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

PubMed

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

2011-04-01

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

Incidence and predictors of new-onset constipation during acute hospitalisation after stroke.

PubMed

Lim, S-F; Ong, S Y; Tan, Y L; Ng, Y S; Chan, Y H; Childs, C

2015-04-01

We investigated new-onset constipation in patients with stroke compared with orthopaedic conditions and explored the predictors associated with constipation during acute hospitalisation. This was a prospective matched cohort study of 110 patients comparing stroke patients (n = 55) with orthopaedic patients (n = 55) admitted to a large tertiary acute hospital. Both cohorts were matched by age and sex. The incidence of new-onset constipation which occurred during a patient's acute hospitalisation was determined. Demographics, comorbidity, clinical factors, laboratory parameters and medications were evaluated as possible predictors of constipation. The incidence of new-onset constipation was high for both stroke (33%) and orthopaedic patients (27%; p = 0.66). Seven stroke patients (39%) and four orthopaedic patients (27%) developed their first onset of constipation on day 2 of admission. Mobility gains (RR 0.741, p < 0.001) and the use of prophylactic laxatives (RR 0.331, p < 0.01) had a protective effect against constipation. Bedpan use (RR 2.058, p < 0.05) and longer length of stay (RR 1.032, p < 0.05) increased the risk of developing new-onset constipation. New-onset constipation is common among patients admitted for stroke and orthopaedic conditions during acute hospitalisation. The early occurrence, on day 2 of admission, calls for prompt preventive intervention for constipation. © 2015 John Wiley & Sons Ltd.

Shoulder pain and concomitant hand oedema among stroke patients with pronounced arm paresis

PubMed Central

2013-01-01

Background The aim of this prospective study was to identify clinical factors associated with the development of shoulder pain in stroke patients with pronounced arm paresis. Methods At stroke onset, 485 patients were initially assessed in 2007–2009. Sixty-three patients with pronounced arm paresis completed the study, and 21 of these developed shoulder pain. Clinical findings were recorded fortnightly by the attending physiotherapist during hospital stay. Results Hand oedema on the paretic side was more common in patients developing shoulder pain compared with those who did not develop shoulder pain. The onset of shoulder pain was associated with concomitant hand oedema. High NIHSS score was associated with developing shoulder pain. Patients with a history of shoulder pain developed pain earlier than those without previous shoulder pain. Patients with haemorrhagic stroke were significantly more prone to developing shoulder pain. Conclusions One-third of the stroke patients with pronounced arm paresis developed shoulder pain. Concomitant hand oedema seems to be an additional symptom of shoulder injury. Patients with low general status are more vulnerable to develop post-stroke shoulder pain. PMID:24765589

Delayed-onset dementia after stroke or transient ischemic attack.

PubMed

Mok, Vincent C T; Lam, Bonnie Y K; Wang, Zhaolu; Liu, Wenyan; Au, Lisa; Leung, Eric Y L; Chen, Sirong; Yang, Jie; Chu, Winnie C W; Lau, Alexander Y L; Chan, Anne Y Y; Shi, Lin; Fan, Florence; Ma, Sze H; Ip, Vincent; Soo, Yannie O Y; Leung, Thomas W H; Kwok, Timothy C Y; Ho, Chi L; Wong, Lawrence K S; Wong, Adrian

2016-11-01

Patients surviving stroke without immediate dementia are at high risk of delayed-onset dementia. Mechanisms underlying delayed-onset dementia are complex and may involve vascular and/or neurodegenerative diseases. Dementia-free patients with stroke and/or transient ischemic attack (TIA; n = 919) were studied for 3 years prospectively, excluding those who developed dementia 3 to 6 months after stroke and/or TIA. Forty subjects (4.4%) developed dementia during the study period. Imaging markers of severe small vessel disease (SVD), namely presence of ≥3 lacunes and confluent white matter changes; history of hypertension and diabetes mellitus independently predicted delayed-onset dementia after adjustment for age, gender, and education. Only 6 of 31 (19.4%) subjects with delayed cognitive decline harbored Alzheimer's disease-like Pittsburg compound B (PiB) retention. Most PiB cases (16/25, 64%) had evidence of severe SVD. Severe SVD contributes importantly to delayed-onset dementia after stroke and/or TIA. Future clinical trials aiming to prevent delayed-onset dementia after stroke and/or TIA should target this high-risk group. Copyright © 2016 The Alzheimer's Association. Published by Elsevier Inc. All rights reserved.

Value of the CHA2DS2-VASc score and Fabry-specific score for predicting new-onset or recurrent stroke/TIA in Fabry disease patients without atrial fibrillation.

PubMed

Liu, Dan; Hu, Kai; Schmidt, Marie; Müntze, Jonas; Maniuc, Octavian; Gensler, Daniel; Oder, Daniel; Salinger, Tim; Weidemann, Frank; Ertl, Georg; Frantz, Stefan; Wanner, Christoph; Nordbeck, Peter

2018-05-24

To evaluate potential risk factors for stroke or transient ischemic attacks (TIA) and to test the feasibility and efficacy of a Fabry-specific stroke risk score in Fabry disease (FD) patients without atrial fibrillation (AF). FD patients often experience cerebrovascular events (stroke/TIA) at young age. 159 genetically confirmed FD patients without AF (aged 40 ± 14 years, 42.1% male) were included, and risk factors for stroke/TIA events were determined. All patients were followed up over a median period of 60 (quartiles 35-90) months. The pre-defined primary outcomes included new-onset or recurrent stroke/TIA and all-cause death. Prior stroke/TIA (HR 19.97, P < .001), angiokeratoma (HR 4.06, P = .010), elevated creatinine (HR 3.74, P = .011), significant left ventricular hypertrophy (HR 4.07, P = .017), and reduced global systolic strain (GLS, HR 5.19, P = .002) remained as independent risk predictors of new-onset or recurrent stroke/TIA in FD patients without AF. A Fabry-specific score was established based on above defined risk factors, proving somehow superior to the CHA 2 DS 2 -VASc score in predicting new-onset or recurrent stroke/TIA in this cohort (AUC 0.87 vs. 0.75, P = .199). Prior stroke/TIA, angiokeratoma, renal dysfunction, left ventricular hypertrophy, and global systolic dysfunction are independent risk factors for new-onset or recurrent stroke/TIA in FD patients without AF. It is feasible to predict new or recurrent cerebral events with the Fabry-specific score based on the above defined risk factors. Future studies are warranted to test if FD patients with high risk for new-onset or recurrent stroke/TIA, as defined by the Fabry-specific score (≥ 2 points), might benefit from antithrombotic therapy. Clinical trial registration HEAL-FABRY (evaluation of HEArt invoLvement in patients with FABRY disease, NCT03362164).

Motor recovery monitoring using acceleration measurements in post acute stroke patients

PubMed Central

2013-01-01

Background Stroke is one of the major causes of morbidity and mortality. Its recovery and treatment depends on close clinical monitoring by a clinician especially during the first few hours after the onset of stroke. Patients who do not exhibit early motor recovery post thrombolysis may benefit from more aggressive treatment. Method A novel approach for monitoring stroke during the first few hours after the onset of stroke using a wireless accelerometer based motor activity monitoring system is developed. It monitors the motor activity by measuring the acceleration of the arms in three axes. In the presented proof of concept study, the measured acceleration data is transferred wirelessly using iMote2 platform to the base station that is equipped with an online algorithm capable of calculating an index equivalent to the National Institute of Health Stroke Score (NIHSS) motor index. The system is developed by collecting data from 15 patients. Results We have successfully demonstrated an end-to-end stroke monitoring system reporting an accuracy of calculating stroke index of more than 80%, highest Cohen’s overall agreement of 0.91 (with excellent κ coefficient of 0.76). Conclusion A wireless accelerometer based ‘hot stroke’ monitoring system is developed to monitor the motor recovery in acute-stroke patients. It has been shown to monitor stroke patients continuously, which has not been possible so far with high reliability. PMID:23590690

Reduction in early stroke risk in carotid stenosis with transient ischemic attack associated with statin treatment

PubMed Central

Merwick, Áine; Albers, Gregory W; Arsava, Ethem M; Ay, Hakan; Calvet, David; Coutts, Shelagh B; Cucchiara, Brett L; Demchuk, Andrew M; Giles, Matthew F; Mas, Jean-Louis; Olivot, Jean Marc; Purroy, Francisco; Rothwell, Peter M; Saver, Jeffrey L; Sharma, Vijay K; Tsivgoulis, Georgios; Kelly, Peter J

2013-01-01

Background and Purpose Statins reduce stroke risk when initiated months after TIA/stroke and reduce early vascular events in acute coronary syndromes, possibly via pleiotropic plaque-stabilisation. Few data exist regarding acute statin use in TIA. We aimed to determine if statin pre-treatment at TIA onset modified early stroke risk in carotid stenosis. Methods We analyzed data from 2770 TIA patients from 11 centres, 387 with ipsilateral carotid stenosis. ABCD2 score, abnormal DWI, medication pre-treatment, and early stroke were recorded. Results In patients with carotid stenosis, 7-day stroke risk was 8.3% (95% confidence interval [CI] 5.7–11.1) compared with 2.7% [CI 2.0–3.4%] without stenosis (p<0.0001) (90-day risks 17.8% and 5.7% [p<0.0001]). Among carotid stenosis patients, non-procedural 7-day stroke risk was 3.8% [CI 1.2–9.7%] with statin treatment at TIA onset, compared to 13.2% [CI 8.5–19.8%] in those not statin pre-treated (p=0.01) (90-day risks 8.9% versus 20.8% [p=0.01]). Statin pre-treatment was associated with reduced stroke risk in carotid stenosis patients (OR for 90-day stroke 0.37, CI 0.17–0.82), but not non-stenosis patients (OR 1.3, CI 0.8–2.24) (p for interaction 0.008). On multivariable logistic regression, the association remained after adjustment for ABCD2 score, smoking, antiplatelet treatment, recent TIA, and DWI hyperintensity (adjusted p for interaction 0.054). Conclusion In acute symptomatic carotid stenosis, statin pre-treatment was associated with reduced stroke risk, consistent with findings from randomized trials in acute coronary syndromes. These data support the hypothesis that statins started acutely after TIA symptom onset may also be beneficial to prevent early stroke. Randomized trials addressing this question are required. PMID:23908061

The Relationship between Frontal Lobe Lesions, Course of Post-Stroke Depression, and 1-year Prognosis in Patients with First-Ever Ischemic Stroke

PubMed Central

Shi, Yu-Zhi; Xiang, Yu-Tao; Wu, Shuo-Lin; Zhang, Ning; Zhou, Juan; Bai, Ying; Wang, Shuo; Wang, Yi-Long; Zhao, Xing-Quan; Ungvari, Gabor S.; Chiu, Helen F. K.; Wang, Yong-Jun; Wang, Chun-Xue

2014-01-01

Background and Purpose Most studies on post-stroke depression (PSD) have focused on a certain time point after stroke instead of the time course of PSD. The aim of this study was to determine the relationship between frontal lobe lesions, course of PSD over a year following the stroke onset, and the 1-year prognosis in patients with first-ever ischemic stroke. Methods A total of 1067 patients from the prospective cohort study on the incidence and outcome of patients with post stroke depression in China who were diagnosed with first-ever ischemic stroke and attended 4 follow-up visits at 14±2 days, 3 months, 6 months, and 1 year after stroke onset, were enrolled in the study. PSD was diagnosed according to DSM-IV. The course of PSD was divided into the following two categories: persistent/recurrent depression and no/transient depression. Patients with any ischemic lesion responsible for the indexed stroke event located in the frontal lobe were defined as patients with frontal lobe lesions. Modified Rankin Scale (mRS) ≥2 at 1-year was considered to be poor prognosis. Results There were 109 patients with and 958 patients without frontal lobe lesions that formed the frontal lobe (FL) and no-frontal lobe (NFL) groups, respectively. After adjusting for confounding variables, frontal lobe lesion was significantly associated with persistent/recurrent PSD (OR 2.025, 95%CI 1.039–3.949). Overall, 32.7% of patients in the FL group had poor prognosis at 1- year compared with 22.7% in the NFL group (P = 0.021). Compared with no/transient depression, persistent/recurrent depression was found to be an independent predictor of poor prognosis at 1-year both in FL and NFL groups. Conclusions Long-term and periodical screening, evaluation and treatment are needed for PSD after the onset of ischemic stroke, particularly for patients with frontal lobe infarction. PMID:25003990

The association between wind-related variables and stroke symptom onset: A case-crossover study on Jeju Island.

PubMed

Kim, Jayeun; Yoon, Khyuhyun; Choi, Jay Chol; Kim, Ho; Song, Jung-Kook

2016-10-01

Although several studies have investigated the effects of ambient temperature on the risk of stroke, few studies have examined the relationship between other meteorological conditions and stroke. Therefore, the aim of this study was to analyze the association between wind-related variables and stroke symptoms onset. Data regarding the onset of stroke symptoms occurring between January 1, 2006, and December 31, 2007 on Jeju Island were collected from the Jeju National University Hospital stroke registry. A fixed-strata case-crossover analysis based on time of onset and adjusted for ambient temperature, relative humidity, air pressure, and pollutants was used to analyze the effects of wind speed, the daily wind speed range (DWR), and the wind chill index on stroke symptom onset using varied lag terms. Models examining the modification effects by age, sex, smoking status, season, and type of stroke were also analyzed. A total of 409 stroke events (381 ischemic and 28 hemorrhagic) were registered between 2006 and 2007. The odds ratios (ORs) for wind speed, DWR, and wind chill among the total sample at lag 0-8 were 1.18 (95% confidence interval (CI): 1.06-1.31), 1.08 (95% CI: 1.02-1.14), and 1.22 (95% CI: 1.07-1.39) respectively. The ORs for wind speed, DWR, and wind chill for ischemic stroke patients were slightly greater than for patients in the total sample (OR=1.20, 95% CI: 1.08-1.34; OR=1.09, 95% CI: 1.03-1.15; and OR=1.22, 95% CI: 1.07-1.39, respectively). Statistically significant season-specific effects were found for spring and winter, and various delayed effects were observed. In addition, age, sex, and smoking status modified the effect size of wind speed, DWR, and wind chill. Our analyses showed that the risk of stroke symptoms onset was associated with wind speed, DWR, and wind chill on Jeju Island. Copyright © 2016 Elsevier Inc. All rights reserved.

Predictors of early and late stroke following cardiac surgery

PubMed Central

Whitlock, Richard; Healey, Jeff S.; Connolly, Stuart J.; Wang, Julie; Danter, Matthew R.; Tu, Jack V.; Novick, Richard; Fremes, Stephen; Teoh, Kevin; Khera, Vikas; Yusuf, Salim

2014-01-01

Background: Much is known about the short-term risks of stroke following cardiac surgery. We examined the rate and predictors of long-term stroke in a cohort of patients who underwent cardiac surgery. Methods: We obtained linked data for patients who underwent cardiac surgery in the province of Ontario between 1996 and 2006. We analyzed the incidence of stroke and death up to 2 years postoperatively. Results: Of 108 711 patients, 1.8% (95% confidence interval [CI] 1.7%–1.9%) had a stroke perioperatively, and 3.6% (95% CI 3.5%–3.7%) had a stroke within the ensuing 2 years. The strongest predictors of both early and late stroke were advanced age (≥ 65 year; adjusted hazard ratio [HR] for all stroke 1.9, 95% CI 1.8–2.0), a history of stroke or transient ischemic attack (adjusted HR 2.1, 95% CI 1.9–2.3), peripheral vascular disease (adjusted HR 1.6, 95% CI 1.5–1.7), combined coronary bypass grafting and valve surgery (adjusted HR 1.7, 95% CI 1.5–1.8) and valve surgery alone (adjusted HR 1.4, 95% CI 1.2–1.5). Preoperative need for dialysis (adjusted odds ratio [OR] 2.1, 95% CI 1.6–2.8) and new-onset postoperative atrial fibrillation (adjusted OR 1.5, 95% CI 1.3–1.6) were predictors of only early stroke. A CHADS2 score of 2 or higher was associated with an increased risk of stroke or death compared with a score of 0 or 1 (19.9% v. 9.3% among patients with a history of atrial fibrillation, 16.8% v. 7.8% among those with new-onset postoperative atrial fibrillation and 14.8% v. 5.8% among those without this condition). Interpretation: Patients who had cardiac surgery were at highest risk of stroke in the early postoperative period and had continued risk over the ensuing 2 years, with similar risk factors over these periods. New-onset postoperative atrial fibrillation was a predictor of only early stroke. The CHADS2 score predicted stroke risk among patients with and without atrial fibrillation. PMID:25047983

Safety of tPA in stroke mimics and neuroimaging-negative cerebral ischemia(Podcast)(e–Pub ahead of print)(CME)

PubMed Central

Chernyshev, O.Y.; Martin-Schild, S.; Albright, K.C.; Barreto, A.; Misra, V.; Acosta, I.; Grotta, J.C.; Savitz, S.I.

2010-01-01

Background: Patients with acute neurologic symptoms may have other causes simulating ischemic stroke, called stroke mimics (SM), but they may also have averted strokes that do not appear as infarcts on neuroimaging, which we call neuroimaging-negative cerebral ischemia (NNCI). We determined the safety and outcome of IV thrombolysis within 3 hours of symptom onset in patients with SM and NNCI. Methods: Patients treated with IV tissue plasminogen activator (tPA) within 3 hours of symptom onset were identified from our stroke registry from June 2004 to October 2008. We collected admission NIH Stroke Scale (NIHSS) score, modified Rankin score (mRS), length of stay (LOS), symptomatic intracerebral hemorrhage (sICH), and discharge diagnosis. Results: Among 512 treated patients, 21% were found not to have an infarct on follow-up imaging. In the SM group (14%), average age was 55 years, median admission NIHSS was 7, median discharge NIHSS was 0, median LOS was 3 days, and there were no instances of sICH. The most common etiologies were seizure, complicated migraine, and conversion disorder. In the NNCI group (7%), average age was 61 years, median admission NIHSS was 7, median discharge NIHSS was 0, median LOS was 3 days, and there were no instances of sICH. Nearly all SM (87%) and NNCI (91%) patients were functionally independent on discharge (mRS 0–1). Conclusions: Our data support the safety of administering IV tissue plasminogen activator to patients with suspected acute cerebral ischemia within 3 hours of symptom onset, even when the diagnosis ultimately is found not to be stroke or imaging does not show an infarct. GLOSSARY AIS = acute ischemic stroke; CI = confidence interval; DWI = diffusion-weighted imaging; ED = emergency department; LOS = length of stay; mRS = modified Rankin score; NIHSS = NIH Stroke Scale; NNCI = neuroimaging-negative cerebral ischemia; OR = odds ratio; sICH = symptomatic intracerebral hemorrhage; SM = stroke mimics; tPA = tissue plasminogen activator. PMID:20335564

[The prevalence and status of pre-hospital treatments of risk factors among patients with stroke in China].

PubMed

Tang, Meilian; Sun, Jiayi; Wang, Wei; Liu, Jing; Chao, Baohua; Liu, Jun; Cao, Lei; Qi, Yue; Wang, Ying; Zhao, Dong

2015-12-01

To analyze the distribution and treatment of risk factors in hospitalized stroke patients before stroke onset. This was a multi-center cross-sectional study. Patients with acute stroke were collected from 41 hospitals in 25 provinces in China from January to May in 2011. A total of 20 570 stoke patients (13 062 men, 7 508 women) aged (63.0 ± 12.9) years were enrolled and analyzed in this study. Among them, 15 329 were first-onset stroke, and 17 052 were ischemic stroke. (1) Of all the subjects, 75.5% were with hypertension, 53.5% with elevated LDL-C, 37.3% with diabetes, and 6.5% with atrial fibrillation. 75.2% of them had two or more above risk factors and 43.0% had three or more risk factors. (2) According to the current definition, 53.3% of the first-onset stroke patients were classified as at high risk and 25.9% were classified as at low risk. Noticeably, 42.1% of the patients below 65 years old were at low risk by the same definition. (3) The awareness rate of hypertension was 70.3% in the first-onset stroke patients. However, only 20.1% of the patients reached the target of blood pressure control in the treatment. Although the awareness rate of hypertension and diabetes among recurrent stroke patients were relatively high, the treatment and control rates of these risk factors were still low. Compared with the other two risk factors, the awareness, treatment and control rates of elevated LDL-C were much lower. Majority of the stroke patients are complicated with multiple risk factors before stroke onset, suggesting a great needs for improving the primary and secondary prevention of stroke in China. In addition, the definition for risk classification of stroke may need to be modified for subjects under 65 years old.

THrombolysis for Acute Wake-up and unclear-onset Strokes with alteplase at 0·6 mg/kg (THAWS) Trial

PubMed Central

Koga, Masatoshi; Toyoda, Kazunori; Kimura, Kazumi; Yamamoto, Haruko; Sasaki, Makoto; Hamasaki, Toshimitsu; Kitazono, Takanari; Aoki, Junya; Seki, Kenta; Homma, Kazunari; Sato, Shoichiro; Minematsu, Kazuo

2014-01-01

Rationale Because of lack of information regarding timing of stroke, patients who suffer stroke during sleep are generally ineligible for intravenous thrombolysis, although many of these patients could potentially recover with this treatment. Magnetic resonance image findings with positive diffusion-weighted imaging and no marked parenchymal hyperintensity on fluid-attenuated inversion recovery (negative pattern) can identify acute ischemic stroke patients within 4·5 h from symptom onset. Aims The THrombolysis for Acute Wake-up and unclear-onset Strokes with alteplase at 0·6 mg/kg trial aims to determine the efficacy and safety of intravenous thrombolysis with alteplase at 0·6 mg/kg body weight, the approved dose for Japanese stroke patients, using magnetic resonance image-based selection in ischemic stroke patients with unclear time of symptom onset, and compare findings with standard treatment. Design This is an investigator-initiated, multicenter, prospective, randomized, open-treatment, blinded-end-point clinical trial. The design is similar to the Efficacy and Safety of MRI-based Thrombolysis in Wake-up Stroke trial. Patients with unclear-onset time of stroke symptoms beyond 4·5 h and within 12 h after the time of the last-known-well period and within 4·5 h after symptom recognition, who showed a negative fluid-attenuated inversion recovery pattern, are randomized to either intravenous thrombolysis or standard treatment. Study outcomes The primary efficacy end-point is modified Rankin Scale 0–1 at 90 days. The safety outcome measures are symptomatic intracranial hemorrhage at 22–36 h, and major bleeding and mortality at 90 days. Discussion This trial may help determine if low-dose alteplase at 0·6 mg/kg should be recommended as a routine clinical strategy for ischemic stroke patients with unclear-onset time. PMID:25088843

Intravenous thrombolysis in ischemic stroke with unknown onset using CT perfusion.

PubMed

Cortijo, E; García-Bermejo, P; Calleja, A I; Pérez-Fernández, S; Gómez, R; del Monte, J M; Reyes, J; Arenillas, J F

2014-03-01

Acute ischemic stroke patients with unclear onset time presenting >4.5 h from last-seen-normal (LSN) time are considered late patients and excluded from i.v. thrombolysis. We aimed to evaluate whether this subgroup of patients is different from patients presenting >4.5 h from a witnessed onset, in terms of eligibility and response to computed tomography perfusion (CTP)-guided i.v. thrombolysis. We prospectively studied consecutive acute non-lacunar middle cerebral artery (MCA) ischemic stroke patients presenting >4.5 h from LSN. All patients underwent multimodal CT and were considered eligible for i.v. thrombolysis according to CTP criteria. Two patient groups were established based on the knowledge of the stroke onset time. We compared the proportion of candidates suitable for intravenous thrombolysis between both groups, and their outcome after thrombolytic therapy. Among 147 MCA ischemic stroke patients presenting >4.5 h from LSN, stroke onset was witnessed in 74 and unknown in 73. Thirty-seven (50%) patients in the first group and 32 (44%) in the second met CTP criteria for thrombolysis (P = 0.7). Baseline variables were comparable between both groups with the exception of age, which was higher in the unclear onset group. The rates of early neurological improvement (54.1% vs 46.9%), 2-h MCA recanalization (43.5% vs 37%), symptomatic hemorrhagic transformation (3% vs 0%) and good 3-month functional outcome (62.2% vs 56.3%) did not differ significantly between both groups. Delayed stroke patients with unknown onset time were no different than patients >4.5 h regarding eligibility and response to CTP-based i.v. thrombolysis. © 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

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

PubMed Central

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

2017-01-01

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

Prevalence of CADASIL and Fabry Disease in a Cohort of MRI Defined Younger Onset Lacunar Stroke

PubMed Central

Kilarski, Laura L.; Rutten-Jacobs, Loes C. A.; Bevan, Steve; Baker, Rob; Hassan, Ahamad; Hughes, Derralynn A.; Markus, Hugh S.

2015-01-01

Background and Purpose Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL), caused by mutations in the NOTCH3 gene, is the most common monogenic disorder causing lacunar stroke and cerebral small vessel disease (SVD). Fabry disease (FD) due to mutations in the GLA gene has been suggested as an underdiagnosed cause of stroke, and one feature is SVD. Previous studies reported varying prevalence of CADASIL and FD in stroke, likely due to varying subtypes studied; no studies have looked at a large cohort of younger onset SVD. We determined the prevalence in a well-defined, MRI-verified cohort of apparently sporadic patients with lacunar infarct. Methods Caucasian patients with lacunar infarction, aged ≤70 years (mean age 56.7 (SD8.6)), were recruited from 72 specialist stroke centres throughout the UK as part of the Young Lacunar Stroke DNA Resource. Patients with a previously confirmed monogenic cause of stroke were excluded. All MRI’s and clinical histories were reviewed centrally. Screening was performed for NOTCH3 and GLA mutations. Results Of 994 subjects five had pathogenic NOTCH3 mutations (R169C, R207C, R587C, C1222G and C323S) all resulting in loss or gain of a cysteine in the NOTCH3 protein. All five patients had confluent leukoaraiosis (Fazekas grade ≥2). CADASIL prevalence overall was 0.5% (95% CI 0.2%-1.1%) and among cases with confluent leukoaraiosis 1.5% (95% CI 0.6%-3.3%). No classic pathogenic FD mutations were found; one patient had a missense mutation (R118C), associated with late-onset FD. Conclusion CADASIL cases are rare and only detected in SVD patients with confluent leukoaraiosis. No definite FD cases were detected. PMID:26305465

A multicenter, randomized trial on neuroprotection with remote ischemic per-conditioning during acute ischemic stroke: the REmote iSchemic Conditioning in acUtE BRAin INfarction study protocol.

PubMed

Pico, Fernando; Rosso, Charlotte; Meseguer, Elena; Chadenat, Marie-Laure; Cattenoy, Amina; Aegerter, Philippe; Deltour, Sandrine; Yeung, Jennifer; Hosseini, Hassan; Lambert, Yves; Smadja, Didier; Samson, Yves; Amarenco, Pierre

2016-10-01

Rationale Remote ischemic per-conditioning-causing transient limb ischemia to induce ischemic tolerance in other organs-reduces final infarct size in animal stroke models. Aim To evaluate whether remote ischemic per-conditioning during acute ischemic stroke (<6 h) reduces brain infarct size at 24 h. Methods and design This study is being performed in five French hospitals using a prospective randomized open blinded end-point design. Adults with magnetic resonance imaging confirmed ischemic stroke within 6 h of symptom onset and clinical deficit of 5-25 according to National Institutes of Health Stroke Scale will be randomized 1:1 to remote ischemic per-conditioning or control (stratified by center and intravenous fibrinolysis use). Remote ischemic per-conditioning will consist of four cycles of electronic tourniquet inflation (5 min) and deflation (5 min) to a thigh within 6 h of symptom onset. Magnetic resonance imaging is repeated 24 h after stroke onset. Sample size estimates For a difference of 15 cm 3 in brain infarct growth between groups, 200 patients will be included for 5% significance and 80% power. Study outcomes The primary outcome will be the difference in brain infarct growth from baseline to 24 h in the intervention versus control groups (by diffusion-weighted image magnetic resonance imaging). Secondary outcomes include: National Institutes of Health Stroke Scale score absolute difference between baseline and 24 h, three-month modified Rankin score and daily living activities, mortality, and tolerance and side effects of remote ischemic per-conditioning. Discussion The only remote ischemic per-conditioning trial in humans with stroke did not show remote ischemic per-conditioning to be effective. REmote iSchemic Conditioning in acUtE BRAin INfarction, which has important design differences, should provide more information on the use of this intervention in patients with acute ischemic stroke.

Returning to Work after the Onset of Illness: Experiences of Right Hemisphere Stroke Survivors

ERIC Educational Resources Information Center

Koch, Lynn; Egbert, Nichole; Coeling, Harriet; Ayers, Denise

2005-01-01

Experiences of right hemisphere stroke survivors in their attempts to return to work after the onset of stroke were explored through an interdisciplinary qualitative investigation. Key findings indicate that (a) participants experienced an array of functional limitations that precipitated employment changes; (b) employment changes had a…

Stroke With Unknown Time of Symptom Onset: Baseline Clinical and Magnetic Resonance Imaging Data of the First Thousand Patients in WAKE-UP (Efficacy and Safety of MRI-Based Thrombolysis in Wake-Up Stroke: A Randomized, Doubleblind, Placebo-Controlled Trial).

PubMed

Thomalla, Götz; Boutitie, Florent; Fiebach, Jochen B; Simonsen, Claus Z; Nighoghossian, Norbert; Pedraza, Salvador; Lemmens, Robin; Roy, Pascal; Muir, Keith W; Ebinger, Martin; Ford, Ian; Cheng, Bastian; Galinovic, Ivana; Cho, Tae-Hee; Puig, Josep; Thijs, Vincent; Endres, Matthias; Fiehler, Jens; Gerloff, Christian

2017-03-01

We describe clinical and magnetic resonance imaging (MRI) characteristics of stroke patients with unknown time of symptom onset potentially eligible for thrombolysis from a large prospective cohort. We analyzed baseline data from WAKE-UP (Efficacy and Safety of MRI-Based Thrombolysis in Wake-Up Stroke: A Randomized, Doubleblind, Placebo-Controlled Trial), an investigator-initiated, randomized, placebo-controlled trial of MRI-based thrombolysis in stroke patients with unknown time of symptom onset. MRI judgment included assessment of the mismatch between visibility of the acute ischemic lesion on diffusion-weighted imaging and fluid-attenuated inversion recovery. Of 1005 patients included, diffusion-weighted imaging and fluid-attenuated inversion recovery mismatch was present in 479 patients (48.0%). Patients with daytime-unwitnessed stroke (n=138, 13.7%) had a shorter delay between symptom recognition and hospital arrival (1.5 versus 1.8 hours; P =0.002), a higher National Institutes of Stroke Scale score on admission (8 versus 6; P <0.001), and more often aphasia (72.5% versus 34.0%; P <0.001) when compared with stroke patients waking up from nighttime sleep. Frequency of diffusion-weighted imaging and fluid-attenuated inversion recovery mismatch was comparable between both groups (43.7% versus 48.7%; P =0.30). Almost half of the patients with unknown time of symptom onset stroke otherwise eligible for thrombolysis had MRI findings making them likely to be within a time window for safe and effective thrombolysis. Patients with daytime onset unwitnessed stroke differ from wake-up stroke patients with regards to clinical characteristics but are comparable in terms of MRI characteristics of lesion age. URL: http://www.clinicaltrials.gov. Unique identifier: NCT01525290. URL: https://www.clinicaltrialsregister.eu. Unique identifier: 2011-005906-32. © 2017 American Heart Association, Inc.

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.

Effects of a Public Education Campaign on the Association Between Knowledge of Early Stroke Symptoms and Intention to Call an Ambulance at Stroke Onset: The Acquisition of Stroke Knowledge (ASK) Study

PubMed Central

Nishikawa, Tomofumi; Okamura, Tomonori; Nakayama, Hirofumi; Miyamatsu, Naomi; Morimoto, Akiko; Toyoda, Kazunori; Suzuki, Kazuo; Toyota, Akihiro; Hata, Takashi; Yamaguchi, Takenori

2016-01-01

Background An immediate ambulance call offers the greatest opportunity for acute stroke therapy. Effectively using ambulance services requires strengthening the association between knowledge of early stroke symptoms and intention to call an ambulance at stroke onset, and encouraging the public to use ambulance services. Methods The present study utilized data from the Acquisition of Stroke Knowledge (ASK) study, which administered multiple-choice, mail-in surveys regarding awareness of early stroke symptoms and response to a stroke attack before and after a 2-year stroke education campaign in two areas subject to intensive and moderate intervention, as well as in a control area, in Japan. In these three areas, 3833 individuals (1680, 1088 and 1065 participants in intensive intervention, moderate intervention, and control areas, respectively), aged 40 to 74 years, who responded appropriately to each survey were included in the present study. Results After the intervention, the number of correctly identified symptoms significantly associated with intention to call an ambulance (P < 0.05) increased (eg, from 4 to 5 correctly identified symptoms), without increasing choice of decoy symptoms in the intensive intervention area. Meanwhile, in other areas, rate of identification of not only correct symptoms but also decoy symptoms associated with intention to call an ambulance increased. Furthermore, the association between improvement in the knowledge of stroke symptoms and intention to call an ambulance was observed only in the intensive intervention area (P = 0.009). Conclusions Our results indicate that intensive interventions are useful for strengthening the association between correct knowledge of early stroke symptoms and intention to call an ambulance, without strengthening the association between incorrect knowledge and intention to call an ambulance. PMID:26441211

The Multidisciplinary Swallowing Team Approach Decreases Pneumonia Onset in Acute Stroke Patients.

PubMed

Aoki, Shiro; Hosomi, Naohisa; Hirayama, Junko; Nakamori, Masahiro; Yoshikawa, Mineka; Nezu, Tomohisa; Kubo, Satoshi; Nagano, Yuka; Nagao, Akiko; Yamane, Naoya; Nishikawa, Yuichi; Takamoto, Megumi; Ueno, Hiroki; Ochi, Kazuhide; Maruyama, Hirofumi; Yamamoto, Hiromi; Matsumoto, Masayasu

2016-01-01

Dysphagia occurs in acute stroke patients at high rates, and many of them develop aspiration pneumonia. Team approaches with the cooperation of various professionals have the power to improve the quality of medical care, utilizing the specialized knowledge and skills of each professional. In our hospital, a multidisciplinary participatory swallowing team was organized. The aim of this study was to clarify the influence of a team approach on dysphagia by comparing the rates of pneumonia in acute stroke patients prior to and post team organization. All consecutive acute stroke patients who were admitted to our hospital between April 2009 and March 2014 were registered. We analyzed the difference in the rate of pneumonia onset between the periods before team organization (prior period) and after team organization (post period). Univariate and multivariate analyses were performed using a Cox proportional hazards model to determine the predictors of pneumonia. We recruited 132 acute stroke patients from the prior period and 173 patients from the post period. Pneumonia onset was less frequent in the post period compared with the prior period (6.9% vs. 15.9%, respectively; p = 0.01). Based on a multivariate analysis using a Cox proportional hazards model, it was determined that a swallowing team approach was related to pneumonia onset independent from the National Institutes of Health Stroke Scale score on admission (adjusted hazard ratio 0.41, 95% confidence interval 0.19-0.84, p = 0.02). The multidisciplinary participatory swallowing team effectively decreased the pneumonia onset in acute stroke patients.

Lack of experience of intravenous thrombolysis for acute ischaemic stroke does not influence the proportion of patients treated

PubMed Central

Kobayashi, Adam; Skowronska, Marta; Litwin, Tomasz; Czlonkowska, Anna

2007-01-01

Objectives To determine the eligibility of patients with ischaemic stroke admitted to the 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland, for intravenous thrombolysis; to identify the major exclusions and assess whether organisational changes in the in‐hospital stroke pathway and informative campaign in the local community and medical services can increase the number of patients treated; and to establish whether lack of previous experience with thrombolytic treatment or trials is predictive of the low proportion of patients treated. Methods A survey of the database of patients with stroke admitted during the first 30 months after the introduction of intravenous thrombolysis for acute ischaemic stroke was conducted to search for all eligible patients. This included patients admitted within 2 h of symptom onset (assuming a 1 h door‐to‐needle time), age <80 years, National Institute of Health Stroke Scale (NIHSS) Score of 5–22, seizures at onset, platelet count >100 000/ml, glycaemia 50–400 mg/dl and international normalised ratio (INR) <1.6. The number of eligible patients was compared with the number actually treated. Results 745 patients with acute ischaemic stroke were admitted during the study period. 18.4% were admitted within 2 h of symptom onset, 71% were aged <80 years, 55.4% had an NIHSS score between 5 and 22, 96.1% had INR <1.6, 98.9% had a platelet count >100 000/ml, 99.4% had blood glucose concentrations of 50–400 mg/dl and 97.4% had no seizures at onset. After adjusting for all inclusion criteria, 7.1% of the patients were found to be potentially eligible and 8.7% were actually treated (p = 0.25). Of the 65 treated patients, 63.1% were independent after 3 months, 16.9% died and none had a symptomatic intracranial haemorrhage. Conclusions The proportion of patients with ischaemic stroke treated with intravenous thrombolysis in a previously inexperienced centre was not lower than in other centres and in countries where this treatment has been provided for a longer period of time. The number of patients treated was higher than that estimated mainly owing to organisational changes introduced in our centre, allowing treatment of those admitted between 2 and 3 h after symptom onset. PMID:17251612

Ischemic stroke enhancement in computed tomography scans using a computational approach

NASA Astrophysics Data System (ADS)

Alves, Allan F. F.; Pavan, Ana L. M.; Jennane, Rachid; Miranda, José R. A.; Freitas, Carlos C. M.; Abdala, Nitamar; Pina, Diana R.

2018-03-01

In this work, a novel approach was proposed to enhance the visual perception of ischemic stroke in computed tomography scans. Through different image processing techniques, we enabled less experienced physicians, to reliably detect early signs of stroke. A set of 40 retrospective CT scans of patients were used, divided into two groups: 25 cases of acute ischemic stroke and 15 normal cases used as control group. All cases were obtained within 4 hours of symptoms onset. Our approach was based on the variational decomposition model and three different segmentation methods. A test determined observers' performance to correctly diagnose stroke cases. The Expectation Maximization method provided the best results among all observers. The overall sensitivity of the observer's analysis was 64% and increased to 79%. The overall specificity was 67% and increased to 78%. These results show the importance of a computational tool to assist neuroradiology decisions, especially in critical situations such as the diagnosis of ischemic stroke.

