sameer C.; Gersner, Roman; Kaye, Harper L.; Oberman, Lindsay M.; Pascual-Leone, Alvaro

2018-01-01

Promising results in adult neurologic and psychiatric disorders are driving active research into transcranial brain stimulation techniques, particularly transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS), in childhood and adolescent syndromes. TMS has realistic utility as an experimental tool tested in a range of pediatric neuropathologies such as perinatal stroke, depression, Tourette syndrome, and autism spectrum disorder (ASD). tDCS has also been tested as a treatment for a number of pediatric neurologic conditions, including ASD, attention-deficit/hyperactivity disorder, epilepsy, and cerebral palsy. Here, we complement recent reviews with an update of published TMS and tDCS results in children, and discuss developmental neuroscience considerations that should inform pediatric transcranial stimulation. PMID:28229395

A Personalized Self-Management Rehabilitation System with an Intelligent Shoe for Stroke Survivors: A Realist Evaluation

PubMed Central

2016-01-01

Background In the United Kingdom, stroke is the most significant cause of adult disability. Stroke survivors are frequently left with physical and psychological changes that can profoundly affect their functional ability, independence, and social participation. Research suggests that long-term, intense, task- and context-specific rehabilitation that is goal-oriented and environmentally enriched improves function, independence, and quality of life after a stroke. It is recommended that rehabilitation should continue until maximum recovery has been achieved. However, the increasing demand on services and financial constraints means that needs cannot be met through traditional face-to-face delivery of rehabilitation. Using a participatory design methodology, we developed an information communication technology–enhanced Personalized Self-Managed rehabilitation System (PSMrS) for stroke survivors with integrated insole sensor technology within an “intelligent shoe.”. The intervention model was based around a rehabilitation paradigm underpinned by theories of motor relearning and neuroplastic adaptation, motivational feedback, self-efficacy, and knowledge transfer. Objective To understand the conditions under which this technology-based rehabilitation solution would most likely have an impact on the motor behavior of the user, what would work for whom, in what context, and how. We were interested in what aspects of the system would work best to facilitate the motor behavior change associated with self-managed rehabilitation and which user characteristics and circumstances of use could promote improved functional outcomes. Methods We used a Realist Evaluation (RE) framework to evaluate the final prototype PSMrS with the assumption that the intervention consists of a series of configurations that include the Context of use, the underlying Mechanisms of change and the potential Outcomes or impacts (CMOs). We developed the CMOs from literature reviews and engagement with clinicians, users, and caregivers during a series of focus groups and home visits. These CMOs were then tested in five in-depth case studies with stroke survivors and their caregivers. Results While two new propositions emerged, the second importantly related to the self-management aspects of the system. The study revealed that the system should also encourage independent use and the setting of personalized goals or activities. Conclusions Information communication technology that purports to support the self-management of stroke rehabilitation should give significant consideration to the need for motivational feedback that provides quantitative, reliable, accurate, context-specific, and culturally sensitive information about the achievement of personalized goal-based activities. PMID:28582250

A Personalized Self-Management Rehabilitation System with an Intelligent Shoe for Stroke Survivors: A Realist Evaluation.

PubMed

Mawson, Susan; Nasr, Nasrin; Parker, Jack; Davies, Richard; Zheng, Huiru; Mountain, Gail

2016-01-07

In the United Kingdom, stroke is the most significant cause of adult disability. Stroke survivors are frequently left with physical and psychological changes that can profoundly affect their functional ability, independence, and social participation. Research suggests that long-term, intense, task- and context-specific rehabilitation that is goal-oriented and environmentally enriched improves function, independence, and quality of life after a stroke. It is recommended that rehabilitation should continue until maximum recovery has been achieved. However, the increasing demand on services and financial constraints means that needs cannot be met through traditional face-to-face delivery of rehabilitation. Using a participatory design methodology, we developed an information communication technology-enhanced Personalized Self-Managed rehabilitation System (PSMrS) for stroke survivors with integrated insole sensor technology within an "intelligent shoe.". The intervention model was based around a rehabilitation paradigm underpinned by theories of motor relearning and neuroplastic adaptation, motivational feedback, self-efficacy, and knowledge transfer. To understand the conditions under which this technology-based rehabilitation solution would most likely have an impact on the motor behavior of the user, what would work for whom, in what context, and how. We were interested in what aspects of the system would work best to facilitate the motor behavior change associated with self-managed rehabilitation and which user characteristics and circumstances of use could promote improved functional outcomes. We used a Realist Evaluation (RE) framework to evaluate the final prototype PSMrS with the assumption that the intervention consists of a series of configurations that include the Context of use, the underlying Mechanisms of change and the potential Outcomes or impacts (CMOs). We developed the CMOs from literature reviews and engagement with clinicians, users, and caregivers during a series of focus groups and home visits. These CMOs were then tested in five in-depth case studies with stroke survivors and their caregivers. While two new propositions emerged, the second importantly related to the self-management aspects of the system. The study revealed that the system should also encourage independent use and the setting of personalized goals or activities. Information communication technology that purports to support the self-management of stroke rehabilitation should give significant consideration to the need for motivational feedback that provides quantitative, reliable, accurate, context-specific, and culturally sensitive information about the achievement of personalized goal-based activities. ©Susan Mawson, Nasrin Nasr, Jack Parker, Richard Davies, Huiri Zheng, Gail Mountain. Originally published in JMIR Rehabilitation and Assistive Technology (http://rehab.jmir.org), 07.01.2016.

Exploring the benefits of a stroke telemedicine programme: An organisational and societal perspective.

PubMed

Bagot, Kathleen L; Bladin, Christopher F; Vu, Michelle; Kim, Joosup; Hand, Peter J; Campbell, Bruce; Walker, Alison; Donnan, Geoffrey A; Dewey, Helen M; Cadilhac, Dominique A

2016-12-01

We undertook a qualitative analysis to identify the broader benefits of a state-wide acute stroke telemedicine service beyond the patient-clinician consultation. Since 2010, the Victorian Stroke Telemedicine (VST) programme has provided a clinical service for regional hospitals in Victoria, Australia. The benefits of the Victorian Stroke Telemedicine programme were identified through document analysis of governance activities, including communications logs and reports from hospital co-ordinators of the programme. Discussions with the Victorian Stroke Telemedicine management were undertaken and field notes were also reviewed. Several benefits of telemedicine were identified within and across participating hospitals, as well as for the state government and community. For hospitals, standardisation of clinical processes was reported, including improved stroke care co-ordination. Capacity building occurred through professional development and educational workshops. Enhanced networking, and resource sharing across hospitals was achieved between hospitals and organisations. Governments leveraged the Victorian Stroke Telemedicine programme infrastructure to provide immediate access to new treatments for acute stroke care in regional areas. Standardised data collection allowed routine quality of care monitoring. Community awareness of stroke symptoms occurred with media reports on the novel technology and improved patient outcomes. The value of telemedicine services extends beyond those involved in the clinical consultation to healthcare funders and the community. © The Author(s) 2016.

Dietary and circulating lycopene and stroke risk: a meta-analysis of prospective studies

PubMed Central

LI, Xinli; XU, Jiuhong

2014-01-01

Epidemiological studies support a protective role of lycopene against stroke occurrence or mortality, but the results have been conflicting. We conducted a meta-analysis to assess the relationship between dietary or circulating lycopene and stroke risk (including stroke occurrence or mortality). Relevant papers were collected by screening the PubMed database through October 2013. Only prospective studies providing relative risk estimates with 95% confidence intervals for the association between lycopene and stroke were included. A random-effects model was used to calculate the pooled estimate. Subgroup analysis was conducted to investigate the effects of various factors on the final results. The pooled analysis of seven prospective studies, with 116,127 participants and 1,989 cases, demonstrated that lycopene decreased stroke risk by 19.3% (RR = 0.807, 95% CI = 0.680–0.957) after adjusting for confounding factors. No heterogeneity was observed (p = 0.234, I2 = 25.5%). Circulating lycopene, not dietary lycopene, was associated with a statistically significant decrease in stroke risk (RR = 0.693, 95% CI = 0.503–0.954). Lycopene could protect European, or males against stroke risk. Duration of follow-up had no effect on the final results. There was no evidence of publication bias. Lycopene, especially circulating lycopene, is negatively associated with stroke risk. PMID:24848940

Stroke rehabilitation evidence and comorbidity: a systematic scoping review of randomized controlled trials.

PubMed

Nelson, Michelle L A; McKellar, Kaileah A; Yi, Juliana; Kelloway, Linda; Munce, Sarah; Cott, Cheryl; Hall, Ruth; Fortin, Martin; Teasell, Robert; Lyons, Renee

2017-07-01

Most strokes occur in the context of other medical diagnoses. Currently, stroke rehabilitation evidence reviews have not synthesized or presented evidence with a focus on comorbidities and correspondingly may not align with current patient population. The purpose of this review was to determine the extent and nature of randomized controlled trial stroke rehabilitation evidence that included patients with multimorbidity. A systematic scoping review was conducted. Electronic databases were searched using a combination of terms related to "stroke" and "rehabilitation." Selection criteria captured inpatient rehabilitation studies. Methods were modified to account for the amount of literature, classified by study design, and randomized controlled trials (RCTs) were abstracted. The database search yielded 10771 unique articles. Screening resulted in 428 included RCTs. Three studies explicitly included patients with a comorbid condition. Fifteen percent of articles did not specify additional conditions that were excluded. Impaired cognition was the most commonly excluded condition. Approximately 37% of articles excluded patients who had experienced a previous stroke. Twenty-four percent excluded patients one or more Charlson Index condition, and 83% excluded patients with at least one other medical condition. This review represents a first attempt to map literature on stroke rehabilitation related to co/multimorbidity and identify gaps in existing research. Existing evidence on stroke rehabilitation often excluded individuals with comorbidities. This is problematic as the evidence that is used to generate clinical guidelines may not match the patient typically seen in practice. The use of alternate research methods are therefore needed for studying the care of individuals with stroke and multimorbidity.

Differences Between US and UK Adults in Stroke Preparedness

PubMed Central

Ford, Gary A.; Morgenstern, Lewis B.; White, Martin; Sniehotta, Falko F.; Mackintosh, Joan E.; Gellert, Paul; Skolarus, Lesli E.

2015-01-01

Background and Purpose— Although time-dependent treatment is available, most people delay contacting emergency medical services for stroke. Given differences in the healthcare system and public health campaigns, exploring between-country differences in stroke preparedness may identify novel ways to increase acute stroke treatment. Methods— A survey was mailed to population-based samples in Ingham County, Michigan, US (n=2500), and Newcastle upon Tyne, UK (n=2500). Surveys included stroke perceptions and stroke/nonstroke scenarios to assess recognition and response to stroke. Between-country differences and associations with stroke preparedness were examined using t tests and linear mixed models. Results— Overall response rate was 27.4%. The mean age of participants was 55 years, and 58% were female. US participants were better in recognizing stroke (70% versus 63%, d=0.27) and were more likely to call emergency medical services (55% versus 52%, d=0.11). After controlling for demographics and comorbidities, US participants remained more likely to recognize stroke but were not more likely to respond appropriately. A greater belief that medical treatment can help with stroke and understanding of stroke was associated with improved stroke recognition and response. Conclusions— Overall, stroke recognition and response were moderate. US participants were modestly better at recognizing stroke, although there was little difference in response to stroke. Future stroke awareness interventions could focus more on stroke outcome expectations and developing a greater understanding of stroke among the public. PMID:26419968

Embracing change: practical and theoretical considerations for successful implementation of technology assisting upper limb training in stroke

PubMed Central

2012-01-01

Background Rehabilitation technology for upper limb training of stroke patients may play an important role as therapy tool in future, in order to meet the increasing therapy demand. Currently, implementation of this technology in the clinic remains low. This study aimed at identifying criteria and conditions that people, involved in development of such technology, should take into account to achieve a (more) successful implementation of the technology in the clinic. Methods A literature search was performed in PubMed and IEEE databases, and semi-structured interviews with therapists in stroke rehabilitation were held, to identify criteria and conditions technology should meet to facilitate (implementation of) technology-assisted arm-hand skills training in rehabilitation therapy of stroke patients. In addition, an implementation strategy frequently applied in general health care was used to compose a stepwise guidance to facilitate successful implementation of this technology in therapy of stroke patients. Implementation-related criteria mentioned by therapists during the interviews were integrated in this guidance. Results Results indicate that, related to therapy content, technology should facilitate repetition of task-related movements, tailored to the patient and patient’s goals, in a meaningful context. Variability and increasing levels of difficulty in exercises should be on offer. Regarding hardware and software design of technology, the system should facilitate quick familiarisation and be easily adjustable to individual patients during therapy by therapists (and assistants). The system should facilitate adaptation to individual patients’ needs and their progression over time, should be adjustable as to various task-related variables, should be able to provide instructions and feedback, and should be able to document patient’s progression. The implementation process of technology in the clinic is provided as a stepwise guidance that consists of five phases therapists have to go through. The guidance includes criteria and conditions that motivate therapists, and make it possible for them, to actually use technology in their daily clinical practice. Conclusions The reported requirements are important as guidance for people involved in the development of rehabilitation technology for arm-hand therapy of stroke patients. The stepwise guide provides a tool for facilitating successful implementation of technology in clinical practice, thus meeting future therapy demand. PMID:22856548

Stroke survivors with severe mental illness: Are they at-risk for increased non-psychiatric hospitalizations?

PubMed

Lilly, Flavius Robert; Culpepper, Joel; Stuart, Mary; Steinwachs, Donald

2017-01-01

This study examined outcomes for two groups of stroke survivors treated in Veteran Health Administration (VHA) hospitals, those with a severe mental illness (SMI) and those without prior psychiatric diagnoses, to examine risk of non-psychiatric medical hospitalizations over five years after initial stroke. This retrospective cohort study included 523 veterans who survived an initial stroke hospitalization in a VHA medical center during fiscal year 2003. The survivors were followed using administrative data documenting inpatient stroke treatment, patient demographics, disease comorbidities, and VHA hospital admissions. Multivariate Poisson regression was used to examine the relationship between patients with and without SMI diagnosis preceding the stroke and their experience with non-psychiatric medical hospitalizations after the stroke. The study included 100 patients with SMI and 423 without SMI. Unadjusted means for pre-stroke non-psychiatric hospitalizations were higher (p = 0.0004) among SMI patients (1.47 ± 0.51) compared to those without SMI (1.00 ± 1.33), a difference which persisted through the first year post-stroke (SMI: 2.33 ± 2.46; No SMI: 1.74 ± 1.86; p = 0.0004). Number of non-psychiatric hospitalizations were not significantly different between the two groups after adjustment for patient sociodemographic, comorbidity, length of stay and inpatient stroke treatment characteristics. Antithrombotic medications significantly lowered risk (OR = 0.61; 95% CI: 0.49-0.73) for stroke-related readmission within 30 days of discharge. No significant differences in medical hospitalizations were present after adjusting for comorbid and sociodemographic characteristics between SMI and non-SMI stroke patients in the five-year follow-up. However, unadjusted results continue to draw attention to disparities, with SMI patients experiencing more non-psychiatric hospitalizations both prior to and up to one year after their initial stroke. Additionally, stroke survivors discharged on antithrombotic medications were at lower risk of re-admission within 30 days suggesting the VHA should continue to focus on effective stroke management irrespective of SMI.

Test-Retest Reproducibility of Two Short-Form Balance Measures Used in Individuals with Stroke

ERIC Educational Resources Information Center

Liaw, Lih-Jiun; Hsieh, Ching-Lin; Hsu, Miao-Ju; Chen, Hui-Mei; Lin, Jau-Hong; Lo, Sing-Kai

2012-01-01

The aim of this study is to determine the test-retest reproducibility of the seven-item Short-Form Berg Balance Scale (SFBBS) and the five-item Short-Form Postural Assessment Scale for Stroke Patients (SFPASS) in individuals with chronic stroke. Fifty-two chronic stroke patients from two rehabilitation departments were included in the study. Both…

Depression is an independent determinant of life satisfaction early after stroke.

PubMed

Oosterveer, Daniëlla M; Mishre, Radha Rambaran; van Oort, Andrea; Bodde, Karin; Aerden, Leo A M

2017-03-06

Life satisfaction is reduced in stroke patients. However, as a rule, rehabilitation goals are not aimed at life satisfaction, but at activities and participation. In order to optimize life satisfaction in stroke patients, rehabilitation should take into account the determinants of life satisfaction. The aim of this study was therefore to determine what factors are independent determinants of life satisfaction in a large group of patients early after stroke. Stroke-surviving patients were examined by a specialized nurse 6 weeks after discharge from hospital or rehabilitation setting. A standardized history and several screening lists, including the Lisat-9, were completed. Step-wise regression was used to identify independent determinants of life satisfaction. A total of 284 stroke-surviving patients were included in the study. Of these, 117 answered all of the Lisat-9 questions. Most patients (66.5%) rated their life as a whole as "satisfying" or "very satisfying". More depressive symptoms were independently associated with lower life satisfaction (p < 0.001). Most stroke-surviving patients are satisfied with their life early after a stroke. The score on the Hospital Anxiety and Depression Scale depression items is independently associated with life satisfaction. Physicians should therefore pay close attention to the mood of these patients.

Etiology of strokes and hemiplegia in children presenting at Ayub Teaching Hospital, Abbottabad.

PubMed

Siddiqui, Tahir Saeed; Rehman, Anis ur; Ahmed, Basharat

2006-01-01

Strokes in pediatric age group are not common. However diagnosing the cause of stroke will help in providing preventive and curative treatment. Present study was conducted to find etiology of strokes/hemiplegia in children. This study was conducted in Department of Pediatrics, Ayub Teaching Hospital Abbottabad from December 2002 to December 2005. All children from two months to fifteen years of age were included in the study. Children with weakness due to acute poliomyelitis and Guillan barre syndrome were excluded. Investigations were based on findings on history and clinical examination and included full blood count, PT, APTT, Platelets count, ECG, Echocardiography, hematocrit, lumber puncture with CSF analysis and culture and CT-scan skull. Data of all the patients presenting with strokes/hemiplegia was entered on prepared proforma. The main etiology of strokes was intracranial infection causing strokes in 23(56.09%)children and majority of children (78.26%) in this group were below five years. Etiology was un-known in 7(17.07%) children after necessary available investigations. Intracranial infection Infections that is meningitis and encephalitis are commonest etiology of strokes and hemiplegia in paediatrics patients presenting at Ayub Teaching Hospital, Abbottabad.

Cardiac magnetic resonance imaging has limited additional yield in cryptogenic stroke evaluation after transesophageal echocardiography.

PubMed

Liberman, Ava L; Kalani, Rizwan E; Aw-Zoretic, Jessie; Sondag, Matthew; Daruwalla, Vistasp J; Mitter, Sumeet S; Bernstein, Richard; Collins, Jeremy D; Prabhakaran, Shyam

2017-12-01

Background The use of cardiac magnetic resonance imaging is increasing, but its role in the diagnostic work-up following ischemic stroke has received limited study. We aimed to explore the added yield of cardiac magnetic resonance imaging to identify cardio-aortic sources not detected by transesophageal echocardiography among patients with cryptogenic stroke. Methods A retrospective single-center cohort study was performed from 01 January 2009 to 01 March 2013. Consecutive patients who had both a stroke protocol cardiac magnetic resonance imaging and a transesophageal echocardiography preformed during a single hospitalization were included. All cardiac magnetic resonance imaging studies underwent independent, blinded review by two investigators. We applied the causative classification system for ischemic stroke to all patients, first blinded to cardiac magnetic resonance imaging results; we then reapplied the causative classification system using cardiac magnetic resonance imaging. Standard statistical tests to evaluate stroke subtype reclassification rates were used. Results Ninety-three patients were included in the final analysis; 68.8% were classified as cryptogenic stroke after initial diagnostic evaluation. Among patients with cryptogenic stroke, five (7.8%) were reclassified due to cardiac magnetic resonance imaging findings: one was reclassified as "cardio-aortic embolism evident" due to the presence of a patent foramen ovale and focal cardiac infarct and four were reclassified as "cardio-aortic embolism possible" due to mitral valve thickening (n = 1) or hypertensive cardiomyopathy (n = 3). Overall, findings on cardiac magnetic resonance imaging reduced the percentage of patients with cryptogenic stroke by slightly more than 1%. Conclusion Our stroke subtype reclassification rate after the addition of cardiac magnetic resonance imaging results to a diagnostic work-up which includes transesophageal echocardiography was very low. Prospective studies evaluating the role of cardiac magnetic resonance imaging and transesophageal echocardiography among patients with cryptogenic stroke should be considered.

Practical aspects of treatment with target specific anticoagulants: initiation, payment and current market, transitions, and venous thromboembolism treatment.

PubMed

Mahan, Charles E

2015-04-01

Target specific anticoagulants (TSOACs) have recently been introduced to the US market for multiple indications including venous thromboembolism (VTE) prevention in total hip and knee replacement surgeries, VTE treatment and reduction in the risk of stroke in patients with non-valvular atrial fibrillation (NVAF). Currently, three TSOACs are available including rivaroxaban, apixaban, and dabigatran with edoxaban currently under Food and Drug Administration review for VTE treatment and stroke prevention in NVAF. The introduction of these agents has created a paradigm shift in anticoagulation by considerably simplifying treatment and anticoagulant initiation for patients by giving clinicians the opportunity to use a rapid onset, rapid offset, oral agent. The availability of these rapid onset TSOACs is allowing for outpatient treatment of low risk pulmonary embolism and deep vein thrombosis which can greatly reduce healthcare costs by avoiding inpatient hospitalizations and treatment for the disease. Additionally with this practice, the complications of an inpatient hospitalization may also be avoided such as nosocomial infections. Single-agent approaches with TSOACs represent a paradigm shift in the treatment of VTE versus the complicated overlap of a parenteral agent with warfarin. Transitions between anticoagulants, including TSOACs, are a high-risk period for the patient, and clinicians must carefully consider patient characteristics such as renal function as well as the agents that are being transitioned. TSOAC use appears to be growing slowly with improved payment coverage throughout the US.

Prevention of Stroke with the Addition of Ezetimibe to Statin Therapy in Patients With Acute Coronary Syndrome in IMPROVE-IT (Improved Reduction of Outcomes: Vytorin Efficacy International Trial).

PubMed

Bohula, Erin A; Wiviott, Stephen D; Giugliano, Robert P; Blazing, Michael A; Park, Jeong-Gun; Murphy, Sabina A; White, Jennifer A; Mach, Francois; Van de Werf, Frans; Dalby, Anthony J; White, Harvey D; Tershakovec, Andrew M; Cannon, Christopher P; Braunwald, Eugene

2017-12-19

Patients who experience an acute coronary syndrome are at heightened risk of recurrent ischemic events, including stroke. Ezetimibe improved cardiovascular outcomes when added to statin therapy in patients stabilized after acute coronary syndrome. We investigated the efficacy of the addition of ezetimibe to simvastatin for the prevention of stroke and other adverse cardiovascular events in IMPROVE-IT (Improved Reduction of Outcomes: Vytorin Efficacy International Trial), with a focus on patients with a stroke before randomization. Patients who experienced acute coronary syndrome were randomized to a placebo/simvastatin or ezetimibe/simvastatin regimen and followed for a median of 6 years. Treatment efficacy was assessed for the entire population and by subgroups for the first and total (first and subsequent) events for the end points of stroke of any etiology, stroke subtypes, and the primary trial end point at 7 years. Of 18 144 patients, 641 (3.5%) experienced at least 1 stroke; most were ischemic (527, 82%). Independent predictors of stroke included prior stroke, older age, atrial fibrillation, congestive heart failure, diabetes mellitus, myocardial infarction, and renal dysfunction. There was a nonsignificant reduction in the first event of stroke of any etiology (4.2% versus 4.8%; hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.73-1.00; P =0.052) with ezetimibe/simvastatin versus placebo/simvastatin, driven by a significant 21% reduction in ischemic stroke (3.4% versus 4.1%; HR, 0.79; 95% CI, 0.67-0.94; P =0.008) and a nonsignificant increase in hemorrhagic stroke (0.8% versus 0.6%; HR, 1.38; 95% CI, 0.93-2.04; P =0.11). Evaluating total events, including the first and all recurrent strokes, ezetimibe/simvastatin reduced stroke of any etiology (HR, 0.83; 95% CI, 0.70-0.98; P =0.029) and ischemic stroke (HR, 0.76; 95% CI, 0.63-0.91; P =0.003). Patients who had experienced a stroke prior to randomization were at a higher risk of recurrence and demonstrated an absolute risk reduction of 8.6% for stroke of any etiology (10.2% versus 18.8%; number needed to treat=12; HR, 0.60; 95% CI, 0.38-0.95; P =0.030) and 7.6% for ischemic stroke (8.7% versus 16.3%; number needed to treat=13; HR, 0.52; 95% CI, 0.31-0.86; P =0.011) with ezetimibe added to simvastatin therapy. The addition of ezetimibe to simvastatin in patients stabilized after acute coronary syndrome reduces the frequency of ischemic stroke, with a particularly large effect seen in patients with a prior stroke. URL: https://www.clinicaltrials.gov. Unique identifier: NCT00202878. © 2017 American Heart Association, Inc.

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.

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

PubMed

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

2017-03-01

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

Demystifying post-stroke pain: from etiology to treatment

PubMed Central

Treister, Andrew K.; Hatch, Maya N.; Cramer, Steven C.; Chang, Eric Y.

2016-01-01

Pain following stroke is commonly reported but often incompletely managed, which prevents optimal recovery. This is in part due to the esoteric nature of post-stroke pain and its limited presence in current discussions of stroke management. The major specific afflictions that affect patients with stroke who develop pain include central post-stroke pain (CPSP), complex regional pain syndrome (CRPS), and pain associated with spasticity and shoulder subluxation. Each disorder carries its own intricacies that require specific approaches to treatment and understanding. This review aims to present and clarify the major pain syndromes that affect patients who have suffered from stroke in order to aid in their diagnosis and treatment. PMID:27317916

Sensitivity and Specificity of an Adult Stroke Screening Tool in Childhood Ischemic Stroke.

PubMed

Neville, Kerri; Lo, Warren

2016-05-01

There are frequent delays in the diagnosis of acute pediatric ischemic stroke. A screening tool that could increase the suspicion of acute ischemic stroke could aid early recognition and might improve initial care. An earlier study reported that children with acute ischemic stroke have signs that can be recognized with two adult stroke scales. We tested the hypothesis that an adult stroke scale could distinguish children with acute ischemic stroke from children with acute focal neurological deficits not due to stroke. We retrospectively applied an adult stroke scale to the recorded examinations of 53 children with acute symptomatic acute ischemic stroke and 53 age-matched control subjects who presented with focal neurological deficits. We examined the sensitivity and specificity of the stroke scale and the occurrence of acute seizures as predictors of stroke status. The total stroke scale did not differentiate children with acute ischemic stroke from those who had acute deficits from nonstroke causes; however, the presence of arm weakness was significantly associated with stroke cases. Acute seizures were significantly associated with stroke cases. An adult stroke scale is not sensitive or specific to distinguish children with acute ischemic stroke from those with nonstroke focal neurological deficits. The development of a pediatric acute ischemic stroke screening tool should include arm weakness and perhaps acute seizures as core elements. Such a scale must account for the limitations of language in young or intellectually disabled children. Copyright © 2016 Elsevier Inc. All rights reserved.

Age and aphasia: a review of presence, type, recovery and clinical outcomes.

PubMed

Ellis, Charles; Urban, Stephanie

2016-12-01

Each year approximately 100,000 stroke survivors are diagnosed with aphasia. Although stroke is associated with age, the relationship between age and aphasia is less clear. To complete a review of the literature to examine the relationship between age and: (a) presence or likelihood of aphasia after stroke, (b) aphasia type, (c) aphasia recovery patterns, and (d) aphasia clinical outcomes. Articles were identified by a comprehensive search of "OneSearch," PubMed, and individual journals: Aphasiology, Stroke and the Journal of Stroke and Cerebrovascular Diseases. Inclusion criteria included: age and incidence of aphasia, likelihood of aphasia, aphasia recovery, and aphasia clinical outcome. Independent searches were completed by the authors. Each author independently assessed the full text of reports meeting inclusion criteria. Differences regarding study eligibility and need to proceed with data extraction were resolved by consensus. 1617 articles were identified during the initial search. Forty studies including 14,795 study participants were included in the review. The review generally demonstrated that: (a) stroke patients with aphasia are typically older than stroke with patients without aphasia and (b) aphasia type and age are associated as younger patients with aphasia are more likely to exhibit non-fluent or Broca's type of aphasia. In contrast, studies examining aphasia recovery and aphasia clinical outcomes did not demonstrate a positive relationship between age and recovery or clinical outcomes. Stroke is a condition of the elderly. However, age appears to only influence likelihood of aphasia and aphasia type.

[The reduction of stroke risk, risk of myocardial infarction and death by healthy diet and physical activity].

PubMed

Droste, D W; Keipes, M

2013-01-01

There is no doubt that a healthy diet and regular physical activity improve risk factors for cerebro-cardio-vascular disease and death. However, there is less evidence from prospective randomised controlled trials that they also reduce the actual risk of stroke, myocardial infarction and death. The only evidence from randomised controlled trials is, that a mediterranean diet with nuts and/or native olive oil considerably reduces stroke risk by 47% respectively 31%, however not the risk of myocardial infarction and death. A low-fat diet, a low-salt diet, and the addition of omega-3 fatty acids have no influence. In case of severe obesity with a BMI of > 34-38 kg/m2, weight reduction is the priority, if necessary by means of bariatric surgery. In longitudinal studies mortality (-29%), stroke (-34%), and myocardial infarction (-29%) could thus be reduced. Regular physical activity, whether endurance or more intense activity, leads to weight loss and improved vascular risk factors. An independent impact on stroke, myocardial infarction and mortality has not yet been demonstrated in prospective studies (double-blinding being impossible). Nevertheless, several epidemiological meta-analyses with observation durations of 4 to 28 years using data of up to 880 000 persons, indicate that there is a 2-3 fold risk reduction of cerebro-cardio-vascular death and global mortality in people with regular physical activity versus sedentary behaviour.

[The application of kinesiotaping for the rehabilitation of the post-stroke patients].

PubMed

Berezutsky, V I

2018-05-21

This review of the scientific literature was designed to consider the prospects for the application of kinesiotaping for the rehabilitation of the post-stroke patients. The relevance of the work arises from the absence of a systemic analysis of the large number of investigations that have been carried out during the past two years. The objective of the present review article was to evaluate the influence of kinesiotaping on the health status of the post-stroke patients and the course of their rehabilitative treatment based on the results of analysis of the scientific reports published during the period from 2015 to 2017. The analysis has demonstrated that the method under consideration makes it possible to effectively reduce spasticity, increase the paretic limb power, improve the static and dynamic balance, and alleviate the pain syndrome by virtue of the ability to improve the articulation proprioception and to regulate the muscle tone. Such effects are known to promote the reduction of muscle tone asymmetry in the patients suffering from hemiparesis and articulation instability which in its turn improves the patients' gait and walking ability, hightens their living standards, and allows to tolerate enhanced physical exertion. Kinesiotaping actually improves the locomotor function in the post-stroke patients Taken together, the advantages of the approach in question give reason to recommend kinesiotaping for the wide application for the combined rehabilitative treatment of the post-stroke patients.

G894T endothelial nitric oxide synthase polymorphism and ischemic stroke in Morocco

PubMed Central

Diakite, Brehima; Hamzi, Khalil; Slassi, Ilham; EL Yahyaoui, Mohammed; EL Alaoui, Moulay M.F.; Habbal, Rachida; Sellama, Nadifi

2014-01-01

Nitric oxide plays a major role in the regulation of cerebral blood flow and loss of its function leads to alteration of the vascular relaxation given its central role in the physiology of the vascular system. G894T eNOS polymorphism could have adverse effects on the expression and activity of endothelial nitric oxide synthase, which can result in functional impairment of the endothelium and contribute to the development of ischemic stroke in the different models of transmission. In this study, genotyping with PCR-RFLP and HRM (high resolution melting) methods were conducted on 165 ischemic stroke patients as well as 182 controls. The goal here was to compare genotyping with PCR-RLFP primer sequences of eNOS gene (size < 300 bp) to HRM. Our data suggests a statistically significant association between G894T eNOS polymorphism and ischemic stroke in recessive, dominant and additive models with P < 0.05 and odds ratio of 2.68 (1.08–6.70), 1.78 (1.16–2.73), and 1.71 (1.21–2.43) respectively. In sum, although the sample size is relatively small, it suggests that G894T eNOS polymorphism could be a potentially important genetic marker of ischemic stroke in the Moroccan population. Future studies should be conducted in this direction taking into consideration the functional activity of eNOS. PMID:25606419

Three upper limb robotic devices for stroke rehabilitation: a review and clinical perspective.

PubMed

Bishop, Lauri; Stein, Joel

2013-01-01

Stroke is a leading cause of disability worldwide. Many survivors of stroke remain with residual disabilities, even years later. Advances in technology have led to the development of a variety of robotic devices for use in rehabilitation. The integration of robotics in the delivery of neurorehabilitation is promising, but still not widely used in clinical settings. The aim of this review is to discuss the general design of three typical upper limb robotic devices, and examine the practical considerations for their use in a clinical environment. Each device is described, the available clinical literature is reviewed and a clinical perspective is given on the usefulness of these robotic devices in rehabilitation of this population. Current literature supports the use of robotics in the clinical environment. However, claims that robotic therapy is more effective than traditional treatment is not substantially supported. The majority of clinical trials reported are small, and lack the use of a control group for comparison treatment. The use of robotics in stroke rehabilitation is still a relatively new treatment platform, and still evolving. As technological advances are made, there is much potential for growth in this field.

Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association.

PubMed

Hemphill, J Claude; Greenberg, Steven M; Anderson, Craig S; Becker, Kyra; Bendok, Bernard R; Cushman, Mary; Fung, Gordon L; Goldstein, Joshua N; Macdonald, R Loch; Mitchell, Pamela H; Scott, Phillip A; Selim, Magdy H; Woo, Daniel

2015-07-01

The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of spontaneous intracerebral hemorrhage. A formal literature search of PubMed was performed through the end of August 2013. The writing committee met by teleconference to discuss narrative text and recommendations. Recommendations follow the American Heart Association/American Stroke Association methods of classifying the level of certainty of the treatment effect and the class of evidence. Prerelease review of the draft guideline was performed by 6 expert peer reviewers and by the members of the Stroke Council Scientific Oversight Committee and Stroke Council Leadership Committee. Evidence-based guidelines are presented for the care of patients with acute intracerebral hemorrhage. Topics focused on diagnosis, management of coagulopathy and blood pressure, prevention and control of secondary brain injury and intracranial pressure, the role of surgery, outcome prediction, rehabilitation, secondary prevention, and future considerations. Results of new phase 3 trials were incorporated. Intracerebral hemorrhage remains a serious condition for which early aggressive care is warranted. These guidelines provide a framework for goal-directed treatment of the patient with intracerebral hemorrhage. © 2015 American Heart Association, Inc.

Post-Stroke Sleep-Disordered Breathing—Pathophysiology and Therapy Options

PubMed Central

Stevens, David; Martins, Rodrigo Tomazini; Mukherjee, Sutapa; Vakulin, Andrew

2018-01-01

Sleep-disordered breathing (SDB), encompassing both obstructive and central sleep apnea, is prevalent in at least 50% of stroke patients. Small studies have shown vast improvements in post-stroke functional recovery outcomes after the treatment of SDB by continuous positive airway pressure. However, compliance to this therapy is very poor in this complex patient group. There are alternative therapy options for SDB that may be more amenable for use in at least some post-stroke patients, including mandibular advancement, supine avoidance, and oxygen therapy. There are few studies, however, that demonstrate efficacy and compliance with these alternative therapies currently. Furthermore, novel SDB-phenotyping approaches may help to provide important clinical information to direct therapy selection in individual patients. Prior to realizing individualized therapy, we need a better understanding of the pathophysiology of SDB in post-stroke patients, including the role of inherent phenotypic traits, as well as the contribution of stroke size and location. This review summarizes the available literature on SDB pathophysiology and treatment in post-stroke patients, identifies gaps in the literature, and sets out areas for further research. PMID:29536012

The associations of diastolic blood pressure with the risk of stroke in Western and Eastern populations.

PubMed

Ni Mhurchu, C; Rodgers, A; MacMahon, S

1999-01-01

This paper reviews evidence from two overviews of prospective, observational studies of the association of diastolic blood pressure (DBP) with the risk of stroke in populations from the US and Europe and populations from China and Japan. The Western overview included seven studies involving a total of 405,511 individuals. During a mean follow-up period of 11 years, 843 strokes were observed. The Eastern overview included 18 cohorts involving a total of 124,774 participants. During a mean follow-up duration of 9 years, 1,798 strokes were observed. The shape of the association between usual DBP and the risk of stroke was similar in Western and Eastern populations, but in Eastern populations the size of the association was about 50% steeper than that in Western populations. This may be due, at least in part, to cerebral haemorrhage comprising a greater proportion of total stroke in Eastern populations. This finding, together with the high stroke rates in many Eastern Asian populations, suggests that the potential benefits of blood pressure lowering may be greater in Eastern Asia.

The potential of tetrandrine as a protective agent for ischemic stroke.

PubMed

Chen, Yun; Tsai, Ya-Hui; Tseng, Sheng-Hong

2011-09-16

Stroke is one of the leading causes of mortality, with a high incidence of severe morbidity in survivors. The treatment to minimize tissue injury after stroke is still unsatisfactory and it is mandatory to develop effective treatment strategies for stroke. The pathophysiology of ischemic stroke is complex and involves many processes including energy failure, loss of ion homeostasis, increased intracellular calcium level, platelet aggregation, production of reactive oxygen species, disruption of blood brain barrier, and inflammation and leukocyte infiltration, etc. Tetrandrine, a bisbenzylisoquinoline alkaloid, has many pharmacologic effects including anti-inflammatory and cytoprotective effects. In addition, tetrandrine has been found to protect the liver, heart, small bowel and brain from ischemia/reperfusion injury. It is a calcium channel blocker, and can inhibit lipid peroxidation, reduce generation of reactive oxygen species, suppress the production of cytokines and inflammatory mediators, inhibit neutrophil recruitment and platelet aggregation, which are all devastating factors during ischemia/reperfusion injury of the brain. Because tetrandrine can counteract these important pathophysiological processes of ischemic stroke, it has the potential to be a protective agent for ischemic stroke.

Meeting stroke survivors' perceived needs: a qualitative study of a community-based exercise and education scheme.

PubMed

Reed, Mary; Harrington, Rachel; Duggan, Aine; Wood, Victorine A

2010-01-01

A qualitative study using a phenomenological approach, to explore stroke survivors' needs and their perceptions of whether a community stroke scheme met these needs. Semi-structured in-depth interviews of 12 stroke survivors, purposively selected from participants attending a new community stroke scheme. Interpretative phenomenological analysis of interviews by two researchers independently. Participants attending the community stroke scheme sought to reconstruct their lives in the aftermath of their stroke. To enable this they needed internal resources of confidence and sense of purpose to 'create their social self', and external resources of 'responsive services' and an 'informal support network', to provide direction and encouragement. Participants felt the community stroke scheme met some of these needs through exercise, goal setting and peer group interaction, which included social support and knowledge acquisition. Stroke survivors need a variety of internal and external resources so that they can rebuild their lives positively post stroke. A stroke-specific community scheme, based on exercise, life-centred goal setting, peer support and knowledge acquisition, is an external resource that can help with meeting some of the stroke survivor's needs.

Relatives' information needs and the characteristics of their search for information--in the words of relatives of stroke survivors.

PubMed

Wallengren, Catarina; Segesten, Kerstin; Friberg, Febe

2010-10-01

To explore relatives' information needs and the characteristics of their information-seeking process shortly after the stroke event and six months later. Providing relatives of stroke survivors with information is important, as lack of information increases their uncertainty and risk becoming the 'second patient in the family' and early death. Therefore, it is essential to be aware of relatives' information needs and information-seeking process the first six months after stroke. This qualitative study has a descriptive design. Open-ended interviews were conducted with sixteen relatives after stroke survivor's admission to stroke unit and six months later with nine of these relatives. Data were analysed by means of content analysis. The identified information needs covered the spectrum from stroke survivor's medical condition because nurses' actions to relatives' changed health and life situation. Furthermore, relatives' information-seeking process was found to be related to their level of personal involvement, situational circumstances, different forms of knowledge and sources of information. Relatives' search for information emerges when health and lifestyle changes occur in survivors or themselves. It is important that this information affect them personally. Also, they need to develop different forms of knowledge when they cannot trust their own competences. As a result, instead of following established curricula based on their beliefs of relatives' information needs, nurses need to practice on identifying relatives' information needs. Different information needs and characteristics described in the study can serve as guidance in the development and implementation of pedagogical interventions to support relatives of stroke survivors. One pedagogical implication is to explore what a specific relative wants to know by how he/she talks or thinks about it. Thus, it must be taken into consideration that level of personal involvement, situational circumstances, sources of information and factual knowledge, understanding and skills are intertwined. © 2010 Blackwell Publishing Ltd.

The Socio-economic Impact of Stroke on Households in Livingstone District, Zambia: A Cross-sectional Study.

PubMed

Mapulanga, M; Nzala, S; Mweemba, C

2014-07-01

Stroke is the leading cause of adult disability. Stroke, which affects mostly the productive age group, leaves about 65% of its victims disabled, leads to increased loss of manpower both at individual and national levels. Little is known about the socio-economic burden of the disease in terms of its impacts on the individual, family and community both directly and indirectly in Sub-Sahara Africa region and Zambia at large. The study was aimed at assessing the socio-economic impact of stroke households in Livingstone district, Zambia. A total of 50 households were randomly selected from the registers of Livingstone General Hospital. Self-administered questionnaires and focus group discussions were used to collect quantitative and qualitative data respectively. The data was analyzed using Statistical Package for Social Sciences version 16 (IBM Corporation) and content analysis. Chi-square test was used to make associations between variables. The social impacts on the victim were depression, difficult to get along with, resentfulness, apathy, needy, separation, divorce, general marital problems, neglect on the part of the victim and fear. The economic impacts were loss of employment, reduced business activity and loss of business on the part of the victim. Economic activities such as food provision, payment of school fees, accommodation were affected as a result of stroke and this led to financial insecurities in households with lost incomes in form of salaries and businesses. The activities forgone by stroke households were food provision, housing and education. The study also revealed an association between period of stroke and relationship changes (P < 0.001). Gender and family relationship changes were highly associated (P < 0.00), as more females than males experienced relationship changes. The results of the present study show that stroke has considerable socio-economic impact on households in Livingstone district, which can deter the victims' development as well as the household and the nation at large.

The H2 robotic exoskeleton for gait rehabilitation after stroke: early findings from a clinical study.

PubMed

Bortole, Magdo; Venkatakrishnan, Anusha; Zhu, Fangshi; Moreno, Juan C; Francisco, Gerard E; Pons, Jose L; Contreras-Vidal, Jose L

2015-06-17

Stroke significantly affects thousands of individuals annually, leading to considerable physical impairment and functional disability. Gait is one of the most important activities of daily living affected in stroke survivors. Recent technological developments in powered robotics exoskeletons can create powerful adjunctive tools for rehabilitation and potentially accelerate functional recovery. Here, we present the development and evaluation of a novel lower limb robotic exoskeleton, namely H2 (Technaid S.L., Spain), for gait rehabilitation in stroke survivors. H2 has six actuated joints and is designed to allow intensive overground gait training. An assistive gait control algorithm was developed to create a force field along a desired trajectory, only applying torque when patients deviate from the prescribed movement pattern. The device was evaluated in 3 hemiparetic stroke patients across 4 weeks of training per individual (approximately 12 sessions). The study was approved by the Institutional Review Board at the University of Houston. The main objective of this initial pre-clinical study was to evaluate the safety and usability of the exoskeleton. A Likert scale was used to measure patient's perception about the easy of use of the device. Three stroke patients completed the study. The training was well tolerated and no adverse events occurred. Early findings demonstrate that H2 appears to be safe and easy to use in the participants of this study. The overground training environment employed as a means to enhance active patient engagement proved to be challenging and exciting for patients. These results are promising and encourage future rehabilitation training with a larger cohort of patients. The developed exoskeleton enables longitudinal overground training of walking in hemiparetic patients after stroke. The system is robust and safe when applied to assist a stroke patient performing an overground walking task. Such device opens the opportunity to study means to optimize a rehabilitation treatment that can be customized for individuals. This study was registered at ClinicalTrials.gov ( https://clinicaltrials.gov/show/NCT02114450 ).

Cannabis, Tobacco, Alcohol Use, and the Risk of Early Stroke: A Population-Based Cohort Study of 45 000 Swedish Men.

PubMed

Falkstedt, Daniel; Wolff, Valerie; Allebeck, Peter; Hemmingsson, Tomas; Danielsson, Anna-Karin

2017-02-01

Current knowledge on cannabis use in relation to stroke is based almost exclusively on clinical reports. By using a population-based cohort, we aimed to find out whether there was an association between cannabis use and early-onset stroke, when accounting for the use of tobacco and alcohol. The cohort comprises 49 321 Swedish men, born between 1949 and 1951, who were conscripted into compulsory military service between the ages of 18 and 20. All men answered 2 detailed questionnaires at conscription and were subject to examinations of physical aptitude, psychological functioning, and medical status. Information on stroke events up to ≈60 years of age was obtained from national databases; this includes strokes experienced before 45 years of age. No associations between cannabis use in young adulthood and strokes experienced ≤45 years of age or beyond were found in multivariable models: cannabis use >50 times, hazard ratios=0.93 (95% confidence interval [CI], 0.34-2.57) and 0.95 (95% CI, 0.59-1.53). Although an almost doubled risk of ischemic stroke was observed in those with cannabis use >50 times, this risk was attenuated when adjusted for tobacco usage: hazards ratio=1.47 (95% CI, 0.83-2.56). Smoking ≥20 cigarettes per day was clearly associated both with strokes before 45 years of age, hazards ratio=5.04 (95% CI, 2.80-9.06), and with strokes throughout the follow-up, hazards ratio=2.15 (95% CI, 1.61-2.88). We found no evident association between cannabis use in young adulthood and stroke, including strokes before 45 years of age. Tobacco smoking, however, showed a clear, dose-response shaped association with stroke. © 2016 American Heart Association, Inc.