Adverse Influence of Pre-Stroke Dementia on Short-Term Functional Outcomes in Patients with Acute Ischemic Stroke: The Fukuoka Stroke Registry.

PubMed

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

2017-01-01

Dementia and stroke are major causes of disability in the elderly. However, the association between pre-stroke dementia and functional outcome after stoke remains unresolved. We aimed to determine this association in patients with acute ischemic stroke. Among patients registered in the Fukuoka Stroke Registry from June 2007 to May 2015, 4,237 patients with ischemic stroke within 24 h of onset, who were functionally independent before the onset, were enrolled in this study. Pre-stroke dementia was defined as any type of dementia that was present prior to the index stroke. Primary and secondary study outcomes were poor functional outcome (modified Rankin Scale 3-6) at 3 months after the stroke onset and neurological deterioration (≥2-point increases on the National Institutes of Health Stroke Scale score during hospitalization), respectively. For propensity score (PS)-matched cohort study to control confounding variables for pre-stroke dementia, 318 pairs of patients with and without pre-stroke dementia were also selected on the basis of 1:1 matching. Multivariable logistic regression models and conditional logistic regression analysis were used to quantify associations between pre-stroke dementia and study outcomes. Of all 4,237 participants, 347 (8.2%) had pre-stroke dementia. The frequencies of neurological deterioration and poor functional outcome were significantly higher in patients with pre-stroke dementia than in those without pre-stroke dementia (neurological deterioration, 16.1 vs. 7.1%, p < 0.01; poor functional outcome, 63.7 vs. 27.1%, p < 0.01). Multivariable analysis showed that pre-stroke dementia was significantly associated with neurological deterioration (OR 1.67; 95% CI 1.14-2.41; p < 0.01) and poor functional outcome (OR 2.91; 95% CI 2.17-3.91; p < 0.01). In the PS-matched cohort study, the same trends were observed between the pre-stroke dementia and neurological deterioration (OR 2.60; 95% CI 1.17-5.78; p < 0.01) and between the dementia and poor functional outcome (OR 3.62; 95% CI 1.89-6.95; p < 0.01). Pre-stroke dementia was significantly associated with higher risks for poor functional outcome at 3 months after stroke onset as well as for neurological deterioration during hospitalization in patients with acute ischemic stroke. © 2016 S. Karger AG, Basel.

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

PubMed

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

2016-01-01

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

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

PubMed

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

2016-01-01

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

Fire-Heat and Qi Deficiency Syndromes as Predictors of Short-term Prognosis of Acute Ischemic Stroke

PubMed Central

Cheng, Shu-Chen; Lin, Chien-Hsiung; Chang, Yeu-Jhy; Lee, Tsong-Hai; Ryu, Shan-Jin; Chen, Chun-Hsien; Chang, Her-Kun; Chang, Chee-Jen

2013-01-01

Abstract Objectives To explore the relationships between traditional Chinese medicine (TCM) syndromes and disease severity and prognoses after ischemic stroke, such as neurologic deficits and decline in activities of daily living (ADLs). Methods The study included 211 patients who met the inclusion criteria of acute ischemic stroke based on clinical manifestations, computed tomography or magnetic resonance imaging findings, and onset of ischemic stroke within 72 hours with clear consciousness. To assess neurologic function and ADLs in patients with different TCM syndromes, the TCM Syndrome Differentiation Diagnostic Criteria for Apoplexy scale (containing assessments of wind, phlegm, blood stasis, fire-heat, qi deficiency, and yin deficiency with yang hyperactivity syndromes) was used within 72 hours of stroke onset, and Western medicine–based National Institutes of Health Stroke Scale (NIHSS) and Barthel Index (BI) assessments were performed at both admission and discharge. Results The most frequent TCM syndromes associated with acute ischemic stroke were wind syndrome, phlegm syndrome, and blood stasis syndrome. Improvement according to the BI at discharge and days of admission were significantly different between patients with and those without fire-heat syndrome. Patients with qi deficiency syndrome had longer hospital stays and worse NIHSS and BI assessments at discharge than patients without qi deficiency syndrome. All the reported differences reached statistical significance. Conclusions These results provide evidence that fire-heat syndrome and qi deficiency syndrome are essential elements that can predict short-term prognosis of acute ischemic stroke. PMID:23600945

Effects of comprehensive education protocol in decreasing pre-hospital stroke delay among Chinese urban community population.

PubMed

Chen, Shengyun; Sun, Haixin; Zhao, Xingquan; Fu, Paul; Yan, Wang; Yilong, Wang; Hongyan, Jia; Yan, Zhang; Wenzhi, Wang

2013-06-01

Studies have shown that awareness of early stroke symptoms and the use of ambulances are two important factors in decreasing pre-hospital stroke delay. The purpose of this study is to evaluate a comprehensive educational stroke protocol in improving stroke response times. Two urban communities in Beijing (population ≍50 000), matched in economic status and geography, were enrolled in this study. A comprehensive educational protocol, which included public lectures and distribution of instructive material for the community and its medical staff, was implemented from August 2008 to December 2010. Surveillance of new onset stroke in both communities was carried out during the same period. Pre-hospital delay time and percentage of patients using emergency medical services (EMS) were compared between the two communities. After comprehensive educational protocol, we found that: (i) pre-hospital delay (time from stroke symptom onset to hospital arrival) decreased from 180 to 79 minutes, (ii) the proportion of patients arriving within three hours of stroke onset increased from 55·8% to 80·4%, (iii) pre-hospital delay of stroke patients with symptoms of paralysis, numbness, and speech impediments was decreased, and (iv) the proportion of stroke patients calling for EMS increased from 50·4% to 60·7%. The comprehensive educational stroke protocol was significantly effective in decreasing pre-hospital stroke delay.

Temporal trends and associated factors for pre-hospital and in-hospital delays of stroke patients over a 16-year period: the Athens study.

PubMed

Papapanagiotou, Panagiotis; Iacovidou, Nicoletta; Spengos, Konstantinos; Xanthos, Theodoros; Zaganas, Ioannis; Aggelina, Afrodite; Alegakis, Athanasios; Vemmos, Konstantinos

2011-01-01

The management and outcome of acute ischemic stroke changed dramatically after the introduction of intravenous thrombolysis. However, relatively few patients have received thrombolytic treatment, mainly due to pre-hospital and/or in-hospital delays. Although the causes of these delays have been adequately studied, their change over a long period has not. All acute first-ever stroke patients (n = 2,746) presenting to our academic center from 1993 to 2008 were prospectively documented in a computerized stroke data bank. The time from symptoms onset to presentation at the emergency room and to acquisition of a brain CT was calculated. Time trends over this period as well as the factors affecting them were analyzed. The final study cohort consisted of 2,326 acute stroke patients after excluding 302 patients with an unknown time of stroke onset and 118 who suffered a stroke during hospitalization for another illness. Over the 16-year period, the median time from stroke onset to presentation at the emergency room decreased significantly from 3.15 h (interquartile range 1.30-10.30) to 2.00 h (range 1.00-4.00) (p < 0.001). The median time from emergency room presentation to CT scan completion also decreased significantly (p < 0.001) from 12.3 h (range 4.1-29.8) to 1.0 h (range 0.31-2.77). As a result, the proportion of patients having a CT scan within 4 h of stroke onset increased significantly from 8.6% in 1993-1994 to 53.6% in 2007-2008 (p < 0.001). Thrombolytic treatment was applied in 4.15% of all ischemic stroke patients in the period from 2003 to 2008. Along with other significant factors, use of an emergency medical service was associated with a 57% greater chance of presenting within 3 h after symptoms onset. These results suggest a continued improvement in pre-hospital and in-hospital delays for stroke management. Public awareness and education regarding medical and paramedical services are necessary for the best early management of acute stroke patients. Copyright © 2010 S. Karger AG, Basel.

Perfusion CT helps decision making for thrombolysis when there is no clear time of onset

PubMed Central

Hellier, K D; Hampton, J L; Guadagno, J V; Higgins, N P; Antoun, N M; Day, D J; Gillard, J H; Warburton, E A; Baron, J‐C

2006-01-01

Current guidelines on thrombolysis post stroke with recombinant tissue plasminogen activator (rt‐PA) exclude its use where time of onset is unknown, thus denying some patients potentially beneficial treatment. Contrast enhanced perfusion computed tomography (pCT) imaging can be used together with plain CT and information on clinical deficits to decide whether or not thrombolysis should be initiated even though the exact time of stroke onset is unknown. Based on the results of pCT and CT, rt‐PA was administered to two patients with unknown time of stroke onset; one of the patients also underwent suction thrombectomy. Results in both cases were excellent. PMID:16484659

In-Hospital Ischemic Stroke

PubMed Central

2015-01-01

Between 2.2% and 17% of all strokes have symptom onset during hospitalization in a patient originally admitted for another diagnosis or procedure. These in-hospital strokes represent a unique population with different risk factors, more mimics, and substantially worsened outcomes compared to community-onset strokes. The fact that these strokes manifest during the acute care hospitalization, in patients with higher rates of thrombolytic contraindications, creates distinct challenges for treatment. However, the best evidence suggests benefit to treating appropriately selected in-hospital ischemic strokes with thrombolysis. Evidence points toward a “quality gap” for in-hospital stroke with longer in-hospital delays to evaluation and treatment, lower rates of evaluation for etiology, and decreased adherence to consensus quality process measures of care. This quality gap for in-hospital stroke represents a focused opportunity for quality improvement. PMID:26288675

“Living With a Ball and Chain”: The Experience of Stroke for Individuals and Their Caregivers in Rural Appalachian Kentucky

PubMed Central

Danzl, Megan M.; Hunter, Elizabeth G.; Campbell, Sarah; Sylvia, Violet; Kuperstein, Janice; Maddy, Katherine; Harrison, Anne

2013-01-01

Purpose Individuals in rural Appalachian Kentucky face health disparities and are at increased risk for negative health outcomes and poor quality of life secondary to stroke. The purpose of this study is to describe the experience of stroke for survivors and their caregivers in this region. A description of their experiences is paramount to developing tailored interventions and ultimately improving health care and support. Methods An interprofessional research team used a qualitative descriptive study design and interviewed 13 individuals with stroke and 12 caregivers, representing 10 rural Appalachian Kentucky counties. The transcripts were analyzed using qualitative content analysis. Findings A descriptive summary of the participants’ experience of stroke is presented within the following structure: 1) Stroke onset, 2) Transition through the health care continuum (including acute care, inpatient rehabilitation, and community-based rehabilitation), and 3) Reintegration into life and rural communities. Conclusions The findings provide insight for rural health care providers and community leaders to begin to understand the experience of stroke in terms of stroke onset, transition through the health care continuum, return to home, and community reintegration. An understanding of these experiences may lead to discussions of how to improve service provision, facilitate reintegration, support positive health outcomes and improve quality of life for stroke survivors and their caregivers. The findings also indicate areas in need of future research including investigation of the effects of support groups, local health navigators to improve access to information and services, involvement of faith communities, proactive screening for management of mental health needs, and caregiver respite services. PMID:24088211

Treatment With Tissue Plasminogen Activator in the Golden Hour and the Shape of the 4.5-Hour Time-Benefit Curve in the National United States Get With The Guidelines-Stroke Population.

PubMed

Kim, Joon-Tae; Fonarow, Gregg C; Smith, Eric E; Reeves, Mathew J; Navalkele, Digvijaya D; Grotta, James C; Grau-Sepulveda, Maria V; Hernandez, Adrian F; Peterson, Eric D; Schwamm, Lee H; Saver, Jeffrey L

2017-01-10

Earlier tissue plasminogen activator treatment improves ischemic stroke outcome, but aspects of the time-benefit relationship still not well delineated are: (1) the degree of additional benefit accrued with treatment in the first 60 minutes after onset, and (2) the shape of the time-benefit curve through 4.5 hours. We analyzed patients who had acute ischemic stroke treated with intravenous tissue plasminogen activator within 4.5 hours of onset from the Get With The Guidelines-Stroke US national program. Onset-to-treatment time was analyzed as a continuous, potentially nonlinear variable and as a categorical variable comparing patients treated within 60 minutes of onset with later epochs. Among 65 384 tissue plasminogen activator-treated patients, the median onset-to-treatment time was 141 minutes (interquartile range, 110-173) and 878 patients (1.3%) were treated within the first 60 minutes. Treatment within 60 minutes, compared with treatment within 61 to 270 minutes, was associated with increased odds of discharge to home (adjusted odds ratio, 1.25; 95% confidence interval, 1.07-1.45), independent ambulation at discharge (adjusted odds ratio, 1.22; 95% confidence interval, 1.03-1.45), and freedom from disability (modified Rankin Scale 0-1) at discharge (adjusted odds ratio, 1.72; 95% confidence interval, 1.21-2.46), without increased hemorrhagic complications or in-hospital mortality. The pace of decline in benefit of tissue plasminogen activator from onset-to-treatment times of 20 through 270 minutes was mildly nonlinear for discharge to home, with more rapid benefit loss in the first 170 minutes than later, and linear for independent ambulation and in-hospital mortality. Thrombolysis started within the first 60 minutes after onset is associated with best outcomes for patients with acute ischemic stroke, and benefit declined more rapidly early after onset for the ability to be discharged home. These findings support intensive efforts to organize stroke systems of care to improve the timeliness of thrombolytic therapy in acute ischemic stroke. © 2016 American Heart Association, Inc.

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

PubMed

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

2018-01-24

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

Dodecafluoropentane Emulsion Decreases Infarct Volume in a Rabbit Ischemic Stroke Model

PubMed Central

Culp, William C.; Woods, Sean D.; Skinner, Robert D.; Brown, Aliza T.; Lowery, John D.; Johnson, Jennifer L. H.; Unger, Evan C.; Hennings, Leah J.; Borrelli, Michael J.; Roberson, Paula K.

2011-01-01

Purpose To assess the efficacy of dodecafluoropentane emulsion (DDFPe), a nano droplet emulsion with significant oxygen transport potential, in decreasing infarct volume using an insoluble emboli rabbit stroke model. Methods New Zealand White rabbits (n=64; 5.1±0.50 kg) received angiography and embolic spheres in the internal carotid artery occluding branches. Rabbits were randomly assigned to groups in 4-hour and 7-hour studies. Four-hour groups included: control (n=7, embolized without treatment) or DDFPe treatment 30-min before stroke (n=7), or at stroke onset (n=8), 30-min after stroke (n=5), 1-hour after stroke (n=7), 2-hours after stroke (n=5), or 3-hours after stroke (n=6). Seven-hour groups included control (n=6), DDFPe at 1-hour after stroke (n=8), and DDFPe at 6-hours after stroke (n=5). DDFPe dose was 2% w/v (weight/volume) intravenous injection, 0.6 mL/kg, and repeated every 90 minutes as time allowed. Following euthanasia infarct volume was determined using vital stains on brain sections. Results At 4-hours, median percent infarct volume decreased for all DDFPe treatment times (pre-treatment=0.30%, p=0.004; onset=0.20%, p=0.004; 30-min=0.35%, p=0.009, 1-hour=0.30%, p=0.01, 2-hours=0.40%, p=0.009, 3-hours=0.25%, p=0.003) compared with controls (3.20%). At 7-hours, median percent infarct volume decreased with treatment at 1-hour (0.25%, p=0.007) but not for 6-hours (1.4%, p=0.49) compared with controls (2.2%). Conclusions Intravenous DDFPe in an animal model decreases infarct volumes and protects brain tissue from ischemia justifying further investigation. PMID:22079515

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

PubMed

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

2018-05-17

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

[Broad ischemic stroke revealing infective endocarditis in a young patient: about a case].

PubMed

Ravelosaona, Fanomezantsoa Noella; Razafimahefa, Julien; Randrianasolo, Rahamefy Odilon; Rakotoarimanana, Solofonirina; Tehindrazanarivelo, Djacoba Alain

2016-01-01

Broad ischemic stroke is mainly due to a cardiac embolus or to an atheromatous plaque. In young subjects, one of the main causes of ischemic stroke (broad ischemic stroke in particolar) is embolic heart disease including infective endocarditis. Infective endocarditis is a contraindication against the anticoagulant therapy (which is indicated for the treatment of embolic heart disease complicated by ischemic stroke). One neurologic complications of infective endocarditis is ischemic stroke which often occurs in multiple sites. We here report the case of a 44-year old man with afebrile acute onset of severe left hemiplegia associated with a sistolic mitral murmur, who had fever in hospital on day 5 with no other obvious source of infection present. Brain CT scan showed full broad ischaemic stroke of the right middle cerebral artery territory and doppler ultrasound, performed after stroke onset, showed infective endocarditis affecting the small mitral valve. He was treated with 4 weeks of antibiotic therapy without anticoagulant therapy ; evolution was marked by the disappearance of mitral valve vegetations and by movement sequelae involving the left side of the body. In practical terms, our problem was the onset of the fever which didn't accompany or pre-exist patient's deficit, leading us to the misdiagnosis of ischemic stroke of cardioembolic origin. This case study underlines the importance of doppler ultrasound, in the diagnosis of all broad ischemic strokes, especially superficial, before starting anticoagulant therapy.

Advanced interatrial block predicts new-onset atrial fibrillation and ischemic stroke in patients with heart failure: The "Bayes' Syndrome-HF" study.

PubMed

Escobar-Robledo, Luis Alberto; Bayés-de-Luna, Antoni; Lupón, Josep; Baranchuk, Adrian; Moliner, Pedro; Martínez-Sellés, Manuel; Zamora, Elisabet; de Antonio, Marta; Domingo, Mar; Cediel, Germán; Núñez, Julio; Santiago-Vacas, Evelyn; Bayés-Genís, Antoni

2018-05-18

Advanced interatrial block (IAB) is characterized by a prolonged (≥120 ms) and bimodal P wave in the inferior leads. The association between advanced IAB and atrial fibrillation (AF) is known as "Bayes' Syndrome", and there is scarce information about it in heart failure (HF). We examined the prevalence of IAB and whether advanced IAB could predict new-onset AF and/or stroke in HF patients. The prospective observational "Bayes' Syndrome-HF" study included consecutive outpatients with chronic HF. The primary endpoints were new-onset AF, ischemic stroke, and the composite of both. A secondary endpoint included all-cause death alone or in combination with the primary endpoint. Comprehensive multivariable Cox regression analyses were performed. Among 1050 consecutive patients, 536 (51.0%) were in sinus rhythm, 464 with a measurable P wave are the focus of this study. Two-hundred and sixty patients (56.0%) had normal atrial conduction, 95 (20.5%) partial IAB, and 109 (23.5%) advanced IAB. During a mean follow-up of 4.5 ± 2.1 years, 235 patients experienced all-cause death, new-onset AF, or stroke. In multivariable comprehensive Cox regression analyses, advanced IAB was associated with new-onset AF (HR 2.71 [1.61-4.56], P < 0.001), ischemic stroke (HR 3.02 [1.07-8.53], P = 0.04), and the composite of both (HR 2.42 [1.41-4.15], P < 0.001). In patients with HF advanced IAB predicts new-onset AF and ischemic stroke. Future studies must assess whether anticoagulant treatment in Bayes' Syndrome leads to better outcomes in HF. Copyright © 2017 Elsevier B.V. All rights reserved.

Predictors of early infection in cerebral ischemic stroke

PubMed Central

Ashour, WMR; Al-Anwar, AD; Kamel, AE; Aidaros, MA

2016-01-01

Background: Infection is the most common complication of stroke. Aim: To determine the risk factors and predictors of post-stroke infection (PSI), which developed within 7 days from the onset of acute ischemic stroke. Subjects: The study included 60 ischemic stroke patients admitted in the Neurology Department of Zagazig University, Egypt, who were subdivided into: [Non Stroke Associated Infection group (nSAI); 30 patients having stroke without any criteria of infection within 7 days from the onset and Stroke Associated Infection group (SAI); 30 patients having stroke with respiratory tract infection (RTI) or urinary tract infection within 7 days], in addition to 30 healthy sex and age-matching subjects as control. Methods: All the patients had a detailed history taking, thorough clinical general and neurological examination, laboratory tests (Urine analysis & urine culture, blood sugar, lipid profile and serum tumor necrosis factor-alpha (TNF-α) and interleukin (IL)-10), a chest radiography to assess RTI and brain computed tomography (CT) to exclude the hemorrhagic stroke and to confirm the ischemic stroke. Results: SAI patients were found to be significantly older with higher baseline blood glucose level. Also the number of patients with tube feeding, lower conscious level, more stroke severity and more large size infarcts were significantly higher in SAI patients. There was a significant elevation in the IL-10, a significant decrease in the TNF-α and a significant decrease in the TNF-α/ IL-10 ratio, in the SAI group. The baseline serum level of IL-10 ≥ 14.5 pg/ ml and size of infarct area > 3.5 cm3 were found to be the independent predictors of PSI. Conclusion: Patients with older age, tube feeding, lower conscious level, worse baseline stroke severity, large cerebral infarcts in CT scan, and increased IL-10 serum level were more susceptible to infection. The baseline serum level of IL-10 ≥ 14.5 pg/ ml and the size of infarct area > 3.5 cm3 were the independent predictors of PSI. PMID:27453748

Quality of care and outcomes for in-hospital ischemic stroke: findings from the National Get With The Guidelines-Stroke.

PubMed

Cumbler, Ethan; Wald, Heidi; Bhatt, Deepak L; Cox, Margueritte; Xian, Ying; Reeves, Mathew; Smith, Eric E; Schwamm, Lee; Fonarow, Gregg C

2014-01-01

Analysis of quality of care for in-hospital stroke has not been previously performed at the national level. This study compares patient characteristics, process measures of quality, and outcomes for in-hospital strokes with those for community-onset strokes in a national cohort. We performed a retrospective cohort study of the Get With The Guidelines-Stroke (GWTG-Stroke) database of The American Heart Association from January 2006 to April 2012, using data from 1280 sites that reported ≥1 in-hospital stroke. Patient characteristics, comorbid illnesses, medications, quality of care measures, and outcomes were analyzed for 21 349 in-hospital ischemic strokes compared with 928 885 community-onset ischemic strokes. Patients with in-hospital stroke had more thromboembolic risk factors, including atrial fibrillation, prosthetic heart valves, carotid stenosis, and heart failure (P<0.0001), and experienced more severe strokes (median National Institutes of Health Stroke Score 9.0 versus 4.0; P<0.0001). Using GWTG-Stroke achievement measures, the proportion of patients with defect-free care was lower for in-hospital strokes (60.8% versus 82.0%; P<0.0001). After accounting for patient and hospital characteristics, patients with in-hospital strokes were less likely to be discharged home (adjusted odds ratio 0.37; 95% confidence intervals [0.35-0.39]) or be able to ambulate independently at discharge (adjusted odds ratio 0.42; 95% confidence intervals [0.39-0.45]). In-hospital mortality was higher for in-hospital stroke (adjusted odds ratio 2.72; 95% confidence intervals [2.57-2.88]). Compared with community-onset ischemic stroke, patients with in-hospital stroke experienced more severe strokes, received lower adherence to process-based quality measures, and had worse outcomes. These findings suggest there is an important opportunity for targeted quality improvement efforts for patients with in-hospital stroke.

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

PubMed

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

2016-09-01

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

Migrainous aura as stroke-mimic: The role of perfusion-computed tomography.

PubMed

Ridolfi, Mariana; Granato, Antonio; Polverino, Paola; Furlanis, Giovanni; Ukmar, Maja; Zorzenon, Irene; Manganotti, Paolo

2018-03-01

The acute-onset of migrainuos aura (MA) can be erroneously diagnosed in Emergency Department (ED) as acute stroke (AS) and it can be classified as "stroke mimic" (SM). Perfusion computer tomography (PCT) may be useful to improve detection of infarcts. The aim of the study was to investigate the role in ED of PCT in improving diagnosis of migrainous aura. Data were compared with the well-defined perfusion patterns in patients with acute ischemic stroke. A standardized Stroke Protocol was planned. The protocol consisted in centralizing in ED all the patients with acute-onset of neurological symptoms compatible with cerebrovascular disease and in performing a general and neurological examination, hematological tests, brain non-contrast computed tomography (NCCT), CT angiography (CTA) of the supra-aortic and intracranial arteries and cerebral PCT. Patients with diagnosis of definite or probable acute stroke were hospitalized in Stroke Unit (SU). A six-months retrospective analysis of all the patients included in the Stroke Protocol and discharged from ED or from SU with a diagnosis of migraine with aura was performed. 172 patients were included in the Stroke Protocol and 6 patients were enrolled. NCCT, CTA and PCT were performed after 60-90 min from symptoms onset and revealed normal perfusion. Intravenous thrombolysis was performed only in one patient. Patients with acute-onset of neurological symptoms, who have rapid progressive improvement of symptoms, normal neuroimaging, in particular PCT, and preceding episodes of migraine with aura, may be considered as suffering from MA. In these cases, even if thrombolysis is safe, clinicians may defer a prompt aggressive treatment. Copyright © 2018 Elsevier B.V. All rights reserved.

Correlation of Longitudinal Gray Matter Volume Changes and Motor Recovery in Patients After Pontine Infarction.

PubMed

Wang, Peipei; Jia, Xiuqin; Zhang, Miao; Cao, Yanxiang; Zhao, Zhilian; Shan, Yi; Ma, Qingfeng; Qian, Tianyi; Wang, Jingjuan; Lu, Jie; Li, Kuncheng

2018-01-01

The mechanisms of motor functional recovery after pontine infarction (PI) remain unclear. Here, we assessed longitudinal changes in gray matter volume (GMV) and examined the relationship between GMV and clinical outcome. Fifteen patients with unilateral PI underwent magnetic resonance imaging and neurological exams five times during a period of 6 months. Another 15 healthy participants were enrolled as the normal control (NC) group and were examined with the same protocol. The MR exam included routine protocol and a 3D T1-weighted magnetization-prepared rapid acquisition gradient echo scan. Changes in GMV were assessed using voxel-based morphometry. Furthermore, the correlations between GMV changes in regions of interest and clinical scores were assessed. Compared with NCs, the decreased GMVs in the contralateral uvula of cerebellum and the ipsilateral tuber of cerebellum were detected at third month after stroke onset. At the sixth month after stroke onset, the decreased GMVs were detected in the contralateral culmen of cerebellum, putamen, as well as in the ipsilateral tuber/tonsil of cerebellum. Compared with NC, the PI group exhibited significant increases in GMV at each follow-up time point relative to stroke onset. Specifically, the significant GMV increase was found in the ipsilateral middle frontal gyrus and ventral anterior nucleus of thalamus at second week after stroke onset. At first month after stroke onset, the increased GMVs in the ipsilateral middle temporal gyrus were detected. The significant GMV increase in the ipsilateral mediodorsal thalamus was noted at third month after stroke onset. At the end of sixth month after stroke onset, the GMV increase was found in the ipsilateral mediodorsal thalamus, superior frontal gyrus, and the contralateral precuneus. Across five times during a period of 6-month, a negative correlation was observed between mean GMV in the contralateral uvula, culmen, putamen, and ipsilateral tuber/tonsil and mean Fugl-Meyer (FM) score. However, mean GMV in the ipsilateral mediodorsal thalamus was positively correlated with mean FM score. Our findings suggest that structural reorganization of the ipsilateral mediodorsal thalamus might contribute to motor functional recovery after PI.

Early-Life Origins of Adult Disease: National Longitudinal Population-Based Study of the United States

PubMed Central

Schoeni, Robert F.

2011-01-01

Objectives. We examined the relation between low birth weight and childhood family and neighborhood socioeconomic disadvantage and disease onset in adulthood. Methods. Using US nationally representative longitudinal data, we estimated hazard models of the onset of asthma, hypertension, diabetes, and stroke, heart attack, or heart disease. The sample contained 4387 children who were members of the Panel Study of Income Dynamics in 1968; they were followed up to 2007, when they were aged 39 to 56 years. Our research design included sibling comparisons of disease onset among siblings with different birth weights. Results. The odds ratios of having asthma, hypertension, diabetes, and stroke, heart attack, or heart disease by age 50 years for low–birth weight babies vs others were 1.64 (P < .01), 1.51 (P < .01), 2.09 (P < .01), and 2.16 (P < .01), respectively. Adult disease prevalence differed substantially by childhood socioeconomic status (SES). After accounting for childhood socioeconomic factors, we found a substantial hazard ratio of disease onset associated with low birth weight, which persisted for sibling comparisons. Conclusions. Childhood SES is strongly associated with the onset of chronic disease in adulthood. Low birth weight plays an important role in disease onset; this relation persists after an array of childhood socioeconomic factors is accounted for. PMID:22021306

Family history of stroke and severity of neurologic deficit after stroke

PubMed Central

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

2008-01-01

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

Classifying Acute Ischemic Stroke Onset Time using Deep Imaging Features

PubMed Central

Ho, King Chung; Speier, William; El-Saden, Suzie; Arnold, Corey W.

2017-01-01

Models have been developed to predict stroke outcomes (e.g., mortality) in attempt to provide better guidance for stroke treatment. However, there is little work in developing classification models for the problem of unknown time-since-stroke (TSS), which determines a patient’s treatment eligibility based on a clinical defined cutoff time point (i.e., <4.5hrs). In this paper, we construct and compare machine learning methods to classify TSS<4.5hrs using magnetic resonance (MR) imaging features. We also propose a deep learning model to extract hidden representations from the MR perfusion-weighted images and demonstrate classification improvement by incorporating these additional imaging features. Finally, we discuss a strategy to visualize the learned features from the proposed deep learning model. The cross-validation results show that our best classifier achieved an area under the curve of 0.68, which improves significantly over current clinical methods (0.58), demonstrating the potential benefit of using advanced machine learning methods in TSS classification. PMID:29854156

Short-Term Exposure to Fine Particulate Matter and Risk of Ischemic Stroke.

PubMed

Matsuo, Ryu; Michikawa, Takehiro; Ueda, Kayo; Ago, Tetsuro; Nitta, Hiroshi; Kitazono, Takanari; Kamouchi, Masahiro

2016-12-01

There is a strong association between ambient concentrations of particulate matter (PM) and cardiovascular disease. However, it remains unclear whether acute exposure to fine PM (PM 2.5 ) triggers ischemic stroke events and whether the timing of exposure is associated with stroke risk. We, therefore, examined the association between ambient PM 2.5 and occurrence of ischemic stroke. We analyzed data for 6885 ischemic stroke patients from a multicenter hospital-based stroke registry in Japan who were previously independent and hospitalized within 24 hours of stroke onset. Time of symptom onset was confirmed, and the association between PM (suspended PM and PM 2.5 ) and occurrence of ischemic stroke was analyzed by time-stratified case-crossover analysis. Ambient PM 2.5 and suspended PM at lag days 0 to 1 were associated with subsequent occurrence of ischemic stroke (ambient temperature-adjusted odds ratio [95% confidence interval] per 10 μg/m 3 : suspended PM, 1.02 [1.00-1.05]; PM 2.5 , 1.03 [1.00-1.06]). In contrast, ambient suspended PM and PM 2.5 at lag days 2 to 3 or 4 to 6 showed no significant association with stroke occurrence. The association between PM 2.5 at lag days 0 to 1 and ischemic stroke was maintained after adjusting for other air pollutants (nitrogen dioxide, photochemical oxidants, or sulfur dioxide) or influenza epidemics and was evident in the cold season. These findings suggest that short-term exposure to PM 2.5 within 1 day before onset is associated with the subsequent occurrence of ischemic stroke. © 2016 American Heart Association, Inc.

Change in blood pressure variability in patients with acute ischemic stroke and its effect on early neurologic outcome

PubMed Central

Hong, Jeong-Ho; Jang, Min Uk; Choi, Nack Cheon; Lee, Ji Sung; Kim, Beom Joon; Han, Moon-Ku; Bae, Hee-Joon

2017-01-01

Background How short-term blood pressure variability (BPV) is affected in the acute stage of ischemic stroke and whether BPV is associated with early neurologic outcomes remains unclear. Methods Patients who admitted for ischemic stroke within 24 h of symptom onset were consecutively identified between January 2010 and January 2015. BP profiles measured in real-time were summarized into short-term, 24-h time intervals, based on standard deviation (SD) and mean of systolic BP (SBPSD) during the first 3 days. The primary outcome was daily assessment of early neurological deterioration (END). The associations between short-term SBPSD values and the secular trend for primary outcome were examined. Results A total of 2,545 subjects (mean age, 67.1 ± 13.5 years old and median baseline National Institutes of Health Stroke Scale score, 3) arrived at the hospital an average of 6.1 ± 6.6 h after symptom onset. SBPSD values at day 1 (SD#D1), SD#D2, and SD#D3 were 14.4 ± 5.0, 12.5 ± 4.5, and 12.2 ± 4.6 mmHg, respectively. Multivariable analyses showed that SD#D2 was independently associated with onset of END at day 2 (adjusted odds ratio, 1.08; 95% confidence interval, 1.03–1.13), and SD#D3 was independently associated with END#D3 (1.07, 1.01–1.14), with adjustments for predetermined covariates, SBPmean, and interactions with daily SBPSD. Conclusion Short-term BPV changed and stabilized from the first day of ischemic stroke. Daily high BPV may be associated with neurological deterioration independent of BPV on the previous day. PMID:29252991

Free radical scavenger, edaravone, reduces the lesion size of lacunar infarction in human brain ischemic stroke

PubMed Central

2011-01-01

Background Although free radicals have been reported to play a role in the expansion of ischemic brain lesions, the effect of free radical scavengers is still under debate. In this study, the temporal profile of ischemic stroke lesion sizes was assessed for more than one year to evaluate the effect of edaravone which might reduce ischemic damage. Methods We sequentially enrolled acute ischemic stroke patients, who admitted between April 2003 and March 2004, into the edaravone(-) group (n = 83) and, who admitted between April 2004 and March 2005, into the edaravone(+) group (n = 93). Because, edaravone has been used as the standard treatment after April 2004 in our hospital. To assess the temporal profile of the stroke lesion size, the ratio of the area [T2-weighted magnetic resonance images (T2WI)/iffusion-weighted magnetic resonance images (DWI)] were calculated. Observations on T2WI were continued beyond one year, and observational times were classified into subacute (1-2 months after the onset), early chronic (3-6 month), late chronic (7-12 months) and old (≥13 months) stages. Neurological deficits were assessed by the National Institutes of Health Stroke Scale upon admission and at discharge and by the modified Rankin Scale at 1 year following stroke onset. Results Stroke lesion size was significantly attenuated in the edaravone(+) group compared with the edaravone(-) group in the period of early and late chronic observational stages. However, this reduction in lesion size was significant within a year and only for the small-vessel occlusion stroke patients treated with edaravone. Moreover, patients with small-vessel occlusion strokes that were treated with edaravone showed significant neurological improvement during their hospital stay, although there were no significant differences in outcome one year after the stroke. Conclusion Edaravone treatment reduced the volume of the infarct and improved neurological deficits during the subacute period, especially in the small-vessel occlusion strokes. PMID:21447190

Dementia in developing countries: Does education play the same role in India as in the West?

PubMed Central

Iyer, Gowri K.; Alladi, Suvarna; Bak, Thomas H.; Shailaja, Mekala; Mamidipudi, Annapurna; Rajan, Amulya; Gollahalli, Divyaraj; Chaudhuri, Jaydip Ray; Kaul, Subhash

2014-01-01

Evidence suggests that education protects from dementia by enhancing cognitive reserve. However, this may be influenced by several socio-demographic factors. Rising numbers of dementia in India, high levels of illiteracy and heterogeneity in socio-demographic factors provide an opportunity to explore this relationship. Objective To study the association between education and age at dementia onset, in relation to socio-demographic factors. Methods Association between age at dementia onset and literacy was studied in relationship to potential confounding factors such as gender, bilingualism, place of dwelling, occupation, vascular risk factors, stroke, family history of dementia and dementia subtypes. Results Case records of 648 dementia patients diagnosed in a specialist clinic in a University hospital in Hyderabad, India were examined. All patients were prospectively enrolled as part of an ongoing longitudinal project that aims to evaluate dementia subjects with detailed clinical, etiological, imaging, and follow-up studies. Of the 648 patients, 98 (15.1%) were illiterate. More than half of illiterate skilled workers were engaged in crafts and skilled agriculture unlike literates who were in trade or clerical jobs. Mean age at onset in illiterates was 60.1 years and in literates 64.5 years (p=0.0002). Factors independently associated with age at dementia onset were bilingualism, rural dwelling and stroke, but not education. Conclusion Our study demonstrates that in India, rural dwelling, bilingualism, stroke and occupation modify the relationship between education and dementia. PMID:29213894

Premature menopause or early menopause and risk of ischemic stroke

PubMed Central

Rocca, Walter A.; Grossardt, Brandon R.; Miller, Virginia M.; Shuster, Lynne T.; Brown, Robert D.

2011-01-01

Objective The general consensus has been that estrogen is invariably a risk factor for ischemic stroke (IS). We reviewed new observational studies that challenge this simple conclusion. Methods This was a review of observational studies of the association of premature or early menopause with stroke or IS published in English from 2006 through 2010. Results Three cohort studies showed an increased risk of all stroke in women who underwent bilateral oophorectomy compared with women who conserved their ovaries before age 50 years. The increased risk of stroke was reduced by hormonal therapy (HT) in one of the studies, suggesting that estrogen deprivation is involved in the association. Four additional observational studies showed an association of all stroke or IS with the early onset of menopause or with a shorter lifespan of ovarian activity. In three of the seven studies, the association was restricted to IS. Age at menopause was more important than type of menopause (natural vs induced). Conclusions The findings from seven recent observational studies challenge the consensus that estrogen is invariably a risk factor for IS and can be reconciled by a unifying timing hypothesis. We hypothesize that estrogen is protective for IS before age 50 years and may become a risk factor for IS after age 50 years or, possibly, after age 60 years. These findings are relevant to women who experienced premature or early menopause, or to women considering prophylactic bilateral oophorectomy before the onset of natural menopause. PMID:21993082

Critical periods after stroke study: translating animal stroke recovery experiments into a clinical trial

PubMed Central

Dromerick, Alexander W.; Edwardson, Matthew A.; Edwards, Dorothy F.; Giannetti, Margot L.; Barth, Jessica; Brady, Kathaleen P.; Chan, Evan; Tan, Ming T.; Tamboli, Irfan; Chia, Ruth; Orquiza, Michael; Padilla, Robert M.; Cheema, Amrita K.; Mapstone, Mark E.; Fiandaca, Massimo S.; Federoff, Howard J.; Newport, Elissa L.