Magnetic resonance angiography detection of abnormal carotid artery plaque in patients with cryptogenic stroke.

PubMed

Gupta, Ajay; Gialdini, Gino; Lerario, Michael P; Baradaran, Hediyeh; Giambrone, Ashley; Navi, Babak B; Marshall, Randolph S; Iadecola, Costantino; Kamel, Hooman

2015-06-15

Magnetic resonance imaging of carotid plaque can aid in stroke risk stratification in patients with carotid stenosis. However, the prevalence of complicated carotid plaque in patients with cryptogenic stroke is uncertain, especially as assessed by plaque imaging techniques routinely included in acute stroke magnetic resonance imaging protocols. We assessed whether the magnetic resonance angiography-defined presence of intraplaque high-intensity signal (IHIS), a marker of intraplaque hemorrhage, is associated with ipsilateral cryptogenic stroke. Cryptogenic stroke patients with magnetic resonance imaging evidence of unilateral anterior circulation infarction and without hemodynamically significant (≥50%) stenosis of the cervical carotid artery were identified from a prospective stroke registry at a tertiary-care hospital. High-risk plaque was assessed by evaluating for IHIS on routine magnetic resonance angiography source images using a validated technique. To compare the presence of IHIS on the ipsilateral versus contralateral side within individual patients, we used McNemar's test for correlated proportions. A total of 54 carotid arteries in 27 unique patients were included. A total of 6 patients (22.2%) had IHIS-positive nonstenosing carotid plaque ipsilateral to the side of ischemic stroke compared to 0 patients who had IHIS-positive carotid plaques contralateral to the side of stroke (P=0.01). Stroke severity measures, diagnostic evaluations, and prevalence of vascular risk factors were not different between the IHIS-positive and IHIS-negative groups. Our findings suggest that a proportion of strokes classified as cryptogenic may be mechanistically related to complicated, nonhemodynamically significant cervical carotid artery plaque that can easily be detected by routine magnetic resonance imaging/magnetic resonance angiography acute stroke protocols. © 2015 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

Exploratory Network Meta Regression Analysis of Stroke Prevention in Atrial Fibrillation Fails to Identify Any Interactions with Treatment Effect.

PubMed

Batson, Sarah; Sutton, Alex; Abrams, Keith

2016-01-01

Patients with atrial fibrillation are at a greater risk of stroke and therefore the main goal for treatment of patients with atrial fibrillation is to prevent stroke from occurring. There are a number of different stroke prevention treatments available to include warfarin and novel oral anticoagulants. Previous network meta-analyses of novel oral anticoagulants for stroke prevention in atrial fibrillation acknowledge the limitation of heterogeneity across the included trials but have not explored the impact of potentially important treatment modifying covariates. To explore potentially important treatment modifying covariates using network meta-regression analyses for stroke prevention in atrial fibrillation. We performed a network meta-analysis for the outcome of ischaemic stroke and conducted an exploratory regression analysis considering potentially important treatment modifying covariates. These covariates included the proportion of patients with a previous stroke, proportion of males, mean age, the duration of study follow-up and the patients underlying risk of ischaemic stroke. None of the covariates explored impacted relative treatment effects relative to placebo. Notably, the exploration of 'study follow-up' as a covariate supported the assumption that difference in trial durations is unimportant in this indication despite the variation across trials in the network. This study is limited by the quantity of data available. Further investigation is warranted, and, as justifying further trials may be difficult, it would be desirable to obtain individual patient level data (IPD) to facilitate an effort to relate treatment effects to IPD covariates in order to investigate heterogeneity. Observational data could also be examined to establish if there are potential trends elsewhere. The approach and methods presented have potentially wide applications within any indication as to highlight the potential benefit of extending decision problems to include additional comparators outside of those of primary interest to allow for the exploration of heterogeneity.

Ischemic Stroke Profile, Risk Factors, and Outcomes in India: The Indo-US Collaborative Stroke Project.

PubMed

Sylaja, P N; Pandian, Jeyaraj Durai; Kaul, Subhash; Srivastava, M V Padma; Khurana, Dheeraj; Schwamm, Lee H; Kesav, Praveen; Arora, Deepti; Pannu, Aman; Thankachan, Tijy K; Singhal, Aneesh B

2018-01-01

The Indo-US Collaborative Stroke Project was designed to characterize ischemic stroke across 5 high-volume academic tertiary hospitals in India. From January 2012 to August 2014, research coordinators and physician coinvestigators prospectively collected data on 2066 patients with ischemic stroke admitted <2 weeks after onset. Investigator training and supervision and data monitoring were conducted by the US site (Massachusetts General Hospital, Boston). The mean age was 58.3±14.7 years, 67.2% men. The median admission National Institutes of Health Stroke Scale score was 10 (interquartile range, 5-15) and 24.5% had National Institutes of Health Stroke Scale ≥16. Hypertension (60.8%), diabetes mellitus (35.7%), and tobacco use (32.2%, including bidi/smokeless tobacco) were common risk factors. Only 4% had atrial fibrillation. All patients underwent computed tomography or magnetic resonance imaging; 81% had cerebrovascular imaging. Stroke etiologic subtypes were large artery (29.9%), cardiac (24.9%), small artery (14.2%), other definite (3.4%), and undetermined (27.6%, including 6.7% with incomplete evaluation). Intravenous or intra-arterial thrombolysis was administered in 13%. In-hospital mortality was 7.9%, and 48% achieved modified Rankin Scale score 0 to 2 at 90 days. On multivariate analysis, diabetes mellitus predicted poor 3-month outcome and younger age, lower admission National Institutes of Health Stroke Scale and small-artery etiology predicted excellent 3-month outcome. These comprehensive and novel clinical imaging data will prove useful in refining stroke guidelines and advancing stroke care in India. © 2017 American Heart Association, Inc.

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

Door-to-door capture of incident and prevalent stroke cases in Durango, Mexico: the Brain Attack Surveillance in Durango Study.

PubMed

Cantu-Brito, Carlos; Majersik, Jennifer J; Sánchez, Brisa N; Ruano, Angel; Becerra-Mendoza, Daniela; Wing, Jeffrey J; Morgenstern, Lewis B

2011-03-01

Stroke incidence and prevalence estimates in developing countries should include stroke cases not presenting to hospital. We performed door-to-door stroke case ascertainment in Durango Municipality, Mexico, to estimate stroke incidence and prevalence and to determine the error made by only ascertaining hospital cases. Between September 2008 and March 2009, 1996 housing units were randomly sampled to screen for stroke in Durango Municipality residents 35 years of age and older. Field workers utilized a validated screening tool. Those screening positive were referred to a neurologist for history and examination and a head CT scan. Prevalence and cumulative incidence from the door-to-door surveillance were calculated and compared with previously reported hospitalization rates during the same defined time. Respondents included 2437 subjects from 1419 homes. The refusal rate was 3.8%. Twenty subjects had verified or probable stroke. The prevalence of probable or verified stroke was 7.7 per 1000 (95% CI, 4.3 per 1000-11.2 per 1000). Five patients had a stroke during the time of the hospital surveillance, yielding a cumulative incidence of 232.3 per 100 000 (95% CI, 27.8-436.9). Two of the 5 cases were captured by door-to-door surveillance but not by hospital surveillance. This study provides the first community-based stroke prevalence and incidence estimates in Mexico. The wide confidence intervals, despite the large number of surveyed housing units, suggest the need for more advanced sampling strategies for stroke surveillance in the developing world.

Door-to-door capture of incident and prevalent stroke cases in Durango, Mexico – the Brain Attack Surveillance in Durango (BASID) Study

PubMed Central

Cantu-Brito, Carlos; Majersik, Jennifer J; Sánchez, Brisa N; Ruano, Angel; Becerra-Mendoza, Daniela; Wing, Jeffrey J; Morgenstern, Lewis B

2011-01-01

Background and Purpose Stroke incidence and prevalence estimates in developing countries should include stroke cases not presenting to hospital. We performed door-to-door stroke case ascertainment in Durango Municipality, Mexico to estimate stroke incidence and prevalence, and to determine the error made by only ascertaining hospital cases. Methods Between September 2008 and March 2009, 1996 housing units were randomly sampled to screen for stroke in Durango Municipality residents ≥35 years of age. Field workers utilized a validated screening tool. Those screening positive were referred to a neurologist for history and examination and if confirmed, a head CT scan. Prevalence and cumulative incidence from the door-to-door surveillance were calculated and compared with previously reported hospitalization rates during the same defined time. Results Respondents included 2437 subjects from 1419 homes. The refusal rate was 3.8%. Twenty subjects had verified or probable stroke. The prevalence of probable or verified stroke was 7.7/1000 (95% CI: 4.3/1000, 11.2/1000). Five patients had a stroke during the time of the hospital surveillance, yielding a cumulative incidence of 232.3/100,000 (95% CI: 27.8, 436.9). Two of the 5 cases were captured by door-to-door surveillance but not by hospital surveillance. Conclusions This study provides the first community-based stroke prevalence and incidence estimates in Mexico. The wide confidence intervals, despite the large number of surveyed housing units, suggest the need for more advanced sampling strategies for stroke surveillance in the developing world. PMID:21212398

Patent foramen ovale (PFO), stroke and pregnancy.

PubMed

Chen, Lei; Deng, Wenjun; Palacios, Igor; Inglessis-Azuaje, Ignacio; McMullin, David; Zhou, Dong; Lo, Eng H; Buonanno, Ferdinando; Ning, MingMing

2016-06-01

Patent foramen ovale (PFO)-related stroke is increasingly recognized as an important etiology of ischemic embolic stroke-accounting for up to 50% of strokes previously considered 'cryptogenic' or with an unknown mechanism. As a 'back door to the brain,' PFO can allow venous clots to enter arterial circulation via interatrial right-to-left shunting, potentially resulting in ischemic stroke. We observe that clinically, PFO-related stroke affects women of childbearing age, and that pregnancy-owing to major changes in hemocoagulative, hormonal, and cardiovascular parameters-can enhance stroke risks. However, no systematic study has been performed and little is known regarding complications, pregnancy outcomes and treatment for PFO-related stroke during pregnancy. To identify and characterize the complications and clinical outcomes related to PFOs during pregnancy, we performed a literature review and analysis from all reported cases of pregnancy with PFO-related complications in the medical literature from 1970 to 2015. We find that during pregnancy and post-partum, PFO is associated with complications affecting multiple organs, including the brain, heart and lung. The three principal complications reported are stroke, pulmonary emboli and myocardial infarction. In contrast to other pregnancy-related stroke etiologies, which peak during later pregnancy and postpartum, PFO-related stroke peaks during early pregnancy (first and second trimester-60%), and most patients had good neurological outcome (77%). In patients with PFO with recurrent stroke during pregnancy, additional key factors include high-risk PFO morphology (atrial septal aneurysm), larger right-to-left shunt, multiple gestation and concurrent hypercoagulability. Compared to strokes of other etiologies during pregnancy, most PFO stroke patients experienced uneventful delivery (93%) of healthy babies with a good clinical outcome. We conclude with recommended clinical treatment strategies for pregnant patients with PFO suggested by the data from these cases, and the clinical experience of our Cardio-Neurology Clinic. Copyright © 2016 American Federation for Medical Research.

Clinical Evidence of Exercise Benefits for Stroke.

PubMed

Han, Peipei; Zhang, Wen; Kang, Li; Ma, Yixuan; Fu, Liyuan; Jia, Liye; Yu, Hairui; Chen, Xiaoyu; Hou, Lin; Wang, Lu; Yu, Xing; Kohzuki, Masahiro; Guo, Qi

2017-01-01

Even though stroke is the third, not the first, most common cause of disability-adjusted life years in developed countries, it is one of the most expensive to treat. Part of the expense is due to secondary problems in the post-stroke period including: cognition, memory, attention span, pain, sensation loss, psychological issues, and problems with mobility and balance. Research has identified that exercise has both positive physical and psychosocial effects for post-stroke patients. Therefore, this scientific statement provides an overview on exercise rehabilitation for post-stroke patients.We will use systematic literature reviews, clinical and epidemiology reports, published morbidity and mortality studies, clinical and public health guidelines, patient files, and authoritative statements to support this overview.Evidence clearly supports the use of various kinds of exercise training (e.g., aerobic, strength, flexibility, neuromuscular, and traditional Chinese exercise) for stroke survivors. Aerobic exercise, the main form of cardiac rehabilitation, may play an important role in improving aerobic fitness, cardiovascular fitness, cognitive abilities, walking speed and endurance, balance, quality of life, mobility, and other health outcomes among stroke patients. Strength exercise, included in national stroke guidelines and recommended for general health promotion for stroke survivors, can lead to improvements in functionality, psychosocial aspects, and quality of life for post-stroke patients. Flexibility exercises can relieve muscle spasticity problems, improve motor function, range of motion, and prevent contractures. Stretching exercises can also prevent joint contractures, muscle shortening, decrease spasticity, reduce joint stiffness and improve a post-stroke patient's overall function. Neuromuscular exercises can improve activities of daily living (ADL) through coordination and balance activities. Traditional Chinese exercises are used to improve walking and balance ability as well as increase muscle strength, which is important for post-stroke patients.The present evidence strongly supports the power of exercise for post-stroke patients, which in this study combined aerobic exercises, strength training, flexibility exercises, neuromuscular exercises, and traditional Chinese exercises. This research can encourage post-stroke survivors to consider the importance of exercise in the rehabilitation process.

Comparison of cardiovascular risk factors and survival in patients with ischemic or hemorrhagic stroke.

PubMed

Henriksson, Karin M; Farahmand, Bahman; Åsberg, Signild; Edvardsson, Nils; Terént, Andreas

2012-06-01

Differences in risk factor profiles between patients with ischemic and hemorrhagic stroke may have an impact on subsequent mortality. To explore cardiovascular disease risk factors, including the CHADS(2) score, with survival after ischemic or hemorrhagic stroke. Between 2001 and 2005, 87 111 (83%) ischemic stroke, 12 497 (12%) hemorrhagic stroke, and 5435 (5%) patients with unspecified stroke were identified in the Swedish Stroke Register. Data on gender, age, and cardiovascular disease risk factors were linked to the Swedish Hospital Discharge and Cause of Death Registers. Adjusted odds and hazard ratios and 95% confidence interval were calculated using logistic and Cox proportional hazard regression models. Hemorrhagic stroke patients were younger than ischemic stroke patients. All cardiovascular disease risk factors studied, alone or combined in the CHADS(2) score, were associated with higher odds ratios for ischemic stroke vs. hemorrhagic stroke. Higher CHADS(2) scores and all studied risk factors except hypertension were associated with higher odds ratio for death by ischemic stroke than hemorrhagic stroke. Ischemic stroke was associated with lower early mortality (within 30 days) vs. hemorrhagic stroke (hazard ratio = 0·28, confidence interval 0·27 to 0·29). Patients with hemorrhagic stroke had a higher risk of dying within the first 30 days after stroke, but the risk of death was similar in the two groups after one-month. Hypertension was the only cardiovascular disease risk factor associated with an increased mortality rate for hemorrhagic stroke as compared to ischemic stroke. © 2011 The Authors. International Journal of Stroke © 2011 World Stroke Organization.

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.

Psychosocial Outcomes in StrokE: the POISE observational stroke study protocol

PubMed Central

Hackett, Maree L; Glozier, Nick; Jan, Stephen; Lindley, Richard

2009-01-01

Background Each year, approximately 12,000 Australians of working age survive a stroke. As a group, younger stroke survivors have less physical impairment and lower mortality after stroke compared with older survivors; however, the psychosocial and economic consequences are potentially substantial. Most of these younger stroke survivors have responsibility for generating an income or providing family care and indicate that their primary objective is to return to work. However, effective vocational rehabilitation strategies to increase the proportion of younger stroke survivors able to return to work, and information on the key target areas for those strategies, are currently lacking. Methods/Design This multi-centre, three year cohort study will recruit a representative sample of younger (< 65 years) stroke survivors to determine the modifiable predictors of subsequent return to work. Participants will be recruited from the New South Wales Stroke Services (SSNSW) network, the only well established and cohesively operating and managed, network of acute stroke units in Australia. It is based within the Greater Metropolitan area of Sydney including Wollongong and Newcastle, and extends to rural areas including Wagga Wagga. The study registration number is ACTRN12608000459325. Discussion The study is designed to identify targets for rehabilitation-, social- and medical-intervention strategies that promote and maintain healthy ageing in people with cardiovascular and mental health conditions, two of the seven Australian national health priority areas. This will rectify the paucity of information internationally around optimal clinical practice and social policy in this area. PMID:19519918

Sex differences in stroke therapies.

PubMed

Sohrabji, Farida; Park, Min Jung; Mahnke, Amanda H

2017-01-02

Stroke is the fifth leading cause of death and acquired disability in aged populations. Women are disproportionally affected by stroke, having a higher incidence and worse outcomes than men. Numerous preclinical studies have discovered novel therapies for the treatment of stroke, but almost all of these have been shown to be unsuccessful in clinical trials. Despite known sex differences in occurrence and severity of stroke, few preclinical or clinical therapeutics take into account possible sex differences in treatment. Reanalysis of data from studies of tissue plasminogen activator (tPA), the only currently FDA-approved stroke therapy, has shown that tPA improves stroke outcomes for both sexes and also shows sexual dimorphism by more robust improvement in stroke outcome in females. Experimental evidence supports the inclusion of sex as a variable in the study of a number of novel stroke drugs and therapies, including preclinical studies of anti-inflammatory drugs (minocycline), stimulators of cell survival (insulin-like growth factor-1), and inhibitors of cell death pathways (pharmacological inhibition of poly[ADP-ribose] polymerase-1, nitric oxide production, and caspase activation) as well as in current clinical trials of stem cell therapy and cortical stimulation. Overall, study design and analysis in clinical trials as well as in preclinical studies must include both sexes equally, consider possible sex differences in the analyses, and report the differences/similarities in more systematic/structured ways to allow promising therapies for both sexes and increase stroke recovery. © 2016 Wiley Periodicals, Inc. © 2016 Wiley Periodicals, Inc.

The importance of psychological and social factors in influencing the uptake and maintenance of physical activity after stroke: a structured review of the empirical literature.

PubMed

Morris, Jacqui; Oliver, Tracey; Kroll, Thilo; Macgillivray, Steve

2012-01-01

Background. People with stroke are not maintaining adequate engagement in physical activity (PA) for health and functional benefit. This paper sought to describe any psychological and social factors that may influence physical activity engagement after stroke. Methods. A structured literature review of studies indexed in MEDLINE, CinAHL, P&BSC, and PsycINFO using search terms relevant to stroke, physical disabilities, and PA. Publications reporting empirical findings (quantitative or qualitative) regarding psychological and/or social factors were included. Results. Twenty studies from 19 publications (9 surveys, 1 RCT, and 10 qualitative studies) were included. Seventeen studies reported findings pertinent to psychological factors and fourteen findings pertinent to social factors. Conclusion. Self-efficacy, physical activity beliefs, and social support appear particularly relevant to physical activity behaviour after stroke and should be included in theoretically based physical interventions. The Transtheoretical Model and the Theory of Planned Behaviour are candidate behavioural models that may support intervention development.

Economic evidence on integrated care for stroke patients; a systematic review

PubMed Central

Tummers, Johanneke F.M.M; Schrijvers, Augustinus J.P; Visser-Meily, Johanna M.A

2012-01-01

Introduction Given the high incidence of stroke worldwide and the large costs associated with the use of health care resources, it is important to define cost-effective and evidence-based services for stroke rehabilitation. The objective of this review was to assess the evidence on the relative cost or cost-effectiveness of all integrated care arrangements for stroke patients compared to usual care. Integrated care was defined as a multidisciplinary tool to improve the quality and efficiency of evidence-based care and is used as a communication tool between professionals to manage and standardize the outcome-orientated care. Methods A systematic literature review of cost analyses and economic evaluations was performed. Study characteristics, study quality and results were summarized. Results Fifteen studies met the inclusion criteria; six on early-supported discharge services, four on home-based rehabilitation, two on stroke units and three on stroke services. The follow-up per patient was generally short; one year or less. The comparators and the scope of included costs varied between studies. Conclusions Six out of six studies provided evidence that the costs of early-supported discharge are less than for conventional care, at similar health outcomes. Home-based rehabilitation is unlikely to lead to cost-savings, but achieves better health outcomes. Care in stroke units is more expensive than conventional care, but leads to improved health outcomes. The cost-effectiveness studies on integrated stroke services suggest that they can reduce costs. For future research we recommend to focus on the moderate and severely affected patients, include stroke severity as variable, adopt a societal costing perspective and include long-term costs and effects. PMID:23593053

Assessing the impact of upper limb disability following stroke: a qualitative enquiry using internet-based personal accounts of stroke survivors.

PubMed

Poltawski, Leon; Allison, Rhoda; Briscoe, Simon; Freeman, Jennifer; Kilbride, Cherry; Neal, Debbie; Turton, Ailie J; Dean, Sarah

2016-01-01

Upper limb disability following stroke may have multiple effects on the individual. Existing assessment instruments tend to focus on impairment and function and may miss other changes that are personally important. This study aimed to identify personally significant impacts of upper limb disability following stroke. Accounts by stroke survivors, in the form of web-based diaries (blogs) and stories, were sought using a blog search engine and in stroke-related web-sites. Thematic analysis using the World Health Organisation's International Classification of Functioning Disability and Health (ICF) was used to identify personal impacts of upper limb disability following stroke. Ninety-nine sources from at least four countries were analysed. Many impacts were classifiable using the ICF, but a number of additional themes emerged, including emotional, cognitive and behavioural changes. Blogs and other web-based accounts were easily accessible and rich sources of data, although using them raised several methodological issues, including potential sample bias. A range of impacts was identified, some of which (such as use of information technology and alienation from the upper limb) are not addressed in current assessment instruments. They should be considered in post-stroke assessments. Blogs may help in the development of more comprehensive assessments. A comprehensive assessment of the upper limb following stroke should include the impact of upper limb problems on social participation, as well as associated emotional, cognitive and behavioural changes. Using personalised assessment instruments alongside standardised measures may help ensure that these broader domains are considered in discussions between clinicians and patients. Rehabilitation researchers should investigate whether and how these domains could be addressed and operationalised in standard upper limb assessment instruments.

Aerobic Exercises for Cognition Rehabilitation following Stroke: A Systematic Review.

PubMed

Zheng, Guohua; Zhou, Wenji; Xia, Rui; Tao, Jing; Chen, Lidian

2016-11-01

Cognitive impairments are highly prevalent in stroke survivors and can substantially affect their physical rehabilitation and quality of life. The management of these impairments currently remains limited, but increasing studies reported the effect of aerobic exercise on cognitive performance in patients suffering from stroke. The purpose of this review was to assess the effects of aerobic exercise on cognitive function following stroke. Seven electronic databases (China National Knowledge Infrastructure [CNKI], Chinese Science and Technology Periodical Database [VIP], Wanfang, China Biology Medicine disc [CBM], Science Citation Index [SCI], EMBASE, and PubMed) were searched from their inception to May 31, 2015, for the effects of aerobic exercise on cognitive ability compared to usual physical activity in stroke survivors. RevMan V5.3 (The Nordic Cochrane Centre) was used to analyze the data and to evaluate the methodological quality of the included studies. Ten eligible studies including 394 participants were identified. Six studies showed that aerobic exercise significantly improved global cognitive ability in stroke survivors. Four studies reported aerobic exercise to be beneficial in improving memory, but only one showed statistical significance. Two studies investigated the effects of aerobic exercise on attention, and one showed a significant improvement. One study reported a significant benefit of aerobic exercise on visuospatial ability in stroke survivors. No adverse events were reported in the included studies. Aerobic exercise may have a positive effect on improving global cognitive ability and a potential benefit on memory, attention, and the visuospatial domain of cognition in stroke survivors. However, further large, rigorously designed trials are needed to confirm these findings. Copyright © 2016 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Cryptogenic Stroke and Nonstenosing Intracranial Calcified Atherosclerosis.

PubMed

Kamel, Hooman; Gialdini, Gino; Baradaran, Hediyeh; Giambrone, Ashley E; Navi, Babak B; Lerario, Michael P; Min, James K; Iadecola, Costantino; Gupta, Ajay

2017-04-01

Because some cryptogenic strokes may result from large-artery atherosclerosis that goes unrecognized as it causes <50% luminal stenosis, we compared the prevalence of nonstenosing intracranial atherosclerotic plaques ipsilateral to cryptogenic cerebral infarcts versus the unaffected side using imaging biomarkers of calcium burden. In a prospective stroke registry, we identified patients with cerebral infarction limited to the territory of one internal carotid artery (ICA). We included patients with stroke of undetermined etiology and, as controls, patients with cardioembolic stroke. We used noncontrast computed tomography to measure calcification in both intracranial ICAs, including qualitative calcium scoring and quantitative scoring utilizing the Agatston-Janowitz (AJ) calcium scoring. Within subjects, the Wilcoxon signed-rank sum test for nonparametric paired data was used to compare the calcium burden in the ICA upstream of the infarction versus the ICA on the unaffected side. We obtained 440 calcium measures from 110 ICAs in 55 patients. Among 34 patients with stroke of undetermined etiology, we found greater calcium in the ICA ipsilateral to the infarction (mean Modified Woodcock Visual Scale score, 6.7 ± 4.6) compared with the contralateral side (5.4 ± 4.1) (P = .005). Among 21 patients with cardioembolic stroke, we found no difference in calcium burden ipsilateral to the infarction (6.7 ± 5.9) versus the contralateral side (7.3 ± 6.3) (P = .13). The results were similar using quantitative calcium measurements, including the AJ calcium scores. In patients with strokes of undetermined etiology, the burden of calcified intracranial large-artery plaque was associated with downstream cerebral infarction. Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.

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.

Primary care interventions and current service innovations in modifying long-term outcomes after stroke: a protocol for a scoping review.

PubMed

Pindus, Dominika M; Lim, Lisa; Rundell, A Viona; Hobbs, Victoria; Aziz, Noorazah Abd; Mullis, Ricky; Mant, Jonathan

2016-10-24

Interventions delivered by primary and/or community care have the potential to reach the majority of stroke survivors and carers and offer ongoing support. However, an integrative account emerging from the reviews of interventions addressing specific long-term outcomes after stroke is lacking. The aims of the proposed scoping review are to provide an overview of: (1) primary care and community healthcare interventions by generalist healthcare professionals to stroke survivors and/or their informal carers to address long-term outcomes after stroke, (2) the scope and characteristics of interventions which were successful in addressing long-term outcomes, and (3) developments in current clinical practice. Studies that focused on adult community dwelling stroke survivors and informal carers were included. Academic electronic databases will be searched to identify reviews of randomised controlled trials (RCTs) and controlled trials, trials from the past 5 years; reviews of observational studies. Practice exemplars from grey literature will be identified through advanced Google search. Reports, guidelines and other documents of major health organisations, clinical professional bodies, and stroke charities in the UK and internationally will be included. Two reviewers will independently screen titles, abstracts and full texts for inclusion of published literature. One reviewer will screen search results from the grey literature and identify relevant documents for inclusion. Data synthesis will include analysis of the number, type of studies, year and country of publication, a summary of intervention components/service or practice, outcomes addressed, main results (an indicator of effectiveness) and a description of included interventions. The review will help identify components of care and care pathways for primary care services for stroke. By comparing the results with stroke survivors' and carers' needs identified in the literature, the review will highlight potential gaps in research and practice relevant to long-term care after stroke. 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/.

Catheter-based interventions for acute ischaemic stroke.

PubMed

Widimsky, Petr; Hopkins, L Nelson

2016-10-21

Catheter-based interventions for acute ischaemic stroke currently include clot removal (usually from the medial cerebral artery) with modern stent-retrievers and in one of five patients (who have simultaneous or stand-alone internal carotid occlusion) also extracranial carotid intervention. Several recently published randomized trials clearly demonstrated superiority of catheter-based interventions (with or without bridging thrombolysis) over best medical therapy alone. The healthcare systems should adopt the new strategies for acute stroke treatment (including fast track to interventional lab) to offer the benefits to all suitable acute stroke patients. © The Author 2015. Published by Oxford University Press on behalf of the European Society of Cardiology.

National data on stroke outcomes in Thailand.

PubMed

Kongbunkiat, Kannikar; Kasemsap, Narongrit; Thepsuthammarat, Kaewjai; Tiamkao, Somsak; Sawanyawisuth, Kittisak

2015-03-01

Stroke is a major public health problem worldwide. There are limited data on national stroke prevalence and outcomes after the beginning of the thrombolytic therapy era in Thailand. This study aimed to investigate the prevalence and factors associated with mortality in stroke patients in Thailand using the national reimbursement databases. Clinical data retrieved included individuals under the universal coverage, social security, and civil servant benefit systems between 1 October 2009 and 30 September 2010. The stroke diagnosis code was based on the International Classification of Diseases 10th revision system including G45 (transient cerebral ischemic attacks and related syndromes), I61 (intracerebral hemorrhage), and I63 (cerebral infarction). The prevalence and stroke outcomes were calculated from these coded data. Factors associated with death were evaluated by multivariable logistic regression analysis. We found that the most frequent stroke subtype was cerebral infarction with a prevalence of 122 patients per 100,000 of population, an average length of hospital stay of 6.8 days, an average hospital charge of 20,740 baht (∼$USD 691), a mortality rate of 7%, and thrombolytic prescriptions of 1%. The significant factors associated with stroke mortality were septicemia, pulmonary embolism, pneumonia, myocardial infarction, status epilepticus, and heart failure. In conclusion, the prevalence and outcomes of stroke in Thailand were comparable with other countries. The era of thrombolytic therapy has just begun in Thailand. Copyright © 2014 Elsevier Ltd. All rights reserved.

Risk factors for falling in home-dwelling older women with stroke: the Women's Health and Aging Study.

PubMed

Lamb, S E; Ferrucci, L; Volapto, S; Fried, L P; Guralnik, J M

2003-02-01

Much of our knowledge of risk factors for falls comes from studies of the general population. The aim of this study was to estimate the risk of falling associated with commonly accepted and stroke-specific factors in a home-dwelling stroke population. This study included an analysis of prospective fall reports in 124 women with confirmed stroke over 1 year. Variables relating to physical and mental health, history of falls, stroke symptoms, self-reported difficulties in activities of daily living, and physical performance tests were collected during home assessments. Risk factors for falling commonly reported in the general population, including performance tests of balance, incontinence, previous falls, and sedative/hypnotic medications, did not predict falls in multivariate analyses. Frequent balance problems while dressing were the strongest risk factor for falls (odds ratio, 7.0). Residual balance, dizziness, or spinning stroke symptoms were also a strong risk factor for falling (odds ratio, 5.2). Residual motor symptoms were not associated with an increased risk of falling. Interventions to reduce the frequency of balance problems during complex tasks may play a significant role in reducing falls in stroke. Clinicians should be aware of the increased risk of falling in women with residual balance, dizziness, or spinning stroke symptoms and recognize that risk assessments developed for use in the general population may not be appropriate for stroke patients.

Risk of hemorrhage in ischemic stroke and its relationship with cerebral microbleeds.

PubMed

Ozbek, Damla; Ozturk Tan, Ozlem; Ekinci, Gazanfer; Midi, Ipek

2018-05-01

Stroke is an important public health problem in most countries. Therefore, the treatment of stroke and its complications is important. Intracerebral hemorrhage is one of the complications of ischemic stroke. This study aimed to investigate the risk of hemorrhage in patients with acute ischemic stroke and prospectively study its relationship with cerebral microbleeds (MBs) using susceptibility-weighted imaging (SWI) that is a magnetic resonance imaging (MRI) sequence. Patients with acute ischemic stroke were included. Those who underwent treatment with tissue plasminogen activator were excluded. The patients were analyzed according to their risk factors for stroke and their relationship with intracerebral hemorrhage. A total of 148 patients were included. Of these, 41 (28%) had hemorrhages in the ischemic area. The mean waist circumferences, left atrium diameter, and heart rate in these patients were higher than those in patients without hemorrhage. MBs were detected in 66 patients (44.6%) using SWI, and there was no significant relationship with the presence of hemorrhage. Intracerebral hemorrhages were significantly associated with the volume and localization of infarcts. Intracerebral hemorrhage in patients with acute ischemic stroke within the first 7 days after stroke onset was related to their waist circumference as well as the volume and localization of the infarct. However, there was no relationship found between the risk of hemorrhage and MBs using SWI. Copyright © 2018 Elsevier B.V. All rights reserved.

Training in positivity for stroke? A qualitative study of acceptability of use of Positive Mental Training (PosMT) as a tool to assist stroke survivors with post-stroke psychological problems and in coping with rehabilitation.

PubMed

Mavaddat, Nahal; Ross, Sheila; Dobbin, Alastair; Williams, Kate; Graffy, Jonathan; Mant, Jonathan

2017-01-01

Post-stroke psychological problems predict poor recovery, while positive affect enables patients to focus on rehabilitation and may improve functional outcomes. Positive Mental Training (PosMT), a guided self-help audio shows promise as a tool in promoting positivity, optimism and resilience. To assess acceptability of training in positivity with PosMT for prevention and management of post-stroke psychological problems and to help with coping with rehabilitation. A modified PosMT tool consisted of 12 audio tracks each lasting 18 minutes, one listened to every day for a week. Survivors and carers were asked to listen for 4 weeks, but could volunteer to listen for more. Interviews took place about experiences of the tool after 4 and 12 weeks. 10 stroke survivors and 5 carers from Stroke Support Groups in the UK. Three stroke survivors did not engage with the tool. The remainder reported positive physical and psychological benefits including improved relaxation, better sleep and reduced anxiety after four weeks. Survivors who completed the programme gained a positive outlook on the future, increased motivation, confidence and ability to cope with rehabilitation. No adverse effects were reported. The PosMT shows potential as a tool for coping with rehabilitation and overcoming post-stroke psychological problems including anxiety and depression.

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.

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

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

PubMed

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

2018-05-01

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

Atrial cardiopathy: a mechanism of cryptogenic stroke.

PubMed

Yaghi, Shadi; Kamel, Hooman; Elkind, Mitchell S V

2017-08-01

Cryptogenic stroke accounts for approximately 30% of all ischemic strokes. Recently, atrial cardiopathy diagnosed by the presence of one of its serum, imaging, or electrocardiogram biomarkers has been shown to be associated with ischemic stroke, particularly of embolic subtypes. Areas covered: This paper aims to summarize data on occult atrial fibrillation and stroke, provide an overview on mechanisms, such as inflammation and fibrosis, of stroke in atrial cardiopathy, critically review data on biomarkers of atrial cardiopathy and their association with stroke, and suggest therapeutic implications, including directions for future research. Expert commentary: Atrial cardiopathy may constitute one of the mechanisms in cryptogenic stroke, and patients with evidence of atrial cardiopathy constitute a group of patients in whom clinical trials are warranted to test anticoagulation versus antiplatelet therapy to reduce stroke recurrence risk. In addition, more studies are needed to determine the degree of overlap between these atrial cardiopathy biomarkers and which one is more useful in predicting the risk of stroke and response to anticoagulation therapy.

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

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

PubMed

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

2013-04-01

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

Relational Processing Following Stroke

ERIC Educational Resources Information Center

Andrews, Glenda; Halford, Graeme S.; Shum, David; Maujean, Annick; Chappell, Mark; Birney, Damian

2013-01-01

The research examined relational processing following stroke. Stroke patients (14 with frontal, 30 with non-frontal lesions) and 41 matched controls completed four relational processing tasks: sentence comprehension, Latin square matrix completion, modified Dimensional Change Card Sorting, and n-back. Each task included items at two or three…

PRIMARY STROKE PREVENTION IN CHILDREN WITH SICKLE CELL ANEMIA LIVING IN AFRICA: THE FALSE CHOICE BETWEEN PATIENT-ORIENTED RESEARCH AND HUMANITARIAN SERVICE

PubMed Central

DEBAUN, MICHAEL R.; GALADANCI, NAJIBAH A.; KASSIM, ADETOLA A.; JORDAN, LORI C.; PHILLIPS, SHARON; ALIYU, MUKTAR H.

2016-01-01

In the United States, primary stroke prevention in children with sickle cell anemia (SCA) is now the standard of care and includes annual transcranial Doppler ultrasound evaluation to detect elevated intracranial velocities; and for those at risk, monthly blood transfusion therapy for at least a year followed by the option of hydroxyurea therapy. This strategy has decreased stroke prevalence in children with SCA from approximately 11% to 1%. In Africa, where 80% of all children with SCA are born, no systematic approach exists for primary stroke prevention. The two main challenges for primary stroke prevention in children with SCA in Africa include: 1) identifying an alternative to blood transfusion therapy, because safe monthly blood transfusion therapy is not feasible; and 2) assembling a health care team to implement and expand this effort. We will emphasize early triumphs and challenges to decreasing the incidence of strokes in African children with SCA. PMID:28066035

Force measuring valve assemblies, systems including such valve assemblies and related methods

DOEpatents

DeWall, Kevin George [Pocatello, ID; Garcia, Humberto Enrique [Idaho Falls, ID; McKellar, Michael George [Idaho Falls, ID

2012-04-17

Methods of evaluating a fluid condition may include stroking a valve member and measuring a force acting on the valve member during the stroke. Methods of evaluating a fluid condition may include measuring a force acting on a valve member in the presence of fluid flow over a period of time and evaluating at least one of the frequency of changes in the measured force over the period of time and the magnitude of the changes in the measured force over the period of time to identify the presence of an anomaly in a fluid flow and, optionally, its estimated location. Methods of evaluating a valve condition may include directing a fluid flow through a valve while stroking a valve member, measuring a force acting on the valve member during the stroke, and comparing the measured force to a reference force. Valve assemblies and related systems are also disclosed.

Level of physical activity in men and women with chronic stroke.

PubMed

Vahlberg, Birgit; Bring, Annika; Hellström, Karin; Zetterberg, Lena

2018-04-16

Community-dwelling stroke survivors generally show low levels of physical activity (PA). An improved understanding of the factors influencing participation in PA after stroke is imperative to improve levels of PA. Furthermore, gender differences in PA have received little attention in stroke research. The objective of this study was to examine gender differences in PA, physical functioning and psychological factors and the association between these factors and PA in men and women 1-3-year post-stroke. A total of 187 community-dwelling individuals with stroke (65-85 years old, 29% women) were included in a secondary analysis based on data from a cross-sectional study. The exclusion criteria were severe cognitive or language dysfunction or dementia. The level of PA was measured by the Physical Activity Scale for the Elderly. Physical function included balance, walking speed and mobility. Psychological factors included depression, health-related quality of life and fall-related self-efficacy. Falls and fear of falling were each measured with a single question. There were no significant differences in PA levels between men and women. In multiple regression analyses, walking speed (p < 0.001) was associated with PA in men, and balance (p = 0.038) was associated with PA in women. The results indicate that strategies to increase PA levels 1-3-year post-stroke could be improved by considering gender-specific factors.

Cupping for stroke rehabilitation: a systematic review.

PubMed

Lee, Myeong Soo; Choi, Tae-Young; Shin, Byung-Cheul; Han, Chang-ho; Ernst, Edzard

2010-07-15

Cupping is often used for stroke rehabilitation in Asian countries. Currently, no systematic review of this topic is available. The aim of this systematic review is to summarize and critically evaluate the evidence for and against the effectiveness of cupping for stroke rehabilitation. Thirteen databases were searched from their inception through March of 2010 without language restrictions. Prospective clinical trials were included if cupping was tested as the sole treatment or as an adjunct to other conventional treatments for stroke rehabilitation. We found 43 potentially relevant articles, of which 5 studies including 3 randomized clinical trials (RCTs) and 2 uncontrolled observational studies (UOSs) met our inclusion criteria. Cupping was compared with acupuncture, electro-acupuncture and warm needling. Some superior effects of cupping were found in two of the RCTs when compared to acupuncture in hemiplegic shoulder pain and high upper-limb myodynamia after stroke. The other RCT failed to show favorable effects of cupping when compared to acupuncture and warm needling in patients with hemiplegic hand edema. The two UOSs reported favorable effects of cupping on aphasia and intractable hiccup after stroke. There are not enough trials to provide evidence for the effectiveness of cupping for stroke rehabilitation because most of the included trials compared the effects with unproven evidence and were not informative. Future RCTs seem warranted but must overcome the methodological shortcomings of the existing evidence. Copyright 2010 Elsevier B.V. All rights reserved.

TMS measures of motor cortex function after stroke: A meta-analysis.

PubMed

McDonnell, Michelle N; Stinear, Cathy M

Transcranial magnetic stimulation (TMS) is commonly used to measure the effects of stroke on corticomotor excitability, intracortical function, and interhemispheric interactions. The interhemispheric inhibition model posits that recovery of motor function after stroke is linked to rebalancing of asymmetric interhemispheric inhibition and corticomotor excitability. This model forms the rationale for using neuromodulation techniques to suppress unaffected motor cortex excitability, and facilitate affected motor cortex excitability. However, the evidence base for using neuromodulation techniques to promote post-stroke motor recovery is inconclusive. The aim of this meta-analysis was to compare measures of corticomotor excitability, intracortical function, and interhemispheric inhibition, between the affected and unaffected hemispheres of people with stroke, and measures made in healthy adults. A literature search was conducted to identify studies that made TMS measures of the motor cortex in adult stroke patients. Two authors independently extracted data, and the quality of included studies was assessed. TMS measures were compared between the affected and unaffected hemispheres of stroke patients, between the affected hemisphere and healthy controls, and between the unaffected hemisphere and healthy controls. Analyses were carried out with data grouped according to the muscle from which responses were recorded, and separately according to time post-stroke (<3 months, and ≥6 months). Meta-analyses were carried out using a random effects model. There were 844 studies identified, and 112 studies included in the meta-analysis. Results were very similar across muscle groups. Affected hemisphere M1 excitability is lower than unaffected and healthy control M1 excitability after stroke. Affected hemisphere short interval intracortical inhibition (SICI) is lower than unaffected and healthy control SICI early after stroke, and not different in the chronic phase. There were no differences detected between the unaffected hemisphere and healthy controls. There were only seven studies of interhemispheric inhibition that could be included, with no clear effects of hemisphere or time post-stroke. The neurophysiological effects of stroke are primarily localised to the affected hemisphere, and there is no clear evidence for hyper-excitability of the unaffected hemisphere or imbalanced interhemispheric inhibition. This indicates that facilitating affected M1 excitability directly may be more beneficial than suppressing unaffected M1 excitability for promoting post-stroke recovery. Copyright © 2017 Elsevier Inc. All rights reserved.

Controversies regarding the new oral anticoagulants for stroke prevention in patients with atrial fibrillation.

PubMed

Mohanty, Bibhu D; Looser, Patrick M; Gokanapudy, Lakshmi R; Handa, Rishi; Mohanty, Sudipta; Choi, Sharon S; Goldman, Martin E; Fuster, Valentin; Halperin, Jonathan L

2014-06-01

Increasing use of the new oral anticoagulants (NOACs) - dabigatran, rivaroxaban, and apixaban - has prompted considerable discussion in the medical community even as warfarin remains the mainstay of therapy. This article raises 10 controversial issues regarding the use of NOACs for stroke prevention in patients with atrial fibrillation, and offers a review of the latest available evidence. We provide a brief overview of the mechanism and dosing of these drugs, as well as a summary of the key clinical trials that have brought them into the spotlight. Comparative considerations relative to warfarin such as NOAC safety, efficacy, bleeding risk, reversibility, drug-transitioning and use in patients well controlled on warfarin are addressed. Use in select populations such as the elderly, those with coronary disease, renal impairment, or on multiple anti-platelet drugs is also discussed. Finally, we consider such specific issues as comparative efficacy, off-label use, cost, rebound and management during events. Ultimately, the rise of the NOACs to mainstream use will depend on further data and clinical experience amongst the medical community. © The Author(s) 2014.

The effects of stroke disability on spousal caregivers.

PubMed

Blonder, Lee X; Langer, Shelby L; Pettigrew, L Creed; Garrity, Thomas F

2007-01-01

To examine the effects of unilateral stroke patients' neurobehavioral characteristics on spousal psychosocial function. The sample consisted of twenty unilateral stroke patients and their spousal caregivers. Patient assessments included mood, affect perception, sensorimotor and cognitive function, marital satisfaction, and activities of daily living. Spousal assessments included mood, marital satisfaction, and perceived stress. To avoid the risk of committing a type I error, the alpha-level of 0.05 was corrected for multiple comparisons involving the three outcome measures, resulting in an adjusted alpha of 0.017 (0.05/3). Using this criterion, the negative correlation between patient depression and spousal marital satisfaction was statistically significant (rs=-0.585, p=0.007). There was also a trend for hemispheric side of stroke to correlate with spousal stress (rs=0.498, p=0.025), such that strokes in the left hemisphere were associated with greater stress, whereas strokes in the right hemisphere were associated with less stress. These results show that patient depression in particular constitutes a risk factor for marital dissatisfaction in the first few months following stroke. Given that spousal partners provide a large portion of informal support to stroke patients, successful treatment of patient depression may have benefits at the level of the individual, family, and community.

Use of Guidelines for Reducing Stroke Risk in Patients With Nonvalvular Atrial Fibrillation: A Review From a Latin American Perspective

PubMed Central

Silva, Gisele Sampaio; Ameriso, Sebastián F.