2015-01-01

Introduction: Seven hundred ninety-five thousand Americans will have a stroke this year, and half will have a chronic hemiparesis. Substantial animal literature suggests that the mammalian brain has much potential to recover from acute injury using mechanisms of neuroplasticity, and that these mechanisms can be accessed using training paradigms and neurotransmitter manipulation. However, most of these findings have not been tested or confirmed in the rehabilitation setting, in large part because of the challenges in translating a conceptually straightforward laboratory experiment into a meaningful and rigorous clinical trial in humans. Through presentation of methods for a Phase II trial, we discuss these issues and describe our approach. Methods: In rodents there is compelling evidence for timing effects in rehabilitation; motor training delivered at certain times after stroke may be more effective than the same training delivered earlier or later, suggesting that there is a critical or sensitive period for strongest rehabilitation training effects. If analogous critical/sensitive periods can be identified after human stroke, then existing clinical resources can be better utilized to promote recovery. The Critical Periods after Stroke Study (CPASS) is a phase II randomized, controlled trial designed to explore whether such a sensitive period exists. We will randomize 64 persons to receive an additional 20 h of upper extremity therapy either immediately upon rehab admission, 2–3 months after stroke onset, 6 months after onset, or to an observation-only control group. The primary outcome measure will be the Action Research Arm Test (ARAT) at 1 year. Blood will be drawn at up to 3 time points for later biomarker studies. Conclusion: CPASS is an example of the translation of rodent motor recovery experiments into the clinical setting; data obtained from this single site randomized controlled trial will be used to finalize the design of a Phase III trial. PMID:25972803

Genome-Wide Association Analysis of Young-Onset Stroke Identifies a Locus on Chromosome 10q25 Near HABP2.

PubMed

Cheng, Yu-Ching; Stanne, Tara M; Giese, Anne-Katrin; Ho, Weang Kee; Traylor, Matthew; Amouyel, Philippe; Holliday, Elizabeth G; Malik, Rainer; Xu, Huichun; Kittner, Steven J; Cole, John W; O'Connell, Jeffrey R; Danesh, John; Rasheed, Asif; Zhao, Wei; Engelter, Stefan; Grond-Ginsbach, Caspar; Kamatani, Yoichiro; Lathrop, Mark; Leys, Didier; Thijs, Vincent; Metso, Tiina M; Tatlisumak, Turgut; Pezzini, Alessandro; Parati, Eugenio A; Norrving, Bo; Bevan, Steve; Rothwell, Peter M; Sudlow, Cathie; Slowik, Agnieszka; Lindgren, Arne; Walters, Matthew R; Jannes, Jim; Shen, Jess; Crosslin, David; Doheny, Kimberly; Laurie, Cathy C; Kanse, Sandip M; Bis, Joshua C; Fornage, Myriam; Mosley, Thomas H; Hopewell, Jemma C; Strauch, Konstantin; Müller-Nurasyid, Martina; Gieger, Christian; Waldenberger, Melanie; Peters, Annette; Meisinger, Christine; Ikram, M Arfan; Longstreth, W T; Meschia, James F; Seshadri, Sudha; Sharma, Pankaj; Worrall, Bradford; Jern, Christina; Levi, Christopher; Dichgans, Martin; Boncoraglio, Giorgio B; Markus, Hugh S; Debette, Stephanie; Rolfs, Arndt; Saleheen, Danish; Mitchell, Braxton D

2016-02-01

Although a genetic contribution to ischemic stroke is well recognized, only a handful of stroke loci have been identified by large-scale genetic association studies to date. Hypothesizing that genetic effects might be stronger for early- versus late-onset stroke, we conducted a 2-stage meta-analysis of genome-wide association studies, focusing on stroke cases with an age of onset <60 years. The discovery stage of our genome-wide association studies included 4505 cases and 21 968 controls of European, South-Asian, and African ancestry, drawn from 6 studies. In Stage 2, we selected the lead genetic variants at loci with association P<5×10(-6) and performed in silico association analyses in an independent sample of ≤1003 cases and 7745 controls. One stroke susceptibility locus at 10q25 reached genome-wide significance in the combined analysis of all samples from the discovery and follow-up stages (rs11196288; odds ratio =1.41; P=9.5×10(-9)). The associated locus is in an intergenic region between TCF7L2 and HABP2. In a further analysis in an independent sample, we found that 2 single nucleotide polymorphisms in high linkage disequilibrium with rs11196288 were significantly associated with total plasma factor VII-activating protease levels, a product of HABP2. HABP2, which encodes an extracellular serine protease involved in coagulation, fibrinolysis, and inflammatory pathways, may be a genetic susceptibility locus for early-onset stroke. © 2016 American Heart Association, Inc.

Inherited and Uncommon Causes of Stroke.

PubMed

Majersik, Jennifer Juhl

2017-02-01

This article is a practical guide to identifying uncommon causes of stroke and offers guidance for evaluation and management, even when large controlled trials are lacking in these rarer forms of stroke. Fabry disease causes early-onset stroke, particularly of the vertebrobasilar system; enzyme replacement therapy should be considered in affected patients. Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL), often misdiagnosed as multiple sclerosis, causes migraines, early-onset lacunar strokes, and dementia. Moyamoya disease can cause either ischemic or hemorrhagic stroke; revascularization is recommended in some patients. Cerebral amyloid angiopathy causes both microhemorrhages and macrohemorrhages, resulting in typical stroke symptoms and progressive dementia. Pregnancy raises the risk of both ischemic and hemorrhagic stroke, particularly in women with preeclampsia/eclampsia. Pregnant women are also at risk for posterior reversible encephalopathy syndrome (PRES), reversible cerebral vasoconstriction syndrome, and cerebral venous sinus thrombosis. Experts recommend that pregnant women with acute ischemic stroke not be systematically denied the potential benefits of IV recombinant tissue plasminogen activator. Neurologists should become familiar with these uncommon causes of stroke to provide future risk assessment and family counseling and to implement appropriate treatment plans to prevent recurrence.

The effects of gardening on quality of life in people with stroke.

PubMed

Ho, Sui-Hua; Lin, Chiuhsiang Joe; Kuo, Fen-Ling

2016-06-27

Compared with traditional rehabilitation, gardening has been viewed as a more occupation-based intervention to help patients improve functional performance. However, there is still a need for evidence-based research into what factors interact to create the beneficial effects of gardening for people who have sustained a cerebral vascular accident (CVA). To explore how plant, gender, and the time after stroke onset influenced improvements in the quality of life of patients in a gardening program. One treatment of tending short-term plants, and another treatment of tending long-term plants were compared. Quality of life improvement was evaluated according to three factors: plant, gender, and the time after stroke onset. The data were analyzed with 2k replicated factorial designs. The 2k factorial design with replication indicated significant effects on both the social role and the family role. For the social role, the interaction of plant and gender difference was significant. For the family role, the significant effects were found on interaction of plant with both gender and the time after stroke onset. Tending plants with different life cycles has varied effects on the quality of life of people who have sustained a CVA. Factors related to gender and the time after stroke onset influenced role competency in this sample.

Seizure development after stroke.

PubMed

Misirli, H; Ozge, A; Somay, G; Erdoğan, N; Erkal, H; Erenoğlu, N Y

2006-12-01

Although there have been many studies on seizures following stroke, there is still much we do not know about them. In this study, we evaluated the characteristics of seizures in stroke patients. There were 2267 patients with a first-ever stroke, and after excluding 387 patients, 1880 were available for analysis. Of these 1880 patients, we evaluated 200 patients with seizures and 400 patients without seizures. We investigated the seizures according to age, gender, stroke type, the aetiology of ischaemic stroke and the localisation of the lesion. The seizures were classified as early onset and late onset and the seizure type as partial, generalised or secondarily generalised. Seizures occurred in 200 (10.6%) of 1880 strokes. The number of patients with seizures were 138 (10.6%) in ischaemic stroke group and 62 (10.7%) in haemorrhagic stroke group. Patients with ischaemic strokes had 41 embolic (29.7%) and 97 thrombotic (70.3%) origin, and these were not statistically significant in comparison with controls. Cortical involvement for the development of seizures was the most important risk factor (odds ratios = 4.25, p < 0.01). It was concluded that embolic strokes, being younger than 65 years old, and cortical localisation of stroke were important risks for developing seizures.

Stroke onset time estimation from multispectral quantitative magnetic resonance imaging in a rat model of focal permanent cerebral ischemia.

PubMed

McGarry, Bryony L; Rogers, Harriet J; Knight, Michael J; Jokivarsi, Kimmo T; Sierra, Alejandra; Gröhn, Olli Hj; Kauppinen, Risto A

2016-08-01

Quantitative T2 relaxation magnetic resonance imaging allows estimation of stroke onset time. We aimed to examine the accuracy of quantitative T1 and quantitative T2 relaxation times alone and in combination to provide estimates of stroke onset time in a rat model of permanent focal cerebral ischemia and map the spatial distribution of elevated quantitative T1 and quantitative T2 to assess tissue status. Permanent middle cerebral artery occlusion was induced in Wistar rats. Animals were scanned at 9.4T for quantitative T1, quantitative T2, and Trace of Diffusion Tensor (Dav) up to 4 h post-middle cerebral artery occlusion. Time courses of differentials of quantitative T1 and quantitative T2 in ischemic and non-ischemic contralateral brain tissue (ΔT1, ΔT2) and volumes of tissue with elevated T1 and T2 relaxation times (f1, f2) were determined. TTC staining was used to highlight permanent ischemic damage. ΔT1, ΔT2, f1, f2, and the volume of tissue with both elevated quantitative T1 and quantitative T2 (V(Overlap)) increased with time post-middle cerebral artery occlusion allowing stroke onset time to be estimated. V(Overlap) provided the most accurate estimate with an uncertainty of ±25 min. At all times-points regions with elevated relaxation times were smaller than areas with Dav defined ischemia. Stroke onset time can be determined by quantitative T1 and quantitative T2 relaxation times and tissue volumes. Combining quantitative T1 and quantitative T2 provides the most accurate estimate and potentially identifies irreversibly damaged brain tissue. © 2016 World Stroke Organization.

Thalamic Hemorrhagic Stroke in the Term Newborn: A Specific Neonatal Syndrome With Non-uniform Outcome.

PubMed

Merlini, Laura; Hanquinet, Sylviane; Fluss, Joel

2017-07-01

Neonatal thalamic hemorrhagic stroke is related to cerebral sinus venous thrombosis and associated with neurological sequelae. Predicting factors are however lacking. Clinical and radiological findings at onset and on follow-up of 5 neonates with thalamic hemorrhage stroke are described. All neonates presented with abrupt lethargy, ophistotonos, irritability and/or seizures. The thalamic hemorrhagic stroke was most often unilateral (4/5), involving the posterior/entire thalamus in 3 cases and the anterior thalamus in 2. Cerebral venous thrombosis was identified in a single patient. At follow-up, children with unilateral anterior thalamic hemorrhagic stroke demonstrated thalamic atrophy without neurological symptoms, whereas children whose thalamus lesion was extensive exhibit a porencephalic cavity and presented with late-onset epilepsy. Although deep cerebral venous thrombosis is probably the cause of neonatal thalamic hemorrhagic stroke, its radiological evidence is challenging. Outcome seems dependent of the size and location of thalamic hemorrhagic stroke. Epilepsy is a frequent morbidity after thalamic hemorrhagic stroke.

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

PubMed

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

2017-11-01

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

Reasons and evolution of non-thrombolysis in acute ischaemic stroke

PubMed Central

Reiff, T; Michel, P

2017-01-01

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

The role of calling EMS versus using private transportation in improving the management of stroke in France.

PubMed

Gache, Kristel; Couralet, Melanie; Nitenberg, Gérard; Leleu, Henri; Minvielle, Etienne

2013-01-01

To compare the time from symptom onset to brain imaging between patients calling emergency medical services (EMS) and those using private means for transportation. We focused on symptom onset-to-brain imaging times of ≤2 hours and ≤3 hours 30 minutes, assuming a one-hour interval between imaging and thrombolysis. Other variables were the patient's age, gender, stroke type, National Institutes of Health Stroke Scale (NIHSS) score, presence of an on-site stroke unit, and period of symptom onset. Univariate analyses and a hierarchical linear regression model were used, as appropriate, and adjusted for these variables. A total of 1,105 stroke patients (28%) were included in the analyses, 40.6% of them transported by EMS. Patients using EMS were significantly older (72.8 vs. 70.5 years; p = 0.008), they had a higher NIHSS score (8 vs. 6.1; p = 0.0001), fewer were ischemic (85.1% vs. 90.6%; p = 0.005), and more of them reached hospitals with an on-site stroke unit (81.3% vs. 72.9%; p = 0.002). For the EMS-call patients, the median symptom onset-to-brain imaging time was significantly shorter (3 hours 21 minutes vs. 5 hours 57 minutes), and after adjustment, maximum delays of 2 hours and 3 hours 30 minutes were independently associated with EMS call: 28% vs. 18% (p = 0.015) and 66% vs. 45% (p < 0.0001) of patients, respectively, leading to an adjusted odds ratio of 2.77 (95% confidence interval, 2.007-3.828; p < 0.0001) for the threshold of 3 hours 30 minutes. The symptom onset-to-brain imaging time was significantly shorter in case of EMS transportation, but most patients did not reach the hospital in time to be eligible for thrombolysis. Efforts are still needed to reduce delays, especially public education and EMS activation. These efforts should be combined with new approaches for the quality management of stroke patients.

Poststroke delirium incidence and outcomes: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU).

PubMed

Mitasova, Adela; Kostalova, Milena; Bednarik, Josef; Michalcakova, Radka; Kasparek, Tomas; Balabanova, Petra; Dusek, Ladislav; Vohanka, Stanislav; Ely, E Wesley

2012-02-01

To describe the epidemiology and time spectrum of delirium using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria and to validate a tool for delirium assessment in patients in the acute poststroke period. A prospective observational cohort study. The stroke unit of a university hospital. A consecutive series of 129 patients with stroke (with infarction or intracerebral hemorrhage, 57 women and 72 men; mean age, 72.5 yrs; age range, 35-93 yrs) admitted to the stroke unit of a university hospital were evaluated for delirium incidence. None. Criterion validity and overall accuracy of the Czech version of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) were determined using serial daily delirium assessments with CAM-ICU by a junior physician compared with delirium diagnosis by delirium experts using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria that began the first day after stroke onset and continued for at least 7 days. Cox regression models using time-dependent covariate analysis adjusting for age, gender, prestroke dementia, National Institutes of Stroke Health Care at admission, first-day Sequential Organ Failure Assessment, and asphasia were used to understand the relationships between delirium and clinical outcomes. An episode of delirium based on reference Diagnostic and Statistical Manual assessment was detected in 55 patients with stroke (42.6%). In 37 of these (67.3%), delirium began within the first day and in all of them within 5 days of stroke onset. A total of 1003 paired CAM-ICU/Diagnostic and Statistical Manual of Mental Disorders daily assessments were completed. Compared with the reference standard for diagnosing delirium, the CAM-ICU demonstrated a sensitivity of 76% (95% confidence interval [CI] 55% to 91%), a specificity of 98% (95% CI 93% to 100%), an overall accuracy of 94% (95% CI 88% to 97%), and high interrater reliability (κ = 0.94; 95% CI 0.83-1.0). The likelihood ratio of the CAM-ICU in the diagnosis of delirium was 47 (95% CI 27-83). Delirium was an independent predictor of increased length of hospital stay (hazard ratio 1.63; 95% CI 1.11-2.38; p = .013). Poststroke delirium may frequently be detected provided that the testing algorithm is appropriate to the time profile of poststroke delirium. Early (first day after stroke onset) and serial screening for delirium is recommended. CAM-ICU is a valid instrument for the diagnosis of delirium and should be considered an aid in delirium screening and assessment in future epidemiologic and interventional studies in patients with stroke.

Identification of nine genes as novel susceptibility loci for early-onset ischemic stroke, intracerebral hemorrhage, or subarachnoid hemorrhage.

PubMed

Yamada, Yoshiji; Kato, Kimihiko; Oguri, Mitsutoshi; Horibe, Hideki; Fujimaki, Tetsuo; Yasukochi, Yoshiki; Takeuchi, Ichiro; Sakuma, Jun

2018-07-01

Given that substantial genetic components have been shown in ischemic stroke, intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH), heritability may be higher in early-onset than late-onset individuals with these conditions. Although genome-wide association studies (GWASs) have identified various genes and loci significantly associated with ischemic stroke, ICH, or intracranial aneurysm mainly in European ancestry populations, genetic variants that contribute to susceptibility to these disorders remain to be identified definitively. We performed exome-wide association studies (EWASs) to identify genetic variants that confer susceptibility to ischemic stroke, ICH, or SAH in early-onset subjects with these conditions. A total of 6,649 individuals aged ≤65 years were examined. For the EWAS of ischemic or hemorrhagic stroke, 6,224 individuals (450 subjects with ischemic stroke, 5,774 controls) or 6,179 individuals (261 subjects with ICH, 176 subjects with SAH, 5,742 controls), respectively, were examined. EWASs were performed with the use of Illumina Human Exome-12 v1.2 DNA Analysis BeadChip or Infinium Exome-24 v1.0 BeadChip. To compensate for multiple comparisons of allele frequencies with ischemic stroke, ICH, or SAH, we applied a false discovery rate (FDR) of <0.05 for statistical significance of association. The association of allele frequencies of 31,245 single nucleotide polymorphisms (SNPs) that passed quality control to ischemic stroke was examined with Fisher's exact test, and 31 SNPs were significantly (FDR <0.05) associated with ischemic stroke. The association of allele frequencies of 31,253 or 30,970 SNPs to ICH or SAH, respectively, was examined with Fisher's exact test, and six or two SNPs were significantly associated with ICH or SAH, respectively. Multivariable logistic regression analysis with adjustment for age, sex, and the prevalence of hypertension and diabetes mellitus revealed that 12 SNPs were significantly [P<0.0004 (0.05/124)] related to ischemic stroke. Similar analysis with adjustment for age, sex, and the prevalence of hypertension revealed that six or two SNPs were significantly [P<0.0016 (0.05/32)] related to ICH or SAH, respectively. After examination of linkage disequilibrium of identified SNPs and results of previous GWASs, we identified HHIPL2, CTNNA3, LOC643770, UTP20 , and TRIB3 as susceptibility loci for ischemic stroke, DNTTIP2 and FAM205A as susceptibility loci for ICH, and FAM160A1 and OR52E4 as such loci for SAH. Therefore, to the best of our knowledge, we have newly identified nine genes that confer susceptibility to early-onset ischemic stroke, ICH, or SAH. Determination of genotypes for the SNPs in these genes may prove informative for assessment of the genetic risk for ischemic stroke, ICH, or SAH in Japanese.

Early seizures predict the development of epilepsy in children and adolescents with stroke.

PubMed

Breitweg, Ina; Stülpnagel, Celina von; Pieper, Tom; Lidzba, Karen; Holthausen, Hans; Staudt, Martin; Kluger, Gerhard

2017-05-01

To identify risk factors for the development of epilepsy after pediatric stroke. Retrospective analysis of hospital charts of 93 children and adolescents with post-neonatal non-traumatic stroke and a minimum follow-up of two years. Seizures during the first 48 h after onset of stroke symptoms were defined as "early seizures"; when two or more seizures occurred after this period, the patient was classified as "epileptic". Early seizures, young age at stroke and MRI evidence of cortical involvement were observed more frequently in the children who developed epilepsy. These factors were, however, significantly interrelated; a stepwise multiple regression analysis in 46/93 patients with complete datasets identified only the occurrence of early seizures as a significant risk factor: 15/19 (79%) children with early seizures developed epilepsy, as opposed to only 7/53 (13%) without early seizures. Children with stroke who show seizures during the first 48 h after onset of stroke symptoms have a high risk to develop post-stroke epilepsy, whereas in children without early seizures, post-stroke epilepsy is rare. Copyright © 2016. Published by Elsevier Ltd.

Diffusion Kurtosis Imaging of Acute Infarction: Comparison with Routine Diffusion and Follow-up MR Imaging.

PubMed

Yin, Jianzhong; Sun, Haizhen; Wang, Zhiyun; Ni, Hongyan; Shen, Wen; Sun, Phillip Zhe

2018-05-01

Purpose To determine the relationship between diffusion-weighted imaging (DWI) and diffusion kurtosis imaging (DKI) in patients with acute stroke at admission and the tissue outcome 1 month after onset of stroke. Materials and Methods Patients with stroke underwent DWI (b values = 0, 1000 sec/mm 2 along three directions) and DKI (b values = 0, 1000, 2000 sec/mm 2 along 20 directions) within 24 hours after symptom onset and 1 month after symptom onset. For large lesions (diameter ≥ 1 cm), acute lesion volumes at DWI and DKI were compared with those at follow-up T2-weighted imaging by using Spearman correlation analysis. For small lesions (diameter < 1 cm), the number of acute lesions at DWI and DKI and follow-up T2-weighted imaging was counted and compared by using the McNemar test. Results Thirty-seven patients (mean age, 58 years; range, 35-82 years) were included. There were 32 large lesions and 138 small lesions. For large lesions, the volumes of acute lesions on kurtosis maps showed no difference from those on 1-month follow-up T2-weighted images (P = .532), with a higher correlation coefficient than those on the apparent diffusion coefficient and mean diffusivity maps (R 2 = 0.730 vs 0.479 and 0.429). For small lesions, the number of acute lesions on DKI, but not on DWI, images was consistent with that on the follow-up T2-weighted images (P = .125). Conclusion DKI complements DWI for improved prediction of outcome of acute ischemic stroke. © RSNA, 2018.

[Primary emergencies: management of acute ischemic stroke].

PubMed

Leys, Didier; Goldstein, Patrick

2012-01-01

The emergency diagnostic strategy for acute ischemic stroke consists of:--identification of stroke, based on clinical examination (sudden onset of a focal neurological deficit);--identification of the ischemic or hemorrhagic nature by MRI or CT;--determination of the early time-course (clinical examination) and the cause. In all strokes (ischemic or hemorrhagic), treatment consists of:--the same general management (treatment of a life-threatening emergency, ensuring normal biological parameters except for blood pressure, and prevention of complications);--decompressive surgery in the rare cases of intracranial hypertension. For proven ischemic stroke, other therapies consist of: rt-PA for patients admitted with 4.5 hours of stroke onset who have no contraindications, and aspirin (160 to 300 mg) for patients who are not eligible for rt-PA. These treatments should be administered within a few hours. A centralized emergency call system (phone number 15 in France) is the most effective way of achieving this objective.

Development, Implementation, and Evaluation of a Telemedicine Service for the Treatment of Acute Stroke Patients: TeleStroke

PubMed Central

2012-01-01

Background Health care service based on telemedicine can reduce both physical and time barriers in stroke treatments. Moreover, this service connects centers specializing in stroke treatment with other centers and practitioners, thereby increasing accessibility to neurological specialist care and fibrinolytic treatment. Objective Development, implementation, and evaluation of a care service for the treatment of acute stroke patients based on telemedicine (TeleStroke) at Virgen del Rocío University Hospital. Methods The evaluation phase, conducted from October 2008 to January 2011, involved patients who presented acute stroke symptoms confirmed by the emergency physician; they were examined using TeleStroke in two hospitals, at a distance of 16 and 110 kilometers from Virgen del Rocío University Hospital. We analyzed the number of interconsultation sheets, the percentage of patients treated with fibrinolysis, and the number of times they were treated. To evaluate medical professionals’ acceptance of the TeleStroke system, we developed a web-based questionnaire using a Technology Acceptance Model. Results A total of 28 patients were evaluated through the interconsultation sheet. Out of 28 patients, 19 (68%) received fibrinolytic treatment. The most common reasons for not treating with fibrinolysis included: clinical criteria in six out of nine patients (66%) and beyond the time window in three out of nine patients (33%). The mean “onset-to-hospital” time was 69 minutes, the mean time from admission to CT image was 33 minutes, the mean “door-to-needle” time was 82 minutes, and the mean “onset-to-needle” time was 150 minutes. Out of 61 medical professionals, 34 (56%) completed a questionnaire to evaluate the acceptability of the TeleStroke system. The mean values for each item were over 6.50, indicating that respondents positively evaluated each item. This survey was assessed using the Cronbach alpha test to determine the reliability of the questionnaire and the results obtained, giving a value of 0.97. Conclusions The implementation of TeleStroke has made it possible for patients in the acute phase of stroke to receive effective treatment, something that was previously impossible because of the time required to transfer them to referral hospitals. PMID:23612154

Safety of Intravenous Thrombolysis within 4.5 h of symptom onset in patients with negative post-treatment stroke imaging for cerebral infarction.

PubMed

Giraldo, Elias A; Khalid, Aisha; Zand, Ramin

2011-08-01

Patients with stroke symptoms but negative diffusion-weighted imaging (DWI) might have transient ischemic attacks (TIA) or stroke mimics. Brain DWI is important for the diagnosis of cerebral infarction but it is not available before thrombolysis for most patients to avoid treatment delay. This study aimed to evaluate the safety of IV thrombolysis in patients with a negative post-treatment DWI for cerebral infarction. We conducted a retrospective study of 89 patients treated with IV recombinant tissue plasminogen activator (rt-PA) within 4.5 h after stroke symptom onset. The patients were identified in our acute stroke registry from January 2009 to September 2010. Information on patients' demographics, clinical characteristics, neuroimaging, treatment complications, and outcomes was obtained and analyzed. Out of 89 patients, 23 patients (26%) had a negative DWI on follow-up stroke imaging. Fourteen patients had a TIA and nine patients had a stroke mimic, including Todd's paralysis, complicated migraine, and somatoform disorder. We found significant differences between patients with a positive and a negative DWI in mean age (62 years vs. 52 years; P < 0.01) and median admission NIH stroke scale score (11 points versus 6 points; P < 0.001). Among patients with a positive DWI, four patients had a symptomatic intracerebral hemorrhage (ICH). No patients with a negative DWI had symptomatic or asymptomatic ICH. Our results suggest that the administration of IV rt-PA within the first 4.5 h of symptom onset in patients with suspected ischemic stroke is safe even when post-treatment DWI does not demonstrate cerebral infarction.

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

PubMed

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

2008-01-01

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

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

PubMed

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

2015-09-01

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

PRospective Observational POLIsh Study on post-stroke delirium (PROPOLIS): methodology of hospital-based cohort study on delirium prevalence, predictors and diagnostic tools.

PubMed

Klimiec, Elzbieta; Dziedzic, Tomasz; Kowalska, Katarzyna; Szyper, Aleksandra; Pera, Joanna; Potoczek, Paulina; Slowik, Agnieszka; Klimkowicz-Mrowiec, Aleksandra

2015-06-19

Between 10 % to 48 % of patients develop delirium in acute phase of stroke. Delirium determinants and its association with other neuropsychiatric disturbances in stroke are poorly understood. The wildly accepted predictive model of post-stroke delirium is still lacking. This is a prospective, observational, single-center study in patients with acute phase of stroke. We aim to include 750 patients ≥18 years with acute stroke or transient ischemic attack admitted to the stroke unit within 48 hours after stroke onset. The goals of the study are: 1) to determine frequency of delirium and subsyndromal delirium in Polish stroke patients within 7 days after admission to the hospital; 2) to determine factors associated with incidence, severity and duration of delirium and subsyndromal delirium and to create a predictive model for post-stroke delirium; 3) to determine the association between delirium and its cognitive, psychiatric, behavioral and functional short and long-term consequences; 4) to validate scales used for delirium diagnosis in stroke population. Patients will be screened for delirium on daily basis. The diagnosis of delirium will be based on DSM-V criteria. Abbreviated version of Confusion Assessment Method and Confusion Assessment Method for the Intensive Care Unit will be used for delirium and sub-delirium screening. Severity of delirium symptoms will be assessed by Delirium Rating Scale Revised 98 and Cognitive Test for Delirium. Patients who survive will undergo extensive neuropsychological, neuropsychiatric and functional assessment 3 and 12 months after the stroke. This study is designed to provide information on clinical manifestation, diagnostic methods and determinants of delirium spectrum disorders in acute stroke phase and their short and long-term consequences. Collected information allow us to create a predictive model for post-stroke delirium.

Relationship Between HbA1c and Complex Regional Pain Syndrome in Stroke Patients With Type 2 Diabetes Mellitus

PubMed Central

2016-01-01

Objective To investigate the relationship between glycosylated hemoglobin A (HbA1c) and complex regional pain syndrome (CRPS) in stroke patients with type 2 diabetes mellitus (T2DM). Methods A retrospective chart review was performed of stroke patients from January 2012 to December 2013. We reviewed 331 patients and included 200 in the analysis. We divided them into CRPS and non-CRPS groups and compared them by age, gender, stroke lesion, cause of stroke, duration of T2DM, HbA1c (%), National Institutes of Health Stroke Scale score, affected shoulder flexor muscle strength, Fugl-Meyer Assessment score, motricity index, Functional Independence Measure, Korean version of Modified Barthel Index, blood glucose level on admission day, duration from stroke onset to HbA1c check, and duration from stroke onset to three-phase bone scan for CRPS diagnosis. Thereafter, we classified the patients into five groups by HbA1c level (group 1, 5.0%–5.9%; group 2, 6.0%–6.9%; group 3, 7.0%–7.9%; group 4, 8.0%–8.9%; and group 5, 9.0%–9.9%) and we investigated the difference in CRPS prevalence between the two groups. Results Of the 200 patients, 108 were in the CRPS group and 92 were in the non-CRPS group. There were significant differences in HbA1c (p<0.05) between the two groups but no significant differences in any other factors. Across the five HbA1c groups, there were significant differences in CRPS prevalence (p<0.01); specifically, it increased as HbA1c increased. Conclusion This study suggests that higher HbA1c relates to higher CRPS prevalence and thus that uncontrolled blood glucose can affect CRPS occurrence in stroke patients with diabetes. PMID:27847707

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.

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

ERIC Educational Resources Information Center

Gebhardt, James G.; Norris, Thomas E.

2006-01-01

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

Obstructive sleep apnea exaggerates cognitive dysfunction in stroke patients.

PubMed

Zhang, Yan; Wang, Wanhua; Cai, Sijie; Sheng, Qi; Pan, Shenggui; Shen, Fang; Tang, Qing; Liu, Yang

2017-05-01

Obstructive sleep apnea (OSA) is very common in stroke survivors. It potentially worsens the cognitive dysfunction and inhibits their functional recovery. However, whether OSA independently damages the cognitive function in stroke patients is unclear. A simple method for evaluating OSA-induced cognitive impairment is also missing. Forty-four stroke patients six weeks after onset and 24 non-stroke patients with snoring were recruited for the polysomnographic study of OSA and sleep architecture. Their cognitive status was evaluated with a validated Chinese version of Cambridge Prospective Memory Test. The relationship between memory deficits and respiratory, sleeping, and dementia-related clinical variables were analyzed with correlation and multiple linear regression tests. OSA significantly and independently damaged time- and event-based prospective memory in stroke patients, although it had less power than the stroke itself. The impairment of prospective memory was correlated with increased apnea-hypopnea index, decreased minimal and mean levels of peripheral oxygen saturation, and disrupted sleeping continuity (reduced sleep efficiency and increased microarousal index). The further regression analysis identified minimal levels of peripheral oxygen saturation and sleep efficiency to be the two most important predictors for the decreased time-based prospective memory in stroke patients. OSA independently contributes to the cognitive dysfunction in stroke patients, potentially through OSA-caused hypoxemia and sleeping discontinuity. The prospective memory test is a simple but sensitive method to detect OSA-induced cognitive impairment in stroke patients. Proper therapies of OSA might improve the cognitive function and increase the life quality of stroke patients. Copyright © 2017 Elsevier B.V. All rights reserved.

MRI based thrombolysis for FLAIR-negative stroke patients within 4.5-6h after symptom onset.

PubMed

Wei, Xiao-Er; Zhou, Jia; Li, Wen-Bin; Zhao, Yu-Wu; Li, Ming-Hua; Li, Yue-Hua

2017-01-15

To investigate the feasibility of DWI-FLAIR mismatch in identifying patients who might benefit from thrombolytic therapy within 4.5-6h, we analyzed the data of 105 ischemic stroke patients with known time of symptom onset who underwent MRI within 6h of stroke and thrombolysis between December 2006 and December 2013. They were divided into three groups: symptom onset within 4.5h (n=66); 4.5-6h and FLAIR images negative (n=9); and 4.5-6h and FLAIR images positive (n=30). Outcome of thrombolysis was assessed for each group by recanalization rate, National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) scores. The results showed that mismatch between positive DWI and negative FLAIR images identified patients within 4.5h of symptom onset with sensitivity, specificity, positive predictive value and negative predictive value of 40.9%, 76.9%, and 75% and 43.5%. Recanalization rate, NIHSS score and mRS score were all better in both the 0-4.5h and 4.5-6h FLAIR-negative groups than in the 4.5-6h FLAIR-positive group (p<0.05). These data demonstrate that within 4.5-6h of symptom onset, patients with negative FLAIR images may benefit from thrombolysis therapy. Copyright © 2016 Elsevier B.V. All rights reserved.

If Time Is Brain Where Is the Improvement in Prehospital Time after Stroke?

PubMed Central

Pulvers, Jeremy N.; Watson, John D. G.

2017-01-01

Despite the availability of thrombolytic and endovascular therapy for acute ischemic stroke, many patients are ineligible due to delayed hospital arrival. The identification of factors related to either early or delayed hospital arrival may reveal potential targets of intervention to reduce prehospital delay and improve access to time-critical thrombolysis and clot retrieval therapy. Here, we have reviewed studies reporting on factors associated with either early or delayed hospital arrival after stroke, together with an analysis of stroke onset to hospital arrival times. Much effort in the stroke treatment community has been devoted to reducing door-to-needle times with encouraging improvements. However, this review has revealed that the median onset-to-door times and the percentage of stroke patients arriving before the logistically critical 3 h have shown little improvement in the past two decades. Major factors affecting prehospital time were related to emergency medical pathways, stroke symptomatology, patient and bystander behavior, patient health characteristics, and stroke treatment awareness. Interventions addressing these factors may prove effective in reducing prehospital delay, allowing prompt diagnosis, which in turn may increase the rates and/or efficacy of acute treatments such as thrombolysis and clot retrieval therapy and thereby improve stroke outcomes. PMID:29209269

Glycated Hemoglobin Independently Predicts Stroke Recurrence within One Year after Acute First-Ever Non-Cardioembolic Strokes Onset in A Chinese Cohort Study

PubMed Central

Wu, Shuolin; Shi, Yuzhi; Wang, Chunxue; Jia, Qian; Zhang, Ning; Zhao, Xingquan; Liu, Gaifen; Wang, Yilong; Liu, Liping; Wang, Yongjun

2013-01-01

Objective Hyperglycemia is related to stroke. Glycated hemoglobin (HbA1c) can reflect pre-stroke glycaemia status. However, the information on the direct association between HbA1c and recurrence after non-cardioembolic acute ischemic strokes is rare and there is no consistent conclusion. Methods The ACROSS-China database comprised of 2186 consecutive first-ever acute ischemic stroke patients with baseline HbA1c values. After excluding patients who died from non-stroke recurrence and patients lost to follow up, 1817 and 1540 were eligible for 3-month and 1-year analyses, respectively. Multivariate Cox regression was performed to evaluate the associations between HbA1c and 3-month and 1-year stroke recurrence. Results The HbA1c values at admission were divided into 4 levels by quartiles: Q1 (<5.5%); Q2 (5.5 to <6.1%); Q3 (6.1% to <7.2%); and Q4 (≥7.2%). The cumulative recurrence rates were 8.3% and 11.0% for 3 months and 1 year, respectively. In multivariate analyses, when compared with Q1, the adjusted hazard ratios (AHRs) were 2.83 (95% confidence interval (CI) 1.28-6.26) in Q3 and 3.71(95% CI 1.68-8.21) in Q4 for 3-month stroke recurrence; 3.30 (95% CI 1.31-8.34) in Q3 and 3.35 (95% CI 1.36-8.21) in Q4 for 1-year stroke recurrence. Adding fasting plasma glucose in the multivariate analyses did not modify the association: AHRs were 2.75 (95% CI 1.24-6.11) in Q3 and 3.67 (95% CI 1.59-8.53) in Q4 for 3-month analysis; AHRs were 3.08 (95% CI 1.10-8.64) in Q3 and 3.31(95% CI 1.35-8.14) in Q4 for 1-year analysis. Conclusions A higher “normal” HbA1c level reflecting pre-stroke glycaemia status independently predicts stroke recurrence within one year after non-cardioembolic acute ischemic stroke onset. HbA1c is recommended as a routine test in acute ischemic stroke patients. PMID:24236195

A startling acoustic stimulus facilitates voluntary lower extremity movements and automatic postural responses in people with chronic stroke.

PubMed

Coppens, Milou J M; Roelofs, Jolanda M B; Donkers, Nicole A J; Nonnekes, Jorik; Geurts, Alexander C H; Weerdesteyn, Vivian

2018-05-14

A startling acoustic stimulus (SAS) involuntary releases prepared movements at accelerated latencies, known as the StartReact effect. Previous work has demonstrated intact StartReact in paretic upper extremity movements in people after stroke, suggesting preserved motor preparation. The question remains whether motor preparation of lower extremity movements is also unaffected after stroke. Here, we investigated StartReact effects on ballistic lower extremity movements and on automatic postural responses (APRs) following perturbations to standing balance. These APRs are particularly interesting as they are critical to prevent a fall following balance perturbations, but show substantial delays and poor muscle coordination after stroke. Twelve chronic stroke patients and 12 healthy controls performed voluntary ankle dorsiflexion movements in response to a visual stimulus, and responded to backward balance perturbations evoking APRs. Twenty-five percent of all trials contained a SAS (120 dB) simultaneously with the visual stimulus or balance perturbation. As expected, in the absence of a SAS muscle and movement onset latencies at the paretic side were delayed compared to the non-paretic leg and to controls. The SAS accelerated ankle dorsiflexion onsets in both the legs of the stroke subjects and in controls. Following perturbations, the SAS accelerated bilateral APR onsets not only in controls, but for the first time, we also demonstrated this effect in people after stroke. Moreover, APR inter- and intra-limb muscle coordination was rather weak in our stroke subjects, but substantially improved when the SAS was applied. These findings show preserved movement preparation, suggesting that there is residual (subcortical) capacity for motor recovery.

Alternative strategies for stroke care: a prospective randomised controlled trial.

PubMed

Kalra, L; Evans, A; Perez, I; Knapp, M; Donaldson, N; Swift, C G

2000-09-09

Organised specialist care for stroke improves outcome, but the merits of different methods of organisation are in doubt. This study compares the efficacy of stroke unit with stroke team or domiciliary care. A single-blind, randomised, controlled trial was undertaken in 457 acute-stroke patients (average age 76 years, 48% women) randomly assigned to stroke unit, general wards with stroke team support, or domiciliary stroke care, within 72 h of stroke onset. Outcome was assessed at 3, 6, and 12 months. The primary outcome measure was death or institutionalisation at 12 months. Analyses were by intention to treat. 152 patients were allocated to the stroke unit, 152 to stroke team, and 153 to domiciliary stroke care. 51 (34%) patients in the domiciliary group were admitted to hospital after randomisation. Mortality or institutionalisation at 1 year were lower in patients on a stroke unit than for those receiving care from a stroke team (21/152 [14%] vs 45/149 [30%]; p<0.001) or domiciliary care (21/152 [14%] vs 34/144 [24%]; p=0.03), mainly as a result of reduction in mortality. The proportion of patients alive without severe disability at 1 year was also significantly higher on the stroke unit compared with stroke team (129/152 [85%] vs 99/149 [66%]; p<0.001) or domiciliary care (129/152 [85%] vs 102/144 [71%]; p=0.002). These differences were present at 3 and 6 months after stroke. Stroke units are more effective than a specialist stroke team or specialist domiciliary care in reducing mortality, institutionalisation, and dependence after stroke.

Vascular risk factor burden and new-onset depression in the community.

PubMed

Adams, Shayna; Conner, Sarah; Himali, Jayandra J; Beiser, Alexa; Vasan, Ramachandran S; Seshadri, Sudha; Pase, Matthew P

2018-06-01

Depression is associated with an increased likelihood of cardiac events and stroke. We hypothesized that the vascular risk factor burden might itself predispose to both cardiovascular events and depression. Therefore, we examined whether aggregate scores of vascular risk factor burden were associated with the new-onset of depression in the community. We studied 2023 depression- and dementia-free Framingham Heart Study (Framingham, USA) Offspring participants who attended both examination cycles 7 (1998-2001) and 8 (2005-2008). The American Heart Association Ideal Cardiovascular Health metric and the Framingham stroke risk profile were calculated at exam seven. New-onset depression was adjudicated at examination cycle eight as antidepressant medication use or Centre for Epidemiologic Studies Depression Scale scores ≥16, after a mean follow-up of 6.6years (standard deviation=0.7). Of the 2023 participants, 269 (13%) developed new-onset depression. Following adjustments for age, sex, education, and the time interval between baseline and follow-up, the odds of new-onset depression decreased by 10% for each one-point increase in ideal cardiovascular health scores (Odds Ratio [OR], 0.90; 95% confidence interval [CI] 0.81-0.99) and increased by 4% for each percentage point increase in the Framingham stroke risk profile (OR, 1.04; CI, 1.00-1.07). Results were not explained by interim clinical stroke or cerebral white matter injury. In conclusion, vascular risk factor burden was associated with the new onset of depression. Shared vascular risk factors may contribute to the increased risk of cardiovascular events observed in persons with depression. Copyright © 2017 Elsevier Inc. All rights reserved.

Left/right judgement does not influence the effect of mirror therapy after stroke.

PubMed

Lundquist, Camilla B; Nielsen, Jørgen F

2014-01-01

To investigate the correlation between left/right judgement and the effect of mirror therapy (MT). A partial aim was to describe adverse effects of MT. This prospective follow-up study included 36 stroke patients, mean time since stroke was 33 d, SD 23. Left/right judgement is the ability to judge a pictured hand as belonging to one side of the body or the other. In this study, left/right judgement was established before the onset of MT by asking the patient to recognise left and right hands in photographs. Patients were tested before and after the intervention with the motor assessment scale (MAS) and two-point discrimination (2PD). The correlation between left/right judgement and the change of effect measured on the MAS and 2PD were tested by Spearman's rank correlation. The ability to perform left/right judgement before the onset of MT had no significant correlation with change of effect measured on the MAS and 2PD (rho -0.169, p = 0.363 and rho = -0.227, p = 0.219). Thirty-one patients completed the intervention without adverse effects. Left/right judgement does not influence the effect of MT. There seems to be no reason to test the ability to perform left/right judgement before the onset of MT. MT is an intervention without major adverse effects. Implications for Rehabilitation Mirror therapy (MT) is a method for treating sensory and motor disturbances post-stroke. It is important to clarify whether the ability to perform left/right judgement influences the effect of MT. In this study, left/right judgement does not influence the effect of MT. Based on the results of this study, testing and training left/right judgement before commencing MT cannot be recommended.

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.

The relationship between frontal lobe lesions, course of post-stroke depression, and 1-year prognosis in patients with first-ever ischemic stroke.

PubMed

Shi, Yu-Zhi; Xiang, Yu-Tao; Wu, Shuo-Lin; Zhang, Ning; Zhou, Juan; Bai, Ying; Wang, Shuo; Wang, Yi-Long; Zhao, Xing-Quan; Ungvari, Gabor S; Chiu, Helen F K; Wang, Yong-Jun; Wang, Chun-Xue

2014-01-01

Most studies on post-stroke depression (PSD) have focused on a certain time point after stroke instead of the time course of PSD. The aim of this study was to determine the relationship between frontal lobe lesions, course of PSD over a year following the stroke onset, and the 1-year prognosis in patients with first-ever ischemic stroke. A total of 1067 patients from the prospective cohort study on the incidence and outcome of patients with post stroke depression in China who were diagnosed with first-ever ischemic stroke and attended 4 follow-up visits at 14±2 days, 3 months, 6 months, and 1 year after stroke onset, were enrolled in the study. PSD was diagnosed according to DSM-IV. The course of PSD was divided into the following two categories: persistent/recurrent depression and no/transient depression. Patients with any ischemic lesion responsible for the indexed stroke event located in the frontal lobe were defined as patients with frontal lobe lesions. Modified Rankin Scale (mRS) ≥2 at 1-year was considered to be poor prognosis. There were 109 patients with and 958 patients without frontal lobe lesions that formed the frontal lobe (FL) and no-frontal lobe (NFL) groups, respectively. After adjusting for confounding variables, frontal lobe lesion was significantly associated with persistent/recurrent PSD (OR 2.025, 95%CI 1.039-3.949). Overall, 32.7% of patients in the FL group had poor prognosis at 1- year compared with 22.7% in the NFL group (P = 0.021). Compared with no/transient depression, persistent/recurrent depression was found to be an independent predictor of poor prognosis at 1-year both in FL and NFL groups. Long-term and periodical screening, evaluation and treatment are needed for PSD after the onset of ischemic stroke, particularly for patients with frontal lobe infarction.

Edaravone with and without .6 Mg/Kg Alteplase within 4.5 Hours after Ischemic Stroke: A Prospective Cohort Study (PROTECT4.5).

PubMed

Yamaguchi, Takenori; Awano, Hideto; Matsuda, Hiroaki; Tanahashi, Norio

2017-04-01

Edaravone is widely used to treat acute ischemic stroke (AIS) within 24 hours of onset. We aimed to evaluate current edaravone treatment practices and the efficacy and safety of edaravone used with recombinant tissue plasminogen activator (tPA) in AIS patients within 4.5 hours of onset. The results were compared with those of the Safe Implementation of Treatments in Stroke-International Stroke Thrombolysis Registry (SITS-ISTR) study. PROTECT4.5 was a prospective observational study conducted from April 2010 to March 2013 in Japan. The primary end points were favorable outcomes (modified Rankin Scale score [mRS] 0-1) at 3 months after onset and incidence of symptomatic intracranial hemorrhage (sICH) within 36 hours of treatment. For comparison with SITS-ISTR, patients were categorized based on the time from onset to treatment (within 3 hours of and 3-4.5 hours after onset) and baseline National Institutes of Health Stroke Scale score (NIHSS). Among the 11,384 registered patients, 11,126 and 8274 patients were included in the safety and efficacy analysis populations, respectively. The proportions of patients with mRS 0-1 receiving edaravone alone and edaravone + tPA were 51.3% (95% confidence interval, 49.7%-52.8%) and 39.0% (37.6%-40.5%), respectively. The incidence of sICH within 36 hours after tPA treatment (edaravone + tPA group) was 1.6% (1.3%-2.0%). When compared with the SITS-ISTR results, those treated with edaravone + tPA appeared to show better outcomes in patients with NIHSS score ≥16. The efficacy and safety of edaravone combined with tPA and administered within 4.5 hours of AIS onset were demonstrated with numerically lower incidence of sICH and better outcomes. Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.

Sodium-23 magnetic resonance imaging has potential for improving penumbra detection but not for estimating stroke onset time

PubMed Central

Wetterling, Friedrich; Gallagher, Lindsay; Mullin, Jim; Holmes, William M; McCabe, Chris; Macrae, I Mhairi; Fagan, Andrew J

2015-01-01

Tissue sodium concentration increases in irreversibly damaged (core) tissue following ischemic stroke and can potentially help to differentiate the core from the adjacent hypoperfused but viable penumbra. To test this, multinuclear hydrogen-1/sodium-23 magnetic resonance imaging (MRI) was used to measure the changing sodium signal and hydrogen-apparent diffusion coefficient (ADC) in the ischemic core and penumbra after rat middle cerebral artery occlusion (MCAO). Penumbra and core were defined from perfusion imaging and histologically defined irreversibly damaged tissue. The sodium signal in the core increased linearly with time, whereas the ADC rapidly decreased by >30% within 20 minutes of stroke onset, with very little change thereafter (0.5–6 hours after MCAO). Previous reports suggest that the time point at which tissue sodium signal starts to rise above normal (onset of elevated tissue sodium, OETS) represents stroke onset time (SOT). However, extrapolating core data back in time resulted in a delay of 72±24 minutes in OETS compared with actual SOT. At the OETS in the core, penumbra sodium signal was significantly decreased (88±6%, P=0.0008), whereas penumbra ADC was not significantly different (92±18%, P=0.2) from contralateral tissue. In conclusion, reduced sodium-MRI signal may serve as a viability marker for penumbra detection and can complement hydrogen ADC and perfusion MRI in the time-independent assessment of tissue fate in acute stroke patients. PMID:25335803

Novel Screening Tool for Stroke Using Artificial Neural Network.

PubMed

Abedi, Vida; Goyal, Nitin; Tsivgoulis, Georgios; Hosseinichimeh, Niyousha; Hontecillas, Raquel; Bassaganya-Riera, Josep; Elijovich, Lucas; Metter, Jeffrey E; Alexandrov, Anne W; Liebeskind, David S; Alexandrov, Andrei V; Zand, Ramin

2017-06-01

The timely diagnosis of stroke at the initial examination is extremely important given the disease morbidity and narrow time window for intervention. The goal of this study was to develop a supervised learning method to recognize acute cerebral ischemia (ACI) and differentiate that from stroke mimics in an emergency setting. Consecutive patients presenting to the emergency department with stroke-like symptoms, within 4.5 hours of symptoms onset, in 2 tertiary care stroke centers were randomized for inclusion in the model. We developed an artificial neural network (ANN) model. The learning algorithm was based on backpropagation. To validate the model, we used a 10-fold cross-validation method. A total of 260 patients (equal number of stroke mimics and ACIs) were enrolled for the development and validation of our ANN model. Our analysis indicated that the average sensitivity and specificity of ANN for the diagnosis of ACI based on the 10-fold cross-validation analysis was 80.0% (95% confidence interval, 71.8-86.3) and 86.2% (95% confidence interval, 78.7-91.4), respectively. The median precision of ANN for the diagnosis of ACI was 92% (95% confidence interval, 88.7-95.3). Our results show that ANN can be an effective tool for the recognition of ACI and differentiation of ACI from stroke mimics at the initial examination. © 2017 American Heart Association, Inc.

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.

Motor recovery monitoring using acceleration measurements in post acute stroke patients.

PubMed

Gubbi, Jayavardhana; Rao, Aravinda S; Fang, Kun; Yan, Bernard; Palaniswami, Marimuthu

2013-04-16

Stroke is one of the major causes of morbidity and mortality. Its recovery and treatment depends on close clinical monitoring by a clinician especially during the first few hours after the onset of stroke. Patients who do not exhibit early motor recovery post thrombolysis may benefit from more aggressive treatment. A novel approach for monitoring stroke during the first few hours after the onset of stroke using a wireless accelerometer based motor activity monitoring system is developed. It monitors the motor activity by measuring the acceleration of the arms in three axes. In the presented proof of concept study, the measured acceleration data is transferred wirelessly using iMote2 platform to the base station that is equipped with an online algorithm capable of calculating an index equivalent to the National Institute of Health Stroke Score (NIHSS) motor index. The system is developed by collecting data from 15 patients. We have successfully demonstrated an end-to-end stroke monitoring system reporting an accuracy of calculating stroke index of more than 80%, highest Cohen's overall agreement of 0.91 (with excellent κ coefficient of 0.76). A wireless accelerometer based 'hot stroke' monitoring system is developed to monitor the motor recovery in acute-stroke patients. It has been shown to monitor stroke patients continuously, which has not been possible so far with high reliability.

Field Validation of the Los Angeles Motor Scale as a Tool for Paramedic Assessment of Stroke Severity.

PubMed

Kim, Joon-Tae; Chung, Pil-Wook; Starkman, Sidney; Sanossian, Nerses; Stratton, Samuel J; Eckstein, Marc; Pratt, Frank D; Conwit, Robin; Liebeskind, David S; Sharma, Latisha; Restrepo, Lucas; Tenser, May-Kim; Valdes-Sueiras, Miguel; Gornbein, Jeffrey; Hamilton, Scott; Saver, Jeffrey L

2017-02-01

The Los Angeles Motor Scale (LAMS) is a 3-item, 0- to 10-point motor stroke-deficit scale developed for prehospital use. We assessed the convergent, divergent, and predictive validity of the LAMS when performed by paramedics in the field at multiple sites in a large and diverse geographic region. We analyzed early assessment and outcome data prospectively gathered in the FAST-MAG trial (Field Administration of Stroke Therapy-Magnesium phase 3) among patients with acute cerebrovascular disease (cerebral ischemia and intracranial hemorrhage) within 2 hours of onset, transported by 315 ambulances to 60 receiving hospitals. Among 1632 acute cerebrovascular disease patients (age 70±13 years, male 57.5%), time from onset to prehospital LAMS was median 30 minutes (interquartile range 20-50), onset to early postarrival (EPA) LAMS was 145 minutes (interquartile range 119-180), and onset to EPA National Institutes of Health Stroke Scale was 150 minutes (interquartile range 120-180). Between the prehospital and EPA assessments, LAMS scores were stable in 40.5%, improved in 37.6%, and worsened in 21.9%. In tests of convergent validity, against the EPA National Institutes of Health Stroke Scale, correlations were r=0.49 for the prehospital LAMS and r=0.89 for the EPA LAMS. Prehospital LAMS scores did diverge from the prehospital Glasgow Coma Scale, r=-0.22. Predictive accuracy (adjusted C statistics) for nondisabled 3-month outcome was as follows: prehospital LAMS, 0.76 (95% confidence interval 0.74-0.78); EPA LAMS, 0.85 (95% confidence interval 0.83-0.87); and EPA National Institutes of Health Stroke Scale, 0.87 (95% confidence interval 0.85-0.88). In this multicenter, prospective, prehospital study, the LAMS showed good to excellent convergent, divergent, and predictive validity, further establishing it as a validated instrument to characterize stroke severity in the field. © 2017 American Heart Association, Inc.

Risks of Death and Stroke in Patients Undergoing Hemodialysis With New-Onset Atrial Fibrillation: A Competing-Risk Analysis of a Nationwide Cohort.

PubMed

Shih, Chia-Jen; Ou, Shuo-Ming; Chao, Pei-Wen; Kuo, Shu-Chen; Lee, Yi-Jung; Yang, Chih-Yu; Tarng, Der-Cherng; Lin, Chih-Ching; Huang, Po-Hsun; Li, Szu-Yuan; Chen, Yung-Tai

2016-01-19

Whether oral anticoagulant use should be considered in patients undergoing hemodialysis with atrial fibrillation (AF) remains controversial because of the uncertainty regarding risk-benefit assessments. The purpose of this study was to investigate the risk of ischemic stroke in patients undergoing hemodialysis with new-onset AF, in comparison with those without arrhythmia. This nationwide, population-based, propensity score-matched cohort study used data from Taiwan's National Health Insurance Research Database during 1998 to 2011 for patients on hemodialysis with new-onset nonvalvular AF and matched subjects without arrhythmia. The clinical end points were ischemic stroke (fatal or nonfatal), all-cause death, and other serious adverse cardiovascular events. In comparison with the matched cohort, patients with AF (n=6772) had higher risks of ischemic stroke (adjusted hazard ratio [aHR], 1.27; 95% confidence interval [CI], 1.13-1.43), all-cause death (aHR, 1.59; 95% CI, 1.52-1.67), in-hospital cardiovascular death (aHR, 1.83; 95% CI, 1.71-1.94), myocardial infarction (aHR, 1.33; 95% CI, 1.17-1.51), and hospitalization for heart failure (aHR, 1.90; 95% CI, 1.76-2.05). After considering in-hospital death as a competing risk, AF significantly increased the risk of heart failure (HR, 1.56; 95% CI, 1.45-1.68), but not those of ischemic stroke and myocardial infarction. Additionally, the predictive value of the CHA2DS2-VASc score for ischemic stroke was diminished in the competing-risk model. The risk of stroke was only modestly higher in patients undergoing hemodialysis with new-onset AF than in those without AF, and it became insignificant when accounting for the competing risk of in-hospital death. © 2015 American Heart Association, Inc.

Stroke localization and classification using microwave tomography with k-means clustering and support vector machine.

PubMed

Guo, Lei; Abbosh, Amin

2018-05-01

For any chance for stroke patients to survive, the stroke type should be classified to enable giving medication within a few hours of the onset of symptoms. In this paper, a microwave-based stroke localization and classification framework is proposed. It is based on microwave tomography, k-means clustering, and a support vector machine (SVM) method. The dielectric profile of the brain is first calculated using the Born iterative method, whereas the amplitude of the dielectric profile is then taken as the input to k-means clustering. The cluster is selected as the feature vector for constructing and testing the SVM. A database of MRI-derived realistic head phantoms at different signal-to-noise ratios is used in the classification procedure. The performance of the proposed framework is evaluated using the receiver operating characteristic (ROC) curve. The results based on a two-dimensional framework show that 88% classification accuracy, with a sensitivity of 91% and a specificity of 87%, can be achieved. Bioelectromagnetics. 39:312-324, 2018. © 2018 Wiley Periodicals, Inc. © 2018 Wiley Periodicals, Inc.

Twelve-month experience of acute stroke thrombolysis in Christchurch, New Zealand: emergency department screening and acute stroke service treatment.

PubMed

Fink, John

2005-05-06

To determine the safety and efficiency of an acute stroke thrombolysis service in a New Zealand public hospital setting. A 12-month audit of patients referred to the Christchurch Hospital Stroke Thrombolysis Service (STS) between 1 April 2002 and 31 March 2003 was undertaken. Sixty-one patients were referred to the STS during the study period, of whom 16 were treated with tissue plasminogen activator (t-PA). For treated patients, the median time from stroke onset to hospital presentation was 60 minutes, 'door-to-CT' time was 60 minutes, and the 'door-to-needle' time was 99 minutes. Minor protocol violations were recorded in two patients, but did not influence outcome. No patient was treated after 3 hours of stroke onset. Intracerebral haemorrhage occurred in two patients: one patient was significantly improved compared with pre-treatment status; a minor temporary deterioration occurred in the other patient. Eight of 16 patients had improved by 4 or more points on the NIH Stroke Scale Score at 24 hours. Acute stroke thrombolysis can be delivered safely and in accordance with internationally accepted guidelines using the Christchurch Hospital STS model of emergency department screening and acute stroke service treatment. Further improvements in performance of the STS remain possible.

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

PubMed

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

2014-01-01

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

Guidelines for the treatment of acute ischaemic stroke.

PubMed

Alonso de Leciñana, M; Egido, J A; Casado, I; Ribó, M; Dávalos, A; Masjuan, J; Caniego, J L; Martínez Vila, E; Díez Tejedor, E; Fuentes, B; Álvarez-Sabin, J; Arenillas, J; Calleja, S; Castellanos, M; Castillo, J; Díaz-Otero, F; López-Fernández, J C; Freijo, M; Gállego, J; García-Pastor, A; Gil-Núñez, A; Gilo, F; Irimia, P; Lago, A; Maestre, J; Martí-Fábregas, J; Martínez-Sánchez, P; Molina, C; Morales, A; Nombela, F; Purroy, F; Rodríguez-Yañez, M; Roquer, J; Rubio, F; Segura, T; Serena, J; Simal, P; Tejada, J; Vivancos, J

2014-03-01

Update of Acute Ischaemic Stroke Treatment Guidelines of the Spanish Neurological Society based on a critical review of the literature. Recommendations are made based on levels of evidence from published data and studies. Organized systems of care should be implemented to ensure access to the optimal management of all acute stroke patients in stroke units. Standard of care should include treatment of blood pressure (should only be treated if values are over 185/105 mmHg), treatment of hyperglycaemia over 155 mg/dl, and treatment of body temperature with antipyretic drugs if it rises above 37.5 °C. Neurological and systemic complications must be prevented and promptly treated. Decompressive hemicraniectomy should be considered in cases of malignant cerebral oedema. Intravenous thrombolysis with rtPA should be administered within 4.5 hours from symptom onset, except when there are contraindications. Intra-arterial pharmacological thrombolysis can be considered within 6 hours, and mechanical thrombectomy within 8 hours from onset, for anterior circulation strokes, while a wider window of opportunity up to 12-24 hours is feasible for posterior strokes. There is not enough evidence to recommend routine use of the so called neuroprotective drugs. Anticoagulation should be administered to patients with cerebral vein thrombosis. Rehabilitation should be started as early as possible. Treatment of acute ischaemic stroke includes management of patients in stroke units. Systemic thrombolysis should be considered within 4.5 hours from symptom onset. Intra-arterial approaches with a wider window of opportunity can be an option in certain cases. Protective and restorative therapies are being investigated. Copyright © 2011 Sociedad Española de Neurología. Published by Elsevier Espana. All rights reserved.

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

PubMed

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

2007-10-01

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

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.

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

PubMed Central

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

2015-01-01

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

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

PubMed Central

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

2017-01-01

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

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

PubMed

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

2017-01-01

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

Power of an Adaptive Trial Design for Endovascular Stroke Studies: Simulations Using IMS (Interventional Management of Stroke) III Data.

PubMed

Lansberg, Maarten G; Bhat, Ninad S; Yeatts, Sharon D; Palesch, Yuko Y; Broderick, Joseph P; Albers, Gregory W; Lai, Tze L; Lavori, Philip W

2016-12-01

Adaptive trial designs that allow enrichment of the study population through subgroup selection can increase the chance of a positive trial when there is a differential treatment effect among patient subgroups. The goal of this study is to illustrate the potential benefit of adaptive subgroup selection in endovascular stroke studies. We simulated the performance of a trial design with adaptive subgroup selection and compared it with that of a traditional design. Outcome data were based on 90-day modified Rankin Scale scores, observed in IMS III (Interventional Management of Stroke III), among patients with a vessel occlusion on baseline computed tomographic angiography (n=382). Patients were categorized based on 2 methods: (1) according to location of the arterial occlusive lesion and onset-to-randomization time and (2) according to onset-to-randomization time alone. The power to demonstrate a treatment benefit was based on 10 000 trial simulations for each design. The treatment effect was relatively homogeneous across categories when patients were categorized based on arterial occlusive lesion and time. Consequently, the adaptive design had similar power (47%) compared with the fixed trial design (45%). There was a differential treatment effect when patients were categorized based on time alone, resulting in greater power with the adaptive design (82%) than with the fixed design (57%). These simulations, based on real-world patient data, indicate that adaptive subgroup selection has merit in endovascular stroke trials as it substantially increases power when the treatment effect differs among subgroups in a predicted pattern. © 2016 American Heart Association, Inc.

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.

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

PubMed

Manawadu, Dulka; Choyi, Jithesh; Kalra, Lalit

2014-01-01

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

Gross domestic product and health expenditure associated with incidence, 30-day fatality, and age at stroke onset: a systematic review.

PubMed

Sposato, Luciano A; Saposnik, Gustavo

2012-01-01

Differences in definitions of socioeconomic status and between study designs hinder their comparability across countries. We aimed to analyze the correlation between 3 widely used macrosocioeconomic status indicators and clinical outcomes. We selected population-based studies reporting incident stroke risk and/or 30-day case-fatality according to prespecified criteria. We used 3 macrosocioeconomic status indicators that are consistently defined by international agencies: per capita gross domestic product adjusted for purchasing power parity, total health expenditures per capita at purchasing power parity, and unemployment rate. We examined the correlation of each macrosocioeconomic status indicator with incident risk of stroke, 30-day case-fatality, proportion of hemorrhagic strokes, and age at stroke onset. Twenty-three articles comprising 30 population-based studies fulfilled the eligibility criteria. Age-adjusted incident risk of stroke using the standardized World Health Organization World population was associated to lower per capita gross domestic product adjusted for purchasing power parity (ρ=-0.661, P=0.027, R(2)=0.32) and total health expenditures per capita at purchasing power parity (ρ=-0.623, P=0.040, R(2)=0.26). Thirty-day case-fatality rates and proportion of hemorrhagic strokes were also related to lower per capita gross domestic product adjusted for purchasing power parity and total health expenditures per capita at purchasing power parity. Moreover, stroke occurred at a younger age in populations with low per capita gross domestic product adjusted for purchasing power parity and total health expenditures per capita at purchasing power parity. There was no correlation between unemployment rates and outcome measures. Lower per capita gross domestic product adjusted for purchasing power parity and total health expenditures per capita at purchasing power parity were associated with higher incident risk of stroke, higher case-fatality, a greater proportion of hemorrhagic strokes, and lower age at stroke onset. As a result, these macrosocioeconomic status indicators may be used as proxy measures of quality of primary prevention and acute care and considered as important factors for developing strategies aimed at improving worldwide stroke care.

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.

Atrial fibrillation and risk of stroke in dialysis patients

PubMed Central

Wetmore, James B.; Ellerbeck, Edward F.; Mahnken, Jonathan D.; Phadnis, Milind; Rigler, Sally K.; Mukhopadhyay, Purna; Spertus, John A.; Zhou, Xinhua; Hou, Qingjiang; Shireman, Theresa I.

2013-01-01

Purpose Both stroke and chronic atrial fibrillation (AF) are common in dialysis patients, but uncertainty exists in the incidence of new strokes and the risk conferred by chronic AF. Methods A cohort of dually-eligible (Medicare & Medicaid) incident dialysis patients was constructed. Medicare claims were used to determine the onset of chronic AF, which was specifically treated as a time-dependent covariate. Cox proportional hazards models were used to model time to stroke. Results Of 56,734 patients studied, 5629 (9.9%) developed chronic AF. There were 22.8 ischemic and 5.0 hemorrhagic strokes per 1000 patient-years, a ratio of approximately 4.5:1. Chronic AF was independently associated with time to ischemic (HR 1.26, 99% CI’s 1.06 – 1.49, P = 0.0005), but not hemorrhagic, stroke. Race was strongly associated with hemorrhagic stroke: African-Americans (HR 1.46, 99% CI’s 1.08 – 1.96), Hispanics (HR 1.64, 99% CI’s 1.16 – 2.31), and others (HR 1.76, 99% CI’s 1.16 – 2.78) had higher rates than did Caucasians (P < 0.001 for all). Conclusions Chronic AF has a significant, but modest, association with ischemic stroke. Race/ethnicity is strongly associated with hemorrhagic strokes. The proportion of strokes due to hemorrhage is much higher than in the general population. PMID:23332588

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

PubMed

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

2017-06-01

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

Does evidence really matter? Professionals’ opinions on the practice of early mobilization after stroke

PubMed Central

Sjöholm, Anna; Skarin, Monica; Linden, Thomas; Bernhardt, Julie

2011-01-01

Introduction: Early mobilization after stroke may be important for a good outcome and it is currently recommended in a range of international guidelines. The evidence base, however, is limited and clear definitions of what constitutes early mobilization are lacking. Aims: To explore stroke care professionals’ opinions about (1) when after stroke, first mobilization should take place, (2) whether early mobilization may affect patients’ final outcome, and (3) what level of evidence they require to be convinced that early mobilization is beneficial. Methods: A nine-item questionnaire was used to interview stroke care professionals during a conference in Sydney, Australia. Results: Among 202 professionals interviewed, 40% were in favor of mobilizing both ischemic and hemorrhagic stroke patients within 24 hours of stroke onset. There was no clear agreement about the optimal time point beyond 24 hours. Most professionals thought that patients’ final motor outcome (76%), cognitive outcome (57%), and risk of depression (75%) depends on being mobilized early. Only 19% required a large randomized controlled trial or a systematic review to be convinced of benefit. Conclusion: The spread in opinion reflects the absence of clear guidelines and knowledge in this important area of stroke recovery and rehabilitation, which suggests further research is required. PMID:22096341

Citicoline for Acute Ischemic Stroke: A Systematic Review and Formal Meta-analysis of Randomized, Double-Blind, and Placebo-Controlled Trials.

PubMed

Secades, Julio J; Alvarez-Sabín, José; Castillo, José; Díez-Tejedor, Exuperio; Martínez-Vila, Eduardo; Ríos, José; Oudovenko, Natalia

2016-08-01

Citicoline is a drug approved for the treatment of acute ischemic stroke. Although evidence of its efficacy has been reported, recently published results of a large placebo-controlled clinical trial did not show differences. This study aims to assess whether starting citicoline treatment within 14 days after stroke onset improves the outcome in patients with acute ischemic stroke, as compared with placebo. A systematic search was performed to identify all published, unconfounded, randomized, double-blind, and placebo-controlled clinical trials of citicoline in acute ischemic stroke. Ten randomized clinical trials met our inclusion criteria. The administration of citicoline was associated with a significant higher rate of independence, independently of the method of evaluation used (odds ratio [OR] 1.56, 95% confidence interval [CI] = 1.12-2.16 under random effects; OR 1.20, 95% CI = 1.06-1.36 under fixed effects). After studying the cumulative meta-analysis, and with the results obtained with the subgroup of patients who were not treated with recombinant tissue plasminogen activator (rtPA) (OR 1.63, 95% CI = 1.18-2.24 under random effects; OR 1.42, 95% CI = 1.22-1.66 under fixed effects), our hypothesis of dilution of the effect of citicoline was confirmed. When we analyzed the effect of citicoline in patients who were not treated with rtPA and were receiving the highest dose of citicoline started in the first 24 hours after onset, based on more recent trials, there was no heterogeneity, and the size of the effect has an OR of 1.27 (95% CI = 1.05-1.53). This systematic review supports some benefits of citicoline in the treatment of acute ischemic stroke. But, on top of the best treatment available (rtPA), citicoline offers a limited benefit. Copyright © 2016 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Post-epilepsy stroke: A review.

PubMed

Jin, Jing; Chen, Rong; Xiao, Zheng

2016-01-01

Stroke and epilepsy are two of the most common neurological disorders and share a complicated relationship. It is well established that stroke is one of the most important causes of epilepsy, particularly new-onset epilepsy among the elderly. However, post-epilepsy stroke has been overlooked. In recent years, it has been demonstrated that epilepsy patients have increased risk and mortality from stroke when compared with the general population. Additionally, it was proposed that post-epilepsy stroke might be associated with antiepileptic drugs (AEDs), epileptic seizures and the lifestyle of epileptic patients. Here, we comprehensively review the epidemiology, causes and interventions for post-epilepsy stroke.

Rapid resolution of diffusion weighted MRI abnormality in a patient with a stuttering stroke

PubMed Central

Peters, Jurriaan M; MacLean, Ainsley V; Young, Geoffrey S

2010-01-01

We report the unusually rapid and spontaneous normalisation of low diffusivity that accompanied resolution of acute neurological deficits in a stroke patient who underwent two magnetic resonance imaging examinations within 24 h of symptom onset. Diffusion weighted imaging obtained within hours of onset of left sided weakness demonstrated a focal right capsular area of low diffusivity that resolved within 24 h, coinciding with resolution of the patient’s symptoms. PMID:22315635

Quality of life in stroke survivors under the sixty years of age.

PubMed

Vidović, Mirjana; Sinanović, Osman; Smajlović, Dzevdet

2007-08-01

The objective of the study was to analyze the quality of life six months after stroke in survivors under sixty years of age, to determine which life activities was the most affected, as well as to correlate the neurological insufficiency and the quality of life. It monitored 200 stroke survivors under sixty years of age treated at the Department of Neurology, University Clinical Centre Tuzla. Average age was 51,83 years (+/-7,02). The ischemic stroke was diagnosed in 77,5% stroke survivors, cerebral hemorrhage in 15%, and subarachnoid hemorrhage in 7,5%. Five stroke survivors suffered hemiplegia (2,5%), 24 (12%) experienced moderate consequences and 143 (71,5%) had mild consequences. No neurological deficit had 28 (14%) stroke survivors. Six months after the onset of disease all stroke survivors have been followed-up and evaluated about quality of life by filling in a modified questionnaire: Questionnaire on Quality of Life after Stroke (2). The questionnaire contained 20 questions covering four fields of life: Working Ability, Home Activity, Family Relations and Leisure Activities. Six months after the onset of stroke a worse quality of life in comparison to the period before the disease was noted in 172 (86%) stroke survivors, the unchanged in 19 (9,5%) and better in 9 (4,5%). The most affected is the field "Leisure Activities", followed by "Family Relations", "Home Activity", and the least affected is "Work Ability". The neurological deficit significantly correlates to the "Home Activities" and "Leisure Activities".

Sleep apnea syndrome and patent foramen ovale: a dangerous association in ischemic stroke?

PubMed

Tur, Silvia; de la Peña, Mónica; Vives, Bárbara; Martínez, Ana Belén; Gorospe, Arantza; Legarda, Inés; Torres, Maria José; Jiménez, Carmen; Soriano, Joan B

2016-09-01

The coexistence of patent foramen ovale (PFO) and sleep apnea syndrome (SAS) might be related to the pathogenesis of cryptogenic stroke (CS). We aimed to determine the prevalence of SAS in patients with cryptogenic stroke and PFO. This is a prospective case-control study in which we included ischemic stroke patients consecutively admitted to our hospital's Acute Stroke Unit. Contrast transcranial Doppler (c-TCD) and sleep polygraphy within the first 72 h after stroke onset were performed to detect PFO and SAS. Demographic and clinical characteristics, time of stroke onset, score in the National Institute of Health Stroke Scale (NIHSS), and stroke subtype were registered. A total of 97 patients were studied. Overall, 76% were men, with a mean ± SD age of 61 ± 13 years, and an NIHSS of 5 ± 5. Subtype of stroke was cryptogenic (CS) in 28 (29%) and non-CS in 69 (71%) of patients. PFO was more frequent among patients with CS (64% vs 29%, p = 0.002) and without SAS (60% vs 32%, p = 0.013). SAS was diagnosed in 74% of the whole group, with a higher prevalence in patients with known stroke etiology (83% vs 53%, p = 0.003). Finally, the prevalence of SAS and PFO coexistence was similar in patients with or without cryptogenic stroke (25% vs 22%, p = 1), and when comparing the group of patients with cryptogenic wake-up stroke to the other stroke patients (43% vs 21%, p = 0.35). According to our results, there is no evidence of an association of PFO and SAS in the pathogenesis of cryptogenic stroke. Copyright © 2016 Elsevier B.V. All rights reserved.

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.

Recovery of Hypersomnia Concurrent With Recovery of an Injured Ascending Reticular Activating System in a Stroke Patient

PubMed Central

Jang, Sung Ho; Lee, Han Do; Chang, Chul Hoon; Jung, Young Jin

2016-01-01

Abstract We report on a stroke patient who showed recovery of hypersomnia concurrent with the recovery of an injured ascending reticular activating system (ARAS), which was demonstrated by diffusion tensor tractography (DTT). A 70-year-old female patient underwent coiling of the left ruptured posterior communicating artery after subarachnoid hemorrhage and both extraventricular drainage for management of an intraventricular hemorrhage. At 2 months after onset, when she started rehabilitation, she exhibited intact consciousness, with the full score on the Glasgow Coma Scale: 15. However, she showed severe hypersomnia: she always fell asleep without external stimulation and the Epworth Sleepiness Scale (EPS) score was 24 (full score: 24, cut off for hypersomnia: 10). She underwent comprehensive rehabilitative therapy, including neurotropic drugs, physical therapy, and occupational therapy. Her hypersomnia has shown improvement as 14 (3 months after onset), 11 (4 months after onset), 7 (12 months after onset), and 6 (24 months after onset), respectively. On 2-month DTT, narrowing of both lower dorsal and ventral ARASs was observed on both sides: in particular, among 4 neural tracts of the lower ARAS, the right lower ventral ARAS was the narrowest. By contrast, on 24-month DTT, the 4 narrowed neural tracts of both lower dorsal and ventral ARASs were thickened compared with those of 2-month DTT. Recovery of hypersomnia with recovery of an injured lower ARAS on DTT was observed in a stroke patient. Our results suggest that evaluation of the lower ARAS using DTT might be useful for stroke patients with hypersomnia. PMID:26765455

Time to Reperfusion and Treatment Effect for Acute Ischemic Stroke: A Randomized Clinical Trial.