2017-01-01

Atrial fibrillation (AF) is a prominent risk factor for stroke and a leading cause of death and disability throughout Latin America. Contemporary evidence-based guidelines for the management of AF and stroke incorporate the use of practical and relatively simple scoring methods to estimate both stroke and bleeding risk, in order to assist in matching patients with appropriate interventions. This review examines consistencies and differences among guidelines for reducing stroke risk in patients with AF, assessing the role of user-friendly scoring methods to determine appropriate patients for anticoagulation and other treatment options. Current options include warfarin and direct oral anticoagulants such as dabigatran, rivaroxaban, apixaban, and edoxaban. These agents have been found to be superior or noninferior to standard vitamin K antagonist anticoagulation in large randomized trials. Potential benefits of these agents mainly include lower ischemic stroke rates, reduced intracranial bleeding, no need for regular monitoring, and fewer drug–drug and drug–food interactions. Expert opinions regarding clinical situations for which data are presently lacking, such as emergency bleeding and stroke in anticoagulated patients, are also provided. Enhanced attention and adherence to evidence-based guidelines are essential components for a strategy to reduce stroke morbidity and mortality across Latin America. PMID:28992764

Self-report of stroke, transient ischemic attack, or stroke symptoms and risk of future stroke in the REasons for Geographic and Racial Differences in Stroke (REGARDS) Study

PubMed Central

Judd, Suzanne E; Kleindorfer, Dawn O; McClure, Leslie A; Rhodes, J. David; Howard, George; Cushman, Mary; Howard, Virginia J.

2013-01-01

Background and Purpose History of stroke and Transient Ischemic Attack (TIA) are documented risk factors for subsequent stroke and all-cause mortality. Recent reports suggest increased risk among those reporting stroke symptoms absent stroke or TIA. However, the relative magnitude of increased stroke risk has not been described across the symptomatic spectrum: 1) asymptomatic (Asx), 2) stroke symptoms only (SS), 3) TIA, 4) stroke in the distant past (DS), and 5) recent stroke (RS). Methods Between 2003–2007 the REasons for Geographic And Racial Differences in Stroke (REGARDS) study enrolled 30,239 black and white Americans aged 45+. DS and RS were defined as self-report of physician diagnosis of stroke >5 or <5 years before baseline, respectively. SS was defined as a history of any of six sudden onset stroke symptoms absent TIA/stroke diagnosis. Kaplan-Meier and proportional hazards analysis were used to contrast stroke risk differences. Results Over 5.0 ± 1.72 years of follow up, 737 strokes were validated. Compared to Asx persons, those with SS, TIA, DS and RS all had increased risk of future stroke. After adjustment for age, race, sex, income, education, alcohol intake, current smoking, and a history of diabetes, hypertension, myocardial infarction, atrial fibrillation, and dyslipidemia, there was 1.20-fold (not statistically significant) increased stroke risk for SS (95% CI 0.96, 1.51), 1.73-fold for TIA (95% CI 1.27, 2.36), 2.23-fold for DS (95% CI 1.61, 3.09) and 2.85-fold for RS (95% CI 2.16, 3.76). Discussion Results suggest a spectrum of risk from stroke symptoms to TIA, distant stroke, and recent stroke, and imply a need for establishing these categories in health screenings to manage risk for future stroke, reinforcing the clinical importance of stroke history including the presence of stroke symptoms. PMID:23233382

Ethical considerations in providing an upper limb exoskeleton device for stroke patients.

PubMed

Bulboacă, Adriana E; Bolboacă, Sorana D; Bulboacă, Angelo C

2017-04-01

The health care system needs to face new and advanced medical technologies that can improve the patients' quality of life by replacing lost or decreased functions. In stroke patients, the disabilities that follow cerebral lesions may impair the mandatory daily activities of an independent life. These activities are dependent mostly on the patient's upper limb function so that they can carry out most of the common activities associated with a normal life. Therefore, an upper limb exoskeleton device for stroke patients can contribute a real improvement of quality of their life. The ethical problems that need to be considered are linked to the correct adjustment of the upper limb skills in order to satisfy the patient's expectations, but within physiological limits. The debate regarding the medical devices dedicated to neurorehabilitation is focused on their ability to be beneficial to the patient's life, keeping away damages, injustice, and risks. Copyright © 2017 Elsevier Ltd. All rights reserved.

The effects of household income distribution on stroke prevalence and its risk factors of high blood pressure and smoking: a cross-sectional study in Saskatchewan, Canada.

PubMed

Bird, Yelena; Lemstra, Mark; Rogers, Marla

2017-03-01

Stroke is a major chronic disease and a common cause of adult disability and mortality. Although there are many known risk factors for stroke, lower income is not one that is often discussed. To determine the unadjusted and adjusted association of income distribution on the prevalence of stroke in Saskatchewan, Canada. Information was collected from the Canadian Community Health Survey conducted by Statistics Canada for 2000-2008. In total, 178 variables were analysed for their association with stroke. Prior to statistical adjustment, stroke was seven times more common for lower income residents than higher income residents. After statistical adjustment, only four covariates were independently associated with stroke prevalence, including having high blood pressure (odds ratio (OR) = 2.62; 95% confidence interval (CI) = 2.12-3.24), having a household income below CAD$30,000 per year (OR = 2.49; 95% CI = 1.88-3.29), being a daily smoker (OR = 1.36; 95% CI = 1.16-1.58) and being physically inactive (OR = 1.27; 95% CI = 1.13-1.43). After statistical adjustment, there were five covariates independently associated with high blood pressure prevalence, including having a household income below CAD$30,000 per year (OR = 1.52; 95% CI = 1.41-1.63). After statistical adjustment, there were five covariates independently associated with daily smoking prevalence, including having a household income below CAD$30,000 per year (OR = 1.29; 95% CI = 1.25-1.33). Knowledge of disparities in the prevalence, severity, disability and mortality of stroke is critically important to medical and public health professionals. Our study found that income distribution was strongly associated with stroke, its main disease intermediary - high blood pressure - and its main risk factor - smoking. As such, income is an important variable worthy of public debate as a modifiable risk factor for stroke.

Prevalence of Imaging Biomarkers to Guide the Planning of Acute Stroke Reperfusion Trials.

PubMed

Jiang, Bin; Ball, Robyn L; Michel, Patrik; Jovin, Tudor; Desai, Manisha; Eskandari, Ashraf; Naqvi, Zack; Wintermark, Max

2017-06-01

Imaging biomarkers are increasingly used as selection criteria for stroke clinical trials. The goal of our study was to determine the prevalence of commonly studied imaging biomarkers in different time windows after acute ischemic stroke onset to better facilitate the design of stroke clinical trials using such biomarkers for patient selection. This retrospective study included 612 patients admitted with a clinical suspicion of acute ischemic stroke with symptom onset no more than 24 hours before completing baseline imaging. Patients with subacute/chronic/remote infarcts and hemorrhage were excluded from this study. Imaging biomarkers were extracted from baseline imaging, which included a noncontrast head computed tomography (CT), perfusion CT, and CT angiography. The prevalence of dichotomized versions of each of the imaging biomarkers in several time windows (time since symptom onset) was assessed and statistically modeled to assess time dependence (not lack thereof). We created tables showing the prevalence of the imaging biomarkers pertaining to the core, the penumbra and the arterial occlusion for different time windows. All continuous imaging features vary over time. The dichotomized imaging features that vary significantly over time include: noncontrast head computed tomography Alberta Stroke Program Early CT (ASPECT) score and dense artery sign, perfusion CT infarct volume, and CT angiography collateral score and visible clot. The dichotomized imaging features that did not vary significantly over time include the thresholded perfusion CT penumbra volumes. As part of the feasibility analysis in stroke clinical trials, this analysis and the resulting tables can help investigators determine sample size and the number needed to screen. © 2017 American Heart Association, Inc.

Help seeking behavior and onset-to-alarm time in patients with acute stroke: sub-study of the preventive antibiotics in stroke study.

PubMed

Zock, E; Kerkhoff, H; Kleyweg, R P; van Bavel-Ta, T B V; Scott, S; Kruyt, N D; Nederkoorn, P J; van de Beek, D

2016-11-25

Patients with acute stroke often do not seek immediate medical help, which is assumed to be driven by lack of knowledge of stroke symptoms. We explored the process of help seeking behavior in patients with acute stroke, evaluating knowledge about stroke symptoms, socio-demographic and clinical characteristics, and onset-to-alarm time (OAT). In a sub-study of the Preventive Antibiotics in Stroke Study (PASS), 161 acute stroke patients were prospectively included in 3 Dutch hospitals. A semi-structured questionnaire was used to assess knowledge, recognition and interpretation of stroke symptoms. With in-depth interviews, response actions and reasons were explored. OAT was recorded and associations with socio-demographic, clinical parameters were assessed. Knowledge about stroke symptoms does not always result in correct recognition of own stroke symptoms, neither into correct interpretation of the situation and subsequent action. In our study population of 161 patients with acute stroke, median OAT was 30 min (interquartile range [IQR] 10-150 min). Recognition of one-sided weakness and/or sensory loss (p = 0.046) and adequate interpretation of the stroke situation (p = 0.003), stroke at daytime (p = 0.002), severe stroke (p = 0.003), calling the emergency telephone number (p = 0.004), and transport by ambulance (p = 0.040) were associated with shorter OAT. Help seeking behavior after acute stroke is a complex process. A shorter OAT after stroke is associated with correct recognition of one-sided weakness and/or sensory loss, adequate interpretation of the stroke situation by the patient and stroke characteristics and logistics of stroke care, but not by knowledge of stroke symptoms.

Upper Limb Kinematics in Stroke and Healthy Controls Using Target-to-Target Task in Virtual Reality.

PubMed

Hussain, Netha; Alt Murphy, Margit; Sunnerhagen, Katharina S

2018-01-01

Kinematic analysis using virtual reality (VR) environment provides quantitative assessment of upper limb movements. This technique has rarely been used in evaluating motor function in stroke despite its availability in stroke rehabilitation. To determine the discriminative validity of VR-based kinematics during target-to-target pointing task in individuals with mild or moderate arm impairment following stroke and in healthy controls. Sixty-seven participants with moderate (32-57 points) or mild (58-65 points) stroke impairment as assessed with Fugl-Meyer Assessment for Upper Extremity were included from the Stroke Arm Longitudinal study at the University of Gothenburg-SALGOT cohort of non-selected individuals within the first year of stroke. The stroke groups and 43 healthy controls performed the target-to-target pointing task, where 32 circular targets appear one after the other and disappear when pointed at by the haptic handheld stylus in a three-dimensional VR environment. The kinematic parameters captured by the stylus included movement time, velocities, and smoothness of movement. The movement time, mean velocity, and peak velocity were discriminative between groups with moderate and mild stroke impairment and healthy controls. The movement time was longer and mean and peak velocity were lower for individuals with stroke. The number of velocity peaks, representing smoothness, was also discriminative and significantly higher in both stroke groups (mild, moderate) compared to controls. Movement trajectories in stroke more frequently showed clustering (spider's web) close to the target indicating deficits in movement precision. The target-to-target pointing task can provide valuable and specific information about sensorimotor impairment of the upper limb following stroke that might not be captured using traditional clinical scale. The trial was registered with register number NCT01115348 at clinicaltrials.gov, on May 4, 2010. URL: https://clinicaltrials.gov/ct2/show/NCT01115348.

Accuracy of Prediction Instruments for Diagnosing Large Vessel Occlusion in Individuals With Suspected Stroke: A Systematic Review for the 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke.

PubMed

Smith, Eric E; Kent, David M; Bulsara, Ketan R; Leung, Lester Y; Lichtman, Judith H; Reeves, Mathew J; Towfighi, Amytis; Whiteley, William N; Zahuranec, Darin B

2018-03-01

Endovascular thrombectomy is a highly efficacious treatment for large vessel occlusion (LVO). LVO prediction instruments, based on stroke signs and symptoms, have been proposed to identify stroke patients with LVO for rapid transport to endovascular thrombectomy-capable hospitals. This evidence review committee was commissioned by the American Heart Association/American Stroke Association to systematically review evidence for the accuracy of LVO prediction instruments. Medline, Embase, and Cochrane databases were searched on October 27, 2016. Study quality was assessed with the Quality Assessment of Diagnostic Accuracy-2 tool. Thirty-six relevant studies were identified. Most studies (21 of 36) recruited patients with ischemic stroke, with few studies in the prehospital setting (4 of 36) and in populations that included hemorrhagic stroke or stroke mimics (12 of 36). The most frequently studied prediction instrument was the National Institutes of Health Stroke Scale. Most studies had either some risk of bias or unclear risk of bias. Reported discrimination of LVO mostly ranged from 0.70 to 0.85, as measured by the C statistic. In meta-analysis, sensitivity was as high as 87% and specificity was as high as 90%, but no threshold on any instruments predicted LVO with both high sensitivity and specificity. With a positive LVO prediction test, the probability of LVO could be 50% to 60% (depending on the LVO prevalence in the population), but the probability of LVO with a negative test could still be ≥10%. No scale predicted LVO with both high sensitivity and high specificity. Systems that use LVO prediction instruments for triage will miss some patients with LVO and milder stroke. More prospective studies are needed to assess the accuracy of LVO prediction instruments in the prehospital setting in all patients with suspected stroke, including patients with hemorrhagic stroke and stroke mimics. © 2018 American Heart Association, Inc.

Clinical Prediction of Functional Outcome after Ischemic Stroke: The Surprising Importance of Periventricular White Matter Disease and Race

PubMed Central

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

2009-01-01

Background We sought 0074o 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 re-stratification as comorbid events accumulate. Methods 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 post-stroke 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. Results Post-stroke medical and psychiatric comorbidities significantly increased short term post-stroke 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. Conclusions 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. PMID:19109548

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.

Patient-centred communication intervention study to evaluate nurse-patient interactions in complex continuing care

PubMed Central

2012-01-01

Background Communication impairment is a frequent consequence of stroke. Patients who cannot articulate their needs respond with frustration and agitation, resulting in poor optimization of post-stroke functions. A key component of patient-centred care is the ability of staff to communicate in a way that allows them to understand the patient’s needs. We developed a patient-centred communication intervention targeting registered and unregulated nursing staff caring for complex continuing care patients with communication impairments post stroke. Research objectives include 1) examining the effects of the intervention on patients’ quality of life, depression, satisfaction with care, and agitation; and (2) examining the extent to which the intervention improves staff’s attitudes and knowledge in caring for patients with communication impairments. The intervention builds on a previous pilot study. Methods/design A quasi-experimental repeated measures non-equivalent control group design in a complex continuing care facility is being used. Patients with a communication impairment post-stroke admitted to the facility are eligible to participate. All staff nurses are eligible. Baseline data are collected from staff and patients. Follow-up will occur at 1 and 3 months post-intervention. Subject recruitment and data collection from 60 patients and 30 staff will take approximately 36 months. The Patient-Centred Communication Intervention consists of three components: (1) development of an individualized patient communication care plan; (2) a one-day workshop focused on communication and behavioural management strategies for nursing staff; and (3) a staff support system. The intervention takes comprehensive patient assessments into account to inform the development of communication and behavioural strategies specifically tailored to each patient. Discussion The Patient-Centred Communication Intervention will provide staff with strategies to facilitate interactions with patients and to minimize agitation associated with considerable stress. The improvement of these interactions will lead to a reduction of agitation, which has the additional significance of increasing patients’ well-being, quality of life, and satisfaction with care. Trial registration ClinicalTrials.gov Identifier NCT01654029 PMID:23050517

Family history: an opportunity for early interventions and improved control of hypertension, obesity and diabetes.

PubMed Central

van der Sande, M. A.; Walraven, G. E.; Milligan, P. J.; Banya, W. A.; Ceesay, S. M.; Nyan, O. A.; McAdam, K. P.

2001-01-01

OBJECTIVE: To examine whether a family history of high-risk groups for major noncommunicable diseases (NCDs) was a significant risk factor for these conditions among family members in a study population in the Gambia, where strong community and family coherence are important determinants that have to be taken into consideration in promoting lifestyle changes. METHODS: We questioned 5389 adults as to any first-degree family history of major noncommunicable diseases (hypertension, obesity, diabetes and stroke), and measured their blood pressure (BP) and body mass index (BMI). Total blood cholesterol, triglyceride, uric acid, and creatinine concentrations were measured in a stratified subsample, as well as blood glucose (2 hours after ingesting 75 g glucose) in persons aged > or = 35 years. FINDINGS: A significant number of subjects reported a family history of hypertension (8.0%), obesity (5.4%), diabetes (3.3%) and stroke (1.4%), with 14.6% of participants reporting any of these NCDs. Subjects with a family history of hypertension had a higher diastolic BP and BMI, higher cholesterol and uric acid concentrations, and an increased risk of obesity. Those with a family history of obesity had a higher BMI and were at increased risk of obesity. Individuals with a family history of diabetes had a higher BMI and higher concentrations of glucose, cholesterol, triglycerides and uric acid, and their risk of obesity and diabetes was increased. Subjects with a family history of stroke had a higher BMI, as well as higher cholesterol, triglyceride and uric acid concentrations. CONCLUSIONS: A family history of hypertension, obesity, diabetes, or stroke was a significant risk factor for obesity and hyperlipidaemia. With increase of age, more pathological manifestations can develop in this high-risk group. Health professionals should therefore utilize every opportunity to include direct family members in health education. PMID:11357211

Combined neuromuscular electrical stimulation (NMES) with fiberoptic endoscopic evaluation of swallowing (FEES) and traditional swallowing rehabilitation in the treatment of stroke-related dysphagia.

PubMed

Sun, Shu-Fen; Hsu, Chien-Wei; Lin, Huey-Shyan; Sun, Hsien-Pin; Chang, Ping-Hsin; Hsieh, Wan-Ling; Wang, Jue-Long

2013-12-01

Dysphagia is common after stroke. Neuromuscular electrical stimulation (NMES) and fiberoptic endoscopic evaluation of swallowing (FEES) for the treatment of dysphagia have gained in popularity, but the combined application of these promising modalities has rarely been studied. We aimed to evaluate whether combined NMES, FEES, and traditional swallowing rehabilitation can improve swallowing functions in stroke patients with moderate to severe dysphagia. Thirty-two patients with moderate to severe dysphagia poststroke (≥3 weeks) were recruited. Patients received 12 sessions of NMES for 1 h/day, 5 days/week within a period of 2-3 weeks. FEES was done before and after NMES for evaluation and to guide dysphagic therapy. All patients subsequently received 12 sessions of traditional swallowing rehabilitation (50 min/day, 3 days/week) for 4 weeks. Primary outcome measure was the Functional Oral Intake Scale (FOIS). Secondary outcome measures included clinical degree of dysphagia, the patient's self-perception of swallowing ability, and the patient's global satisfaction with therapy. Patients were assessed at baseline, after NMES, at 6-month follow-up, and at 2-year follow-up. Twenty-nine patients completed the study. FOIS, degree of dysphagia, and patient's self-perception of swallowing improved significantly after NMES, at the 6-month follow-up, and at the 2-year follow-up (p < 0.001, each compared with baseline). Most patients reported considerable satisfaction with no serious adverse events. Twenty-three of the 29 (79.3 %) patients maintained oral diet with no pulmonary complications at 2-year follow-up. This preliminary case series demonstrated that combined NMES, FEES, and traditional swallowing rehabilitation showed promise for improving swallowing functions in stroke patients with moderate-to-severe dysphagia. The benefits were maintained for up to 2 years. The results are promising enough to justify further studies.

Dietary sodium, sodium-to-potassium ratio, and risk of stroke: A systematic review and nonlinear dose-response meta-analysis.

PubMed

Jayedi, Ahmad; Ghomashi, Farnoosh; Zargar, Mahdieh Sadat; Shab-Bidar, Sakineh

2018-06-01

The association of high sodium intake with risk of stroke has been accepted. But considering the proposed J/U-shaped association between sodium intake and risk of all-cause mortality, the shape of the dose-response relationship has not been determined yet. This study aimed to test the dose-response association of dietary sodium and sodium-to-potassium ratio with risk of stroke in adults aged 18 years or older. We performed a systematic search using PubMed and Scopus, from database inception up to October 2017. Prospective and retrospective observational studies reporting risk estimates of stroke for three or more quantitative categories of dietary sodium or sodium-to-potassium ratio were included. Studies that reported results as continuous were also included. Two independent authors extracted the information and assessed the quality of included studies. Pooled relative risk (RR) was calculated using a random-effects model. Publication bias was tested. Sensitivity and subgroup analyses were done. Of initial 20,412 studies identified, 14 prospective cohort studies, one case-cohort study, and one case-control study (total n = 261,732) with 10,150 cases of stroke were included. The Pooled RRs of stroke were 1.06 (95%CI: 1.02, 1.10; I 2  = 60%, n = 14 studies) for a 1 gr/d increment in dietary sodium intake, and 1.22 (95%CI: 1.04, 1.41; I 2  = 60%, n = 5 studies) for a one-unit increment in dietary sodium-to-potassium ratio (mmol/mmol). The risk of stroke increased linearly with increasing dietary sodium intake, and also along with the increase in dietary sodium-to-potassium ratio. No evidence of a J/U-shaped association was found in the analyses of total stroke, stroke incidence, and stroke mortality. High sodium intake was associated with a somewhat worse prognosis among Asian countries as compared to westerns. Higher sodium intake and higher dietary sodium-to-potassium ratio were associated with a higher risk of stroke. Reducing dietary sodium-to-potassium ratio can be considered as a supplementary approach in parallel with the decrease in sodium intake in order to decrease stroke risk. The interpretation of the results is limited by observational nature of studies examined. Copyright © 2018 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

Stroke-induced immunodepression and dysphagia independently predict stroke-associated pneumonia - The PREDICT study.

PubMed

Hoffmann, Sarah; Harms, Hendrik; Ulm, Lena; Nabavi, Darius G; Mackert, Bruno-Marcel; Schmehl, Ingo; Jungehulsing, Gerhard J; Montaner, Joan; Bustamante, Alejandro; Hermans, Marcella; Hamilton, Frank; Göhler, Jos; Malzahn, Uwe; Malsch, Carolin; Heuschmann, Peter U; Meisel, Christian; Meisel, Andreas

2017-12-01

Stroke-associated pneumonia is a frequent complication after stroke associated with poor outcome. Dysphagia is a known risk factor for stroke-associated pneumonia but accumulating evidence suggests that stroke induces an immunodepressive state increasing susceptibility for stroke-associated pneumonia. We aimed to confirm that stroke-induced immunodepression syndrome is associated with stroke-associated pneumonia independently from dysphagia by investigating the predictive properties of monocytic HLA-DR expression as a marker of immunodepression as well as biomarkers for inflammation (interleukin-6) and infection (lipopolysaccharide-binding protein). This was a prospective, multicenter study with 11 study sites in Germany and Spain, including 486 patients with acute ischemic stroke. Daily screening for stroke-associated pneumonia, dysphagia and biomarkers was performed. Frequency of stroke-associated pneumonia was 5.2%. Dysphagia and decreased monocytic HLA-DR were independent predictors for stroke-associated pneumonia in multivariable regression analysis. Proportion of pneumonia ranged between 0.9% in the higher monocytic HLA-DR quartile (≥21,876 mAb/cell) and 8.5% in the lower quartile (≤12,369 mAb/cell). In the presence of dysphagia, proportion of pneumonia increased to 5.9% and 18.8%, respectively. Patients without dysphagia and normal monocytic HLA-DR expression had no stroke-associated pneumonia risk. We demonstrate that dysphagia and stroke-induced immunodepression syndrome are independent risk factors for stroke-associated pneumonia. Screening for immunodepression and dysphagia might be useful for identifying patients at high risk for stroke-associated pneumonia.

Stroke and methamphetamine use in young adults: a review.