PubMed

Fransen, Puck S S; Berkhemer, Olvert A; Lingsma, Hester F; Beumer, Debbie; van den Berg, Lucie A; Yoo, Albert J; Schonewille, Wouter J; Vos, Jan Albert; Nederkoorn, Paul J; Wermer, Marieke J H; van Walderveen, Marianne A A; Staals, Julie; Hofmeijer, Jeannette; van Oostayen, Jacques A; Lycklama À Nijeholt, Geert J; Boiten, Jelis; Brouwer, Patrick A; Emmer, Bart J; de Bruijn, Sebastiaan F; van Dijk, Lukas C; Kappelle, L Jaap; Lo, Rob H; van Dijk, Ewoud J; de Vries, Joost; de Kort, Paul L M; van den Berg, J S Peter; van Hasselt, Boudewijn A A M; Aerden, Leo A M; Dallinga, René J; Visser, Marieke C; Bot, Joseph C J; Vroomen, Patrick C; Eshghi, Omid; Schreuder, Tobien H C M L; Heijboer, Roel J J; Keizer, Koos; Tielbeek, Alexander V; den Hertog, Heleen M; Gerrits, Dick G; van den Berg-Vos, Renske M; Karas, Giorgos B; Steyerberg, Ewout W; Flach, H Zwenneke; Marquering, Henk A; Sprengers, Marieke E S; Jenniskens, Sjoerd F M; Beenen, Ludo F M; van den Berg, René; Koudstaal, Peter J; van Zwam, Wim H; Roos, Yvo B W E M; van Oostenbrugge, Robert J; Majoie, Charles B L M; van der Lugt, Aad; Dippel, Diederik W J

2016-02-01

Intra-arterial treatment (IAT) for acute ischemic stroke caused by intracranial arterial occlusion leads to improved functional outcome in patients treated within 6 hours after onset. The influence of treatment delay on treatment effect is not yet known. To evaluate the influence of time from stroke onset to the start of treatment and from stroke onset to reperfusion on the effect of IAT. The Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands (MR CLEAN) was a multicenter, randomized clinical open-label trial of IAT vs no IAT in 500 patients. The time to the start of treatment was defined as the time from onset of symptoms to groin puncture (TOG). The time from onset of treatment to reperfusion (TOR) was defined as the time to reopening the vessel occlusion or the end of the procedure in cases for which reperfusion was not achieved. Data were collected from December 3, 2010, to June 3, 2014, and analyzed (intention to treat) from July 1, 2014, to September 19, 2015. Main outcome was the modified Rankin Scale (mRS) score for functional outcome (range, 0 [no symptoms] to 6 [death]). Multiple ordinal logistic regression analysis estimated the effect of treatment and tested for the interaction of time to randomization, TOG, and TOR with treatment. The effect of treatment as a risk difference on reaching independence (mRS score, 0-2) was computed as a function of TOG and TOR. Calculations were adjusted for age, National Institutes of Health Stroke Scale score, previous stroke, atrial fibrillation, diabetes mellitus, and intracranial arterial terminus occlusion. Among 500 patients (58% male; median age, 67 years), the median TOG was 260 (interquartile range [IQR], 210-311) minutes; median TOR, 340 (IQR, 274-395) minutes. An interaction between TOR and treatment (P = .04) existed, but not between TOG and treatment (P = .26). The adjusted risk difference (95% CI) was 25.9% (8.3%-44.4%) when reperfusion was reached at 3 hours, 18.8% (6.6%-32.6%) at 4 hours, and 6.7% (0.4%-14.5%) at 6 hours. For every hour of reperfusion delay, the initially large benefit of IAT decreases; the absolute risk difference for a good outcome is reduced by 6% per hour of delay. Patients with acute ischemic stroke require immediate diagnostic workup and IAT in case of intracranial arterial vessel occlusion. trialregister.nl Identifier: NTR1804.

Clinical tests performed in acute stroke identify the risk of falling during the first year: postural stroke study in Gothenburg (POSTGOT).

PubMed

Persson, Carina U; Hansson, Per-Olof; Sunnerhagen, Katharina S

2011-03-01

To assess the likelihood of clinical tests for postural balance, walking and motor skills, performed during the first week after stroke, identifying the risk of falling. Prospective study. Patients with first stroke. Assessments were carried out during the first week, and the occurrence of falls was recorded 3, 6 and 12 months after stroke onset. The tests used were: 10-Metre Walking Test (10MWT), Timed Up & Go, Swedish Postural Assessment Scale for Stroke Patients, Berg Balance Scale and Modified Motor Assessment Scale. Cut-off levels were obtained by receiver operation characteristic curves, and odds ratios were used to assess cut-off levels for falling. The analyses were based on 96 patients. Forty-eight percent had at least one fall during the first year. All tests were associated with the risk of falling. The highest predictive values were found for the 10MWT (positive predictive value 64%, negative predictive value 76%). Those subjects who were unable to perform the 10MWT had the highest odds ratio, 6.06 (95% confidence interval 2.66-13.84, p<0.001) of falling. Clinical tests used during the first week after stroke onset can, to some extent, identify those patients at risk of falling during the first year after stroke.

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

Ethnicity and Onset of Cardiovascular Disease: A CALIBER Study

ClinicalTrials.gov

2017-06-07

Abdominal Aortic Aneurysm; Coronary Heart Disease; Sudden Cardiac Death; Intracerebral Haemorrhage; Heart Failure; Ischemic Stroke; Myocardial Infarction; Stroke; Peripheral Arterial Disease; Stable Angina Pectoris; Subarachnoid Haemorrhage; Transient Ischemic Attack; Unstable Angina; Cardiac Arrest

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.

Surgical decompression for space-occupying cerebral infarction (the Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema Trial [HAMLET]): a multicentre, open, randomised trial.

PubMed

Hofmeijer, Jeannette; Kappelle, L Jaap; Algra, Ale; Amelink, G Johan; van Gijn, Jan; van der Worp, H Bart

2009-04-01

Patients with space-occupying hemispheric infarctions have a poor prognosis, with case fatality rates of up to 80%. In a pooled analysis of randomised trials, surgical decompression within 48 h of stroke onset reduced case fatality and improved functional outcome; however, the effect of surgery after longer intervals is unknown. The aim of HAMLET was to assess the effect of decompressive surgery within 4 days of the onset of symptoms in patients with space-occupying hemispheric infarction. Patients with space-occupying hemispheric infarction were randomly assigned within 4 days of stroke onset to surgical decompression or best medical treatment. The primary outcome measure was the modified Rankin scale (mRS) score at 1 year, which was dichotomised between good (0-3) and poor (4-6) outcome. Other outcome measures were the dichotomy of mRS score between 4 and 5, case fatality, quality of life, and symptoms of depression. Analysis was by intention to treat. This trial is registered, ISRCTN94237756. Between November, 2002, and October, 2007, 64 patients were included; 32 were randomly assigned to surgical decompression and 32 to best medical treatment. Surgical decompression had no effect on the primary outcome measure (absolute risk reduction [ARR] 0%, 95% CI -21 to 21) but did reduce case fatality (ARR 38%, 15 to 60). In a meta-analysis of patients in DECIMAL (DEcompressive Craniectomy In MALignant middle cerebral artery infarction), DESTINY (DEcompressive Surgery for the Treatment of malignant INfarction of the middle cerebral arterY), and HAMLET who were randomised within 48 h of stroke onset, surgical decompression reduced poor outcome (ARR 16%, -0.1 to 33) and case fatality (ARR 50%, 34 to 66). Surgical decompression reduces case fatality and poor outcome in patients with space-occupying infarctions who are treated within 48 h of stroke onset. There is no evidence that this operation improves functional outcome when it is delayed for up to 96 h after stroke onset. The decision to perform the operation should depend on the emphasis patients and relatives attribute to survival and dependency.

ACE-inhibitors versus angiotensin receptor blockers for prevention of events in cardiovascular patients without heart failure - A network meta-analysis.

PubMed

Ricci, Fabrizio; Di Castelnuovo, Augusto; Savarese, Gianluigi; Perrone Filardi, Pasquale; De Caterina, Raffaele

2016-08-15

Angiotensin receptor blockers (ARBs) are a valuable option to reduce cardiovascular (CV) mortality and morbidity in cardiac patients in whom ACE-inhibitors (ACE-Is) cannot be used. However, clinical outcome data from direct comparisons between ACE-Is and ARBs are scarce, and some data have recently suggested superiority of ACE-Is over ARBs. We performed a Bayesian network-meta-analysis, with data from both direct and indirect comparisons, from 27 randomized controlled trials (RCTs), including a total population of 125,330 patients, to assess the effects of ACE-Is and ARBs on the composite endpoint of CV death, myocardial infarction (MI) and stroke, and on all-cause death, new-onset heart failure (HF) and new-onset diabetes mellitus (DM) in high CV risk patients without HF. Using placebo as a common comparator, we found no significant differences between ACE-Is and ARBs in preventing the composite endpoint of CV death, MI and stroke (RR: 0.92; 95% CI 0.78-1.08). When components of the composite outcome were analysed separately, ACEi and ARBs were associated with a similar risk of CV death (RR: 0.92; 95% CI 0.73-1.10), MI (RR: 0.91; 95% CI 0.78-1.07) and stroke (RR: 0.97; 95% CI 0.79-1.19), as well as a similar incident risk of all-cause death (RR: 0.94; 95% CI 0.85-1.05), new-onset HF (RR: 0.92; 95% CI 0.77-1.15) and new-onset DM (RR: 99; 95% CI 0.81-1.21). With the limitations of indirect comparisons, we found that in patients at high CV risk without HF, ARBs were similar to ACE-Is in preventing the composite endpoint of CV death, MI and stroke. Compared with ARBs, we found no evidence of statistical superiority for ACE-Is, as a class, in preventing incident risk of all-cause death, CV death, MI, stroke, new-onset DM and new-onset HF. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Accuracy of paramedic identification of stroke and transient ischemic attack in the field.

PubMed

Smith, W S; Isaacs, M; Corry, M D

1998-01-01

To determine the accuracy of acute stroke identification by paramedics in an urban emergency medical services system. Retrospective chart review of all patient encounters by paramedics resulting in transport to two university hospitals during a six-month period. Subjects were identified by paramedic coding of stroke/transient ischemic attach (TIA) or final hospital discharge ICD-9 diagnosis of acute stroke and TIA. The sensitivity and positive predictive value for paramedic identification of stroke were calculated, and the time intervals from symptom onset to various points along the patients' prehospital and hospital courses were identified. Ninety-six patients were identified, of whom 81 met the diagnosis of acute stroke or TIA. Paramedics identified 49 of these 81 patients (sensitivity 61%). Fifteen patients were identified by paramedics as having a stroke when the patient ultimately had a different diagnosis (positive predictive value 77%) Patients or their families waited on average 2.5 +/- 3.6 (SD) hours before accessing 911, and a mean of 5.1 +/- 4.0 (SD) hours elapsed from symptom onset until head imaging studies were obtained. Paramedics in San Francisco County were correct three-fourths of the time when their documentation listed patients as having stroke/TIA. However, they did not identify 39% of stroke victims, a patient population who may benefit from urgent therapy. A substantial period elapses before stroke victims access 911. This highlights the need to develop an educational program for the community at risk for stroke, and another for paramedics directed toward more accurate identification of acute stroke victims.

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

PubMed

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

2017-01-15

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

Changes in Depressive Symptoms and Subsequent Risk of Stroke in the Cardiovascular Health Study

PubMed Central

Gilsanz, Paola; Kubzansky, Laura D.; Tchetgen Tchetgen, Eric J.; Wang, Qianyi; Kawachi, Ichiro; Patton, Kristen K.; Fitzpatrick, Annette L.; Kop, Willem J.; Longstreth, W.T.; Glymour, M. Maria

2016-01-01

Background and Purpose Depression is associated with stroke, but the effects of changes in depressive symptoms on stroke risk are not well understood. This study examined whether depressive symptom changes across two successive annual assessments were associated with incident stroke the following year. Methods We used visit data from 4,319 participants of the Cardiovascular Health Study who were stroke-free at baseline to examine whether changes in depressive symptoms classified across two consecutive annual assessments predicted incident first stroke during the subsequent year. Depressive symptoms were assessed using the 10-item Center for Epidemiologic Studies Depression scale (CES-D; high vs. low at ≥10). Survival models were inverse probability weighted to adjust for demographics, health behaviors, medical conditions, past depressive symptoms, censoring, and survival. Results During follow-up, 334 strokes occurred. Relative to stable low scores of depressive symptoms, improved depression symptoms were associated with almost no excess risk of stroke (aHR=1.02; 95% CI: 0.66–1.58). New-onset symptoms were non-significantly associated with elevated stroke risk (aHR=1.44; 95% CI: 0.97–2.14) while persistently high depressive symptoms were associated with elevated adjusted hazard of all-cause stroke (aHR=1.65; 95% CI: 1.06–2.56). No evidence for effect modification by race, age, or sex was found. Conclusions Persistently high symptoms of depression predicted elevated hazard of stroke. Participants with improved depressive symptoms had no elevation in stroke risk. Such findings suggest that strategies to reduce depressive symptoms may ameliorate stroke risk. PMID:27924053

Migratory stroke-like lesions in a case of adult-onset mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome and a review of imaging findings.

PubMed

Cai, Stephen S; von Coelln, Rainer; Kouo, Theresa J

2016-12-01

Imaging findings of adult-onset mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome is poorly documented. The authors present a 48-year-old woman with subacute onset of word-finding difficulties and right arm stiffness. Magnetic resonance imaging performed 2 weeks prior revealed left temporal lobe diffusion and fluid-attenuated inversion recovery hyperintensity predominantly involving the cortex. The apparent diffusion coefficient map showed preserved signal in the temporal cortex. Subsequent magnetic resonance imagings demonstrated a new diffusion signal abnormality extending to the left parietal cortex and occipital cortex with resolving diffusion hyperintensity in the temporal lobe. MR spectroscopy showed scattered areas of lactate deposition. Diagnosis of MELAS syndrome was confirmed by genetic analysis. Fluctuating, migratory stroke-like lesions with a predilection for the parietal, temporal, and occipital cortex that do not conform to a vascular territory and a lactate spike at 1.3 ppm on MR spectroscopy are characteristic of MELAS syndrome. Preserved signal intensity on apparent diffusion coefficient is useful to distinguish MELAS syndrome from ischemic infarction where the signal is typically reduced.

Denial and Self-Image in Stroke, Lung Cancer, and Heart Disease Patients

ERIC Educational Resources Information Center

Levine, Jacob; Zigler, Edward

1975-01-01

Stroke, lung cancer, and heart disease patients were found to employ denial, as indicated by the relatively small difference between their real and ideal selves before and after the onset of illness. The greatest amount of denial was found for stroke patients. Cancer patients displayed more denial than did heart patients. (Author)

Hypertension-Induced Vascular Remodeling Contributes to Reduced Cerebral Perfusion and the Development of Spontaneous Stroke in Aged SHRSP Rats

DTIC Science & Technology

2010-01-01

recanalization and reperfusion occurs in up to 50% of cases within 24 h of stroke onset ( Kassem -Moussa and Graffagnino, 2002; Merino et al, 2008...stroke-prone spontaneously hypertensive rat. Eur I Pharmacol574:158-71 Kassem -Moussa H, Graffagnino C (2002) Nonocclusion and spontaneous

Effects of low-level laser therapy (LLLT 808 nm) on lower limb spastic muscle activity in chronic stroke patients.

PubMed

das Neves, Marcele Florêncio; Dos Reis, Mariana César Ribeiro; de Andrade, Eliana Aparecida Fonseca; Lima, Fernanda Pupio Silva; Nicolau, Renata Amadei; Arisawa, Emília Ângela Loschiavo; Andrade, Adriano Oliveira; Lima, Mário Oliveira

2016-09-01

A cerebrovascular accident (CVA) may affect basic motor functions, including spasticity that may be present in the upper extremity and/or the lower extremity, post-stroke. Spasticity causes pain, muscle force reduction, and decreases the time to onset of muscle fatigue. Several therapeutic resources have been employed to treat CVA to promote functional recovery. The clinical use of low-level laser therapy (LLLT) for rehabilitation of muscular disorders has provided better muscle responses. Thus, the aim of this study was to evaluate the effect of the application of LLLT in spastic muscles in patients with spasticity post-CVA. A double-blind clinical trial was conducted with 15 volunteer stroke patients who presented with post-stroke spasticity. Both males and females were treated; the average age was 51.5 ± 11.8 years old; the participants entered the study ranging from 11 to 48 months post-stroke onset. The patients participated in three consecutive phases (control, placebo, and real LLLT), in which all tests of isometric endurance of their hemiparetic lower limb were performed. LLLT (diode laser, 100 mW 808 nm, beam spot area 0.0314 cm(2), 127.39 J/cm(2)/point, 40 s) was applied before isometric endurance. After the real LLLT intervention, we observed significant reduction in the visual analogue scale for pain intensity (p = 0.0038), increased time to onset of muscle fatigue (p = 0.0063), and increased torque peak (p = 0.0076), but no significant change in the root mean square (RMS) value (electric signal in the motor unit during contraction, as obtained with surface electromyography). Our results suggest that the application of LLLT may contribute to increased recruitment of muscle fibers and, hence, to increase the onset time of the spastic muscle fatigue, reducing pain intensity in stroke patients with spasticity, as has been observed in healthy subjects and athletes.

Time-Dependent Computed Tomographic Perfusion Thresholds for Patients With Acute Ischemic Stroke.

PubMed

d'Esterre, Christopher D; Boesen, Mari E; Ahn, Seong Hwan; Pordeli, Pooneh; Najm, Mohamed; Minhas, Priyanka; Davari, Paniz; Fainardi, Enrico; Rubiera, Marta; Khaw, Alexander V; Zini, Andrea; Frayne, Richard; Hill, Michael D; Demchuk, Andrew M; Sajobi, Tolulope T; Forkert, Nils D; Goyal, Mayank; Lee, Ting Y; Menon, Bijoy K

2015-12-01

Among patients with acute ischemic stroke, we determine computed tomographic perfusion (CTP) thresholds associated with follow-up infarction at different stroke onset-to-CTP and CTP-to-reperfusion times. Acute ischemic stroke patients with occlusion on computed tomographic angiography were acutely imaged with CTP. Noncontrast computed tomography and magnectic resonance diffusion-weighted imaging between 24 and 48 hours were used to delineate follow-up infarction. Reperfusion was assessed on conventional angiogram or 4-hour repeat computed tomographic angiography. Tmax, cerebral blood flow, and cerebral blood volume derived from delay-insensitive CTP postprocessing were analyzed using receiver-operator characteristic curves to derive optimal thresholds for combined patient data (pooled analysis) and individual patients (patient-level analysis) based on time from stroke onset-to-CTP and CTP-to-reperfusion. One-way ANOVA and locally weighted scatterplot smoothing regression was used to test whether the derived optimal CTP thresholds were different by time. One hundred and thirty-two patients were included. Tmax thresholds of >16.2 and >15.8 s and absolute cerebral blood flow thresholds of <8.9 and <7.4 mL·min(-1)·100 g(-1) were associated with infarct if reperfused <90 min from CTP with onset <180 min. The discriminative ability of cerebral blood volume was modest. No statistically significant relationship was noted between stroke onset-to-CTP time and the optimal CTP thresholds for all parameters based on discrete or continuous time analysis (P>0.05). A statistically significant relationship existed between CTP-to-reperfusion time and the optimal thresholds for cerebral blood flow (P<0.001; r=0.59 and 0.77 for gray and white matter, respectively) and Tmax (P<0.001; r=-0.68 and -0.60 for gray and white matter, respectively) parameters. Optimal CTP thresholds associated with follow-up infarction depend on time from imaging to reperfusion. © 2015 American Heart Association, Inc.

Factors that influence clinicians' decisions to offer intravenous alteplase in acute ischemic stroke patients with uncertain treatment indication: Results of a discrete choice experiment.

PubMed

De Brún, Aoife; Flynn, Darren; Ternent, Laura; Price, Christopher I; Rodgers, Helen; Ford, Gary A; Rudd, Matthew; Lancsar, Emily; Simpson, Stephen; Teah, John; Thomson, Richard G

2018-01-01

Background Treatment with intravenous alteplase for eligible patients with acute ischemic stroke is underused, with variation in treatment rates across the UK. This study sought to elucidate factors influencing variation in clinicians' decision-making about this thrombolytic treatment. Methods A discrete choice experiment using hypothetical patient vignettes framed around areas of clinical uncertainty was conducted with UK-based clinicians. Mixed logit regression analyses were conducted on the data. Results A total of 138 clinicians completed the discrete choice experiment. Seven patient factors were individually predictive of increased likelihood of immediately offering IV alteplase (compared to reference levels in brackets): stroke onset time 2 h 30 min [50 min]; pre-stroke dependency mRS 3 [mRS 4]; systolic blood pressure 185 mm/Hg [140 mm/Hg]; stroke severity scores of NIHSS 5 without aphasia, NIHSS 14 and NIHSS 23 [NIHSS 2 without aphasia]; age 85 [68]; Afro-Caribbean [white]. Factors predictive of withholding treatment with IV alteplase were: age 95 [68]; stroke onset time of 4 h 15 min [50 min]; severe dementia [no memory problems]; SBP 200 mm/Hg [140 mm/Hg]. Three clinician-related factors were predictive of an increased likelihood of offering IV alteplase (perceived robustness of the evidence for IV alteplase; thrombolyzing more patients in the past 12 months; and high discomfort with uncertainty) and one with a decreased likelihood (high clinician comfort with treating patients outside the licensing criteria). Conclusions Both patient- and clinician-related factors have a major influence on the use of alteplase to treat patients with acute ischemic stroke. Clinicians' views of the evidence, comfort with uncertainty and treating patients outside the license criteria are important factors to address in programs that seek to reduce variation in care quality regarding treatment with IV alteplase. Further research is needed to further understand the differences in clinical decision-making about treating patients with acute ischemic stroke with IV alteplase.

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

PubMed Central

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

2017-01-01

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

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

PubMed Central

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

2013-01-01

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

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

PubMed

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

2018-06-20

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

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

PubMed

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

2017-12-01

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

External validation of the DRAGON score in an elderly Spanish population: prediction of stroke prognosis after IV thrombolysis.

PubMed

Giralt-Steinhauer, Eva; Rodríguez-Campello, Ana; Cuadrado-Godia, Elisa; Ois, Ángel; Jiménez-Conde, Jordi; Soriano-Tárraga, Carolina; Roquer, Jaume

2013-01-01

Intravenous (i.v.) thrombolysis within 4.5 h of symptom onset has proven efficacy in acute ischemic stroke treatment, although half of all outcomes are unfavorable. The recently published DRAGON score aims to predict the 3-month outcome in stroke patients who have received i.v. alteplase. The purpose of this study was an external validation of the results of the DRAGON score in a Spanish cohort. Patients with acute stroke treated with alteplase were prospectively registered in our BasicMar database. We collected demographic characteristics, vascular risk factors, the time from stroke onset to treatment, baseline serum glucose levels and stroke severity for this population. We then reviewed hyperdense cerebral artery signs and signs of early infarct on the admission CT scan. We calculated the DRAGON score and used the developers' 3-month prognosis categories: good [modified Rankin Scale score (mRS) 0-2], poor (mRS 3-6) and miserable (mRS 5-6) outcome. Discrimination was tested using the area under the receiver operator curve (AUC-ROC). Calibration was assessed by the Hosmer-Lemeshow test. Our final cohort of 297 patients was older (median age 74 years, IQR 65-80) and had more risk factors and severe strokes [median National Institutes of Health Stroke Scale (NIHSS) points 13, IQR 7-19] than the original study population. Poor prognosis was observed in 143 (48.1%) patients. Higher DRAGON scores were associated with a higher risk of poor prognosis. None of our treated stroke patients with a DRAGON score ≥8 at admission experienced a favorable outcome after 3 months. All DRAGON variables were significantly associated with a worse outcome in the multivariate analysis except for onset-to-treatment time (p = 0.334). Discrimination to predict poor prognosis was very good (AUC-ROC 0.84) and the score had good Hosmer-Lemeshow calibration (p = 0.84). The DRAGON score is easy to perform and offers a rapid, reliable prediction of poor prognosis in acute-stroke patients treated with alteplase. This study replicates the original results in a different population. Copyright © 2013 S. Karger AG, Basel.

Cost-effectiveness of optimizing acute stroke care services for thrombolysis.

PubMed

Penaloza-Ramos, Maria Cristina; Sheppard, James P; Jowett, Sue; Barton, Pelham; Mant, Jonathan; Quinn, Tom; Mellor, Ruth M; Sims, Don; Sandler, David; McManus, Richard J

2014-02-01

Thrombolysis in acute stroke is effective up to 4.5 hours after symptom onset but relies on early recognition, prompt arrival in hospital, and timely brain scanning. This study aimed to establish the cost-effectiveness of increasing thrombolysis rates through a series of hypothetical change strategies designed to optimize the acute care pathway for stroke. A decision-tree model was constructed, which relates the acute management of patients with suspected stroke from symptom onset to outcome. Current practice was modeled and compared with 7 change strategies designed to facilitate wider eligibility for thrombolysis. The model basecase consisted of data from consenting patients following the acute stroke pathway recruited in participating hospitals with data on effectiveness of treatment and costs from published sources. All change strategies were cost saving while increasing quality-adjusted life years gained. Using realistic estimates of effectiveness, the change strategy with the largest potential benefit was that of better recording of onset time, which resulted in 3.3 additional quality-adjusted life years and a cost saving of US $46,000 per 100,000 population. All strategies increased the number of thrombolysed patients and the number requiring urgent brain imaging (by 9% to 21% dependent on the scenario). Assuming a willingness-to-pay of US $30,000 per quality-adjusted life year gained, the potential budget available to deliver the interventions in each strategy ranged from US $50,000 to US $144,000. These results suggest that any strategy that increases thrombolysis rates will result in cost savings and improved patient quality of life. Healthcare commissioners could consider this model when planning improvements in stroke care.

Social factors influencing hospital arrival time in acute ischemic stroke patients.

PubMed

Iosif, Christina; Papathanasiou, Mathilda; Staboulis, Eleftherios; Gouliamos, Athanasios

2012-04-01

This is a multi-center, hospital-based study aiming to estimate social factors influencing pre-hospital times of arrival in acute ischemic stroke, with a perspective of finding ways to reduce arrival time and to augment the number of patients eligible for intra-arterial thrombolysis. Acute ischemic stroke patients who presented at the emergency units of four major general public hospitals were registered. We assessed information concerning demographics, time of presentation, clinical situation, imaging, treatment, and socioeconomic factors. The sample was divided in two sub-samples, based on the time of arrival since onset of symptoms, and was statistically analyzed. During one calendar year (2005), 907 patients were registered. Among them 34.6% arrived in the first 6 h from symptom onset, 38.7% arrived between 6 and 24 h, 18.1% after 24 h and for 8.6% the time of onset was unknown. Younger age (P = 0.007), transfer with ambulatory service (Ρ = 0.002), living with a mate (Ρ = 0.004), and higher educational level (P < 0.005) were factors which correlated significantly with early arrival at the hospital. Instructing patients at high risk for stroke to live with a housemate appears beneficial for timely arrival at the hospital. The establishment of dedicated acute stroke call and transportation center should improve the percentage of early arrival. A national information campaign is needed to increase the level of awareness of the population concerning beneficial social behaviors and optimal reaction to symptoms of acute ischemic stroke.

ABCD² score may discriminate minor stroke from TIA on patient admission.

PubMed

Zhao, Hui; Li, Qingjie; Lu, Mengru; Shao, Yuan; Li, Jingwei; Xu, Yun

2014-02-01

With the advent of time-dependent thrombolytic therapy for ischemic stroke, it has become increasingly important to differentiate transient ischemic attack (TIA) from minor stroke patients after symptom onset quickly. This study investigated the difference between TIA and minor stroke based on age, blood pressure, clinical features, duration of TIA, presence of diabetes, ABCD² score, digital subtraction angiography (DSA) and blood lipids. One hundred seventy-one patients with clinical manifestations as transient neurological deficits in Nanjing Drum Tower Hospital were studied retrospectively. All patients were evaluated by ABCD² score, blood lipid test, fibrinogen, and Holter electrocardiograph and DSA on admission. Patients were categorized into TIA group or minor stroke group according to CT and MRI scan 24 h within symptom onset. The study suggested that minor stroke patients were more likely to have a higher ABCD² score (odds ratio (OR) 2.060; 95% confidence interval (CI) 1.293-3.264). Receiver-operating characteristic curves identified ABCD² score >4 as the optimal cut-off for minor stroke diagnosis. Total serum cholesterol seemed a better diagnostic indicator to discriminate minor stroke from TIA (OR 4.815; 95% CI 0.946-1.654) than other blood lipids in simple logistic regression, but not valuable for the differentiation between TIA and minor stroke in multivariate logistic regression. Higher severity of intracranial internal carotid stenosis, especially >90%, were more likely to have minor stroke, but was not a reliable diagnostic indicator (P > 0.05). ABCD² could help clinicians to differentiate possible TIA from minor stroke at hospital admission while blood lipid parameters and artery stenosis location offer limited help.

NEUROIMAGING CHARACTERISTICS AND POST-STROKE FATIGUE WITHIN THE FIRST 6 MONTHS AFTER ISCHEMIC STROKES.

PubMed

Delva, M; Delva, I

2017-10-01

Aim - identify neuroimaging characteristics associated with different post-stroke fatigue (PSF) domains within first 6 months after ischemic strokes. There were enrolled in the study 107 patients with acute ischemic strokes. General PSF and certain PSF domains (global, physical, mental, motivational, activity-related) were measured by multidimensional fatigue inventory-20 (MFI-20) scale at hospital stay, in 1, 3 and 6 months after stroke occurrence. Brain MRI studies included cerebral infarct localization, planimetric measurements of infarct volumes, measurement of brain atrophy indexes (bifrontal, bicaudate, cortical atrophy indexes, width of third ventricle) and evaluation of leukoaraiosis severity, according to Fazekas scale. In univariate logistic regression analysis infarcts volumes as well as brain atrophy indexes were not significantly associated with risk of any PSF domain at any time points within first 6 months after ischemic strokes. On the other hand, it had been found reliable associations between subcortical infarcts and increased risk of PSF domains which are related just to physical activity (physical PSF, activity-related PSF) in 1 month after stroke onset and later, as well as reliable associations between infratentorial infarcts and risk of global PSF domain in 3 months after stroke and later. Moreover, it have been revealed significant direct associations between severity of white matter lesions and risk of mental PSF in 3 months after stroke onset and later. Subcortical infarcts may be risk factors for development of physical PSF domain, infratentorial infarcts - risk factors for development of global PSF domain, leukoaraiosis extension - risk factor for development of mental PSF domain but not early than 1 month after stroke occurrence.

Effects of edaravone on muscle atrophy and locomotor function in patients with ischemic stroke: a randomized controlled pilot study.

PubMed

Naritomi, Hiroaki; Moriwaki, Hiroshi; Metoki, Norifumi; Nishimura, Hiroyuki; Higashi, Yasuto; Yamamoto, Yasumasa; Yuasa, Hiroyuki; Oe, Hiroshi; Tanaka, Kortaro; Saito, Kozue; Terayama, Yasuo; Oda, Tadafumi; Tanahashi, Norio; Kondo, Hisao

2010-01-01

Stroke patients with severe leg paralysis are often bedridden in the acute and subacute phase, which increases the risk of disuse muscle atrophy in the chronic phase. The evidence to date indicates that oxidative stress plays an important role in the mechanism of disuse muscle atrophy. Therefore, the aim of this study was to determine if long-term radical scavenger treatment with edaravone following an acute stroke prevents the progression of disuse muscle atrophy and improves leg locomotor function in the chronic phase. This randomized controlled pilot study was conducted at 19 acute stroke and rehabilitation centers across Japan. Forty-seven ischemic stroke patients with at least leg motor weakness admitted within 24 hours of onset were randomly assigned to receive continuous intravenous infusions of edaravone 30 mg twice daily for 3 days (short-term group) or 10-14 days (long-term group). The primary endpoints of the study included the degree of leg disuse muscle atrophy, as measured by the percentage change from baseline in femoral muscle circumference 15 cm above the knee, and the improvement in leg locomotor function, as assessed by the maximum walking speed over 10 m, 3 months after the onset of stroke. Three-month follow-up was completed by a total of 41 patients (21 in the short-term group and 20 in the long-term group). On admission, there was no significant difference in the severity of stroke or the grade of leg paresis between the two treatment groups. The grade of disuse muscle atrophy and incidence of gait impairment 3 weeks after stroke onset were also similar between the short- and long-term groups. However, disuse muscle atrophy of the paretic and non-paretic legs was significantly less severe in the long-term versus the short-term treatment group (3.6 ± 5.9% and 1.5 ± 6.0% vs 8.3 ± 5.2% and 5.7 ± 6.4%; p < 0.01 and p < 0.05) 3 months after stroke onset. Additionally, the maximum walking speed over a distance of 10 m was significantly greater in the long-term group (98 ± 67 vs 54 ± 55 cm/sec; p < 0.05). Edaravone treatment for up to 14 days suppresses the progression of disuse muscle atrophy and improves leg locomotor function to a greater extent than shorter-term treatment in acute stroke patients. This suggests that the management of stroke may be improved with long-term edaravone therapy by providing myoprotective effects that ameliorate functional outcome in the chronic phase.

Combining Standard Conventional Measures and Ecological Momentary Assessment of Depression, Anxiety and Coping Using Smartphone Application in Minor Stroke Population: A Longitudinal Study Protocol

PubMed Central

Vansimaeys, Camille; Zuber, Mathieu; Pitrat, Benjamin; Join-Lambert, Claire; Tamazyan, Ruben; Farhat, Wassim; Bungener, Catherine

2017-01-01

Context: Stroke has several consequences on survivors’ daily life even for those who experience short-lasting neurological symptoms with no functional disability. Depression and anxiety are common psychological disorders occurring after a stroke. They affect long-term outcomes and quality of life but they are difficult to diagnose because of the neurobiological consequences of brain lesions. Current research priority is given to the improvement of the detection and prevention of those post-stroke psychological disorders. Although previous studies have brought promising perspectives, their designs based on retrospective tools involve some limits regarding their ecological validity. Ecological Momentary Assessment (EMA) is an alternative to conventional instruments that could be a key in research for understanding processes that underlined post-stroke depression and anxiety onset. We aim to evaluate the feasibility and validity of anxiety, depression and coping EMA for minor stroke patients. Methods: Patients hospitalized in an Intensive Neuro-vascular Care Unit between April 2016 and January 2017 for a minor stroke is involved in a study based on an EMA methodology. We use a smartphone application in order to assess anxiety and depression symptoms and coping strategies four times a day during 1 week at three different times after stroke (hospital discharge, 2 and 4 months). Participants’ self-reports and clinician-rates of anxiety, depression and coping are collected simultaneously using conventional and standard instruments. Feasibility of the EMA method will be assessed considering the participation and compliance rate. Validity will be the assessed by comparing EMA and conventional self-report and clinician-rated measures. Discussion: We expect this study to contribute to the development of EMA using smartphone in minor stroke population. EMA method offers promising research perspective in the assessment and understanding of post-stroke psychological disorders. The development of EMA in stroke population could lead to clinical implications such as remotely psychological follow-ups during early supported discharge. Trial registration: European Clinical Trials Database Number 2014-A01937-40 PMID:28747895

Community awareness of stroke in Accra, Ghana

PubMed Central

2014-01-01

Background Community awareness of stroke, especially the risk factors and warning signs is important in the control of the disease. In sub-Saharan Africa, little is known about community awareness of stroke though the brunt of stroke is currently borne in this region. The aim of the study was to evaluate stroke awareness in Accra (capital city of Ghana) particularly, the risk factors and warning signs. Methods This was a cross-sectional study involving systematic sampling of 63 households in each of the 11 sub metropolitan areas of Accra. A structured questionnaire was used to collect stroke awareness data from respondents randomly sampled in the selected households. Logistic regression analyses were done to identify predictors of the main outcome variables including recognition of stroke risk factors, stroke warning signs and the organ affected by stroke. Results Only 40% (n = 277) of the 693 respondents correctly identified the brain as the organ affected in stroke. Similarly, less than half of the respondents could recognize any of the established stroke risk factors as well as any of the established stroke warning signs. Over 70% (n > 485) of the respondents either believed that stroke is a preventable disease, or lifestyle alterations can be made to reduce the risk of stroke, or stroke requires emergency treatment. In multivariate analysis, predictors of stroke awareness were: age <50 years (OR = 0.56, CI = 0.35-0.92, p = 0.021), presence of a stroke risk factor (OR = 2.37, CI = 1.52-3.71, p < 0.001) and Christian Religion (OR = 14.86, CI = 1.37-161.01, p = 0.03). Conclusion Though stroke is perceived as a serious and preventable disease in Accra, community awareness of the risk factors and warning signs is sub-optimal. This indicates that community-based education programs to increase public awareness of stroke could contribute to decreasing the risk of stroke and to increasing the speed of hospital presentation after stroke onset. PMID:24559414

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

PubMed Central

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

2016-01-01

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

Long-term outcomes of patent foramen ovale closure or medical therapy after cryptogenic stroke: A meta-analysis of randomized trials.

PubMed

Abdelaziz, Hesham K; Saad, Marwan; Abuomara, Hossamaldin Z; Nairooz, Ramez; Pothineni, Naga Venkata K; Madmani, Mohamed E; Roberts, David H; Mahmud, Ehtisham

2018-05-04

To examine long-term clinical outcomes with transcatheter patent foramen ovale (PFO) closure versus medical therapy alone in patients with cryptogenic stroke. A long-standing debate regarding the optimal approach for the management of patients with PFO after a cryptogenic stroke exists. An electronic search was performed for randomized clinical trials (RCTs) reporting clinical outcomes with PFO closure vs. medical therapy alone after stroke. Random effects DerSimonian-Laird risk ratios (RR) were calculated. The main outcome was recurrence of stroke. Other outcomes included transient ischemic attack (TIA), new-onset atrial fibrillation/flutter (AF/AFL), major bleeding, serious adverse events, and device-related complications. All-cause mortality was also examined. Five RCTs with a total of 3,440 patients were included. At a mean follow-up of 4.02 ± 1.57 years, PFO closure was associated with less recurrence of stroke (RR = 0.43; 95% CI 0.19-0.91; P = .027) compared with medical therapy alone. No difference was observed between both strategies for TIA (P = .21), major bleeding (P = .69), serious adverse events (P = .35), and all-cause death (P = .48). However, PFO closure, was associated with increased new-onset AF/AFL (P < .001), risk of pulmonary embolism (P = .04), and device-related complications (P < .001). On a subgroup analysis, stroke recurrence rate remained lower in PFO closure arm regardless of the type of closure device used (P interaction  = .50), or the presence of substantial shunt in the majority of study population (P interaction  = .13). Transcatheter PFO closure reduces the recurrence of stroke compared with medical therapy alone, with no significant safety concerns. Close follow-up of patients after PFO closure is recommended to detect new-onset atrial arrhythmias. © 2018 Wiley Periodicals, Inc.

A One Year Prospective Study of Neurogenic Stuttering Following Stroke: Incidence and Co-Occurring Disorders

ERIC Educational Resources Information Center

Theys, C.; van Wieringen, A.; Sunaert, S.; Thijs, V.; De Nil, L. F.

2011-01-01

In this prospective study, data on incidence, stuttering characteristics, co-occurring speech disorders, and recovery of neurogenic stuttering in a large sample of stroke participants were assessed. Following stroke onset, 17 of 319 participants (5.3%; 95% CI, 3.2-8.3) met the criteria for neurogenic stuttering. Stuttering persisted in at least…

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

PubMed

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

2015-11-03

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

[Long-term effect of policosanol on the functional recovery of non-cardioembolic ischemic stroke patients: a one year study].

PubMed

Sanchez, J; Illnait, J; Mas, R; Mendoza, S; Fernandez, L; Mesa, M; Vega, H; Fernandez, J; Reyes, P; Ruiz, D

2017-02-16

Stroke is a leading cause of mortality and disability. Policosanol has been effective in brain ischemia models. The aim of this study is to investigate whether policosanol, added to aspirin therapy within 30 days of stroke onset, is better than placebo + aspirine for the long-term recovery of non-cardioembolic ischemic stroke subjects. Randomized, double-blind, placebo-controlled study. Eighty patients (mean age: 69 years) within 30 days of onset, with a modified Rankin Scale score (mRS) 2 to 4, were included. They were randomized in two groups (policosanol + aspirine or placebo + aspirine) for 12 months. Policosanol + aspirine decreased significantly mean mRS from the first interim check-up (1.5 months). The treatment even improved after long-term therapy. More policosanol + aspirin (87.5%) than placebo + aspirine (0%) patients achieved mRSs <= 1. Policosanol + aspirine increased significantly Barthel Index, lowered LDL-cholesterol and increased HDL-cholesterol versus placebo + aspirin. Long-term (12 months) administration of policosanol + aspirin given after suffering non-cardioembolic ischemic stroke was shown to be better than placebo + aspirin in improving functional outcomes when used among patients with non-cardioembolic ischemic stroke of moderate severity.

Sarcopenia and Physical Function in Middle-Aged and Older Stroke Survivors.

PubMed

Ryan, Alice S; Ivey, Frederick M; Serra, Monica C; Hartstein, Joseph; Hafer-Macko, Charlene E

2017-03-01

To determine the prevalence of sarcopenia in stroke survivors using different methodologies, and compare a subset of the stroke group to age-, sex-, and body mass index (BMI)-matched nonstroke control counterparts. Cohort study. A Veterans Affairs medical center and a university hospital. Mild to moderately disabled participants >6 months after onset of stroke aged 40 to 84 years (N=190, 61% men, 57% African American; mean BMI ± SEM, 29±1kg/m 2 ). Not applicable. Dual-energy x-ray absorptiometry scans to assess appendicular lean mass (ALM). Rates of sarcopenia were determined using 4 established methods: (1) ALM/height 2 (ALM/ht 2 ); (2) European Working Group on Sarcopenia in Older Persons; (3) International Working Group on Sarcopenia; and (4) ALM/BMI. Sarcopenia prevalence in our stroke cohort ranged between 14% and 18%. The stroke survivor subset (n=38) matched one-for-one with control counterparts for race, sex, age ±4 years and BMI ±2.5kg/m 2 had higher prevalence rates compared with their nonstroke counterparts (13.2% vs 5.3%, P<.0001). ALM/ht 2 was related to 6-minute walking speed (r=.28, P<.01) and peak oxygen consumption (L/min: r=.58, P<.0001) for the stroke group. Stroke survivors show an elevated prevalence of sarcopenia when considering age, sex, and race compared with nonstroke individuals. Published by Elsevier Inc.

Association between implementation of a code stroke system and poststroke epilepsy.

PubMed

Chen, Ziyi; Churilov, Leonid; Chen, Ziyuan; Naylor, Jillian; Koome, Miriam; Yan, Bernard; Kwan, Patrick

2018-03-27

We aimed to investigate the effect of a code stroke system on the development of poststroke epilepsy. We retrospectively analyzed consecutive patients treated with IV thrombolysis under or outside the code stroke system between 2003 and 2012. Patients were followed up for at least 2 years or until death. Factors with p < 0.1 in univariate comparisons were selected for multivariable logistic and Cox regression. A total of 409 patients met the eligibility criteria. Their median age at stroke onset was 75 years (interquartile range 64-83 years); 220 (53.8%) were male. The median follow-up duration was 1,074 days (interquartile range 119-1,671 days). Thirty-two patients (7.8%) had poststroke seizures during follow-up, comprising 7 (1.7%) with acute symptomatic seizures and 25 (6.1%) with late-onset seizures. Twenty-six patients (6.4%) fulfilled the definition of poststroke epilepsy. Three hundred eighteen patients (77.8%) were treated with the code stroke system while 91 (22.2%) were not. After adjustment for age and stroke etiology, use of the code stroke system was associated with decreased odds of poststroke epilepsy (odds ratio = 0.36, 95% confidence interval 0.14-0.87, p = 0.024). Cox regression showed lower adjusted hazard rates for poststroke epilepsy within 5 years for patients managed under the code stroke system (hazard ratio = 0.60, 95% confidence interval 0.47-0.79, p < 0.001). The code stroke system was associated with reduced odds and instantaneous risk of poststroke epilepsy. Further studies are required to identify the contribution of the individual components and mechanisms against epileptogenesis after stroke. This study provides Class III evidence that for people with acute ischemic stroke, implementation of a code stroke system reduces the risk of poststroke epilepsy. © 2018 American Academy of Neurology.

Life satisfaction two-years after stroke onset: the effects of gender, sex occupational status, memory function and quality of life among stroke patients (Newsqol) and their family caregivers (Whoqol-bref) in Luxembourg

PubMed Central

2012-01-01

Background Life satisfaction (LS) of cerebrovascular disease survivors and their family caregivers may relate to socioeconomic factors, impaired functions, health-related quality of life (QoL), but their respective influences remain unclear. This study assessed, two years post-stroke onset, the effects of these factors on patients’ LS and family caregivers’ LS in Luxembourg. Methods All stroke patients admitted to all hospitals in Luxembourg were identified by the ‘Inspection Général de la Sécurité Sociale’ using the only national system database for care expenditure reimbursement. Their diagnosis was confirmed by medical investigator. The sample included ninety four patients living at home having given consent (mean age 65.5 years) and sixty two main caregivers (mean age 59.3 years). Questionnaires were completed during face-to-face interviews. LS was assessed via European single question (range 1–10), survivors’ QoL via Newsqol (11 dimensions), and caregivers’ QoL via Whoqol-bref (4 domains) (range 0–100). Data were analysed using multiple regression models. Results Two years after stroke onset, 44.7% of patients suffered from impaired sensory function, 35.1% from impaired motor function, and 31.9% from impaired memory function. Mean patient’ LS was 7.1/10 (SD 1.9). It was higher in women (+12.4) and lower among unemployed socioeconomically active patients (−13.1, vs. retired people). Adjusted for sex, occupation, impaired motor and memory functions, LS positively correlated with scores of Newsqol feelings, sleep, emotion, cognition and pain dimensions (slopes 0.20 to 0.31), but did not correlate with those of caregivers’ Whoqol-bref domains. Family caregiver’ LS was 7.2 (SD 1.7). It was lower in those with patients suffering from impaired memory function (−12.8) as well as from feelings and emotion issues (slopes 0.22). It was associated with all caregivers’ Whoqol-bref domains (physical health, psychological health, environment, and social relationships) (slopes 0.53 to 0.68). Conclusions Two-year post-cerebrovascular disease patient’ LS was associated with gender, occupation, and impaired memory function. It correlated with feelings, sleep, emotion, cognition, and pain issues. Family caregivers of patients with impaired memory function had lower LS. Family caregiver’ LS correlated with dimensions of patients’ feelings (less independent, yourself, life changed, depressed, useless, less control because of stroke) and emotion (get more emotional, fear of another stroke or to become dependent on others), and with their own QoL. LS, Newsqol, and Whoqol appeared to be appropriate tools. Our findings may be useful for policy makers in relation to family and medical-social issues of stroke home-based rehabilitation. PMID:23009364

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

PubMed

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

2004-10-01

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

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

PubMed

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

2013-01-01

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

A comparison of stroke rehabilitation; data from two national cohorts.

PubMed

Bērziņa, G; Vētra, A; Sunnerhagen, K S

2016-10-01

Inpatient rehabilitation is a commonly used complex intervention to improve a person's independence after stroke. Evaluation and comparison of the effects of routine clinical practice could provide a contribution towards optimization of stroke care. The aim of this study is to describe results of inpatient rehabilitation as a complex intervention for persons after stroke and explore possible differences between two countries. Data from 1055 Latvian and 1748 Swedish adult patients after stroke receiving inpatient rehabilitation, during 2011-2013, were used for this retrospective cohort study. Qualitative description of systems, as well as information on basic medical and sociodemographic information, and organizational aspects were reported. Change in the Functional Independence Measure during rehabilitation was investigated. In six domains of the instrument, the shifts for three levels of dependence were analysed using ordinal regression analysis. The components of stroke care seem to be similar in Latvia and Sweden. However, the median time since stroke onset until the start of rehabilitation was 13 weeks in Latvia and 2 weeks in Sweden. The median length of rehabilitation was 12 and 49 days, respectively. The level of dependency at start, time since stroke onset and length of the period had an impact on the results of the rehabilitation. Although components of the rehabilitation are reported as being the same, characteristics and the outcome of the inpatient rehabilitation are different. Therefore, comparison of stroke rehabilitation between countries requires caution. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

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

PubMed Central

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

2014-01-01

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

Prehospital use of magnesium sulfate as neuroprotection in acute stroke.

PubMed

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

2015-02-05

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

Hip Hop Stroke: Study Protocol for a Randomized Controlled Trial to Address Stroke Literacy

PubMed Central

Williams, Olajide; Leighton-Herrmann, Ellyn; DeSorbo, Alexandra; Hecht, Mindy; Hedmann, Monique; Huq, Saima; Gerin, William; Chinchilli, Vernon; Ogedegbe, Gbenga; Noble, James

2015-01-01

Objective Stroke is the fifth leading cause of death and the leading cause of serious long-term adult disability in the US. Acute stroke treatments with intravenous thrombolysis and endovascular therapy are proven to reduce disability, however a critical limitation on their effectiveness is the narrow time window for administration, which is 4.5 hours and 6 hours respectively from the onset of symptoms. Our overarching goal is to reduce pre-hospital delays to acute stroke treatments in economically disadvantaged minority communities where the greatest delays exist, using Hip Hop Stroke. Methods Hip Hop Stroke (HHS) is a school-based, child-mediated, culturally-tailored stroke communication multimedia intervention developed using validated models of behavior change and designed to improve stroke literacy (knowledge of stroke symptoms, the urgent need to call 911, and prevention measures) of 4th, 5th and 6th grade students and their parents residing in poor urban communities. Children in the intervention arm will receive the HHS intervention, while those in the attentional control arm will receive standardized nutrition education based on the USDA's MyPyramid program. Children will be trained and motivated to share stroke information with their parents or other adult caregiver. Both children and parents will complete a stroke knowledge assessment at baseline, immediately following the program, and at 3-months post-program. The primary outcome is the effect of the child mediation on parental stroke literacy. Conclusion Stroke literate children, a captive audience in school systems, may represent a viable channel for spreading stroke information into households of poor urban communities where mass media stroke campaigns have shown the lowest penetration. These children may also call 911 when witnessing a stroke in their homes or communities. The HHS program may highlight the potential role of children in the chain of stroke recovery as a strategy for reducing prehospital delays to acute stroke treatment. PMID:26779395

A three-item scale for the early prediction of stroke recovery.

PubMed

Baird, A E; Dambrosia, J; Janket, S; Eichbaum, Q; Chaves, C; Silver, B; Barber, P A; Parsons, M; Darby, D; Davis, S; Caplan, L R; Edelman, R E; Warach, S

2001-06-30

Accurate assessment of prognosis in the first hours of stroke is desirable for best patient management. We aimed to assess whether the extent of ischaemic brain injury on magnetic reasonance diffusion-weighted imaging (MR DWI) could provide additional prognostic information to clinical factors. In a three-phase study we studied 66 patients from a North American teaching hospital who had: MR DWI within 36 h of stroke onset; the National Institutes of Health Stroke Scale (NIHSS) score measured at the time of scanning; and the Barthel Index measured no later than 3 months after stroke. We used logistic regression to derive a predictive model for good recovery. This logistic regression model was applied to an independent series of 63 patients from an Australian teaching hospital, and we then developed a three-item scale for the early prediction of stroke recovery. Combined measurements of the NIHSS score (p=0.01), time in hours from stroke onset to MR DWI (p=0.02), and the volume of ischaemic brain tissue on MR DWI (p=0.04) gave the best prediction of stroke recovery. The model was externally validated on the Australian sample with 0.77 sensitivity and 0.88 specificity. Three likelihood levels for stroke recovery-low (0-2), medium (3-4), and high (5-7)-were identified on the three-item scale. The combination of clinical and MR DWI factors provided better prediction of stroke recovery than any factor alone, shortly after admission to hospital. This information was incorporated into a three-item scale for clinical use.

Spontaneous Swallowing Frequency [Has Potential to] Identify Dysphagia in Acute Stroke

PubMed Central

Carnaby, Giselle D; Sia, Isaac; Khanna, Anna; Waters, Michael

2014-01-01

Background and Purpose Spontaneous swallowing frequency has been described as an index of dysphagia in various health conditions. This study evaluated the potential of spontaneous swallow frequency analysis as a screening protocol for dysphagia in acute stroke. Methods In a cohort of 63 acute stroke cases swallow frequency rates (swallows per minute: SPM) were compared to stroke and swallow severity indices, age, time from stroke to assessment, and consciousness level. Mean differences in SPM were compared between patients with vs. without clinically significant dysphagia. ROC analysis was used to identify the optimal threshold in SPM which was compared to a validated clinical dysphagia examination for identification of dysphagia cases. Time series analysis was employed to identify the minimally adequate time period to complete spontaneous swallow frequency analysis. Results SPM correlated significantly with stroke and swallow severity indices but not with age, time from stroke onset, or consciousness level. Patients with dysphagia demonstrated significantly lower SPM rates. SPM differed by dysphagia severity. ROC analysis yielded a threshold of SPM ≤ 0.40 which identified dysphagia (per the criterion referent) with 0.96 sensitivity, 0.68 specificity, and 0.96 negative predictive value. Time series analysis indicated that a 5 to 10 minute sampling window was sufficient to calculate spontaneous swallow frequency to identify dysphagia cases in acute stroke. Conclusions Spontaneous swallowing frequency presents high potential to screen for dysphagia in acute stroke without the need for trained, available personnel. PMID:24149008

Fifty-Year Trends in Atrial Fibrillation Prevalence, Incidence, Risk Factors, and Mortality in the Community

PubMed Central

Schnabel, Renate B.; Yin, Xiaoyan; PhilimonGona; Larson, Martin G.; Beiser, Alexa S.; McManus, David D.; Newton-Cheh, Christopher; Lubitz, Steven A.; Magnani, Jared W.; Ellinor, Patrick T.; SudhaSeshadri; Wolf, Philip A; Vasan, Ramachandran S.; Benjamin, Emelia J.; Levy, Daniel

2015-01-01

Summary Background Comprehensive long-term data on atrial fibrillation trends in men and women are scant. Methods We investigated trends in atrial fibrillation incidence, prevalence, and risk factors, and in stroke and mortality following its onset in Framingham Heart Study participants (n=9511) from 1958 to 2007. To accommodate sex differences in atrial fibrillation risk factors and disease manifestations, sex-stratified analyses were performed. Findings During 50 years of observation (202,417 person-years), there were 1,544 new-onset atrial fibrillation cases (46.8% women). We observed about a fourfold increase in the age-adjusted prevalence and more than a tripling in age-adjusted incidence of atrial fibrillation (prevalence 20.4 versus 96.2 per 1000 person-years in men; 13.7 versus 49.4 in women; incidence rates in first versus last decade 3.7 versus 13.4 per 1000 person-years in men; 2.5 versus 8.6 in women, ptrend<0.0001). For atrial fibrillation diagnosed by ECG during routine Framingham examinations, age-adjusted prevalence increased (12.6versus 25.7 per 1000 person-years in men; 8.1 versus 11.8 in women, ptrend<0.0001). The age-adjusted incidence increased, but did not achieve statistical significance. Although the prevalence of most risk factors changed over time, their associated hazards for atrial fibrillation changed little. Multivariable-adjusted proportional hazards models revealed a 73.5% decline in stroke and a 25.4% decline in mortality following atrial fibrillation onset (ptrend=0.0001, ptrend=0.003, respectively). Interpretation Our data suggest that observed trends of increased incidence of atrial fibrillation in the community were partially due to enhanced surveillance. Stroke occurrence and mortality following atrial fibrillation onset declined over the decades, and prevalence increased approximately fourfold. The hazards for atrial fibrillation risk factors remained fairly constant. Our data indicate a need for measures to enhance early detection of atrial fibrillation through increased awareness coupled with targeted screening programs, and risk factor-specific prevention. PMID:25960110

Vasomotor symptoms and cardiovascular events in postmenopausal women

PubMed Central

Szmuilowicz, Emily D.; Manson, JoAnn E.; Rossouw, Jacques E.; Howard, Barbara V.; Margolis, Karen L.; Greep, Nancy C.; Brzyski, Robert G.; Stefanick, Marcia L.; O'Sullivan, Mary Jo; Wu, Chunyuan; Allison, Matthew; Grobbee, Diederick E.; Johnson, Karen C.; Ockene, Judith K.; Rodriguez, Beatriz L.; Sarto, Gloria E.; Vitolins, Mara Z.; Seely, Ellen W.

2010-01-01

Objective Emerging evidence suggests that women with menopausal vasomotor symptoms (VMS) have increased cardiovascular disease (CVD) risk as measured by surrogate markers. We investigated the relationships between VMS and clinical CVD events and all-cause mortality in the Women's Health Initiative Observational Study (WHI-OS). Methods We compared the risk of incident CVD events and all-cause mortality between four groups of women (total N=60,027): (1) No VMS at menopause onset and no VMS at WHI-OS enrollment (no VMS [referent group]); (2) VMS at menopause onset, but not at WHI-OS enrollment (early VMS); (3) VMS at both menopause onset and WHI-OS enrollment (persistent VMS [early and late]); and (4) VMS at WHI-OS enrollment, but not at menopause onset (late VMS). Results For women with early VMS (N=24,753), compared to no VMS (N=18,799), hazard ratios (HRs) and 95% confidence intervals (CIs) in fully-adjusted models were: major CHD, 0.94 (0.84, 1.06); stroke, 0.83 (0.72, 0.96); total CVD, 0.89 (0.81, 0.97); and all-cause mortality, 0.92 (0.85, 0.99). For women with persistent VMS (N=15,084), there was no significant association with clinical events. For women with late VMS (N=1,391) compared to no VMS, HRs and 95% CIs were: major CHD, 1.32 (1.01, 1.71); stroke, 1.14 (0.82, 1.59); total CVD, 1.23 (1.00, 1.52); and all-cause mortality, 1.29 (1.08, 1.54). Conclusions Early VMS were not associated with increased CVD risk. Rather, early VMS were associated with decreased risk of stroke, total CVD events, and all-cause mortality. Late VMS were associated with increased CHD risk and all-cause mortality. The predictive value of VMS for clinical CVD events may vary with onset of VMS at different stages of menopause. Further research examining the mechanisms underlying these associations is needed. Future studies will also be necessary to investigate whether VMS that develop for the first time in the later postmenopausal years represent a pathophysiologic process distinct from classical perimenopausal VMS. PMID:21358352

Comparison of frequency of postoperative stroke in off-pump coronary artery bypass grafting versus on-pump coronary artery bypass grafting versus percutaneous coronary intervention.

PubMed

Marui, Akira; Kimura, Takeshi; Tanaka, Shiro; Okabayashi, Hitoshi; Komiya, Tatsuhiko; Furukawa, Yutaka; Kita, Toru; Sakata, Ryuzo

2012-12-15

The stroke rate after coronary artery bypass grafting (CABG) compared to percutaneous coronary intervention (PCI) is generally considered high because cardiopulmonary bypass and aortic manipulations are often associated with cerebrovascular complications. However, an increasing number of CABGs performed without cardiopulmonary bypass (OPCAB) may improve those outcomes. Of 6,323 patients with multivessel and/or left main coronary artery disease, 3,877 patients underwent PCI, 1,381 conventional on-pump CABG, and 1,065 OPCAB. Median follow-up was 3.4 years. Stroke types were classified as early (onset of stroke within 24 hours after revascularization), delayed (within 30 days), and late (after 30 days). Propensity score analysis showed that the incidences of early, delayed, and late stroke did not differ between PCI and OPCAB (0.65, 95% confidence interval 0.08 to 5.45, p = 1.00; 0.36, 0.10 to 1.29, p = 0.23; 0.81, 0.52 to 1.27, p = 0.72, respectively). In contrast, incidence of early stroke after on-pump CABG was higher than after OPCAB (7.22, 1.67 to 31.3, p = 0.01), but incidences of delayed and late stroke were not different (1.66, 0.70 to 3.91, p = 0.50; 1.18, 0.83 to 1.69, p = 0.73). In conclusion, occurrence of stroke was not found to differ in patients after PCI versus OPCAB regardless of onset of stroke. Occurrence of early stroke after OPCAB was lower than that after on-pump CABG, yet occurrences of delayed and late strokes were similar for the 3 revascularization strategies. Copyright © 2012 Elsevier Inc. All rights reserved.

Insulin resistance and clinical outcomes after acute ischemic stroke.

PubMed

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

2018-04-24

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

Early introduction of direct oral anticoagulants in cardioembolic stroke patients with non-valvular atrial fibrillation.

PubMed

Cappellari, Manuel; Carletti, Monica; Danese, Alessandra; Bovi, Paolo

2016-10-01

Direct oral anticoagulants (DOACs) are superior to warfarin in reduction of the intracranial bleeding risk. The aim of the present study was to assess whether early DOAC introduction (1-3 days after onset) in stroke patients with non-valvular atrial fibrillation (nVAF) may be safe and effective, compared with DOAC introduction after 4-7 days. We conducted a prospective analysis based on data collected from 147 consecutive nVAF patients who started DOAC within 7 days after stroke onset. In all patients, we performed pre-DOAC CT scan 24-36 h after onset and follow-up CT scan at 7 days after DOAC introduction. Outcome measures were post-DOAC intracranial bleeding (new any intracerebral hemorrhage (ICH) in patients with pre-DOAC infarct without hemorrhagic transformation (HT) or expansion of ICH in patients with pre-DOAC infarct with asymptomatic HT) and post-DOAC recurrent ischemic stroke (any new ischemic infarct) on follow-up CT scan. 97 patients started DOAC after 1-3 days and 50 patients started DOAC after 4-7 days. On pre-DOAC CT scan, 132 patients had an infarct without HT and 15 an infarct with asymptomatic HT. On follow-up CT scan, new any ICH was noted in seven patients (asymptomatic in 6) and asymptomatic expansion of ICH in one patient. We found no association between early DOAC introduction and intracranial bleeding. Large infarct remained the only independent predictor of post-DOAC intracranial bleeding. No patients suffered recurrent ischemic stroke after DOAC introduction. Early DOAC introduction might be safe in carefully selected patients with nVAF who experience small- and medium-sized cardioembolic ischemic strokes. Further investigation will be needed.

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.

Thrombolysis with Intravenous Tissue Plasminogen Activator (rt-PA) Predicts Favorable Discharge Disposition in Patients with Acute Ischemic Stroke

PubMed Central

Ifejika-Jones, Nneka L.; Harun, Nusrat; Mohammed-Rajput, Nareesa A.; Noser, Elizabeth A.; Grotta, James C.

2011-01-01

Background and Purpose Acute ischemic stroke patients receiving IV tissue plasminogen activator (rt-PA) within 3 hours of symptom onset are 30% more likely to have minimal disability at three months. During hospitalization, short-term disability is subjectively measured by discharge disposition, whether to home, Inpatient Rehabilitation (IR), Skilled Nursing Facility (SNF) or Subacute Care (Sub). There are no studies assessing the role of rt-PA use as a predictor of post-stroke disposition. Methods Retrospective analysis of all ischemic stroke patients admitted to the University of Texas Houston Medical School (UTHMS) Stroke Service between Jan 2004 and Oct 2009. Baseline demographics and National Institute of Health Stroke Scale (NIHSS) score were collected. Cerebrovascular disease risk factors were used for risk stratification. Results Home vs. IR, SNF, Sub Of 2225 acute ischemic stroke patients, 1019 were discharged home, 1206 to another level of care. Patients who received rt-PA therapy were 1.9 times more likely to be discharged home (P = <0.0001; OR 1.945, 95% CI 1.538 to 2.459). IR vs. SNF, Sub / SNF vs. Sub Of 1206 acute ischemic stroke patients, 719 patients were discharged to acute IR, 371 were discharged to SNF, 116 to Sub. There were no differences in disposition between patients who received rt-PA therapy. Conclusions Stroke patients who receive IV rt-PA for acute ischemic stroke are more 1.9 times more likely to be discharged directly home after hospitalization. This study is limited by its retrospective nature and the undetermined role of psychosocial factors related to discharge. PMID:21293014

Hemorrhagic transformation after ischemic stroke in animals and humans

PubMed Central

Jickling, Glen C; Liu, DaZhi; Stamova, Boryana; Ander, Bradley P; Zhan, Xinhua; Lu, Aigang; Sharp, Frank R

2014-01-01

Hemorrhagic transformation (HT) is a common complication of ischemic stroke that is exacerbated by thrombolytic therapy. Methods to better prevent, predict, and treat HT are needed. In this review, we summarize studies of HT in both animals and humans. We propose that early HT (<18 to 24 hours after stroke onset) relates to leukocyte-derived matrix metalloproteinase-9 (MMP-9) and brain-derived MMP-2 that damage the neurovascular unit and promote blood–brain barrier (BBB) disruption. This contrasts to delayed HT (>18 to 24 hours after stroke) that relates to ischemia activation of brain proteases (MMP-2, MMP-3, MMP-9, and endogenous tissue plasminogen activator), neuroinflammation, and factors that promote vascular remodeling (vascular endothelial growth factor and high-moblity-group-box-1). Processes that mediate BBB repair and reduce HT risk are discussed, including transforming growth factor beta signaling in monocytes, Src kinase signaling, MMP inhibitors, and inhibitors of reactive oxygen species. Finally, clinical features associated with HT in patients with stroke are reviewed, including approaches to predict HT by clinical factors, brain imaging, and blood biomarkers. Though remarkable advances in our understanding of HT have been made, additional efforts are needed to translate these discoveries to the clinic and reduce the impact of HT on patients with ischemic stroke. PMID:24281743

Effect of forced use of the lower extremity on gait performance and mobility of post-acute stroke patients

PubMed Central

Yu, Wen-Hsiu; Liu, Wen-Yu; Wong, Alice May-Kuen; Wang, Tzu-Chi; Li, Yen-Chen; Lien, Hen-Yu

2015-01-01

[Purpose] The purpose of this study was to investigate the effects of a forced-use training program on gait, mobility and quality of life of post-acute stroke patients. [Subjects] Twenty-one individuals with unilateral stroke participated in this study. All participants had suffered from first-ever stroke with time since onset of at least 3 months. [Methods] A single-blinded, non-equivalent, pre-post controlled design with 1-month follow-up was adopted. Participants received either a forced-use or a conventional physical therapy program for 2 weeks. The main outcomes assessed were preferred and fastest walking velocities, spatial and temporal symmetry indexes of gait, the timed up and go test, the Rivermead Mobility Index, and the Stroke-Specific Quality of Life Scale (Taiwan version). [Results] Forced-use training induced greater improvements in gait and mobility than conventional physical therapy. In addition, compared to pre-training, patients in the conventional physical therapy group walked faster but more asymmetrically after training. However, neither program effectively improved in-hospital quality of life. [Conclusion] The forced-use approach can be successfully applied to the lower extremities of stroke patients to improve mobility, walking speeds and symmetry of gait. PMID:25729182

Long-term incidence of depression and predictors of depressive symptoms in older stroke survivors.

PubMed

Allan, Louise M; Rowan, Elise N; Thomas, Alan J; Polvikoski, Tuomo M; O'Brien, John T; Kalaria, Raj N

2013-12-01

Depression is common and an important consequence of stroke but there is limited information on the longer-term relationship between these conditions. To identify the prevalence, incidence and predictors of depression in a secondary-care-based cohort of stroke survivors aged over 75 years, from 3 months to up to 10 years post-stroke. Depression was assessed annually by three methods: major depression by DSM-IV criteria, the self-rated Geriatric Depression Scale (GDS) and the observer-rated Cornell scale. We found the highest rates, 31.7% baseline prevalence, of depressive symptoms with the GDS compared with 9.7% using the Cornell scale and 1.2% using DSM-IV criteria. Incidence rates were 36.9, 5.90 and 4.18 episodes per 100 person years respectively. Baseline GDS score was the most consistent predictor of depressive symptoms at all time points in both univariate and multivariate analyses. Other predictors included cognitive impairment, impaired activities of daily living and in the early period, vascular risk factor burden and dementia. Our results emphasise the importance of psychiatric follow-up for those with early-onset post-stroke depression and long-term monitoring of mood in people who have had a stroke and remain at high risk of depression.

High serum uric acid levels are a protective factor against unfavourable neurological functional outcome in patients with ischaemic stroke.

PubMed

Wang, Yu-Fang; Li, Jiao-Xing; Sun, Xun-Sha; Lai, Rong; Sheng, Wen-Li

2018-05-01

Objective We aimed to evaluate the association between serum uric acid levels at the onset and prognostic outcome in patients with acute ischaemic stroke. Methods We retrospectively analysed the outcomes of 1166 patients with ischaemic stroke who were hospitalized in our centre during August 2008 to November 2012. Correlations of serum uric acid levels and prognostic outcomes were analysed. Results Men had higher serum uric acid levels and better neurological functional outcomes compared with women. There was a strong negative correlation between serum uric acid levels and unfavourable neurological functional outcomes. Generalized estimated equation analysis showed that a higher serum uric acid level (>237 µmol/L) was a protective factor for neurological functional outcome in male, but not female, patients. Among five trial of ORG 10172 in acute stroke treatment classification subtypes, only patients with the large-artery atherosclerosis subtype had a significant protective effect of serum uric acid levels on neurological outcome. Conclusions Our study shows that high serum uric acid levels are a significant protective factor in men and in the large-artery atherosclerosis subtype in patients with ischaemic stroke. This is helpful for determining the prognostic value of serum uric acid levels for neurological outcome of acute ischaemic stroke.

Effectiveness of finger-equipped electrode (FEE)-triggered electrical stimulation improving chronic stroke patients with severe hemiplegia.

PubMed

Inobe, Jun-ichi; Kato, Takashi

2013-01-01

Electric stimulation (ES) has been recognized as an effective method to improve motor function to paralysed patients with stroke. It is important for ES to synchronize with voluntary movement. To enhance this co-ordination, the finger-equipped electrode (FEE) was developed. The purpose of this study was to evaluate FEE in improving motor function of upper extremities (UEs) in patients with chronic stroke. The study participants included four patients with chronic stroke who received FEE electronic stimulation (FEE-ES) plus passive and active training and three control patients who underwent training without FEE-ES. The patients were treated five times weekly for 4 weeks. UE motor function was evaluated before and after treatment using Fugl-Meyer Assessment (FMA) and Brunnstrom recovery staging. The mean age of patients in each group was 60-years and there was a mean of 49 months since the onset of symptoms. All patients had severe UE weakness. The patients receiving FEE-ES had greater improvement in UE function than control patients (total, proximal and distal FMA, p < 0.05; Brunnstrom staging of UE, p < 0.05). The results indicate that FEE-ES may be an effective treatment for patients with chronic stroke.

Regional Pediatric Acute Stroke Protocol: Initial Experience During 3 Years and 13 Recanalization Treatments in Children.

PubMed

Tabone, Laurence; Mediamolle, Nicolas; Bellesme, Celine; Lesage, Fabrice; Grevent, David; Ozanne, Augustin; Naggara, Olivier; Husson, Beatrice; Desguerre, Isabelle; Lamy, Catherine; Denier, Christian; Kossorotoff, Manoelle

2017-08-01

To evaluate hyperacute management of pediatric arterial ischemic stroke, setting up dedicated management pathways is the first recommended step to prove the feasibility and safety of such treatments. A regional pediatric stroke alert protocol including 2 centers in the Paris-Ile-de-France area, France, was established. Consecutive pediatric patients (28 days-18 years) with confirmed arterial ischemic stroke who had acute recanalization treatment (intravenous r-tPA [recombinant tissue-type plasminogen activator], endovascular procedure, or both) according to the regional pediatric stroke alert were retrospectively reviewed during a 40-month period. Thirteen children, aged 3.7 to 16.6 years, had recanalization treatment. Median time from onset to magnetic resonance imaging was 165 minutes (150-300); 9 out of 13 had large-vessel occlusion. Intravenous r-tPA was used in 11 out of 13 patients, with median time from onset to treatment of 240 minutes (178-270). Endovascular procedure was performed in patients time-out for intravenous r-tPA (n=2) or after intravenous r-tPA inefficiency (n=2). No intracranial or peripheral bleeding was reported. One patient died of malignant stroke; outcome was favorable in 11 out of 12 survivors (modified Rankin Scale score 0-2). Hyperacute recanalization treatment in pediatric stroke, relying on common protocols and adult/pediatric ward collaboration, is feasible. Larger systematic case collection is encouraged. © 2017 American Heart Association, Inc.

Effect of methylphenidate and/or levodopa combined with physiotherapy on mood and cognition after stroke: a randomized, double-blind, placebo-controlled trial.

PubMed

Delbari, Ahmad; Salman-Roghani, Reza; Lokk, Johan

2011-01-01

Stimulant medications can enhance mood and cognition in stroke rehabilitation, but human clinical trial results are inconclusive. We sought to prospectively study the effects of levodopa (LD) and/or methylphenidate (MPH) in combination with physiotherapy on mood and cognition following stroke in human subjects. Ischemic stroke patients were enrolled in our study 15 to 180 days after stroke onset. The patients were randomized into four medication groups (MPH, LD, MPH + LD, or placebo) and received a 15-day course of medication therapy (1 dose daily) and 45-min standard physiotherapy treatment daily. Mood and cognitive function were assessed at the study onset and 15, 90 and 180 days after study enrollment. The strongest improvement of mood and cognition was found between baseline and the first follow-up immediately after the intervention. A significant improvement in mood was also found in the combined treatment group (MPH + LD) at 90 and 180 days, compared to the placebo group. A 15-day course of daily MPH + LD combined with physiotherapy over a 3-week period was safe and significantly improved mood status in ischemic stroke patients. Future studies are needed which determine the optimal therapeutic window for and dosage of psychostimulants as well as identify those stroke patients who might benefit the most from treatment. Copyright © 2011 S. Karger AG, Basel.

Intravenous thrombolysis guided by a telemedicine consultation system for acute ischaemic stroke patients in China: the protocol of a multicentre historically controlled study

PubMed Central

Yuan, Ziwen; Wang, Bo; Li, Feijiang; Wang, Jing; Zhi, Jin; Luo, Erping; Liu, Zhirong; Zhao, Gang

2015-01-01

Introduction The rate of intravenous thrombolysis with tissue-type plasminogen activator or urokinase for stroke patients is extremely low in China. It has been demonstrated that a telestroke service may help to increase the rate of intravenous thrombolysis and improve stroke care quality in local hospitals. The aim of this study, also called the Acute Stroke Advancing Program, is to evaluate the effectiveness and safety of decision-making concerning intravenous thrombolysis via a telemedicine consultation system for acute ischaemic stroke patients in China. Methods and analysis This is a multicentre historically controlled study with a planned enrolment of 300 participants in each of two groups. The telestroke network consists of one hub hospital and 14 spoke hospitals in underserved regions of China. The usual stroke care quality in the spoke hospitals without guidance from the hub hospital will be used as the historical control. The telemedicine consultation system is an interactive, two-way, wireless, audiovisual system accessed on portable devices. The primary outcome is the percentage of patients treated with intravenous thrombolysis within 4.5 h of stroke onset. Ethics and dissemination The project has been approved by the Institutional Review Board of Xijing Hospital. The results will be published in scientific journals and presented to local government and relevant institutes. Trial registration number NCT02088346 (12 March 2014). PMID:25979867

Cell free DNA: A Novel Predictor of Neurological Outcome after Intravenous Thrombolysis and/or Mechanical Thrombectomy in Acute Ischemic Stroke Patients

PubMed Central

Wijatmiko, Teddy; Vajpeyee, Manisha; Taywade, Onjal

2018-01-01

Purpose Several blood markers have been evaluated in stroke patients, but their role remains limited in clinical practice. This study was designed to evaluate the utility of cell free DNA (cf DNA) in stroke patients undergoing therapeutic intervention in the form of mechanical thrombectomy in acute ischemic stroke patients. Materials and Methods Twenty-six patients with ischemic stroke who were managed with interventions like intravenous thrombolysis (IVT) and mechanical thrombectomy were recruited consecutively in this study. The cf DNA was extracted by using circulating nucleic acid kit and measured by real-time quantitative PCR assay for β-globin gene. The neurological outcome was measured by modified Rankin scale (mRS) score at three months after the onset of symptoms. Results Cf DNA levels correlated with severity of stroke at the time of admission (r=0.421, P=0.032) and poor outcome at three months (r=0.606, P=0.001). Therapeutic intervention in the form of mechanical thrombectomy or IVT was associated with improved outcome in patients with cf DNA <10,000 kilogenome-equivalents/L (P=<0.05). Conclusion Cf DNA level correlated well with the 3 month outcome in acute ischemic stroke patients. It can be a potential supplementary marker to predict neurological outcome after therapeutic intervention. PMID:29535894

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.

Edaravone offers neuroprotection for acute diabetic stroke patients.