PubMed

Lappin, Julia M; Darke, Shane; Farrell, Michael

2017-12-01

Methamphetamine use and stroke are significant public health problems. Strokes among people aged below 45 years are much less common than in older age groups but have significant mortality and morbidity. Methamphetamine is a putative cause of strokes among younger people. A review of methamphetamine-related strokes was conducted. Bibliographic databases were searched until February 2017 for articles related to methamphetamine and stroke. Both haemorrhagic and ischaemic strokes were considered. Of 370 articles screened, 77 were selected for inclusion. There were 81 haemorrhagic and 17 ischaemic strokes reported in case reports and series. Both types were approximately twice as common in males. Route of administration associated with haemorrhagic stroke was typically oral or injecting, but for ischaemic stroke inhalation was most common. Haemorrhagic stroke was associated with vascular abnormalities in a third of cases. One quarter of individuals completely recovered, and a third died following haemorrhagic stroke. One-fifth completely recovered, and one-fifth died following ischaemic stroke. There is a preponderance of haemorrhagic strokes associated with methamphetamine use in young people, and methamphetamine-related stroke is associated with poor clinical outcomes. Mechanisms of methamphetamine-associated stroke include hypertension, vasculitis, direct vascular toxicity and vasospasm. In a period of rising worldwide methamphetamine use, the incidence of methamphetamine-related stroke will increase, with a consequent increase in the burden of disease contributed by such events. © 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.

Access to Expert Stroke Care with Telemedicine: REACH MUSC

PubMed Central

Kazley, Abby Swanson; Wilkerson, Rebecca C.; Jauch, Edward; Adams, Robert J.

2012-01-01

Stroke is a leading cause of death and disability, and recombinant tissue plasminogen activator (rtPA) can significantly reduce the long-term impact of acute ischemic stroke (AIS) if given within 3 h of symptom onset. South Carolina is located in the “stroke belt” and has a high rate of stroke and stroke mortality. Many small rural SC hospitals do not maintain the expertise needed to treat AIS patients with rtPA. MUSC is an academic medical center using REACH MUSC telemedicine to deliver stroke care to 15 hospitals in the state, increasing the likelihood of timely treatment with rtPA. The purpose of this study is to determine the increase in access to rtPA through the use of telemedicine for AIS in the general population and in specific segments of the population based on age, gender, race, ethnicity, education, urban/rural residence, poverty, and stroke mortality. We used a retrospective cross-sectional design examining Census data from 2000 and geographic information systems analysis to identify South Carolina residents that live within 30 or 60 min of a primary stroke center (PSC) or a REACH MUSC site. We include all South Carolina citizens in our analysis and specifically examine the population’s age, gender, race, ethnicity, education, urban/rural residence, poverty, and stroke mortality. Our sample includes 4,012,012 South Carolinians. The main measure is access to expert stroke care at a PSC or a REACH MUSC hospital within 30 or 60 min. We find that without REACH MUSC, only 38% of the population has potential access to expert stroke care in SC within 60 min given that most PSCs will maintain expert stroke coverage. REACH MUSC allows 76% of the population to be within 60 min of expert stroke care, and 43% of the population to be within 30 min drive time of expert stroke care. These increases in access are especially significant for groups that have faced disparities in care and high rates of AIS. The use of telemedicine can greatly increase access to care for residents throughout South Carolina. PMID:22461780

A cross-sectional observational study comparing foot and ankle characteristics in people with stroke and healthy controls.

PubMed

Kunkel, Dorit; Potter, Julia; Mamode, Louis

2017-06-01

The purpose of this study was to explore and compare foot and ankle characteristics in people with stroke and healthy controls; and between stroke fallers and non-fallers. Participants were recruited from community groups and completed standardized tests assessing sensation, foot posture, foot function, ankle dorsiflexion and first metatarsal phalangeal joint range of motion (1st MPJ ROM), hallux valgus presence and severity. Twenty-three stroke participants (mean age 75.09 ± 7.57 years; 12 fallers) and 16 controls (mean age 73.44 ± 8.35 years) took part. Within the stroke group, reduced 1st MPJ sensation (p = 0.016) and 1st MPJ ROM (p = 0.025) were observed in the affected foot in comparison to the non-affected foot; no other differences were apparent. Pooled data (for both feet) was used to explore between stroke/control (n = 78 feet) and stroke faller/non-faller (n = 46 feet) group differences. In comparison to the control group, stroke participants exhibited reduced sensation of the 1st MPJ (p = 0.020), higher Foot Posture Index scores (indicating greater foot pronation, p = 0.008) and reduced foot function (p = 0.003). Stroke fallers exhibited significantly greater foot pronation in comparison to non-fallers (p = 0.027). Results indicated differences in foot and ankle characteristics post stroke in comparison to healthy controls. These changes may negatively impact functional ability and the ability to preserve balance. Further research is warranted to explore the influence of foot problems on balance ability and falls in people with stroke. Implications for Rehabilitation Foot problems are common post stroke. As foot problems have been linked to increased fall risk among the general population we recommend that it would be beneficial to include foot and ankle assessments or a referral to a podiatrist for people with stroke who report foot problems. Further research is needed to explore if we can improve functional performance post stroke and reduce fall risk if treatment or prevention of foot problems can be included in stroke rehabilitation.

Factors influencing the decline in stroke mortality: a statement from the American Heart Association/American Stroke Association.

PubMed

Lackland, Daniel T; Roccella, Edward J; Deutsch, Anne F; Fornage, Myriam; George, Mary G; Howard, George; Kissela, Brett M; Kittner, Steven J; Lichtman, Judith H; Lisabeth, Lynda D; Schwamm, Lee H; Smith, Eric E; Towfighi, Amytis

2014-01-01

Stroke mortality has been declining since the early 20th century. The reasons for this are not completely understood, although the decline is welcome. As a result of recent striking and more accelerated decreases in stroke mortality, stroke has fallen from the third to the fourth leading cause of death in the United States. This has prompted a detailed assessment of the factors associated with the change in stroke risk and mortality. This statement considers the evidence for factors that have contributed to the decline and how they can be used in the design of future interventions for this major public health burden. Writing group members were nominated by the committee chair and co-chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association Stroke Council's Scientific Statements Oversight Committee and the American Heart Association Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiological studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize evidence and to indicate gaps in current knowledge. All members of the writing group had the opportunity to comment on this document and approved the final version. The document underwent extensive American Heart Association internal peer review, Stroke Council leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee. The decline in stroke mortality over the past decades represents a major improvement in population health and is observed for both sexes and for all racial/ethnic and age groups. In addition to the overall impact on fewer lives lost to stroke, the major decline in stroke mortality seen among people <65 years of age represents a reduction in years of potential life lost. The decline in mortality results from reduced incidence of stroke and lower case-fatality rates. These significant improvements in stroke outcomes are concurrent with cardiovascular risk factor control interventions. Although it is difficult to calculate specific attributable risk estimates, efforts in hypertension control initiated in the 1970s appear to have had the most substantial influence on the accelerated decline in stroke mortality. Although implemented later, diabetes mellitus and dyslipidemia control and smoking cessation programs, particularly in combination with treatment of hypertension, also appear to have contributed to the decline in stroke mortality. The potential effects of telemedicine and stroke systems of care appear to be strong but have not been in place long enough to indicate their influence on the decline. Other factors had probable effects, but additional studies are needed to determine their contributions. The decline in stroke mortality is real and represents a major public health and clinical medicine success story. The repositioning of stroke from third to fourth leading cause of death is the result of true mortality decline and not an increase in mortality from chronic lung disease, which is now the third leading cause of death in the United States. There is strong evidence that the decline can be attributed to a combination of interventions and programs based on scientific findings and implemented with the purpose of reducing stroke risks, the most likely being improved control of hypertension. Thus, research studies and the application of their findings in developing intervention programs have improved the health of the population. The continued application of aggressive evidence-based public health programs and clinical interventions is expected to result in further declines in stroke mortality.

Investigation of Stroke Needs (INVISION) Study: Stroke Awareness and Education

PubMed Central

Ing, Marissa M; Linton, Kristen F; Vento, Megan A

2015-01-01

The objective of this study was to assess the overall understanding and effectiveness of current inpatient stroke education practice by using the data from the Investigation of Stroke Needs (INVISION) Study, a qualitative study assessing various challenges and barriers of the hemorrhagic stroke survivors and their caregivers. Semi-structured interviews were conducted on patients who were recently hospitalized with intracerebral hemorrhage (ICH) and their caregivers during the follow-up visits. The electronic medical record for each patient was reviewed to assess whether they received standard stroke education material during their hospitalization. A phenomenological approach was utilized to identify gaps of education and knowledge in the targeted sample. A total of 21 participants were interviewed. Despite receiving formal stroke education material during their hospitalization, there were three major gaps in stroke knowledge that participants noted, including (1) lack of stroke knowledge/awareness, (2) need for stroke education, and (3) fear of recurrent stroke and comorbid diseases. The majority of ICH survivors had no memory of their hospitalization. This study suggests a need for increased continuity and communication with health-care providers to address the evolving educational and practical needs of stroke patients and their caregivers after hospital discharge. PMID:25954601

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.

Photoelectric return-stroke velocity and peak current estimates in natural and triggered lightning

NASA Technical Reports Server (NTRS)

Mach, Douglas M.; Rust, W. David

1989-01-01

Two-dimensional photoelectric return stroke velocities from 130 strokes are presented, including 86 negative natural, 41 negative triggered, one positive triggered, and two positive natural return strokes. For strokes starting near the ground and exceeding 500 m in length, the average velocity is 1.3 + or - 0.3 X 10 to the 8th m/s for natural return strokes and 1.2 + or - 0.3 X 10 to the 8th m/s for triggered return strokes. For strokes with lengths less than 500 m, the average velocities are slightly higher. Using the transmission line model (TLM), the shortest segment one-dimensional return stroke velocity, and either the maximum or plateau electric field, it is shown that natural strokes have a peak current distribution that is lognormal with a median value of 16 kA (maximum E) or 12 kA (plateau E). Triggered lightning has a medium peak current value of 21 kA (maximum E) or 15 kA (plateau E). Correlations are found between TLM peak currents and velocities for triggered and natural subsequent return strokes, but not between TLM peak currents and natural first return stroke velocities.

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

PubMed

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

2017-03-01

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

Optimal combination treatment and vascular outcomes in recent ischemic stroke patients by premorbid risk level.

PubMed

Park, Jong-Ho; Ovbiagele, Bruce

2015-08-15

Optimal combination of secondary stroke prevention treatment including antihypertensives, antithrombotic agents, and lipid modifiers is associated with reduced recurrent vascular risk including stroke. It is unclear whether optimal combination treatment has a differential impact on stroke patients based on level of vascular risk. We analyzed a clinical trial dataset comprising 3680 recent non-cardioembolic stroke patients aged ≥35 years and followed for 2 years. Patients were categorized by appropriateness levels 0 to III depending on the number of the drugs prescribed divided by the number of drugs potentially indicated for each patient (0=none of the indicated medications prescribed and III=all indicated medications prescribed [optimal combination treatment]). High-risk was defined as having a history of stroke or coronary heart disease (CHD) prior to the index stroke event. Independent associations of medication appropriateness level with a major vascular event (stroke, CHD, or vascular death), ischemic stroke, and all-cause death were analyzed. Compared with level 0, for major vascular events, the HR of level III in the low-risk group was 0.51 (95% CI: 0.20-1.28) and 0.32 (0.14-0.70) in the high-risk group; for stroke, the HR of level III in the low-risk group was 0.54 (0.16-1.77) and 0.25 (0.08-0.85) in the high-risk group; and for all-cause death, the HR of level III in the low-risk group was 0.66 (0.09-5.00) and 0.22 (0.06-0.78) in the high-risk group. Optimal combination treatment is related to a significantly lower risk of future vascular events and death among high-risk patients after a recent non-cardioembolic stroke. Copyright © 2015 Elsevier B.V. All rights reserved.

Comparison of Risk Factor Control in the Year After Discharge for Ischemic Stroke Versus Acute Myocardial Infarction.

PubMed

Bravata, Dawn M; Daggy, Joanne; Brosch, Jared; Sico, Jason J; Baye, Fitsum; Myers, Laura J; Roumie, Christianne L; Cheng, Eric; Coffing, Jessica; Arling, Greg

2018-02-01

The Veterans Health Administration has engaged in quality improvement to improve vascular risk factor control. We sought to examine blood pressure (<140/90 mm Hg), lipid (LDL [low-density lipoprotein] cholesterol <100 mg/dL), and glycemic control (hemoglobin A1c <9%), in the year post-hospitalization for acute ischemic stroke or acute myocardial infarction (AMI). We identified patients who were hospitalized (fiscal year 2011) with ischemic stroke, AMI, congestive heart failure, transient ischemic attack, or pneumonia/chronic obstructive pulmonary disease. The primary analysis compared risk factor control after incident ischemic stroke versus AMI. Facilities were included if they cared for ≥25 ischemic stroke and ≥25 AMI patients. A generalized linear mixed model including patient- and facility-level covariates compared risk factor control across diagnoses. Forty thousand two hundred thirty patients were hospitalized (n=75 facilities): 2127 with incident ischemic stroke and 4169 with incident AMI. Fewer stroke patients achieved blood pressure control than AMI patients (64%; 95% confidence interval, 0.62-0.67 versus 77%; 95% confidence interval, 0.75-0.78; P <0.0001). After adjusting for patient and facility covariates, the odds of blood pressure control were still higher for AMI than ischemic stroke patients (odds ratio, 1.39; 95% confidence interval, 1.21-1.51). There were no statistical differences for AMI versus stroke patients in hyperlipidemia ( P =0.534). Among patients with diabetes mellitus, the odds of glycemic control were lower for AMI than ischemic stroke patients (odds ratio, 0.72; 95% confidence interval, 0.54-0.96). Given that hypertension control is a cornerstone of stroke prevention, interventions to improve poststroke hypertension management are needed. © 2017 The Authors.

Ischemic Stroke: What Does the Histological Composition Tell Us About the Origin of the Thrombus?

PubMed

Sporns, Peter B; Hanning, Uta; Schwindt, Wolfram; Velasco, Aglaé; Minnerup, Jens; Zoubi, Tarek; Heindel, Walter; Jeibmann, Astrid; Niederstadt, Thomas Ulrich

2017-08-01

The introduction of stent retrievers allows for a complete extraction and histological analysis of human thrombi. Ischemic stroke is a major health issue, and differentiation of underlying causes is highly relevant to prevent recurrent stroke. Therefore, histopathologic analysis of the embolic clots after removal may provide valuable information about underlying pathologies. This study analyzes histological clot composition and aims to identify specific patterns that might help to distinguish causes of ischemic stroke. Patients with occlusion of the carotid-T or middle cerebral artery who underwent thrombectomy at our university medical center between December 2013 and February 2016 were included. Samples were histologically analyzed (hematoxylin and eosin, Elastica van Gieson, and Prussian blue), additionally immunohistochemistry for CD3, CD20, and CD68/KiM1P was performed. These data, along with additional clinical and interventional parameters, were compared for different stroke subtypes, as defined by the TOAST (Trial of Org 10172 in Acute Stroke Treatment) classification. One hundred eighty-seven patients were included, of these, in 77 patients, cardioembolic; in 46 patients, noncardioembolic; and in 64 patients, cryptogenic pathogenesis was determined. Cardioembolic thrombi had higher proportions of fibrin/platelets ( P =0.027), less erythrocytes ( P =0.005), and more leucocytes ( P =0.026) than noncardioembolic thrombi. We observed a strong overlap of cryptogenic strokes and cardioembolic strokes concerning thrombus histology. The immunohistochemical parameters CD3, CD20, and CD68/KiM1P showed no statistically noticeable differences between stroke subtypes. Histological thrombus features vary significantly according to the underlying cause and may help to differentiate between cardioembolic and noncardioembolic stroke. In addition, our study supports the hypothesis that most cryptogenic strokes have a cardioembolic cause. © 2017 American Heart Association, Inc.

Stroke: roles of B vitamins, homocysteine and antioxidants.

PubMed

Sánchez-Moreno, Concepción; Jiménez-Escrig, Antonio; Martín, Antonio

2009-06-01

In the present review concerning stroke, we evaluate the roles of B vitamins, homocysteine and antioxidant vitamins. Stroke is a leading cause of death in developed countries. However, current therapeutic strategies for stroke have been largely unsuccessful. Several studies have reported important benefits on reducing the risk of stroke and improving the post-stroke-associated functional declines in patients who ate foods rich in micronutrients, including B vitamins and antioxidant vitamins E and C. Folic acid, vitamin B6 and vitamin B12 are all cofactors in homocysteine metabolism. Growing interest has been paid to hyperhomocysteinaemia as a risk factor for CVD. Hyperhomocysteinaemia has been linked to inadequate intake of vitamins, particularly to B-group vitamins and therefore may be amenable to nutritional intervention. Hence, poor dietary intake of folate, vitamin B6 and vitamin B12 are associated with increased risk of stroke. Elevated consumption of fruits and vegetables appears to protect against stroke. Antioxidant nutrients have important roles in cell function and have been implicated in processes associated with ageing, including vascular, inflammatory and neurological damage. Plasma vitamin E and C concentrations may serve as a biological marker of lifestyle or other factors associated with reduced stroke risk and may be useful in identifying those at high risk of stroke. After reviewing the observational and intervention studies, there is an incomplete understanding of mechanisms and some conflicting findings; therefore the available evidence is insufficient to recommend the routine use of B vitamins, vitamin E and vitamin C for the prevention of stroke. A better understanding of mechanisms, along with well-designed controlled clinical trials will allow further progress in this area.

Recurrent Stroke in Minor Ischemic Stroke or Transient Ischemic Attack With Metabolic Syndrome and/or Diabetes Mellitus.

PubMed

Chen, Weiqi; Pan, Yuesong; Jing, Jing; Zhao, Xingquan; Liu, Liping; Meng, Xia; Wang, Yilong; Wang, Yongjun

2017-06-01

We aimed to determine the risk conferred by metabolic syndrome (METS) and diabetes mellitus (DM) to recurrent stroke in patients with minor ischemic stroke or transient ischemic attack from the CHANCE (Clopidogrel in High-risk patients with Acute Non-disabling Cerebrovascular Events) trial. In total, 3044 patients were included. Patients were stratified into 4 groups: neither, METS only, DM only, or both. METS was defined using the Chinese Diabetes Society (CDS) and International Diabetes Foundation (IDF) definitions. The primary outcome was new stroke (including ischemic and hemorrhagic) at 90 days. A multivariable Cox regression model was used to assess the relationship of METS and DM status to the risk of recurrent stroke adjusted for potential covariates. Using the CDS criteria of METS, 53.2%, 17.2%, 19.8%, and 9.8% of patients were diagnosed as neither, METS only, DM only, and both, respectively. After 90 days of follow-up, there were 299 new strokes (293 ischemic, 6 hemorrhagic). Patients with DM only (16.1% versus 6.8%; adjusted hazard ratio 2.50, 95% CI 1.89-3.39) and both (17.1% versus 6.8%; adjusted hazard ratio 2.76, 95% CI 1.98-3.86) had significantly increased rates of recurrent stroke. No interaction effect of antiplatelet therapy by different METS or DM status for the risk of recurrent stroke ( P =0.82 for interaction in the fully adjusted model of CDS) was observed. Using the METS (IDF) criteria demonstrated similar results. Concurrent METS and DM was associated with an increased risk of recurrent stroke in patients with minor stroke and transient ischemic attack. © 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

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.

Characteristics of Inpatient Care and Rehabilitation for Acute First-Ever Stroke Patients

PubMed Central

Chang, Won Hyuk; Shin, Yong-Il; Lee, Sam-Gyu; Oh, Gyung-Jae; Lim, Young Shil

2015-01-01

Purpose The purpose of this study was to analyze the status of inpatient care for acute first-ever stroke at three general hospitals in Korea to provide basic data and useful information on the development of comprehensive and systematic rehabilitation care for stroke patients. Materials and Methods This study conducted a retrospective complete enumeration survey of all acute first-ever stroke patients admitted to three distinct general hospitals for 2 years by reviewing medical records. Both ischemic and hemorrhagic strokes were included. Survey items included demographic data, risk factors, stroke type, state of rehabilitation treatment, discharge destination, and functional status at discharge. Results A total of 2159 patients were reviewed. The mean age was 61.5±14.4 years and the ratio of males to females was 1.23:1. Proportion of ischemic stroke comprised 54.9% and hemorrhagic stroke 45.1%. Early hospital mortality rate was 8.1%. Among these patients, 27.9% received rehabilitation consultation and 22.9% underwent inpatient rehabilitation treatment. The mean period from admission to rehabilitation consultation was 14.5 days. Only 12.9% of patients were transferred to a rehabilitation department and the mean period from onset to transfer was 23.4 days. Improvements in functional status were observed in the patients who had received inpatient rehabilitation treatment after acute stroke management. Conclusion Our analysis revealed that a relatively small portion of patients who suffered from an acute first-ever stroke received rehabilitation consultation and inpatient rehabilitation treatment. Thus, applying standardized clinical practice guidelines for post-acute rehabilitation care is needed to provide more effective and efficient rehabilitation services to patients with stroke. PMID:25510773

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

PubMed

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

2016-11-01

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

Association Between Troponin Levels and Embolic Stroke of Undetermined Source.

PubMed

Merkler, Alexander E; Gialdini, Gino; Murthy, Santosh B; Salehi Omran, Setareh; Moya, Antonio; Lerario, Michael P; Chong, Ji; Okin, Peter M; Weinsaft, Jonathan W; Safford, Monika M; Fink, Matthew E; Navi, Babak B; Iadecola, Costantino; Kamel, Hooman

2017-09-22

Our aim was to determine whether patients with embolic strokes of undetermined source (ESUS) have higher rates of elevated troponin than patients with noncardioembolic strokes. CAESAR (The Cornell Acute Stroke Academic Registry) prospectively enrolled all adults with acute stroke from 2011 to 2014. Two neurologists used standard definitions to retrospectively ascertain the etiology of stroke, with a third resolving disagreements. In this analysis we included patients with ESUS and, as controls, patients with small- and large-artery strokes; only patients with a troponin measured within 24 hours of stroke onset were included. A troponin elevation was defined as a value exceeding our laboratory's upper limit (0.04 ng/mL) without a clinically recognized acute ST-segment elevation myocardial infarction. Multiple logistic regression was used to evaluate the association between troponin elevation and ESUS after adjustment for demographics, stroke severity, insular infarction, and vascular risk factors. In a sensitivity analysis we excluded patients diagnosed with atrial fibrillation after discharge. Among 512 patients, 243 (47.5%) had ESUS, and 269 (52.5%) had small- or large-artery stroke. In multivariable analysis an elevated troponin was independently associated with ESUS (odds ratio 3.3; 95% confidence interval 1.2, 8.8). This result was unchanged after excluding patients diagnosed with atrial fibrillation after discharge (odds ratio 3.4; 95% confidence interval 1.3, 9.1), and the association remained significant when troponin was considered a continuous variable (odds ratio for log[troponin], 1.4; 95% confidence interval 1.1, 1.7). Elevations in cardiac troponin are more common in patients with ESUS than in those with noncardioembolic strokes. © 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

Impact of SAMMPRIS on the future of intracranial atherosclerotic disease management: polling results from the ICAD symposium at the International Stroke Conference.