PubMed

Zheng, J; Chen, X

2016-11-01

Edaravone, a novel free-radical scavenger, has been shown to alleviate cerebral ischemic injury and protect against vascular endothelial dysfunction. However, the effects of edaravone in acute diabetic stroke patients remain undetermined. A randomized, double-blind, placebo-controlled study was performed to prospectively evaluate the effects of edaravone on acute diabetic stroke patients admitted to our hospital within 24 h of stroke onset. The edaravone group received edaravone (30 mg twice per day) diluted with 100 ml of saline combined with antiplatelet drug aspirin and atorvastatin for 14 days. The non-edaravone group was treated only with 100 ml of saline twice per day combined with aspirin and atorvastatin. Upon admission, and on days 7, 14 post-stroke onset, neurological deficits and activities of daily living were assessed using the National Institutes of Health Stroke Scale (NIHSS) and the Barthel Index (BI), respectively. The occurrence of hemorrhage transformation, pulmonary infection, progressive stroke and epilepsy was also evaluated on day 14 post-treatment. A total of 65 consecutive acute diabetic stroke patients were enrolled, of whom 35 were allocated to the edaravone group and 30 to the non-edaravone group. There was no significant group difference in baseline clinical characteristics, but mean NIHSS scores were lower (60 %), and BI scores were 1.7-fold higher, in edaravone-treated patients vs. controls on day 14. Furthermore, the incidence of hemorrhage transformation, pulmonary infection, progressive stroke and epilepsy was markedly reduced in the edaravone vs. non-edaravone group. Edaravone represents a promising neuroprotectant against cerebral ischemic injury in diabetic patients.

Cross-level interaction between individual socioeconomic status and regional deprivation on overall survival after onset of ischemic stroke: National health insurance cohort sample data from 2002 to 2013.

PubMed

Shin, Jaeyong; Choi, Young; Kim, Seung Woo; Lee, Sang Gyu; Park, Eun-Cheol

2017-08-01

The literature on stroke mortality and neighborhood effect is characterized by studies that are often Western society-oriented, with a lack of racial and cultural diversity. We estimated the effect of cross-level interaction between individual and regional socioeconomic status on the survival after onset of ischemic stroke. We selected newly diagnosed ischemic stroke patients from 2002 to 2013 using stratified representative sampling data of 1,025,340 subjects. A total of 37,044 patients over the 10 years from 2004 to 2013 had newly diagnosed stroke. We calculated hazard ratios (HR) of 12- and 36-month mortality using the Cox proportional hazard model, with the reference group as stroke patients with high income in advantaged regions. For the middle income level, the patients in advantaged regions showed low HRs for overall mortality (12-month HR 1.27; 95% confidence interval [CI], 1.13-1.44; 36-month HR 1.25; 95% CI, 1.14-1.37) compared to the others in disadvantaged regions (12-month HR 1.36; 95% CI, 1.19-1.56; 36-month HR 1.30; 95% CI, 1.17-1.44). Interestingly, for the low income level, the patients in advantaged regions showed high HRs for overall mortality (12-month HR 1.27; 95% CI, 1.13-1.44; 36-month HR 1.33; 95% CI, 1.22-1.46) compared to the others in disadvantaged regions (12-month HR 1.25; 95% CI, 1.09-1.43; 36-month HR 1.30; 95% CI, 1.18-1.44). Although we need to perform further investigations to determine the exact mechanisms, regional deprivation, as well as medical factors, might be associated with survival after onset of ischemic stroke in low-income patients. Copyright © 2017 The Authors. Production and hosting by Elsevier B.V. All rights reserved.

Thrombolysis for acute ischaemic stroke with alteplase in an Asian population: results of the multicenter, multinational Safe Implementation of Thrombolysis in Stroke-Non-European Union World (SITS-NEW).

PubMed

Rha, Joung-Ho; Shrivastava, Vasantha Padma; Wang, Yongjun; Lee, Kim En; Ahmed, Niaz; Bluhmki, Erich; Hermansson, Karin; Wahlgren, Nils

2014-10-01

Safe Implementation of Thrombolysis in Stroke-Non-European Union World was a multinational, prospective, open, monitored, observational study of intravenous alteplase as thrombolytic therapy in clinical practice. Safe Implementation of Thrombolysis in Stroke-Non-European Union World was required to assess the safety of alteplase in an Asian population by comparison with results from the European Safe Implementation of Thrombolysis in Stroke-Monitoring Study and pooled results from randomized controlled trials. To evaluate the efficacy and safety of intravenous alteplase (0·9 mg/kg) as thrombolytic therapy within three-hours of onset of acute ischaemic stroke in an Asian population. The 591 patients included were treated at 48 centers in four countries (South Korea, China, India, and Singapore) between 2006 and 2008. Primary outcomes were symptomatic (deterioration in National Institutes of Health Stroke Scale score ≥4 or death within the first 24 h) intracerebral haemorrhage type 2 22-36 h after the thrombolysis and mortality at three-month follow-up. The secondary outcome was functional independence (modified Rankin Scale score 0-2) at three-months. Results were compared with those from Safe Implementation of Thrombolysis in Stroke-Monitoring Study (n = 6483) and pooled results of patients (n = 415) who received intravenous alteplase (0·9 mg/kg) zero- to three-hours from onset of stroke symptoms in four randomized controlled trials (National Institute of Neurological Disorders and Stroke A and B, Altephase Thrombolysis for Acute Noninterventional Therapy in Ischaemic Stroke, and European Cooperative Acute Stroke Study II). Results are presented as Safe Implementation of Thrombolysis in Stroke-Non-European Union World vs. Safe Implementation of Thrombolysis in Stroke-Monitoring Study vs. pooled randomized controlled trials. Median age was 64 vs. 68 vs. 70 years, National Institutes of Health Stroke Scale score at baseline was 12 vs. 12 vs. 13, time from stroke onset to treatment was 130 vs. 140 vs. 135 mins, and females were 36·4% vs. 39·8% vs. 41·2%. Main outcomes (proportion of patients and 95% confidence intervals) were symptomatic intracerebral haemorrhage: 1·9% (1·1-3·3) vs. 1·7% (1·4-2·0) vs. 3·1% (1·8-5·3); mortality: 10·2% (8·0-12·9) vs. 11·3% (10·5-12·1) vs. 16·4% (13·1-20·3); and functional independence: 62·5% (58·5-66·4) vs. 54·8% (53·5-56·0) vs. 50·1% (45·3-54·9) at three-months. Adjusted odds ratio (95% confidence intervals) between Safe Implementation of Thrombolysis in Stroke-Non-European Union World and Safe Implementation of Thrombolysis in Stroke-Monitoring Study, and between Safe Implementation of Thrombolysis in Stroke-Non-European Union World and the pooled trials were 1·83 (0·89-3·77; P = 0·1156) and 0·63 (0·19-2·07; P = 0·4470) for symptomatic intracerebral haemorrhage, 0·90 (0·64-1·25; P = 0·5092) and 0·93 (0·52-1·64; P = 0·7915) for mortality at three-months, and 1·57 (1·25-1·96; P < 0·0001) and 1·35 (0·91-2·00; P = 0·1325) for functional independence. These data demonstrate the safety and efficacy of the standard dose of intravenous alteplase (0·9 mg/kg) in an Asian population, as previously observed in the European population studied in Safe Implementation of Thrombolysis in Stroke-Monitoring Study and the populations in pooled randomized controlled trials, when used in routine clinical practice within three-hours of stroke onset. The findings should encourage wider use of thrombolytic therapy in Asian countries for suitable patients treated in stroke centers. © 2012 The Authors. International Journal of Stroke © 2012 World Stroke Organization.

Telmisartan to prevent recurrent stroke and cardiovascular events.

PubMed

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

2008-09-18

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

Predictors of early infection in cerebral ischemic stroke.

PubMed

Ashour, Wmr; Al-Anwar, A D; Kamel, A E; Aidaros, M A

2016-01-01

Infection is the most common complication of stroke. To determine the risk factors and predictors of post-stroke infection (PSI), which developed within 7 days from the onset of acute ischemic stroke. The study included 60 ischemic stroke patients admitted in the Neurology Department of Zagazig University, Egypt, who were subdivided into: [Non Stroke Associated Infection group (nSAI); 30 patients having stroke without any criteria of infection within 7 days from the onset and Stroke Associated Infection group (SAI); 30 patients having stroke with respiratory tract infection (RTI) or urinary tract infection within 7 days], in addition to 30 healthy sex and age-matching subjects as control. All the patients had a detailed history taking, thorough clinical general and neurological examination, laboratory tests (Urine analysis & urine culture, blood sugar, lipid profile and serum tumor necrosis factor-alpha (TNF-α) and interleukin (IL)-10), a chest radiography to assess RTI and brain computed tomography (CT) to exclude the hemorrhagic stroke and to confirm the ischemic stroke. SAI patients were found to be significantly older with higher baseline blood glucose level. Also the number of patients with tube feeding, lower conscious level, more stroke severity and more large size infarcts were significantly higher in SAI patients. There was a significant elevation in the IL-10, a significant decrease in the TNF-α and a significant decrease in the TNF-α/ IL-10 ratio, in the SAI group. The baseline serum level of IL-10 ≥ 14.5 pg/ ml and size of infarct area > 3.5 cm3 were found to be the independent predictors of PSI. Patients with older age, tube feeding, lower conscious level, worse baseline stroke severity, large cerebral infarcts in CT scan, and increased IL-10 serum level were more susceptible to infection. The baseline serum level of IL-10 ≥ 14.5 pg/ ml and the size of infarct area > 3.5 cm3 were the independent predictors of PSI.

Patent Foramen Ovale: Is Stroke Due to Paradoxical Embolism?

NASA Technical Reports Server (NTRS)

Ranoux, D.; Cohen, A.; Cabanes, L.; Amarenco, P.; Bousser, M. G.; Mas, J. L.

1993-01-01

Background and Purpose: A patent foramen ovale has been reported to be significantly more frequent in young stroke patients than in matched control subjects, and paradoxical embolism has been suggested as the main mechanism of stroke in-this situation. The present study was designed to test this hypothesis. Methods: Sixty-eight consecutive patients under 55 years of age presenting with an ischemic stroke had an extensive workup, including transesophageal echocardiography with contrast. We compared the prevalence of criteria for the diagnosis of paradoxical embolism in patients with and without a patent foramen ovale. Results: A patent foramen ovale was found in 32 patients (47%). A Valsalva-provoking activity was present at stroke onset in six patients with a patent foramen ovale and in eight patients with no patent foramen ovale (X(sup 2)=0.1, nonsignificant). Clinical/radiological features suggestive of an embolic mechanism were not more frequent in patients with a patent foramen ovale. Clinical evidence of deep vein thrombosis was present in one patient with a patent foramen ovale and in none of the others. No occult venous thrombosis was found in a subgroup of patients with a patent foramen ovale and no definite cause for stroke who underwent venography (n=13). Conclusions. Our results do not support the hypothesis that paradoxical embolism is the primary mechanism of stroke in patients with a patent foramen ovale. (Stroke 1993;24:31-34) KEY WORDS e cerebral ischemia e embolism foramen ovale, patent

Early Initiation of Anticoagulation with Direct Oral Anticoagulants in Patients after Transient Ischemic Attack or Ischemic Stroke.

PubMed

Macha, Kosmas; Volbers, Bastian; Bobinger, Tobias; Kurka, Natalia; Breuer, Lorenz; Huttner, Hagen B; Schwab, Stefan; Köhrmann, Martin

2016-09-01

Direct oral anticoagulants (DOACs) are increasingly used for secondary prevention of cardioembolic stroke. While DOACs are associated with a long-term reduced risk of intracranial hemorrhage compared to vitamin K antagonists, pivotal trials avoided the very early period after stroke and few data exist on early initiation of DOAC therapy post stroke. We retrospectively analyzed data from our prospective database of all consecutive transient ischemic attack (TIA) or ischemic stroke patients with atrial fibrillation treated with DOACs during hospital stay. As per our institutional treatment algorithm for patients with cardioembolic ischemia DOACs are started immediately in TIA and minor stroke (group 1), within days 3-5 in patients with infarcts affecting one third or less of the middle cerebral artery, the anterior cerebral artery, or the posterior cerebral artery territories (group 2) as well as in infratentorial stroke (group 3) and after 1-2 weeks in patients with large infarcts (>⅓MCA territory, group 4). We investigated baseline characteristics, time to initiation of DOAC therapy after symptom onset, and hemorrhagic complications. In 243 included patients, administration of DOAC was initiated 40.5 hours (interquartile range [IQR] 23.0-65.5) after stroke onset in group 1 (n = 41) and after 76.7 hours (IQR 48.0-134.0), 108.4 hours (IQR 67.3-176.4), and 161.8 hours (IQR 153.9-593.8) in groups 2-4 (n = 170, 28, and 4), respectively. Two cases of asymptomatic intracranial hemorrhage (.8%) and 1 case of symptomatic intracranial hemorrhage (.4%) were observed, both in group 2. No severe safety issues were observed in early initiation of DOACs for secondary prevention after acute stroke in our in-patient cohort. Copyright © 2016 National Stroke Association. Published by Elsevier Inc. All rights reserved.

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

PubMed

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

2009-08-01

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

HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging.

PubMed

Kattah, Jorge C; Talkad, Arun V; Wang, David Z; Hsieh, Yu-Hsiang; Newman-Toker, David E

2009-11-01

Acute vestibular syndrome (AVS) is often due to vestibular neuritis but can result from vertebrobasilar strokes. Misdiagnosis of posterior fossa infarcts in emergency care settings is frequent. Bedside oculomotor findings may reliably identify stroke in AVS, but prospective studies have been lacking. The authors conducted a prospective, cross-sectional study at an academic hospital. Consecutive patients with AVS (vertigo, nystagmus, nausea/vomiting, head-motion intolerance, unsteady gait) with >or=1 stroke risk factor underwent structured examination, including horizontal head impulse test of vestibulo-ocular reflex function, observation of nystagmus in different gaze positions, and prism cross-cover test of ocular alignment. All underwent neuroimaging and admission (generally <72 hours after symptom onset). Strokes were diagnosed by MRI or CT. Peripheral lesions were diagnosed by normal MRI and clinical follow-up. One hundred one high-risk patients with AVS included 25 peripheral and 76 central lesions (69 ischemic strokes, 4 hemorrhages, 3 other). The presence of normal horizontal head impulse test, direction-changing nystagmus in eccentric gaze, or skew deviation (vertical ocular misalignment) was 100% sensitive and 96% specific for stroke. Skew was present in 17% and associated with brainstem lesions (4% peripheral, 4% pure cerebellar, 30% brainstem involvement; chi(2), P=0.003). Skew correctly predicted lateral pontine stroke in 2 of 3 cases in which an abnormal horizontal head impulse test erroneously suggested peripheral localization. Initial MRI diffusion-weighted imaging was falsely negative in 12% (all <48 hours after symptom onset). Skew predicts brainstem involvement in AVS and can identify stroke when an abnormal horizontal head impulse test falsely suggests a peripheral lesion. A 3-step bedside oculomotor examination (HINTS: Head-Impulse-Nystagmus-Test-of-Skew) appears more sensitive for stroke than early MRI in AVS.

Economic Evaluation Plan (EEP) for A Very Early Rehabilitation Trial (AVERT): An international trial to compare the costs and cost-effectiveness of commencing out of bed standing and walking training (very early mobilization) within 24 h of stroke onset with usual stroke unit care.

PubMed

Sheppard, Lauren; Dewey, Helen; Bernhardt, Julie; Collier, Janice M; Ellery, Fiona; Churilov, Leonid; Tay-Teo, Kiu; Wu, Olivia; Moodie, Marj

2016-06-01

A key objective of A Very Early Rehabilitation Trial is to determine if the intervention, very early mobilisation following stroke, is cost-effective. Resource use data were collected to enable an economic evaluation to be undertaken and a plan for the main economic analyses was written prior to the completion of follow up data collection. To report methods used to collect resource use data, pre-specify the main economic evaluation analyses and report other intended exploratory analyses of resource use data. Recruitment to the trial has been completed. A total of 2,104 participants from 56 stroke units across three geographic regions participated in the trial. Resource use data were collected prospectively alongside the trial using standardised tools. The primary economic evaluation method is a cost-effectiveness analysis to compare resource use over 12 months with health outcomes of the intervention measured against a usual care comparator. A cost-utility analysis is also intended. The primary outcome in the cost-effectiveness analysis will be favourable outcome (modified Rankin Scale score 0-2) at 12 months. Cost-utility analysis will use health-related quality of life, reported as quality-adjusted life years gained over a 12 month period, as measured by the modified Rankin Scale and the Assessment of Quality of Life. Outcomes of the economic evaluation analysis will inform the cost-effectiveness of very early mobilisation following stroke when compared to usual care. The exploratory analysis will report patterns of resource use in the first year following stroke. © 2016 World Stroke Organization.

Increased prevalence of potential right-to-left shunting in children with sickle cell anaemia and stroke.

PubMed

Dowling, Michael M; Quinn, Charles T; Ramaciotti, Claudio; Kanter, Julie; Osunkwo, Ifeyinwa; Inusa, Baba; Iyer, Rathi; Kwiatkowski, Janet L; Johnson, Clarissa; Rhodes, Melissa; Owen, William; Strouse, John J; Panepinto, Julie A; Neumayr, Lynne; Sarnaik, Sharada; Plumb, Patricia A; Dlamini, Nomazulu; Kirkham, Fenella; Hynan, Linda S

2017-01-01

'Paradoxical' embolization via intracardiac or intrapulmonary right-to-left shunts (RLS) is an established cause of stroke. Hypercoagulable states and increased right heart pressure, which both occur in sickle cell anaemia (SCA), predispose to paradoxical embolization. We hypothesized that children with SCA and overt stroke (SCA + stroke) have an increased prevalence of potential RLS. We performed contrasted transthoracic echocardiograms on 147 children (aged 2-19 years) with SCA + stroke) mean age 12·7 ± 4·8 years, 54·4% male) and a control group without SCA or stroke (n = 123; mean age 12·1 ± 4·9 years, 53·3% male). RLS was defined as any potential RLS detected by any method, including intrapulmonary shunting. Echocardiograms were masked and adjudicated centrally. The prevalence of potential RLS was significantly higher in the SCA+stroke group than controls (45·6% vs. 23·6%, P < 0·001). The odds ratio for potential RLS in the SCA + stroke group was 2·7 (95% confidence interval: 1·6-4·6) vs controls. In post hoc analyses, the SCA + stroke group had a higher prevalence of intrapulmonary (23·8% vs. 5·7%, P < 0·001) but not intracardiac shunting (21·8% vs. 18·7%, P = 0·533). SCA patients with potential RLS were more likely to report headache at stroke onset than those without. Intrapulmonary and intracardiac shunting may be an overlooked, independent and potentially modifiable risk factor for stroke in SCA. © 2016 John Wiley & Sons Ltd.

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

Genome-wide association analysis of ischemic stroke in young adults.

PubMed

Cheng, Yu-Ching; O'Connell, Jeffrey R; Cole, John W; Stine, O Colin; Dueker, Nicole; McArdle, Patrick F; Sparks, Mary J; Shen, Jess; Laurie, Cathy C; Nelson, Sarah; Doheny, Kimberly F; Ling, Hua; Pugh, Elizabeth W; Brott, Thomas G; Brown, Robert D; Meschia, James F; Nalls, Michael; Rich, Stephen S; Worrall, Bradford; Anderson, Christopher D; Biffi, Alessandro; Cortellini, Lynelle; Furie, Karen L; Rost, Natalia S; Rosand, Jonathan; Manolio, Teri A; Kittner, Steven J; Mitchell, Braxton D

2011-11-01

Ischemic stroke (IS) is among the leading causes of death in Western countries. There is a significant genetic component to IS susceptibility, especially among young adults. To date, research to identify genetic loci predisposing to stroke has met only with limited success. We performed a genome-wide association (GWA) analysis of early-onset IS to identify potential stroke susceptibility loci. The GWA analysis was conducted by genotyping 1 million SNPs in a biracial population of 889 IS cases and 927 controls, ages 15-49 years. Genotypes were imputed using the HapMap3 reference panel to provide 1.4 million SNPs for analysis. Logistic regression models adjusting for age, recruitment stages, and population structure were used to determine the association of IS with individual SNPs. Although no single SNP reached genome-wide significance (P < 5 × 10(-8)), we identified two SNPs in chromosome 2q23.3, rs2304556 (in FMNL2; P = 1.2 × 10(-7)) and rs1986743 (in ARL6IP6; P = 2.7 × 10(-7)), strongly associated with early-onset stroke. These data suggest that a novel locus on human chromosome 2q23.3 may be associated with IS susceptibility among young adults.

Beyond the Time Window of Intravenous Thrombolysis: Standing by or by Stenting?

PubMed Central

Liu, Xinfeng

2012-01-01

Intravenous administration of tissue plasminogen activator within 4.5 h of symptom onset is presently the ‘golden rule’ for treating acute ischemic stroke. However, many patients miss the time window and others reject this treatment due to a long list of contraindications. Mechanical embolectomy has recently progressed as a potential alternative for treating patients beyond the time window for IV thrombolysis. In this paper, recent progress in mechanical embolectomy, angioplasty, and stenting in acute stroke is reviewed. Despite worries concerning the long-term clinical outcomes and increased risk of intracranial hemorrhage, favorable clinical outcomes may be achieved after mechanical embolectomy in carefully selected patients even 4.5 h after stroke onset. Potential steps should be prepared and attempted in these patients whose opportunity for recovery will elapse in a flash. PMID:25187761

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

PubMed

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

2013-10-01

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

Management of recent-onset sustained atrial fibrillation: pharmacologic and nonpharmacologic strategies.

PubMed

Lau, Dennis H; Kalman, Jonathan; Sanders, Prashanthan

2014-09-01

Recent studies have highlighted significant variations in the management of recent-onset sustained atrial fibrillation (AF). We aim to provide a succinct and clear management algorithm for physicians treating patients with recent-onset sustained AF. We performed a comprehensive search of the literature on the management of recent-onset sustained AF with focus on studies reporting cardioversion of AF, antiarrhythmic agents, and anticoagulation. We also reviewed recent practice guidelines on AF management. This review provides a guide on a tailored management approach of patients with recent-onset sustained AF. After initial detailed clinical assessment, optimal rate and rhythm control options can be provided, depending on hemodynamic stability, duration of AF episode, and AF stroke risk. Issues surrounding electrical and pharmacologic cardioversion are discussed in detail. We emphasize the importance of thromboembolic risk assessment and appropriate anticoagulation surrounding the point of cardioversion. Last, we highlighted the need for appropriate specialized follow-up care after acute AF management. Despite the highly heterogeneous clinical presentations, management of recent-onset sustained AF must include stroke risk assessment, appropriate anticoagulation, and follow-up care in all patients beyond optimum rate and rhythm control strategies. Copyright © 2014. Published by Elsevier Inc.

Brain Natriuretic Peptide Is a Powerful Predictor of Outcome in Stroke Patients with Atrial Fibrillation

PubMed Central

Maruyama, Kenji; Uchiyama, Shinichiro; Shiga, Tsuyoshi; Iijima, Mutsumi; Ishizuka, Kentaro; Hoshino, Takao; Kitagawa, Kazuo

2017-01-01

Background Since stroke patients with nonvalvular atrial fibrillation (NVAF) have poor outcomes in general, the prediction of outcomes following discharge is of utmost concern for these patients. We previously reported that brain natriuretic peptide (BNP) levels were significantly higher in NVAF patients with larger infarcts, higher modified Rankin Scale (mRS) score, and higher CHADS2 score. In the present study, we evaluated an array of variables, including BNP, in order to determine significant predictors for functional outcome in patients with NVAF after acute ischemic stroke (AIS). Methods A total of 615 consecutive patients with AIS within 48 h of symptom onset, admitted to our hospital between April 2010 and October 2015, were retrospectively searched. Among these patients, we enrolled consecutive patients with NVAF. We evaluated the mRS score 3 months after onset of stroke and investigated associations between mRS score and the following clinical and echocardiographic variables. Categorical variables included male sex, current smoking, alcohol intake, hypertension, diabetes mellitus, dyslipidemia, coronary artery disease, peripheral artery disease, use of antiplatelet drugs, anticoagulants, or tissue plasminogen activator (tPA), and infarct size. Continuous variables included age, systolic blood pressure (SBP), diastolic blood pressure, hemoglobin, creatinine, D-dimer, brain natriuretic peptide (BNP), left atrial diameter, left ventricular ejection fraction (EF), and early mitral inflow velocity/diastolic mitral annular velocity (E/e’). We also analyzed the association of prestroke CHADS2, CHA2DS2-VASc, and R2CHADS2 scores, and National Institutes of Health Stroke Scale (NIHSS) score on admission with mRS score 3 months after the onset of stroke. Patients were classified into 2 groups according to mRS score: an mRS score ≤2 was defined as good outcome, an mRS score ≥3 was defined as poor outcome. To clarify the correlations between categorical or continuous variables and mRS score, uni- and multivariate logistic regression models using the stepwise variable selection method were applied. Results Among 157 patients with NVAF after AIS, 63.7% were male and the mean age was 75.9 years. In univariate regression analysis, poor outcome (mRS score ≥3) was associated with use of tPA, infarct size, age, SBP, BNP, EF, and NIHSS score. In multivariate regression analysis, BNP levels (odds ratio [OR] 6.40; 95% confidence interval [CI] 1.26–32.43; p = 0.0235) and NIHSS score (OR 2.87; 95% CI 1.84–4.47; p < 0.001) were significantly associated with poor outcome (mRS score ≥3) after adjusting for use of tPA, infarct size, age, BNP, EF, and NIHSS score. Conclusions Apart from NIHSS score, BNP was a very useful predictor for long-term outcomes of patients with NVAF after AIS. PMID:28253498

A pragmatic approach to sonothrombolysis in acute ischaemic stroke: the Norwegian randomised controlled sonothrombolysis in acute stroke study (NOR-SASS).

PubMed

Nacu, Aliona; Kvistad, Christopher E; Logallo, Nicola; Naess, Halvor; Waje-Andreassen, Ulrike; Aamodt, Anne Hege; Solhoff, Ragnar; Lund, Christian; Tobro, Håkon; Rønning, Ole Morten; Salvesen, Rolf; Idicula, Titto T; Thomassen, Lars

2015-07-11

Ultrasound accelerates thrombolysis with tPA (sonothrombolysis). Ultrasound in the absence of tPA also accelerates clot break-up (sonolysis). Adding intravenous gaseous microbubbles may potentiate the effect of ultrasound in both sonothrombolysis and sonolysis. The Norwegian Sonothrombolysis in Acute Stroke Study aims in a pragmatic approach to assess the effect and safety of contrast enhanced ultrasound treatment in unselected acute ischaemic stroke patients. Acute ischaemic stroke patients ≥ 18 years, with or without visible arterial occlusion on computed tomography angiography (CTA) and treatable ≤ 4(½) hours after symptom onset, are included in NOR-SASS. NOR-SASS is superimposed on a separate trial randomising patients with acute ischemic stroke to either tenecteplase or alteplase (The Norwegian Tenecteplase Stroke Trial NOR-TEST). The NOR-SASS trial has two arms: 1) the thrombolysis-arms (NOR-SASS A and B) includes patients given intravenous thrombolysis (tenecteplase or alteplase), and 2) the no-thrombolysis-arm (NOR-SASS C) includes patients with contraindications to thrombolysis. First step randomisation of NOR-SASS A is embedded in NOR-TEST as a 1:1 randomisation to either tenecteplase or alteplase. Second step NOR-SASS randomisation is 1:1 to either contrast enhanced sonothrombolysis (CEST) or sham CEST. Randomisation in NOR-SASS B (routine alteplase group) is 1:1 to either CEST or sham CEST. Randomisation of NOR-SASS C is 1:1 to either contrast enhanced sonolysis (CES) or sham CES. Ultrasound is given for one hour using a 2-MHz pulsed-wave diagnostic ultrasound probe. Microbubble contrast (SonoVue®) is given as a continuous infusion for ~30 min. Recanalisation is assessed at 60 min after start of CEST/CES. Magnetic resonance imaging and angiography is performed after 24 h of stroke onset. Primary study endpoints are 1) major neurological improvement measured with NIHSS score at 24 h and 2) favourable functional outcome defined as mRS 0-1 at 90 days. NOR-SASS is the first randomised controlled trial designed to test the superiority of contrast enhanced ultrasound treatment given ≤ 4(½) hours after stroke onset in an unselected acute ischaemic stroke population eligible or not eligible for intravenous thrombolysis, with or without a defined arterial occlusion on CTA. If a positive effect and safety can be proven, contrast enhanced ultrasound treatment will be an option for all acute ischaemic stroke patients. EudraCT No 201200032341; www.clinicaltrials.gov NCT01949961.

Decreased risk of pneumonia in stroke patients receiving acupuncture: A nationwide matched-pair retrospective cohort study

PubMed Central

Chang, Chuen-Chau; Chen, Ta-Liang; Lin, Chao-Shun; Chung, Chi-Li; Yeh, Chun-Chieh; Hu, Chaur-Jong; Lane, Hsin-Long

2018-01-01

Background Acupuncture treatment is common among stroke patients, but there is limited information available on whether acupuncture effectively prevents post-stroke pneumonia. The aim of this study was to analyze the differential risk of pneumonia after stroke between patients who did and did not receive acupuncture after discharge. Methods We used the Taiwan National Health Insurance Research Database to conduct a retrospective cohort study using propensity score matched-pairs of new stroke patients in 2000–2004 who did and did not receive acupuncture post-stroke. Both cohorts were followed up until the end of 2009 for new-onset pneumonia. After correcting for immortal time bias, the incidence and adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) of pneumonia associated with acupuncture use were calculated using multivariate Cox proportional hazard models. Results Overall, 12557 stroke patients with 12557 paired controls were included in the analysis; pneumonia was diagnosed in 6796 (27.1%). Stroke patients receiving acupuncture had a lower incidence of pneumonia than those without acupuncture (53.4 vs. 58.9 per 1000 person-years), with an adjusted HR of 0.86 (95% CI 0.82–0.90). The association between pneumonia risk and acupuncture use was significant in men (HR 0.92, 95% CI 0.86–0.98) and women (HR 0.79, 95% 0.70–0.82) and was also observed in every age group from 20–79 years. Conclusion Stroke patients receiving acupuncture had a lower risk of pneumonia than those who did not. Further randomized control studies are needed to validate the protective effect of acupuncture on the risk of pneumonia among stroke patients. PMID:29782526

Self-reported transient ischemic attack and stroke symptoms: methods and baseline prevalence. The ARIC Study, 1987-1989.

PubMed

Toole, J F; Lefkowitz, D S; Chambless, L E; Wijnberg, L; Paton, C C; Heiss, G

1996-11-01

As part of the Atherosclerosis Risk in Communities (ARIC) Study assessment of the etiology and sequelae of atherosclerosis, a standardized questionnaire on transient ischemic attack (TIA) and nonfatal stroke and a computerized diagnostic algorithm simulating clinical reasoning were developed and tested at the four ARIC field centers: Forsyth County, North Carolina; Minneapolis, Minnesota; Jackson, Mississippi; and Washington County, Maryland. The diagnostic algorithm used participant responses to a series of questions about six neurologic trigger symptoms to identify symptoms of TIA or stroke and their vascular distribution. Among 12,205 ARIO participants reporting their lifetime occurrence of one or more symptoms probably due to cerebrovascular causes, nearly half (47%) reported the sudden onset of at least one symptom sometime prior to their ARIC examination. Of those with at least one symptom, only 12.9% were classified by the computer algorithm as having symptoms of TIA or stroke. Dizziness/loss of balance was the most frequently reported symptom (36%); 1.2% of these persons were classified by the algorithm as having a TIA/stroke event. Positive symptoms of speech dysfunction were classified most often (77.%) as being symptoms of TIA or stroke. Symptoms suggesting TIA were reported more frequently than symptoms suggesting stroke by both sexes. TIA or stroke-like phenomena were more frequent (p < 0.001) in females (7%) than in males (5%) and increased with age in both sexes (p = 0.13 for females; p = 0.02 for males). In Forsyth County, TIA and stroke symptoms were greater in African Americans than in Caucasians (p = 0.05, controlling for sex). The association of algorithmically defined symptoms of TIA or stroke with traditional cerebrovascular risk factors is the subject of a companion paper.

Details of a prospective protocol for a collaborative meta-analysis of individual participant data from all randomized trials of intravenous rt-PA vs. control: statistical analysis plan for the Stroke Thrombolysis Trialists' Collaborative meta-analysis.

PubMed

2013-06-01

Thrombolysis with intravenous alteplase is both effective and safe when administered to particular types of patient within 4·5 hours of having an ischemic stroke. However, the extent to which effects might vary in different types of patient is uncertain. We describe the protocol for an updated individual patient data meta-analysis of trials of intravenous alteplase, including results from the recently reported third International Stroke Trial, in which a wide range of patients enrolled up to six-hours after stroke onset were randomized to alteplase vs. control. This protocol will specify the primary outcome for efficacy, specified prior to knowledge of the results from the third International Stroke Trial, as the proportion of patients having a 'favorable' stroke outcome, defined by modified Rankin Score 0-1 at final follow-up at three- to six-months. The primary analysis will be to estimate the extent to which the known benefit of alteplase on modified Rankin Score 0-1 diminishes with treatment delay, and the extent to which it is independently modified by age and stroke severity. Key secondary outcomes include effect of alteplase on death within 90 days; analyses of modified Rankin Score using ordinal, rather than dichotomous, methods; and effects of alteplase on symptomatic intracranial hemorrhage, fatal intracranial hemorrhage, symptomatic ischemic brain edema and early edema, effacement and/or midline shift. This collaborative meta-analysis of individual participant data from all randomized trials of intravenous alteplase vs. control will demonstrate how the known benefits of alteplase on ischemic stroke outcome vary across different types of patient. © 2013 The Authors. International Journal of Stroke © 2013 World Stroke Organization.

A simple prediction score for developing a hospital-acquired infection after acute ischemic stroke.

PubMed

Friedant, Adam J; Gouse, Brittany M; Boehme, Amelia K; Siegler, James E; Albright, Karen C; Monlezun, Dominique J; George, Alexander J; Beasley, Timothy Mark; Martin-Schild, Sheryl

2015-03-01

Hospital-acquired infections (HAIs) are a major cause of morbidity and mortality in acute ischemic stroke patients. Although prior scoring systems have been developed to predict pneumonia in ischemic stroke patients, these scores were not designed to predict other infections. We sought to develop a simple scoring system for any HAI. Patients admitted to our stroke center (July 2008-June 2012) were retrospectively assessed. Patients were excluded if they had an in-hospital stroke, unknown time from symptom onset, or delay from symptom onset to hospital arrival greater than 48 hours. Infections were diagnosed via clinical, laboratory, and imaging modalities using standard definitions. A scoring system was created to predict infections based on baseline patient characteristics. Of 568 patients, 84 (14.8%) developed an infection during their stays. Patients who developed infection were older (73 versus 64, P < .0001), more frequently diabetic (43.9% versus 29.1%, P = .0077), and had more severe strokes on admission (National Institutes of Health Stroke Scale [NIHSS] score 12 versus 5, P < .0001). Ranging from 0 to 7, the overall infection score consists of age 70 years or more (1 point), history of diabetes (1 point), and NIHSS score (0-4 conferred 0 points, 5-15 conferred 3 points, >15 conferred 5 points). Patients with an infection score of 4 or more were at 5 times greater odds of developing an infection (odds ratio, 5.67; 95% confidence interval, 3.28-9.81; P < .0001). In our sample, clinical, laboratory, and imaging information available at admission identified patients at risk for infections during their acute hospitalizations. If validated in other populations, this score could assist providers in predicting infections after ischemic stroke. Copyright © 2015 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Predictive Value of Pulse Pressure in Acute Ischemic Stroke for Future Major Vascular Events.

PubMed

Lee, Keon-Joo; Kim, Beom Joon; Han, Moon-Ku; Kim, Joon-Tae; Cho, Ki-Hyun; Shin, Dong-Ick; Yeo, Min-Ju; Cha, Jae-Kwan; Kim, Dae-Hyun; Nah, Hyun-Wook; Kim, Dong-Eog; Ryu, Wi-Sun; Park, Jong-Moo; Kang, Kyusik; Lee, Soo Joo; Oh, Mi-Sun; Yu, Kyung-Ho; Lee, Byung-Chul; Hong, Keun-Sik; Cho, Yong-Jin; Choi, Jay Chol; Sohn, Sung Il; Hong, Jeong-Ho; Park, Tai Hwan; Park, Sang-Soon; Kwon, Jee-Hyun; Kim, Wook-Joo; Lee, Jun; Lee, Ji Sung; Lee, Juneyoung; Gorelick, Philip B; Bae, Hee-Joon

2018-01-01

This study aimed to investigate whether pulse pressure (PP) obtained during the acute stage of ischemic stroke can be used as a predictor for future major vascular events. Using a multicenter prospective stroke registry database, patients who were hospitalized for ischemic stroke within 48 hours of onset were enrolled in this study. We analyzed blood pressure (BP) data measured during the first 3 days from onset. Primary and secondary outcomes were time to a composite of stroke recurrence, myocardial infarction, all-cause death, and time to stroke recurrence, respectively. Of 9840 patients, 4.3% experienced stroke recurrence, 0.2% myocardial infarction, and 7.3% death during a 1-year follow-up period. In Cox proportional hazards models including both linear and quadratic terms of PP, PP had a nonlinear J-shaped relationship with primary (for a quadratic term of PP, P =0.004) and secondary ( P <0.001) outcomes. The overall effects of PP and other BP parameters on primary and secondary outcomes were also significant ( P <0.05). When predictive power of BP parameters was compared using a statistic of -2 log-likelihood differences, PP was a stronger predictor than systolic BP (8.49 versus 5.91; 6.32 versus 4.56), diastolic BP (11.42 versus 11.05; 10.07 versus 4.56), and mean atrial pressure (8.75 versus 5.91; 7.03 versus 4.56) for the primary and secondary outcomes, respectively. Our study shows that PP when measured in the acute period of ischemic stroke has nonlinear J-shaped relationships with major vascular events and stroke recurrence, and may have a stronger predictive power than other commonly used BP parameters. © 2017 American Heart Association, Inc.

Quercetin protects against heat stroke-induced myocardial injury in male rats: Antioxidative and antiinflammatory mechanisms.