PubMed

Zaidat, Osama O; Castonguay, Alicia C; Nguyen, Thanh N; Becker, Kyra J; Derdeyn, Colin P; Nelson, Peter K; Amarenco, Pierre; Brott, Thomas G

2014-04-01

There are few data regarding the effect of the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) trial results on the management of intracranial atherosclerotic disease (ICAD). We sought to understand the impact of the SAMMPRIS trial on current ICAD clinical practices and future trial design. During the ICAD symposium at the 2012 International Stroke Conference, electronic data were collected regarding attendees' clinical management of ICAD and opinions on the feasibility of future trials post-SAMMPRIS. 217 attendees from different specialties, including neurologists (57%), neurointerventionalists (9%) and neurosurgeons (5%), participated in the session. The majority of respondents (77%) indicated that the results of SAMMPRIS have impacted their consideration for intracranial stenting. Post-SAMMPRIS, 84% selected 'SAMMPRIS-style' medical management for the treatment of ICAD. For patients with ICAD who failed aggressive medical therapy, 82% would consider an alternative approach to continuing medical therapy (30% considered clinical trial enrollment, 28% suggested angioplasty and stenting and 24% angioplasty). The majority of participants (85%) were willing to randomize patients with symptomatic ICAD in future trials. For the next ICAD trial, 29% indicated that angioplasty alone should be compared with aggressive medical therapy. Our polling results suggest that the SAMMPRIS trial has had an impact on the current treatment of ICAD. Treatment of patients who failed medical therapy varied widely from aggressive medical therapy to balloon angioplasty, stenting or enrollment in future clinical trials. The willingness to continue clinical trials and randomize patients supports the need for future ICAD studies.

Laser system refinements to reduce variability in infarct size in the rat photothrombotic stroke model

PubMed Central

Alaverdashvili, Mariam; Paterson, Phyllis G.; Bradley, Michael P.

2015-01-01

Background The rat photothrombotic stroke model can induce brain infarcts with reasonable biological variability. Nevertheless, we observed unexplained high inter-individual variability despite using a rigorous protocol. Of the three major determinants of infarct volume, photosensitive dye concentration and illumination period were strictly controlled, whereas undetected fluctuation in laser power output was suspected to account for the variability. New method The frequently utilized Diode Pumped Solid State (DPSS) lasers emitting 532 nm (green) light can exhibit fluctuations in output power due to temperature and input power alterations. The polarization properties of the Nd:YAG and Nd:YVO4 crystals commonly used in these lasers are another potential source of fluctuation, since one means of controlling output power uses a polarizer with a variable transmission axis. Thus, the properties of DPSS lasers and the relationship between power output and infarct size were explored. Results DPSS laser beam intensity showed considerable variation. Either a polarizer or a variable neutral density filter allowed adjustment of a polarized laser beam to the desired intensity. When the beam was unpolarized, the experimenter was restricted to using a variable neutral density filter. Comparison with existing method(s) Our refined approach includes continuous monitoring of DPSS laser intensity via beam sampling using a pellicle beamsplitter and photodiode sensor. This guarantees the desired beam intensity at the targeted brain area during stroke induction, with the intensity controlled either through a polarizer or variable neutral density filter. Conclusions Continuous monitoring and control of laser beam intensity is critical for ensuring consistent infarct size. PMID:25840363

Rapid recovery from aphasia after infarction of Wernicke's area.

PubMed

Yagata, Stephanie A; Yen, Melodie; McCarron, Angelica; Bautista, Alexa; Lamair-Orosco, Genevieve; Wilson, Stephen M

2017-01-01

Aphasia following infarction of Wernicke's area typically resolves to some extent over time. The nature of this recovery process and its time course have not been characterized in detail, especially in the acute/subacute period. The goal of this study was to document recovery after infarction of Wernicke's area in detail in the first 3 months after stroke. Specifically, we aimed to address two questions about language recovery. First, which impaired language domains improve over time, and which do not? Second, what is the time course of recovery? We used quantitative analysis of connected speech and a brief aphasia battery to document language recovery in two individuals with aphasia following infarction of the posterior superior temporal gyrus. Speech samples were acquired daily between 2 and 16 days post stroke, and also at 1 month and 3 months. Speech samples were transcribed and coded using the CHAT system, in order to quantify multiple language domains. A brief aphasia battery was also administered at a subset of five time points during the 3 months. Both patients showed substantial recovery of language function over this time period. Most, but not all, language domains showed improvements, including fluency, lexical access, phonological retrieval and encoding, and syntactic complexity. The time course of recovery was logarithmic, with the greatest gains taking place early in the course of recovery. There is considerable potential for amelioration of language deficits when damage is relatively circumscribed to the posterior superior temporal gyrus. Quantitative analysis of connected speech samples proved to be an effective, albeit time-consuming, approach to tracking day-by-day recovery in the acute/subacute post-stroke period.

Airplane stroke syndrome.

PubMed

Humaidan, Hani; Yassi, Nawaf; Weir, Louise; Davis, Stephen M; Meretoja, Atte

2016-07-01

Only 37 cases of stroke during or soon after long-haul flights have been published to our knowledge. In this retrospective observational study, we searched the Royal Melbourne Hospital prospective stroke database and all discharge summaries from 1 September 2003 to 30 September 2014 for flight-related strokes, defined as patients presenting with stroke within 14days of air travel. We hypothesised that a patent foramen ovale (PFO) is an important, but not the only mechanism, of flight-related stroke. We describe the patient, stroke, and flight characteristics. Over the study period, 131 million passengers arrived at Melbourne airport. Our centre admitted 5727 stroke patients, of whom 42 (0.73%) had flight-related strokes. Flight-related stroke patients were younger (median age 65 versus 73, p<0.001), had similar stroke severity, and received intravenous thrombolysis more often than non-flight-related stroke patients. Seven patients had flight-related intracerebral haemorrhage. The aetiology of the ischaemic strokes was cardioembolic in 14/35 (40%), including seven patients with confirmed PFO, one with atrial septal defect, four with atrial fibrillation, one with endocarditis, and one with aortic arch atheroma. Paradoxical embolism was confirmed in six patients. Stroke related to air travel is a rare occurrence, less than one in a million. Although 20% of patients had a PFO, distribution of stroke aetiologies was diverse and was not limited to PFO and paradoxical embolism. Copyright © 2016 Elsevier Ltd. All rights reserved.

External Validation of the Prestroke Independence, Sex, Age, National Institutes of Health Stroke Scale Score for Predicting Pneumonia After Stroke Using Data From the China National Stroke Registry.

PubMed

Zhang, Runhua; Ji, Ruijun; Pan, Yuesong; Jiang, Yong; Liu, Gaifen; Wang, Yilong; Wang, Yongjun

2017-05-01

Pneumonia is an important risk factor for mortality and morbidity after stroke. The Prestroke Independence, Sex, Age, National Institutes of Health Stroke Scale (ISAN) score was shown to be a useful tool for predicting stroke-associated pneumonia based on UK multicenter cohort study. We aimed to externally validate the score using data from the China National Stroke Registry (CNSR). Eligible patients with acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH) in the CNSR from 2007 to 2008 were included. The area under the receiver operating characteristic (AUC) curve was used to evaluate discrimination. The Hosmer-Lemeshow goodness of fit test and Pearson correlation coefficient were performed to assess calibration of the model. A total of 19,333 patients (AIS = 14400; ICH = 4933) were included and the overall pneumonia rate was 12.7%. The AUC was .76 (95% confidence interval [CI]: .75-.78) for the subgroup of AIS and .70 (95% CI: .68-.72) for the subgroup of ICH. The Hosmer-Lemeshow test showed the ISAN score with the good calibration for AIS and ICH (P = .177 and .405, respectively). The plot of observed versus predicted pneumonia rates suggested higher correlation for patients with AIS than with ICH (Pearson correlation coefficient = .99 and .83, respectively). The ISAN score was a useful tool for predicting in-hospital pneumonia after acute stroke, especially for patients with AIS. Further validations need to be done in different populations. Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Arsenic Exposure in Relation to Ischemic Stroke: The Reasons for Geographic and Racial Differences in Stroke Study.

PubMed

Tsinovoi, Cari L; Xun, Pengcheng; McClure, Leslie A; Carioni, Vivian M O; Brockman, John D; Cai, Jianwen; Guallar, Eliseo; Cushman, Mary; Unverzagt, Frederick W; Howard, Virginia J; He, Ka

2018-01-01

The purpose of this case-cohort study was to examine urinary arsenic levels in relation to incident ischemic stroke in the United States. We performed a case-cohort study nested within the REGARDS (REasons for Geographic and Racial Differences in Stroke) cohort. A subcohort (n=2486) of controls was randomly sampled within region-race-sex strata while all incident ischemic stroke cases from the full REGARDS cohort (n=671) were included. Baseline urinary arsenic was measured by inductively coupled plasma-mass spectrometry. Arsenic species, including urinary inorganic arsenic and its metabolites monomethylarsonic acid and dimethylarsinic acid, were measured in a random subset (n=199). Weighted Cox's proportional hazards models were used to calculate hazard ratios and 95% confidence intervals of ischemic stroke by arsenic and its species. The average follow-up was 6.7 years. Although incident ischemic stroke showed no association with total arsenic or total inorganic arsenic, for each unit higher level of urinary monomethylarsonic acid on a log-scale, after adjustment for potential confounders, ischemic stroke risk increased ≈2-fold (hazard ratio=1.98; 95% confidence interval: 1.12-3.50). Effect modification by age, race, sex, or geographic region was not evident. A metabolite of arsenic was positively associated with incident ischemic stroke in this case-cohort study of the US general population, a low-to-moderate exposure area. Overall, these findings suggest a potential role for arsenic methylation in the pathogenesis of stroke, having important implications for future cerebrovascular research. © 2017 American Heart Association, Inc.

Association of ideomotor apraxia with lesion site, etiology, neglect, and functional independence in patients with first ever stroke.

PubMed

Civelek, Gul Mete; Atalay, Ayce; Turhan, Nur

2015-04-01

Ideomotor apraxia (IMA) is characterized by the inability to correctly imitate hand gestures and voluntarily pantomime tool use. The relationship between IMA and characteristics of stroke has not been totally elucidated. This study aimed to find out associations between presence of IMA and stroke etiology, site of the lesions, neglect, and temporal and functional parameters of stroke in patients with first ever stroke. Thirty-nine patients with first ever stroke were included. Patients with severe cognitive deficits were excluded. Assessment tools included Ideomotor Apraxia Test, Functional Independence Measure (FIM), Brunnstrom recovery stages, Mini Mental Test (MMT), and star cancellation test. Etiology (hemorrhagic or ischemic) and site of stroke was assessed through brain imaging methods. Location and size of ischemic lesion was determined by using the Oxfordshire Community Stroke Project system. IMA was identified in 35.9% of the patients. Patients with IMA had significantly lower FIM scores both on admission and discharge (P = 0.001, P = 0.001). Presence of IMA was significantly associated with the presence of neglect (P = 0.004), total anterior circulation ischemia (TACI) (P < 0.001), and lower MMT scores (P < 0.001). Lesion site, patient age, time since onset, and stroke etiology had no impact on the presence of IMA. IMA was in concordance with poor cognitive and functional state and was not limited to left hemisphere lesions. The study revealed strong associations between IMA, neglect, and TACI. Every patient with stroke should be evaluated for the presence of IMA on admission to rehabilitation unit.

Diagnostic value of prehospital ECG in acute stroke patients.

PubMed

Bobinger, Tobias; Kallmünzer, Bernd; Kopp, Markus; Kurka, Natalia; Arnold, Martin; Heider, Stefan; Schwab, Stefan; Köhrmann, Martin

2017-05-16

To investigate the diagnostic yield of prehospital ECG monitoring provided by emergency medical services in the case of suspected stroke. Consecutive patients with acute stroke admitted to our tertiary stroke center via emergency medical services and with available prehospital ECG were prospectively included during a 12-month study period. We assessed prehospital ECG recordings and compared the results to regular 12-lead ECG on admission and after continuous ECG monitoring at the stroke unit. Overall, 259 patients with prehospital ECG recording were included in the study (90.3% ischemic stroke, 9.7% intracerebral hemorrhage). Atrial fibrillation (AF) was detected in 25.1% of patients, second-degree or greater atrioventricular block in 5.4%, significant ST-segment elevation in 5.0%, and ventricular ectopy in 9.7%. In 18 patients, a diagnosis of new-onset AF with direct clinical consequences for the evaluation and secondary prevention of stroke was established by the prehospital recordings. In 2 patients, the AF episodes were limited to the prehospital period and were not detected by ECG on admission or during subsequent monitoring at the stroke unit. Of 126 patients (48.6%) with relevant abnormalities in the prehospital ECG, 16.7% received medical antiarrhythmic therapy during transport to the hospital, and 6.4% were transferred to a cardiology unit within the first 24 hours in the hospital. In a selected cohort of patients with stroke, the in-field recordings of the ECG detected a relevant rate of cardiac arrhythmia. The results can add to the in-hospital evaluation and should be considered in prehospital care of acute stroke. © 2017 American Academy of Neurology.

Educational needs of patients with a stroke and their caregivers: a systematic review of the literature.

PubMed

Hafsteinsdóttir, Thóra B; Vergunst, Martine; Lindeman, Eline; Schuurmans, Marieke

2011-10-01

To systematically review the research on stroke patients' and caregivers' educational needs. A search of the literature prior to and including the year January 2009 was conducted using Medline, CINAHL, EMBASE, PsychINFO and the Cochrane Library, yielding 959 articles. Of these, 21 studies were included in the review. Stroke patients and caregivers reported many and diverse educational needs, which often were not met. The educational needs of stroke patients and caregivers concerned knowledge about the clinical aspects of stroke, prevention, treatment and functional recovery. The most commonly reported needs of caregivers involved patients' moving and lifting, exercises, psychological changes and nutritional issues. Patients and caregivers wanted information that was tailored to their situation. Patients and caregivers have many unmet educational needs. The findings call for improved education of patients and caregivers on various issues that are specific to the various recovery phases after stroke. The findings of this review can be used to develop educational interventions for stroke patients and caregivers. Further research is needed to investigate the feasibility and effects of educational interventions and whether they meet the educational needs of patients and caregivers. Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.

[Etiologic classification of cerebral infarct. Experience from a prospective data register].

PubMed

Brainin, M

1990-12-01

Most classifications of stroke include clinically heterogeneous subgroups and therefore are of limited value for comparative studies or clinical protocols. The view is held that a classification according to stroke etiology is clinically more reasonable and more consistent for therapeutic strategies. In order to determine the frequency of various etiological subgroups in a series of stroke cases, the results of the Klosterneuburger Schlaganfall-Datenbank (KSDB) are reported. This stroke registry has prospectively recorded over 300 items on all stroke cases referred to one center since March 1988. Investigation rates include CT in almost 100% and the investigation of cerebral vessels in over 90% of all cases. By applying defined etiological categories (undetermined etiology, atherosclerosis of the large craniocervical vessels, cardiogenic embolism, lacunar, primary hemorrhage, and multiple and other causes) to the first 420 patients registered within the first two years it can be shown that even with CT and neurosonology in routine use, in 29% of all cases the cause of the stroke cannot be determined. To investigate this largest subgroup by means of additional new methods as well as by investigating the long-term natural course represents an important challenge for clinical stroke research.

Neighborhood Differences in Post-Stroke Mortality

PubMed Central

Osypuk, Theresa L.; Ehntholt, Amy; Moon, J. Robin; Gilsanz, Paola; Glymour, M. Maria

2017-01-01

Background Post-stroke mortality is higher among residents of disadvantaged neighborhoods, but it is not known whether neighborhood inequalities are specific to stroke survival or similar to mortality patterns in the general population. We hypothesized that neighborhood disadvantage would predict higher post-stroke mortality and neighborhood effects would be relatively larger for stroke patients than for individuals with no history of stroke. Methods and Results Health and Retirement Study participants aged 50+ without stroke at baseline (n=15,560) were followed up to 12 years for incident stroke (1,715 events over 159,286 person-years) and mortality (5,325 deaths). Baseline neighborhood characteristics included objective measures based on census tracts (family income, poverty, deprivation, residential stability, and percent white, black or foreign-born) and self-reported neighborhood social ties. Using Cox proportional hazard models, we compared neighborhood mortality effects for people with versus without a history of stroke. Most neighborhood variables predicted mortality for both stroke patients and the general population in demographic-adjusted models. Neighborhood percent white predicted lower mortality for stroke survivors (HR=0.75 for neighborhoods in highest 25th percentile vs. below, 95 % CI: 0.62, 0.91) more strongly than for stroke-free adults (HR=0.92 (0.83, 1.02); p=0.04 for stroke-by-neighborhood interaction). No other neighborhood characteristic had different effects for people with versus without stroke. Neighborhood-mortality associations emerged within three months after stroke, when associations were often stronger than among stroke-free individuals. Conclusions Neighborhood characteristics predict post-stroke mortality, but most effects are similar for individuals without stroke. Eliminating disparities in stroke survival may require addressing pathways that are not specific to traditional post-stroke care. PMID:28228449

Incidence of Hospitalized Stroke in the Czech Republic: The National Registry of Hospitalized Patients.

PubMed

Sedova, Petra; Brown, Robert D; Zvolsky, Miroslav; Kadlecova, Pavla; Bryndziar, Tomas; Kubelka, Tomáš; Weiss, Viktor; Volný, Ondřej; Bednarik, Josef; Mikulik, Robert

2017-05-01

Contemporary stroke incidence data are not available in some countries and regions, including in Eastern Europe. Based on previous validation of the accuracy of the National Registry of Hospitalized Patients (NRHOSP), we report the incidence of hospitalized stroke in the Czech Republic (CR) using the NRHOSP. The results of the prior validation study assessing the accuracy of coding of stroke diagnoses in the NRHOSP were applied, and we calculated (1) the overall incidence of hospitalized stroke and (2) the incidence rates of hospitalized stroke for the three main stroke types: cerebral infarction (International Classification of Diseases Tenth Revision, CI I63), subarachnoid hemorrhage (SAH I60), and intracerebral hemorrhage (ICH I61). We calculated the average annual age- and sex-standardized incidence. The overall incidence of hospitalized stroke was 241 out of 100,000 individuals. The incidence of hospitalized stroke for the main stroke types was 8.2 cases in SAH, 29.5 in ICH, and 211 in CI per 100,000 individuals. The standardized annual stroke incidence adjusted to the 2000 World Health Organization population for overall stroke incidence of hospitalized stroke was 131 per 100,000 individuals. Standardized stroke incidence for stroke subtypes was 5.7 cases in SAH, 16.7 in ICH, and 113 in CI per 100,000 individuals. These studies provide an initial assessment of the burden of stroke in this part of the world. The estimates of hospitalized stroke in the CR and Eastern Europe suggest that ICH is about three times more common than SAH, and hemorrhagic stroke makes up about 18% of strokes. Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Risk factors and incidence of ischemic stroke in Taiwanese with nonvalvular atrial fibrillation-- a nation wide database analysis.

PubMed

Lin, Lian-Yu; Lee, Chang-Hsing; Yu, Chih-Chieh; Tsai, Chia-Ti; Lai, Ling-Pin; Hwang, Juey-Jen; Chen, Pau-Chung; Lin, Jiunn-Lee

2011-07-01

Atrial fibrillation (AF) is a risk factor for ischemic stroke. Stroke-prevention strategies based on risk schemes have been developed but most of the data are from western people. Our goal is to investigate the risk factors of ischemic stroke in Taiwanese with AF in a nation-wide database. A universal national health insurance (NHI) program has been implemented in Taiwan since 1995. We used system sampling database from 1997 to 2008 with a total of 1,000,000 subjects. By using ambulatory and inpatient claim data, we included subjects with AF and were above 20 years old. We excluded those who had ever taken warfarin or aspirin or had valvular heart diseases. A total of 7920 patients (3633 women, 4287 men) were included in the final analyses. Cox regression analysis showed that the risk factors for ischemic stroke were age (OR=1.338 for age 65-74 years vs. age 20-64 years, P=0.014; OR=1.652 for age over 75 years vs. age 20-64 years, P<0.001), hypertension (HTN) (OR=2.656, P<0.001), diabetes mellitus (DM) (OR=1.341, P=0.005), heart failure (OR=1.611, P<0.001), previous ischemic stroke or transient ischemic accident (TIA) (OR=2.752, P<0.001) and peripheral arterial disease (PAD) (OR=1.814, P=0.006). The gender, coronary artery disease, history of myocardial infarction and chronic renal insufficiency were not associated with ischemic stroke. The rate of ischemic stroke was much lower in current cohort as compared with that in whites. Frequent used risk schemes including CHADS₂ and CHA₂DS₂-VASC had comparable but only limited ability to predict ischemic stroke in subjects with AF. Compare with western people, hypertension plays a more important role in ischemic stroke in Taiwanese with AF and the incidence is lower. A substantial number of ischemic strokes cannot be accurately predicted by current risk schemes. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.

Postacute Stroke Rehabilitation Utilization: Are There Differences between Rural-Urban Patients and Taxonomies?

ERIC Educational Resources Information Center

Jia, Huanguang; Cowper, Diane C.; Tang, Yuhong; Litt, Eric; Wilson, Lauren

2012-01-01

Purpose: To assess the association between Veterans Affairs (VA) stroke patients' poststroke rehabilitation utilization and their residential settings by using 2 common rural-urban taxonomies. Methods: This retrospective study included all VA stroke inpatients in 2001 and 2002. Rehabilitation utilization referred to rehabilitation therapy received…

Stroke doctors: Who are we? A World Stroke Organization survey.

PubMed

Meretoja, Atte; Acciarresi, Monica; Akinyemi, Rufus O; Campbell, Bruce; Dowlatshahi, Dar; English, Coralie; Henninger, Nils; Poppe, Alexandre; Putaala, Jukka; Saini, Monica; Sato, Shoichiro; Wu, Bo; Brainin, Michael; Norrving, Bo; Davis, Stephen

2017-10-01

Background Specialist training provides skilled workforce for service delivery. Stroke medicine has evolved rapidly in the past years. No prior information exists on background or training of stroke doctors globally. Aims To describe the specialties that represent stroke doctors, their training requirements, and the scientific organizations ensuring continuous medical education. Methods The World Stroke Organization conducted an expert survey between June and November 2014 using e-mailed questionnaires. All Organization for Economic Co-operation and Development countries with >1 million population and other countries with >50 million population were included ( n = 49, total 5.6 billion inhabitants, 85% of global strokes). Two stroke experts from each selected country were surveyed, discrepancies resolved, and further information on identified stroke-specific curricula sought. Results We received responses from 48 (98%) countries. Of ischemic stroke patients, 64% were reportedly treated by neurologists, ranging from 5% in Ireland to 95% in the Netherlands. Per thousand annual strokes there were average six neurologists, ranging from 0.3 in Ethiopia to 33 in Israel. Of intracerebral hemorrhage patients, 29% were reportedly treated by neurosurgeons, ranging from 5% in Sweden to 79% in Japan, with three neurosurgeons per thousand strokes, ranging from 0.1 in Ethiopia to 24 in South Korea. Most countries had a stroke society (86%) while only 10 (21%) had a degree or subspecialty for stroke medicine. Conclusions Stroke doctor numbers, background specialties, and opportunities to specialize in stroke vary across the globe. Most countries have a scientific society to pursue advancement of stroke medicine, but few have stroke curricula.

Stroke mortality and its determinants in a resource-limited setting: A prospective cohort study in Yaounde, Cameroon.

PubMed

Nkoke, Clovis; Lekoubou, Alain; Balti, Eric; Kengne, Andre Pascal

2015-11-15

About three quarters of stroke deaths occur in developing countries including those in sub-Saharan African. Short and long-term stroke fatality data are needed for health service and policy formulation. We prospectively followed up from stroke onset, 254 patients recruited from the largest reference hospitals in Yaounde (Cameroon). Mortality and determinants were investigated using the accelerated failure time regression analysis. Stroke mortality rates at one-, six- and 12 months were respectively 23.2% (Ischemic strokes: 20.4%, hemorrhagic strokes: 26.1%, and undetermined strokes: 34.8, p=0.219), 31.5% (ischemic strokes: 31.5%, hemorrhagic strokes: 30.4%, and undetermined strokes: 34.8%, p=0.927), and 32.7% (ischemic strokes: 32.1%, hemorrhagic strokes: 30.4%, undetermined strokes: 43.5%, p=0.496). Fever, swallowing difficulties, and admission NIHSS independently predicted mortality at one month, six and 12 months. Elevated systolic blood pressure (BP) predicted mortality at one month. Elevated diastolic blood pressure was a predictor of mortality at one month in participants with hemorrhagic stroke. Low hemoglobin level on admission only predicted long term mortality. In this resource-limited setting, post-stroke mortality was high with 1 out of 5 deaths occurring at one month and up to 30% deaths at six and twelve months after the index event. Fever, stroke severity, elevated BP and anemia increased the risk of death. Our findings add to the body of evidence for the poor outcome after stroke in resource limited environments. Copyright © 2015 Elsevier B.V. All rights reserved.

Hospital recruitment for a pragmatic cluster-randomized clinical trial: Lessons learned from the COMPASS study.

PubMed

Johnson, Anna M; Jones, Sara B; Duncan, Pamela W; Bushnell, Cheryl D; Coleman, Sylvia W; Mettam, Laurie H; Kucharska-Newton, Anna M; Sissine, Mysha E; Rosamond, Wayne D

2018-01-26

Pragmatic randomized clinical trials are essential to determine the effectiveness of interventions in "real-world" clinical practice. These trials frequently use a cluster-randomized methodology, with randomization at the site level. Despite policymakers' increased interest in supporting pragmatic randomized clinical trials, no studies to date have reported on the unique recruitment challenges faced by cluster-randomized pragmatic trials. We investigated key challenges and successful strategies for hospital recruitment in the Comprehensive Post-Acute Stroke Services (COMPASS) study. The COMPASS study is designed to compare the effectiveness of the COMPASS model versus usual care in improving functional outcomes, reducing the numbers of hospital readmissions, and reducing caregiver strain for patients discharged home after stroke or transient ischemic attack. This model integrates early supported discharge planning with transitional care management, including nurse-led follow-up phone calls after 2, 30, and 60 days and an in-person clinic visit at 7-14 days involving a functional assessment and neurological examination. We present descriptive statistics of the characteristics of successfully recruited hospitals compared with all eligible hospitals, reasons for non-participation, and effective recruitment strategies. We successfully recruited 41 (43%) of 95 eligible North Carolina hospitals. Leading, non-exclusive reasons for non-participation included: insufficient staff or financial resources (n = 33, 61%), lack of health system support (n = 16, 30%), and lack of support of individual decision-makers (n = 11, 20%). Successful recruitment strategies included: building and nurturing relationships, engaging team members and community partners with a diverse skill mix, identifying gatekeepers, finding mutually beneficial solutions, having a central institutional review board, sharing published pilot data, and integrating contracts and review board administrators. Although we incorporated strategies based on the best available evidence at the outset of the study, hospital recruitment required three times as much time and considerably more staff than anticipated. To reach our goal, we tailored strategies to individuals, hospitals, and health systems. Successful recruitment of a sufficient number and representative mix of hospitals requires considerable preparation, planning, and flexibility. Strategies presented here may assist future trial organizers in implementing cluster-randomized pragmatic trials. Clinicaltrials.gov, NCT02588664 . Registered on 23 October 2015.

Self-report of stroke, transient ischemic attack, or stroke symptoms and risk of future stroke in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study.

PubMed

Judd, Suzanne E; Kleindorfer, Dawn O; McClure, Leslie A; Rhodes, J David; Howard, George; Cushman, Mary; Howard, Virginia J

2013-01-01

History of stroke and transient ischemic attack (TIA) are documented risk factors for subsequent stroke and all-cause mortality. Recent reports suggest increased risk among those reporting stroke symptoms absent stroke or TIA. However, the relative magnitude of increased stroke risk has not been described across the symptomatic spectrum: (1) asymptomatic, (2) stroke symptoms (SS) only, (3) TIA, (4) distant stroke (DS), and (5) recent stroke (RS). Between 2003 and 2007, the REasons for Geographic And Racial Differences in Stroke (REGARDS) study enrolled 30 239 black and white Americans ≥45 years of age. DS and RS were defined as self-report of physician diagnosis of stroke >5 or <5 years before baseline, respectively. SS was defined as a history of any of 6 sudden onset stroke symptoms absent TIA/stroke diagnosis. Kaplan-Meier and proportional hazards analysis were used to contrast stroke risk differences. Over 5.0±1.72 years of follow-up, 737 strokes were validated. Compared with asymptomatic persons, those with SS, TIA, DS, and RS all had increased risk of future stroke. After adjustment for age, race, sex, income, education, alcohol intake, current smoking, and a history of diabetes mellitus, hypertension, myocardial infarction, atrial fibrillation, and dyslipidemia, there was 1.20-fold (not statistically significant) increased stroke risk for SS (95% CI, 0.96-1.51), 1.73-fold for TIA (95% CI, 1.27-2.36), 2.23-fold for DS (95% CI, 1.61- 3.09), and 2.85-fold for RS (95% CI, 2.16-3.76). Results suggest a spectrum of risk from stroke symptoms to TIA, DS, and RS, and imply a need for establishing these categories in health screenings to manage risk for future stroke, reinforcing the clinical importance of stroke history including the presence of stroke symptoms.

Deep into the Brain: Artificial Intelligence in Stroke Imaging

PubMed Central

Lee, Eun-Jae; Kim, Yong-Hwan; Kim, Namkug; Kang, Dong-Wha

2017-01-01

Artificial intelligence (AI), a computer system aiming to mimic human intelligence, is gaining increasing interest and is being incorporated into many fields, including medicine. Stroke medicine is one such area of application of AI, for improving the accuracy of diagnosis and the quality of patient care. For stroke management, adequate analysis of stroke imaging is crucial. Recently, AI techniques have been applied to decipher the data from stroke imaging and have demonstrated some promising results. In the very near future, such AI techniques may play a pivotal role in determining the therapeutic methods and predicting the prognosis for stroke patients in an individualized manner. In this review, we offer a glimpse at the use of AI in stroke imaging, specifically focusing on its technical principles, clinical application, and future perspectives. PMID:29037014

Deep into the Brain: Artificial Intelligence in Stroke Imaging.

PubMed

Lee, Eun-Jae; Kim, Yong-Hwan; Kim, Namkug; Kang, Dong-Wha

2017-09-01

Artificial intelligence (AI), a computer system aiming to mimic human intelligence, is gaining increasing interest and is being incorporated into many fields, including medicine. Stroke medicine is one such area of application of AI, for improving the accuracy of diagnosis and the quality of patient care. For stroke management, adequate analysis of stroke imaging is crucial. Recently, AI techniques have been applied to decipher the data from stroke imaging and have demonstrated some promising results. In the very near future, such AI techniques may play a pivotal role in determining the therapeutic methods and predicting the prognosis for stroke patients in an individualized manner. In this review, we offer a glimpse at the use of AI in stroke imaging, specifically focusing on its technical principles, clinical application, and future perspectives.

Ischemic stroke and select adipose-derived and sex hormones: a review.

PubMed

Meadows, Kristy L

2018-06-06

Ischemic stroke is the fifth leading cause of death in the USA and is the leading cause of serious, long-term disability worldwide. The principle sex hormones (estrogen, progesterone, and testosterone), both endogenous and exogenous, have profound effects on various stroke outcomes and have become the focus of a number of studies evaluating risk factors and treatment options for ischemic stroke. In addition, the expression of other hormones that may influence stroke outcome, including select adipose-derived hormones (adiponectin, leptin, and ghrelin), can be regulated by sex hormones and are also the focus of several ischemic stroke studies. This review aims to summarize some of the preclinical and clinical studies investigating the principle sex hormones, as well as select adipose-derived hormones, as risk factors or potential treatments for ischemic stroke. In addition, the potential for relaxin, a lesser studied sex hormone, as a novel treatment option for ischemic stroke is explored.

An assessment of the cost-effectiveness of magnetic resonance, including diffusion-weighted imaging, in patients with transient ischaemic attack and minor stroke: a systematic review, meta-analysis and economic evaluation.

PubMed

Wardlaw, Joanna; Brazzelli, Miriam; Miranda, Hector; Chappell, Francesca; McNamee, Paul; Scotland, Graham; Quayyum, Zahid; Martin, Duncan; Shuler, Kirsten; Sandercock, Peter; Dennis, Martin

2014-04-01

Patients with transient ischaemic attack (TIA) or minor stroke need rapid treatment of risk factors to prevent recurrent stroke. ABCD2 score or magnetic resonance diffusion-weighted brain imaging (MR DWI) may help assessment and treatment. Is MR with DWI cost-effective in stroke prevention compared with computed tomography (CT) brain scanning in all patients, in specific subgroups or as 'one-stop' brain-carotid imaging? What is the current UK availability of services for stroke prevention? Published literature; stroke registries, audit and randomised clinical trials; national databases; survey of UK clinical and imaging services for stroke; expert opinion. Systematic reviews and meta-analyses of published/unpublished data. Decision-analytic model of stroke prevention including on a 20-year time horizon including nine representative imaging scenarios. The pooled recurrent stroke rate after TIA (53 studies, 30,558 patients) is 5.2% [95% confidence interval (CI) 3.9% to 5.9%] by 7 days, and 6.7% (5.2% to 8.7%) at 90 days. ABCD2 score does not identify patients with key stroke causes or identify mimics: 66% of specialist-diagnosed true TIAs and 35-41% of mimics had an ABCD2 score of ≥ 4; 20% of true TIAs with ABCD2 score of < 4 had key risk factors. MR DWI (45 studies, 9078 patients) showed an acute ischaemic lesion in 34.3% (95% CI 30.5% to 38.4%) of TIA, 69% of minor stroke patients, i.e. two-thirds of TIA patients are DWI negative. TIA mimics (16 studies, 14,542 patients) make up 40-45% of patients attending clinics. UK survey (45% response) showed most secondary prevention started prior to clinic, 85% of primary brain imaging was same-day CT; 51-54% of patients had MR, mostly additional to CT, on average 1 week later; 55% omitted blood-sensitive MR sequences. Compared with 'CT scan all patients' MR was more expensive and no more cost-effective, except for patients presenting at > 1 week after symptoms to diagnose haemorrhage; strategies that triaged patients with low ABCD2 scores for slow investigation or treated DWI-negative patients as non-TIA/minor stroke prevented fewer strokes and increased costs. 'One-stop' CT/MR angiographic-plus-brain imaging was not cost-effective. Data on sensitivity/specificity of MR in TIA/minor stroke, stroke costs, prognosis of TIA mimics and accuracy of ABCD2 score by non-specialists are sparse or absent; all analysis had substantial heterogeneity. Magnetic resonance with DWI is not cost-effective for secondary stroke prevention. MR was most helpful in patients presenting at > 1 week after symptoms if blood-sensitive sequences were used. ABCD2 score is unlikely to facilitate patient triage by non-stroke specialists. Rapid specialist assessment, CT brain scanning and identification of serious underlying stroke causes is the most cost-effective stroke prevention strategy. The National Institute for Health Research Health Technology Assessment programme.

Sex differences in antiplatelet response in ischemic stroke.

PubMed

Meyer, Dawn M; Eastwood, Jo-Ann; Compton, Margaret P; Gylys, Karen; Zivin, Justin A; Ovbiagele, Bruce

2011-07-01

Sex differences exist in the occurrence, treatment and outcome of ischemic stroke. Compared with men, women have more stroke events and are less likely to fully recover from a stroke. Given the rapidly aging population, stroke incidence and mortality among women are projected to substantially rise by 2050. This has important public health consequences. Mitigating the burden of stroke among women will require a fundamental understanding of sex differences and sex-specific issues including cerebrovascular disease pathophysiology, treatment and outcome. An aspect of stroke treatment receiving increasing but insufficient attention involves possible interactions between estrogen levels, antiplatelet drugs and stroke outcome. Emerging evidence suggests that antiplatelet therapy may provide primary stroke protection but not primary myocardial infarction prevention in women, while the opposite may be true among men. Understanding sex-specific issues related to women who experience stroke is critical to clinicians who treat women with antiplatelet medications as part of a secondary stroke prevention regimen; however, the ideal antiplatelet medication, and dose, in women requires further research. In this article we present a conceptual framework for sex differences in antiplatelet treatment response in ischemic stroke, thrombus formation and the mediating role of estrogen, sex differences in antiplatelet treatment response in clinical trials, and sex differences in antiplatelet treatment use in ischemic stroke.

Sex differences in antiplatelet response in ischemic stroke

PubMed Central

Meyer, Dawn M; Eastwood, Jo-Ann; Compton, Margaret P; Gylys, Karen; Zivin, Justin A; Ovbiagele, Bruce

2011-01-01

Sex differences exist in the occurrence, treatment and outcome of ischemic stroke. Compared with men, women have more stroke events and are less likely to fully recover from a stroke. Given the rapidly aging population, stroke incidence and mortality among women are projected to substantially rise by 2050. This has important public health consequences. Mitigating the burden of stroke among women will require a fundamental understanding of sex differences and sex-specific issues including cerebrovascular disease pathophysiology, treatment and outcome. An aspect of stroke treatment receiving increasing but insufficient attention involves possible interactions between estrogen levels, antiplatelet drugs and stroke outcome. Emerging evidence suggests that antiplatelet therapy may provide primary stroke protection but not primary myocardial infarction prevention in women, while the opposite may be true among men. Understanding sex-specific issues related to women who experience stroke is critical to clinicians who treat women with antiplatelet medications as part of a secondary stroke prevention regimen; however, the ideal antiplatelet medication, and dose, in women requires further research. In this article we present a conceptual framework for sex differences in antiplatelet treatment response in ischemic stroke, thrombus formation and the mediating role of estrogen, sex differences in antiplatelet treatment response in clinical trials, and sex differences in antiplatelet treatment use in ischemic stroke. PMID:21790339

Safety of Transcranial Direct Current Stimulation: Evidence Based Update 2016.

PubMed

Bikson, Marom; Grossman, Pnina; Thomas, Chris; Zannou, Adantchede Louis; Jiang, Jimmy; Adnan, Tatheer; Mourdoukoutas, Antonios P; Kronberg, Greg; Truong, Dennis; Boggio, Paulo; Brunoni, André R; Charvet, Leigh; Fregni, Felipe; Fritsch, Brita; Gillick, Bernadette; Hamilton, Roy H; Hampstead, Benjamin M; Jankord, Ryan; Kirton, Adam; Knotkova, Helena; Liebetanz, David; Liu, Anli; Loo, Colleen; Nitsche, Michael A; Reis, Janine; Richardson, Jessica D; Rotenberg, Alexander; Turkeltaub, Peter E; Woods, Adam J

2016-01-01

This review updates and consolidates evidence on the safety of transcranial Direct Current Stimulation (tDCS). Safety is here operationally defined by, and limited to, the absence of evidence for a Serious Adverse Effect, the criteria for which are rigorously defined. This review adopts an evidence-based approach, based on an aggregation of experience from human trials, taking care not to confuse speculation on potential hazards or lack of data to refute such speculation with evidence for risk. Safety data from animal tests for tissue damage are reviewed with systematic consideration of translation to humans. Arbitrary safety considerations are avoided. Computational models are used to relate dose to brain exposure in humans and animals. We review relevant dose-response curves and dose metrics (e.g. current, duration, current density, charge, charge density) for meaningful safety standards. Special consideration is given to theoretically vulnerable populations including children and the elderly, subjects with mood disorders, epilepsy, stroke, implants, and home users. Evidence from relevant animal models indicates that brain injury by Direct Current Stimulation (DCS) occurs at predicted brain current densities (6.3-13 A/m(2)) that are over an order of magnitude above those produced by conventional tDCS. To date, the use of conventional tDCS protocols in human trials (≤40 min, ≤4 milliamperes, ≤7.2 Coulombs) has not produced any reports of a Serious Adverse Effect or irreversible injury across over 33,200 sessions and 1000 subjects with repeated sessions. This includes a wide variety of subjects, including persons from potentially vulnerable populations. Copyright © 2016 Elsevier Inc. All rights reserved.

Safety of transcranial Direct Current Stimulation: Evidence Based Update 2016

PubMed Central

Bikson, Marom; Grossman, Pnina; Thomas, Chris; Zannou, Adantchede Louis; Jiang, Jimmy; Adnan, Tatheer; Mourdoukoutas, Antonios P; Kronberg, Greg; Truong, Dennis; Boggio, Paulo; Brunoni, André R.; Charvet, Leigh; Fregni, Felipe; Fritsch, Brita; Gillick, Bernadette; Hamilton, Roy H.; Hampstead, Benjamin M.; Jankord, Ryan; Kirton, Adam; Knotkova, Helena; Liebetanz, David; Liu, Anli; Loo, Colleen; Nitsche, Michael A.; Reis, Janine; Richardson, Jessica D.; Rotenberg, Alexander; Turkeltaub, Peter E.; Woods, Adam J.

2016-01-01

This review updates and consolidates evidence on the safety of transcranial Direct Current Stimulation (tDCS). Safety is here operationally defined by, and limited to, the absence of evidence for a Serious Adverse Effect, the criteria for which are rigorously defined. This review adopts an evidence-based approach, based on an aggregation of experience from human trials, taking care not to confuse speculation on potential hazards or lack of data to refute such speculation with evidence for risk. Safety data from animal tests for tissue damage are reviewed with systematic consideration of translation to humans. Arbitrary safety considerations are avoided. Computational models are used to relate dose to brain exposure in humans and animals. We review relevant dose-response curves and dose metrics (e.g. current, duration, current density, charge, charge density) for meaningful safety standards. Special consideration is given to theoretically vulnerable populations including children and the elderly, subjects with mood disorders, epilepsy, stroke, implants, and home users. Evidence from relevant animal models indicates that brain injury by Direct Current Stimulation (DCS) occurs at predicted brain current densities (6.3–13 A/m2) that are over an order of magnitude above those produced by conventional tDCS. To date, the use of conventional tDCS protocols in human trials (≤40 min, ≤4 mA, ≤7.2 Coulombs) has not produced any reports of a Serious Adverse Effect or irreversible injury across over 33,200 sessions and 1,000 subjects with repeated sessions. This includes a wide variety of subjects, including persons from potentially vulnerable populations. PMID:27372845

Patterns in the collaboration of practitioners and researchers in the use of electrical stimulation to treat stroke patients: a literature review.

PubMed

Fujimoto, Shuhei; Kon, Noriko; Takashi, Naoki; Otaka, Yohei; Nakayama, Takeo

2015-09-01

[Purpose] The purpose of this study was to investigate the degree of collaboration between practitioners and researchers through research papers related to the implementation of electrical stimulation (ES) for stroke patients. [Methods] A systematic review of the literature was conducted to collect data from ES studies published before January 7, 2015. Five databases were searched for search terms related to stroke and ES. Inclusion criteria were original papers that reported on ES of the upper or lower limbs following stroke, after the exclusion of case reports, brain stimulation studies, and papers written in any languages other than English or Japanese. The outcome was the prevalence of research papers that included a practitioner as an author, that included a practitioner as an author or in the acknowledgements, and in which the practitioner was the first author. [Results] Based on the selection criteria, 165 papers were included in the final analysis. The prevalence of papers in which a practitioner was included as an author was 39%. The prevalence of papers in which a practitioner was included as an author or in the acknowledgements was 50%. A practitioner was the first author of 34% of the papers. [Conclusion] Collaboration on research papers related to ES for stroke patients is limited.

Sleep apnoea and stroke

PubMed Central

Sharma, Sameer; Culebras, Antonio

2016-01-01

Sleep disorders have been known to physicians for a long time. In his famous aphorisms, Hippocrates said “Sleep or watchfulness exceeding that which is customary, augurs unfavorably”. Modern medicine has been able to disentangle some of the phenomena that disturb sleep. Among the most notable offenders is sleep apnoea that has gained prominence in the past few decades. It is being proposed as one of the potentially modifiable risk factors for vascular diseases including stroke. The pathological mechanisms linking sleep apnoea to vascular risk factors include hypoxia, cardiac arrhythmias, dysautonomia, impaired glucose tolerance, hypertension, dyslipidaemia and inflammation. In this article, we review literature linking sleep apnoea and stroke, including sleep apnoea as a risk factor for primary prevention with the potential to improve outcome after acute stroke and as a secondary risk factor, amenable to modification and hence vascular risk reduction. PMID:28959482

Association of Phosphodiesterase 4D with ischemic stroke: a population-based case-control study.

PubMed

Woo, Daniel; Kaushal, Ritesh; Kissela, Brett; Sekar, Padmini; Wolujewicz, Michael; Pal, Prodipto; Alwell, Kathleen; Haverbusch, Mary; Ewing, Irene; Miller, Rosie; Kleindorfer, Dawn; Flaherty, Matthew; Chakraborty, Ranajit; Deka, Ranjan; Broderick, Joseph

2006-02-01

The Phosphodiesterase 4D (PDE4D) gene was reported recently to be associated with ischemic stroke in an Icelandic population. The association was found predominately with large vessel and cardioembolic stroke. However, 2 recent reports were unable to confirm this association, although a trend toward association with cardioembolic stroke was reported. None of the reports included significant proportions of blacks. We tested for genotype and haplotype association of polymorphisms of the PDE4D gene with ischemic stroke in a population-based, biracial, case-control study. A total of 357 cases of ischemic stroke and 482 stroke-free controls from the same community were examined. Single nucleotide polymorphisms (SNPs) were chosen based on significant associations reported previously. Linkage disequilibrium (LD), SNP, and haplotype association analysis was performed using PHASE 2.0 and Haploview 3.2. Although several univariate associations were identified, only 1 SNP (rs2910829) was found to be significantly associated with cardioembolic stroke among both whites and blacks. The rs152312 SNP was associated with cardioembolic stroke among whites after multiple comparison corrections. The same SNP was not associated with cardioembolic stroke among blacks. However, significant haplotype association was identified for both whites and blacks for all ischemic stroke, cardioembolic stroke, and stroke of unknown origin. Haplotype association was identified for small vessel stroke among whites. PDE4D is a risk factor for ischemic stroke and, in particular, for cardioembolic stroke, among whites and blacks. Further study of this gene is warranted.