PubMed

Lin, Xiaojing; Lin, Cheng-Hsien; Zhao, Tingbao; Zuo, Dan; Ye, Zhujun; Liu, Lin; Lin, Mao-Tsun

2017-03-01

Heat stroke is characterized by hyperthermia, systemic inflammation, and multiple organ failure including arterial hypotension. This definition can be fulfilled by a rat model of heat stroke used in the present study. Anesthetized animals were exposed to heat exposure (43 °C for 70 min) and then returned to room temperature (26 °C) for recovery. One hour before heat exposure, an intraperitoneal dose of quercetin (30 mg/kg) or vehicle (normal saline 1 ml/kg) was administered to the experimental groups of rats. Additional injection was administered immediately after the onset of heat stroke. Immediately after the onset of heat stroke. Vehicle-treated rats displayed (i) hyperthermia; (ii) suppressed left ventricular function; (iii) decreased contents of cardiac total antioxiant capacity (e.g., superoxide dismutase, glutathione peroxidase, catalase); (iv) increased contents of cardiac oxidative capacity malondialdehyde and thiobarbituric acid reactive substances; (v) increased cardiac levels of pro-inflammatory cytokines tumor necrosis factor-α and interleukin-6; and (vi) decreased cardiac levels of an anti-inflammatory cytokine interleukin 10. Histopathologic and survival observation provided supportive evidence for biochemical analyses. These heat stroke reactions all can be significantly attenuated by quercetin therapy. Our data suggest that quercetin therapy might improve outcomes of heat stroke in rats by attenuating excessive hyperthermia as well as myocardial injury. The protective effects of quercetin could be attributed to anti-lipid peroxidative, anti-oxidant, and anti-inflammatory properties. Copyright © 2017 Elsevier B.V. All rights reserved.

Mobilisation of Hematopoietic CD34+ Precursor Cells in Patients with Acute Stroke Is Safe - Results of an Open-Labeled Non Randomized Phase I/II Trial

PubMed Central

Kraemer, Mathias; Schormann, Thorsten; Schlachetzki, Felix; Schuierer, Gerhard; Luerding, Ralph; Hennemann, Burkhard; Orso, Evelyn; Dabringhaus, Andreas; Winkler, Jürgen; Bogdahn, Ulrich

2011-01-01

Background Regenerative strategies in the treatment of acute stroke may have great potential. Hematopoietic growth factors mobilize hematopoietic stem cells and may convey neuroprotective effects. We examined the safety, potential functional and structural changes, and CD34+ cell–mobilization characteristics of G-CSF treatment in patients with acute ischemic stroke. Methods and Results Three cohorts of patients (8, 6, and 6 patients per cohort) were treated subcutaneously with 2.5, 5, or 10 µg/kg body weight rhG-CSF for 5 consecutive days within 12 hrs of onset of acute stroke. Standard treatment included IV thrombolysis. Safety monitoring consisted of obtaining standardized clinical assessment scores, monitoring of CD34+ stem cells, blood chemistry, serial neuroradiology, and neuropsychology. Voxel-guided morphometry (VGM) enabled an assessment of changes in the patients' structural parenchyma. 20 patients (mean age 55 yrs) were enrolled in this study, 5 of whom received routine thrombolytic therapy with r-tPA. G-CSF treatment was discontinued in 4 patients because of unrelated adverse events. Mobilization of CD34+ cells was observed with no concomitant changes in blood chemistry, except for an increase in the leukocyte count up to 75,500/µl. Neuroradiological and neuropsychological follow-up studies did not disclose any specific G-CSF toxicity. VGM findings indicated substantial atrophy of related hemispheres, a substantial increase in the CSF space, and a localized increase in parenchyma within the ischemic area in 2 patients. Conclusions We demonstrate a good safety profile for daily administration of G-CSF when begun within 12 hours after onset of ischemic stroke and, in part in combination with routine IV thrombolysis. Additional analyses using VGM and a battery of neuropsychological tests indicated a positive functional and potentially structural effect of G-CSF treatment in some of our patients. Trial Registration German Clinical Trial Register DRKS 00000723 PMID:21887230

Acute cardioembolic cerebral infarction: answers to clinical questions.

PubMed

Arboix, Adria; Alio, Josefina

2012-02-01

Cardioembolic cerebral infarction (CI) is the most severe subtype of ischaemic stroke but some clinical aspects of this condition are still unclear. This article provides the reader with an overview and up-date of relevant aspects related to clinical features, specific cardiac disorders and prognosis of CI. CI accounts for 14-30% of ischemic strokes; patients with CI are prone to early and long-term stroke recurrence, although recurrences may be preventable by appropriate treatment during the acute phase and strict control at follow-up. Certain clinical features are suggestive of CI, including sudden onset to maximal deficit, decreased level of consciousness at onset, Wernicke's aphasia or global aphasia without hemiparesis, a Valsalva manoeuvre at the time of stroke onset, and co-occurrence of cerebral and systemic emboli. Lacunar clinical presentations, a lacunar infarct and especially multiple lacunar infarcts, make cardioembolic origin unlikely. The most common disorders associated with a high risk of cardioembolism include atrial fibrillation, recent myocardial infarction, mechanical prosthetic valve, dilated myocardiopathy and mitral rheumatic stenosis. Patent foramen ovale and complex atheromatosis of the aortic arch are potentially emerging sources of cardioembolic infarction. Mitral annular calcification can be a marker of complex aortic atheroma in stroke patients of unkown etiology. Transthoracic and transesophageal echocardiogram can disclose structural heart diseases. Paroxysmal atrial dysrhythmia can be detected by Holter monitoring. Magnetic resonance imaging, transcranial Doppler, and electrophysiological studies are useful to document the source of cardioembolism. In-hospital mortality in cardioembolic stroke (27.3%, in our series) is the highest as compared with other subtypes of cerebral infarction. Secondary prevention with anticoagulants should be started immediately if possible in patients at high risk for recurrent cardioembolic stroke in which contraindications, such as falls, poor compliance, uncontrolled epilepsy or gastrointestinal bleeding are absent. Dabigatran has been shown to be non-inferior to warfarin in the prevention of stroke or systemic embolism. All significant structural defects, such as atrial septal defects, vegetations on valve or severe aortic disease should be treated. Aspirin is recommended in stroke patients with a patent foramen ovale and indications of closure should be individualized. CI is an important topic in the frontier between cardiology and vascular neurology, occurs frequently in daily practice, has a high impact for patients, and health care systems and merits an update review of current clinical issues, advances and controversies.

Menopause and Ischemic Stroke: A Brief Review

PubMed Central

Shekhar, Shashank; Travis, Olivia K; He, Xiaochen; Roman, Richard J; Fan, Fan

2017-01-01

Ischemic stroke is one of the leading causes of morbidity and mortality worldwide. Females are protected against stroke before the onset of menopause. Menopause results in increased incidence of stroke when compared to men. The mechanisms of these differences remain to be elucidated. Considering that there is a postmenopausal phenomenon and females in general, are living longer sex hormone-dependent mechanisms have been postulated to be the primary factors responsible for the premenopausal protection from stroke and later to be responsible for the higher incidence and increased the severity of stroke after menopause. Animal studies suggest that administration of estrogen and progesterone is neuroprotective and decreases the incidence of stroke. However, the real-world outcomes of hormone replacement therapy have failed to decrease the stroke risk. Despite the multifactorial nature of sex differences in stroke, here, we briefly discuss the pathophysiology of sex steroid hormones, the molecular mechanisms of estrogen receptor-dependent signaling pathways in stroke, and the potential factors that determine the discrepant effects of hormone replacement therapy in stroke. PMID:28936482

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.

[Correlation between post-stroke pneumonia and outcome in patients with acute brain infarction].

PubMed

Li, S J; Hu, H Q; Wang, X L; Cao, B Z

2016-09-20

Objective: To investigate the correlation between post-stroke pneumonia and outcome in patients with acute brain infarction. Methods: Consecutive acute cerebral infarction patients who were hospitalized in Department of Neurology, Jinan Military General Hospital were prospectively recruited from August 2010 to August 2014. The baseline data including age, sex, the National Institute of Health Stroke Scale (NIHSS) scores, type of Oxfordshire Community Stroke Project (OCSP: total anterior circulation infarct, partial anterior circulation infarct, posterior circulation infarct and lacunar infarct), fasting blood glucose etc. after admission were recorded. Post-stroke pneumonia was diagnosed by treating physician according to criteria for hospital-acquired pneumonia of the Centers for Disease Control and Prevention. Recovery was assessed by modified Rankin Scale (mRS) 180 days after stroke by telephone interview (mRS≤2 reflected good prognosis, and mRS>2 reflected unfavorable prognosis). Multinominal Logistic regression analysis, Kaplan-Meier curve and log rank test were used. Results: A total of 1 249 patients were enrolled, among them 173 patients were lost during follow-up. A total of 159 patients had post-stroke pneumonia, while 1 090 patients were without post-stroke. Compared with patients without post-stoke pneumonia, patients with post-stroke pneumonia were older (67±13 vs 63±12 years, P =0.000), more severe (NIHSS, 15(14) vs 4(4), P =0.000). Compared with patients without post-stoke pneumonia, more patients with post-stroke pneumonia suffered from heart failure (12.58% vs 3.40%, P =0.000), atrial fibrillation (26.42% vs 8.81%, P =0.000), myocardial infarction (10.06% vs 5.05%, P =0.016), recurrent brain infarction (30.19% vs 22.66%, P =0.045), total anterior circulation infarct type of OCSP (46.54% vs 19.63%, P =0.000), posterior circulation infarct of OCSP (39.62% vs 25.51%, P =0.001); more patients suffered from disorder of consciousness (60.38% vs 9.27%, P =0.000), dysphagia (34.59% vs 19.89%, P =0.000), vomiting (26.42% vs 8.81%, P =0.000), aphasia (35.85% vs 16.61%, P =0.000) since onset. The morbidity of post-stroke pneumonia among patients with unfavorable outcome (29.37%(111/378)) was significantly higher than that among patients with favorable outcome (3.73%(26/698)) ( P =0.000). Post-stroke pneumonia was an independent prognostic factor for long-term unfavorable outcome ( OR =2.414, 95% CI : 1.336-4.361, P =0.004) and long-term mortality ( OR =2.132, 95% CI : 1.229-3.699, P =0.007). According Kaplan-Meier estimation, the cumulative 180 days survival of patients with post-stroke pneumonia was lower than those without post-stroke pneumonia (62.04%(85/137) vs 93.29%(876/939)); Log-rank test: χ 2 =137.32, P =0.000. Conclusions: Acute brain infarction patients with post-stroke pneumonia are older, more severe; more suffering from heart failure, atrial fibrillation, myocardial infarction; more suffering from disorder of consciousness since onset. Post-stroke pneumonia is an independent prognostic factor for long-term unfavorable outcome and for long term mortality in patients with acute brain infarction.

Dementia in developing countries: Does education play the same role in India as in the West?

PubMed

Iyer, Gowri K; Alladi, Suvarna; Bak, Thomas H; Shailaja, Mekala; Mamidipudi, Annapurna; Rajan, Amulya; Gollahalli, Divyaraj; Chaudhuri, Jaydip Ray; Kaul, Subhash

2014-01-01

Evidence suggests that education protects from dementia by enhancing cognitive reserve. However, this may be influenced by several socio-demographic factors. Rising numbers of dementia in India, high levels of illiteracy and heterogeneity in socio-demographic factors provide an opportunity to explore this relationship. To study the association between education and age at dementia onset, in relation to socio-demographic factors. Association between age at dementia onset and literacy was studied in relationship to potential confounding factors such as gender, bilingualism, place of dwelling, occupation, vascular risk factors, stroke, family history of dementia and dementia subtypes. Case records of 648 dementia patients diagnosed in a specialist clinic in a University hospital in Hyderabad, India were examined. All patients were prospectively enrolled as part of an ongoing longitudinal project that aims to evaluate dementia subjects with detailed clinical, etiological, imaging, and follow-up studies. Of the 648 patients, 98 (15.1%) were illiterate. More than half of illiterate skilled workers were engaged in crafts and skilled agriculture unlike literates who were in trade or clerical jobs. Mean age at onset in illiterates was 60.1 years and in literates 64.5 years (p=0.0002). Factors independently associated with age at dementia onset were bilingualism, rural dwelling and stroke, but not education. Our study demonstrates that in India, rural dwelling, bilingualism, stroke and occupation modify the relationship between education and dementia.

Significance of Large Vessel Intracranial Occlusion Causing Acute Ischemic Stroke and TIA

PubMed Central

Smith, Wade S.; Lev, Michael H.; English, Joey D.; Camargo, Erica C.; Chou, Maggie; Johnston, S. Claiborne; Gonzalez, Gilberto; Schaefer, Pamela W.; Dillon, William P.; Koroshetz, Walter J.; Furie, Karen L.

2009-01-01

Background: Acute ischemic stroke due to large vessel occlusion (LVO)-vertebral, basilar, carotid terminus, middle and anterior cerebral arteries- likely portends a worse prognosis than stroke unassociated with LVO. Because little prospective angiographic data has been reported on a cohort of unselected stroke and TIA patients, the clinical impact of LVO has been difficult to quantify. Methods: The STOP-Stroke Study is a prospective imaging-based study of stroke outcomes performed at two academic medical centers. Patients with suspected acute stroke who presented within 24 hours of symptom onset and who underwent multi-modality CT/CTA were approached for consent for collection of clinical data and 6 month assessment of outcome. Demographic and clinical variables and 6-month modified Rankin scores (mRS) were collected and combined with blinded interpretation of the CTA data. The odds ratio (OR) of each variable including occlusion of intracranial vascular segment in predicting good outcome and 6-month mortality was calculated using univariate and multivariate logistic regression. Results: Over a 33 month period, 735 patients with suspected stroke were enrolled. Of these, 578 were adjudicated as stroke and 97 as TIA. Among stroke patients, 267 (46%) had LVO accounting for the stroke and 13 (13%) of TIA patients had LVO accounting for TIA symptoms. LVO predicted six-month mortality (OR 4.5; 95% CI 2.7-7.3; p<0.001). Six-month good outcome (mRS≤ 2) was negatively predicted by LVO (0.33; 0.24-0.45; p<0.001). Based on multivariate analysis, the presence of basilar and internal carotid terminus occlusions, in addition to NIHSS and age, independently predicted outcome. Conclusion: Large vessel intracranial occlusion accounted for nearly half of acute ischemic strokes in unselected patients presenting to academic medical centers. In addition to age and baseline stroke severity, occlusion of either the basilar or internal carotid terminus segment is an independent predictor of outcome at 6 months. PMID:19834014

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

PubMed

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

2016-11-01

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

Outcomes of General Anesthesia and Conscious Sedation in Endovascular Treatment for Stroke.

PubMed

Just, Caroline; Rizek, Philippe; Tryphonopoulos, Peter; Pelz, David; Arango, Miguel

2016-09-01

Background Recent studies have strongly indicated the benefits of endovascular therapy for acute ischemic stroke, but what remains a continued debate is the role for general anaesthesia versus conscious sedation (CS) for such procedures. Retrospective studies have found poorer neurological outcomes in patients who underwent general anesthesia (GA); however, some have revealed worse baseline stroke severity in these patients. Methods This study is a retrospective cohort study aimed at comparing mortality and morbidity of GA versus CS in patients treated with endovascular intervention in acute ischemic stroke. Chi-square and t-test analyses were used. Results Patients in the GA (n=42) group were more likely to be deceased than those in the CS (n=67) group at hospital discharge, 3 months, and 6 months poststroke onset. Morbidity, as defined by modified Rankin Score, was significantly greater in the GA group at hospital discharge, and a similar trend was seen in morbidity at 3 months postdischarge. Conclusion General anesthesia for endovascular intervention in acute ischemic stroke was associated with increased mortality and poorer neurological incomes compared with conscious sedation. In our study, age, gender, history of hypertension, history of diabetes, and baseline National Institute of Health Stroke Scale were not significantly different between the groups. Although the need for a randomized, prospective study on this topic is clear, our study represents further corroboration of the safety and efficacy of conscious sedation in these procedures.

Eligibility and Predictors for Acute Revascularization Procedures in a Stroke Center.

PubMed

Vanacker, Peter; Lambrou, Dimitris; Eskandari, Ashraf; Mosimann, Pascal J; Maghraoui, Ali; Michel, Patrik

2016-07-01

Endovascular treatment (EVT) is a new standard of care for selected, large vessel occlusive strokes. We aimed to determine frequency of potentially eligible patients for intravenous thrombolysis (IVT) and EVT in comprehensive stroke centers. In addition, predictors of EVT eligibility were derived. Patients from a stroke center-based registry (2003-2014), admitted within 24 hours of last proof of usual health, were selected if they had all data to determine IVT and EVT eligibility according to American Heart Association/American Stroke Association (AHA/ASA) guidelines (class I-IIa recommendations). Moreover, less restrictive criteria adapted from randomized controlled trials and clinical practice were tested. Maximum onset-to-door time windows for IVT eligibility were 3.5 hours (allowing door-to-needle delay of ≤60 minutes) and 4.5 hours for EVT eligibility (door-to-groin delay ≤90 minutes). Demographic and clinical information were used in logistic regression analysis to derive variables associated with EVT eligibility. A total of 2704 patients with acute ischemic stroke were included, of which 26.8% were transfers. Of all patients with stroke arriving at our comprehensive stroke center, a total proportion of 12.4% patients was eligible for IVT. Frequency of EVT eligibility differed between AHA/ASA guidelines and less restrictive approach: 2.9% versus 4.9%, respectively, of all patients with acute ischemic stroke and 10.5% versus 17.7%, respectively, of all patients arriving within <6 hours. Predictors for AHA-EVT eligibility were younger, shorter onset-to-admission delays, higher National Institutes of Health Stroke Scale (NIHSS), decreased vigilance, hemineglect, absent cerebellar signs, atrial fibrillation, smoking, and decreasing glucose levels (area under the curve=0.86). Of patients arriving within 6 hours at a comprehensive stroke center, 10.5% are EVT eligible according to AHA/ASA criteria, 17.7% according to criteria resembling randomized controlled trials, and twice as many patients are IVT eligible (36.2%). © 2016 American Heart Association, Inc.

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

PubMed

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

2015-12-01

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

Positron Emission Tomography and Autoradiography Imaging of P-selectin Activation Using 68Ga-Fucoidan in Photothrombotic Stroke in Rats.

PubMed

Israel, Ina; Fluri, Felix; Schadt, Fabian; Buck, Adreas; Samnick, Samuel

2018-03-19

P-selectin is activated early after stroke, followed by a rapid decline. This time course can be used to generate important information on stroke onset. The latter is crucial for therapeutic decision-making of wake-up strokes (i.e. thrombolysis or not). Here we evaluated the specific p-selectin inhibitor 68Ga-Fucoidan for assessing p-selectin activation after ischemic stroke using PET. 68Ga-Fucoidan was investigated in rats brain at 2-5 h (n=16), and additionally at 24-26 h (n=9) and 48 h (n=3) after induction of photothrombic stroke or in sham operated animals (n=6). Correlation of cerebral 68Ga-Fucoidan uptake with p-selectin activation was determined by exposing freshly cut brain cryosections to autoradiography and immunostaining using specific antibodies against p-selectin. PET scans showed an increased accumulation of 68Ga-Fucoidan in the histologically proven ischemic stroke, as compared to the corresponding contralateral hemisphere in all except one animal. The median ratio between the uptake in the ischemic lesion and the contralateral region was 1.95 (1.45-2.41) at 2-5 h, 1.38 (1.05-1.89) at 24-26 h, and 1.09 (0.81-1.38) at 48 h after stroke, compared to 1.22 (0.99-1.49) for sham operated animals. In the ex vivo autoradiography, 68Ga-Fucoidan accumulation co-localized with p-selectin as assessed by immunostaining. Control animals and those scanned at 24-26 h and 48 h after stroke exhibited no elevated 68Ga-Fucoidan uptake in either hemisphere. PET imaging using 68Ga-Fucoidan represents a valuable tool for assessing p-selectin activation in vivo and to discriminate ischemic stroke early after stroke onset. Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.org.

Differences in Characteristics and Outcomes Between Asian and Non-Asian Patients in the TIAregistry.org.

PubMed

Hoshino, Takao; Uchiyama, Shinichiro; Wong, Lawrence K S; Sissani, Leila; Albers, Gregory W; Bornstein, Natan M; Caplan, Louis R; Donnan, Geoffrey A; Ferro, José M; Hennerici, Michael G; Labreuche, Julien; Lavallée, Philippa C; Molina, Carlos; Rothwell, Peter M; Steg, Philippe Gabriel; Touboul, Pierre-Jean; Vicaut, Éric; Amarenco, Pierre

2017-07-01

This study provides the contemporary causes and prognosis of transient ischemic attack (TIA) and minor stroke in Asians and the direct comparisons with non-Asians. The TIAregistry.org enrolled 4789 patients (1149 Asians and 3640 non-Asians) with a TIA or minor ischemic stroke within 7 days of onset. Every participating facility had systems dedicated to urgent intervention of TIA/stroke patients by specialists. The primary outcome was a composite of cardiovascular death, nonfatal stroke, and nonfatal acute coronary syndrome. Approximately 80% of patients were evaluated within 24 hours of symptom onset. At 1 year, there were no differences in the rates of composite cardiovascular events (6.8% versus 6.0%; P =0.38) and stroke (6.0% versus 4.8%; P =0.11) between Asians and non-Asians. Asians had a lower risk of cerebrovascular disease (stroke or TIA) than non-Asians (adjusted hazard ratio, 0.79; 95% confidence interval, 0.63-0.98; P =0.03); the difference was primarily driven by a lower rate of TIA in Asians (4.2% versus 8.3%; P <0.001). Moderately severe bleeding was more frequent in Asians (0.8% versus 0.3%; P =0.02). In multivariable analysis, multiple acute infarcts ( P =0.005) and alcohol consumption ( P =0.02) were independent predictors of stroke recurrence in Asians, whereas intracranial stenosis ( P <0.001), ABCD 2 score ( P <0.001), atrial fibrillation ( P =0.008), extracranial stenosis ( P =0.03), and previous stroke or TIA ( P =0.03) were independent predictors in non-Asians. The short-term stroke risk after a TIA or minor stroke was lower than expected when urgent evidence-based care was delivered, irrespective of race/ethnicity or region. However, the predictors of stroke were different for Asians and non-Asians. © 2017 American Heart Association, Inc.

Durability of the beneficial effect of MLC601 (NeuroAiD™) on functional recovery among stroke patients from the Philippines in the CHIMES and CHIMES-E studies.

PubMed

Navarro, Jose C; Chen, Christopher Lh; Lee, Chun F; Gan, Herminigildo H; Lao, Annabelle Y; Baroque, Alejandro C; Hiyadan, John Harold B; Chua, Carlos L; San Jose, Ma Cristina; Advincula, Joel M; Venketasubramanian, Narayanaswamy

2017-04-01

Background and Aim A pre-specified country analysis of subjects from the Philippines in the CHInese Medicine NeuroAiD Efficacy on Stroke recovery (CHIMES) Study showed significantly improved functional and neurological outcomes on MLC601 at month (M) 3. We aimed to assess these effects on long-term functional recovery in the Filipino cohort. Methods The CHIMES-E (extension) Study evaluated subjects who completed three months of randomized placebo-controlled treatment in CHIMES up to two years. Blinding of treatment allocation was maintained and all subjects received standard stroke care and rehabilitation. Modified Rankin Score (mRS) and Barthel Index (BI) were assessed in-person at M3 and by telephone at M6, M12, M18, M24. Odds ratios (OR) with corresponding 95% confidence intervals (CI) for functional recovery using ordinal analysis of mRS and for achieving functional independence (mRS 0-1 or BI ≥ 95) at each time point were calculated, adjusting for age, sex, baseline National Institute of Health Stroke Scale (NIHSS), onset-to-treatment time (OTT) and pre-stroke mRS. Results The 378 subjects (MLC601 192, placebo 186) included in CHIMES-E from the Philippines (mean age 60.2 ± 11.1) had more women ( p < 0.001), worse baseline NIHSS ( p < 0.001) and longer onset to treatment time ( p = 0.002) compared to other countries. Baseline characteristics were similar between treatment groups. The treatment effect of MLC601 seen at M3 peaked at M6 with OR for mRS shift of 1.53 (95% CI 1.05-2.22), mRS dichotomy 0-1 of 1.77 (95% CI 1.10-2.83), and BI ≥ 95 of 1.87 (95% CI 1.16-3.02). The beneficial effect persisted up to M24. Conclusion The beneficial effect of MLC601 seen at M3 in the Filipino cohort is durable up to two years after stroke.

Instantaneous stroke volume in man during lower body negative pressure /LBNP/

NASA Technical Reports Server (NTRS)

Loeppky, J. A.; Richards, K. L.; Greene, E. R.; Eldridge, M. W.; Hoekenga, D. E.; Venters, M. D.; Luft, U. C.

1982-01-01

Results of an examination of the instantaneous time course of the stroke volume (SV) and cardiac output (Q) in response to the onset and release of -50 torr lower body negative pressure (LBNP) are reported. Six male subjects were sealed into a LBNP box up to the iliac crest while being monitored by echocardiograph for centerlamina blood velocity, fluid displacement, stroke volume, heart rate, and leg volume. Particular use was made of pulsed ultrasonic Doppler velocity meters for measuring the blood velocities and flow dynamics. Measurements were made of the subjects continuously beginning from 20 sec prior to and one min after LBNP onset and release. A linear fall in the SV was observed with LBNP at 49% of the baseline value after 33 sec. A 62% drop, the lowest, was detected after 8 min of LBNP. The leg volume was inversely related to Q for the duration of the experiment.

Pathological Laughter as a Symptom of Midbrain Infarction

PubMed Central

Dabby, Ron; Watemberg, Nathan; Lampl, Yair; Eilam, Anda; Rapaport, Abraham; Sadeh, Menachem

2004-01-01

Pathological laughter is an uncommon symptom usually caused by bilateral, diffuse cerebral lesions. It has rarely been reported in association with isolated cerebral lesions. Midbrain involvement causing pathological laughter is extremely unusual. We describe three patients who developed pathological laughter after midbrain and pontine-midbrain infarction. In two patients a small infarction in the left paramedian midbrain was detected, whereas the third one sustained a massive bilateral pontine infarction extending to the midbrain. Laughter heralded stroke by one day in one patient and occurred as a delayed phenomenon three months after stroke in another. Pathological laughter ceased within a few days in two patients and was still present at a two year follow-up in the patient with delayed-onset laughter. Pathological laughter can herald midbrain infarction or follow stroke either shortly after onset of symptoms or as a delayed phenomenon. Furthermore, small unilateral midbrain infarctions can cause this rare complication. PMID:15706050

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

PubMed Central

2011-01-01

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

Impact of pre-existing or new-onset atrial fibrillation on 30-day clinical outcomes following transcatheter aortic valve replacement: Results from the BRAVO 3 randomized trial.

PubMed

Hengstenberg, Christian; Chandrasekhar, Jaya; Sartori, Samantha; Lefevre, Thierry; Mikhail, Ghada; Meneveau, Nicolas; Tron, Christophe; Jeger, Raban; Kupatt, Christian; Vogel, Birgit; Farhan, Serdar; Sorrentino, Sabato; Sharma, Madhav; Snyder, Clayton; Husser, Oliver; Boekstegers, Peter; Hambrecht, Rainer; Widder, Julian; Hildick-Smith, David; De Carlo, Marco; Wijngaard, Peter; Deliargyris, Efthymios; Bernstein, Debra; Baber, Usman; Mehran, Roxana; Anthopoulos, Prodromos; Dangas, George

2017-11-15

Prior studies have suggested that patients with atrial fibrillation (AF) undergoing transcatheter aortic valve replacement (TAVR) are at higher risk for adverse cardiovascular events. Whether procedural bivalirudin compared with unfractionated heparin (UFH) has a beneficial effect on early outcomes in these patients is unknown. We examined for the effect of baseline or new-onset AF within 30 days of TAVR and explored for the effect of bivalirudin versus UFH by AF status, on 30-day outcomes from the BRAVO 3 trial. The BRAVO-3 trial multicenter randomized trial included 802 patients undergoing transfemoral TAVR randomized to bivalirudin or UFH. We compared AF and no-AF groups and examined for 30-day Bleeding Academic Research Consortium type ≥3b bleeding, major vascular complications and all ischemic endpoints. Adjusted outcomes were analyzed using logistic regression methods. Of the study population, 41.4% (n = 332) patients had baseline or new-onset AF within 30 days of TAVR, whereas 58.6% (n = 470) had no AF. Patients with AF had greater prevalence of renal dysfunction, lower left ventricular ejection fraction, and higher euroSCORE I compared with their counterparts without AF. Among AF and no-AF patients, there were no significant baseline differences between bivalirudin and UFH groups. At 30 days the incidence of death (6.0 vs. 4.5%, P = 0.324) and stroke (3.9 vs. 2.6%, P = 0.274) was similar in AF vs. no-AF patients. However, new-onset AF (n = 38) was associated with significantly greater crude risk of 30-day stroke compared with no AF (HR 4.49, 95% CI 1.37-14.67). Regardless of AF status, there were no differences in 30-day death (P-int = 0.652) or stroke (P-int = 0.066) by anticoagulation type. Prior or new-onset AF is noted in more than one-third of patients undergoing transfemoral TAVR. Despite greater baseline comorbidities than non-AF patients, AF was not associated with significantly higher risk of adjusted 30-day outcomes. In the BRAVO 3 trial, early outcomes were similar regardless of anticoagulant strategy in each group. © 2017 Wiley Periodicals, Inc.

Rethinking the continuum of stroke rehabilitation.

PubMed

Teasell, Robert W; Murie Fernandez, Manuel; McIntyre, Amanda; Mehta, Swati

2014-04-01

Suffering a stroke can be a devastating and life-changing event. Although there is a large evidence base for stroke rehabilitation in the acute and subacute stages, it has been long accepted that patients with stroke reach a plateau in their rehabilitation recovery relatively early. We have recently published the results of a systematic review designed to identify all randomized controlled trials (RCTs) where a rehabilitation intervention was initiated more than 6 months after the onset of the stroke. Of the trials identified, 339 RCTs met inclusion criteria, demonstrating an evidence base for stroke rehabilitation in the chronic phase as well. This seems at odds with the assumption that further recovery is unlikely and the subsequent lack of resources devoted to chronic stroke rehabilitation and management. Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.

Current management of symptomatic intracranial stenosis.

PubMed

Taylor, Robert A; Weigele, John B; Kasner, Scott E

2011-08-01

Intracranial arterial stenosis (IAS) is the cause of about 10% of all ischemic strokes in the United States, but may account for about 40% of strokes in some populations. After a stroke or transient ischemic attack due to IAS, patients face a 12% annual risk of recurrent stroke on medical therapy, with most strokes occurring in the first year. Warfarin is no better than aspirin in preventing recurrent strokes but poses a higher risk of serious bleeding and death. Groups with the highest risk of recurrent stroke are those with high-grade (≥ 70%) stenosis, those with recent symptom onset, those with symptoms precipitated by hemodynamic maneuvers, and women. Endovascular treatment of IAS is a rapidly evolving therapeutic option. Antiplatelet agents are currently recommended as the primary treatment for symptomatic IAS, with endovascular therapy reserved for appropriate high-risk cases refractory to medical therapy.

What is the value of conducting a trial of r-tPA for the treatment of mild stroke patients?

PubMed

Guzauskas, Gregory F; Chen, Er; Lalla, Deepa; Yu, Elaine; Tayama, Darren; Veenstra, David L

2017-02-01

Background The Phase IIIb, Double-Blind, Multicenter Study to Evaluate the Efficacy and Safety of Alteplase in Patients With Mild Stroke: Rapidly Improving Symptoms and Minor Neurologic Deficits (PRISMS) trial will assess r-tPA in ischemic stroke patients who present with mild deficits (i.e. mild stroke). Aims To assess PRISMS's societal value in clarifying the optimal care for patients with mild ischemic stroke. Methods A value of information (VOI) decision model was developed to compare the outcomes of mild stroke patients treated vs. not treated with r-tPA. Model inputs were derived from a subset of Third International Stroke Trial patients, a recent meta-analysis of r-tPA trials, expert opinion, and other published sources. VOI analyses were also used to assess the expected US societal value of the PRISMS trial and the expected value of reducing uncertainty in key trial estimates. Results The expected net societal value of the PRISMS trial was approximately $210 million ($160 m-$260 m), representing a six-fold return on investment. The value of reducing uncertainty in r-tPA efficacy was approximately $150 million ($100 m-$200 m), while reducing uncertainty in r-tPA safety (increased risk for symptomatic intracranial hemorrhage) did not add additional value in comparison. Conclusions Developing a better understanding of the outcomes of r-tPA treatment in patients with mild ischemic stroke will provide tremendous societal value by clarifying current uncertainty around treatment effectiveness. Enrollment in the PRISMS trial for patients presenting with mild ischemic stroke within 0-3 h of symptom onset should be highly encouraged.

Practice advisory: Recurrent stroke with patent foramen ovale (update of practice parameter)

PubMed Central

Messé, Steven R.; Gronseth, Gary; Kent, David M.; Kizer, Jorge R.; Homma, Shunichi; Rosterman, Lee; Kasner, Scott E.

2016-01-01

Objective: To update the 2004 American Academy of Neurology guideline for patients with stroke and patent foramen ovale (PFO) by addressing whether (1) percutaneous closure of PFO is superior to medical therapy alone and (2) anticoagulation is superior to antiplatelet therapy for the prevention of recurrent stroke. Methods: Systematic review of the literature and structured formulation of recommendations. Conclusions: Percutaneous PFO closure with the STARFlex device possibly does not provide a benefit in preventing stroke vs medical therapy alone (risk difference [RD] 0.13%, 95% confidence interval [CI] −2.2% to 2.0%). Percutaneous PFO closure with the AMPLATZER PFO Occluder possibly decreases the risk of recurrent stroke (RD −1.68%, 95% CI −3.18% to −0.19%), possibly increases the risk of new-onset atrial fibrillation (AF) (RD 1.64%, 95% CI 0.07%–3.2%), and is highly likely to be associated with a procedural complication risk of 3.4% (95% CI 2.3%–5%). There is insufficient evidence to determine the efficacy of anticoagulation compared with antiplatelet therapy in preventing recurrent stroke (RD 2%, 95% CI −21% to 25%). Recommendations: Clinicians should not routinely offer percutaneous PFO closure to patients with cryptogenic ischemic stroke outside of a research setting (Level R). In rare circumstances, such as recurrent strokes despite adequate medical therapy with no other mechanism identified, clinicians may offer the AMPLATZER PFO Occluder if it is available (Level C). In the absence of another indication for anticoagulation, clinicians may routinely offer antiplatelet medications instead of anticoagulation to patients with cryptogenic stroke and PFO (Level C). PMID:27466464

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

PubMed Central

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

2014-01-01

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

Intravenous Thrombolysis for Stroke and Presumed Stroke in Human Immunodeficiency Virus-Infected Adults: A Retrospective, Multicenter US Study.

PubMed

AbdelRazek, Mahmoud A; Gutierrez, Jose; Mampre, David; Cervantes-Arslanian, Anna; Ormseth, Cora; Haussen, Diogo; Thakur, Kiran T; Lyons, Jennifer L; Smith, Bryan R; O'Connor, Owen; Willey, Joshua Z; Mateen, Farrah J

2018-01-01

Human immunodeficiency virus (HIV) infection has been shown to increase both ischemic and hemorrhagic stroke risks, but there are limited data on the safety and outcomes of intravenous thrombolysis with tPA (tissue-type plasminogen activator) for acute ischemic stroke in HIV-infected patients. A retrospective chart review of intravenous tPA-treated HIV patients who presented with acute stroke symptoms was performed in 7 large inner-city US academic centers (various search years between 2000 and 2017). We collected data on HIV, National Institutes of Health Stroke Scale score, ischemic stroke risk factors, opportunistic infections, intravenous drug abuse, neuroimaging findings, and modified Rankin Scale score at last follow-up. We identified 33 HIV-infected patients treated with intravenous tPA (mean age, 51 years; 24 men), 10 of whom were stroke mimics. Sixteen of 33 (48%) patients had an HIV viral load less than the limit of detection while 10 of 33 (30%) had a CD4 count <200/mm 3 . The median National Institutes of Health Stroke Scale score at presentation was 9, and mean time from symptom onset to tPA was 144 minutes (median, 159). The median modified Rankin Scale score for the 33-patient cohort was 1 and for the 23-patient actual stroke cohort was 2, measured at a median of 90 days poststroke symptom onset. Two patients had nonfatal hemorrhagic transformation (6%; 95% confidence interval, 1%-20%), both in the actual stroke group. Two patients had varicella zoster virus vasculitis of the central nervous system, 1 had meningovascular syphilis, and 7 other patients were actively using intravenous drugs (3 cocaine, 1 heroin, and 3 unspecified), none of whom had hemorrhagic transformation. Most HIV-infected patients treated with intravenous tPA for presumed and actual acute ischemic stroke had no complications, and we observed no fatalities. Stroke mimics were common, and thrombolysis seems safe in this group. We found no data to suggest an increased risk of intravenous tPA-related complications because of concomitant opportunistic infections or intravenous drug abuse. © 2017 American Heart Association, Inc.

Prediction of infarction volume and infarction growth rate in acute ischemic stroke.

PubMed

Kamran, Saadat; Akhtar, Naveed; Alboudi, Ayman; Kamran, Kainat; Ahmad, Arsalan; Inshasi, Jihad; Salam, Abdul; Shuaib, Ashfaq; Qidwai, Uvais

2017-08-08

The prediction of infarction volume after stroke onset depends on the shape of the growth dynamics of the infarction. To understand growth patterns that predict lesion volume changes, we studied currently available models described in literature and compared the models with Adaptive Neuro-Fuzzy Inference System [ANFIS], a method previously unused in the prediction of infarction growth and infarction volume (IV). We included 67 patients with malignant middle cerebral artery [MMCA] stroke who underwent decompressive hemicraniectomy. All patients had at least three cranial CT scans prior to the surgery. The rate of growth and volume of infarction measured on the third CT was predicted with ANFIS without statistically significant difference compared to the ground truth [P = 0.489]. This was not possible with linear, logarithmic or exponential methods. ANFIS was able to predict infarction volume [IV3] over a wide range of volume [163.7-600 cm 3 ] and time [22-110 hours]. The cross correlation [CRR] indicated similarity between the ANFIS-predicted IV3 and original data of 82% for ANFIS, followed by logarithmic 70%, exponential 63% and linear 48% respectively. Our study shows that ANFIS is superior to previously defined methods in the prediction of infarction growth rate (IGR) with reasonable accuracy, over wide time and volume range.

Study protocol to a nationwide prospective cohort study on return to gainful occupation after stroke in Denmark 1996 - 2006

PubMed Central

2010-01-01

Background Successful return to work is regarded as one of the most important outcome factors for working-age post stroke patients. The present study will estimate the effect of various predictors on the odds of returning to work after stroke. Nearly twenty thousand 20-57 year-old stroke patients in Denmark who were gainfully occupied prior to the stroke will be included in the study. Methods/design Stroke patients will be followed prospectively through national registers. Multi-level logistic regression will be used to model the odds of being gainfully occupied ca. two years after the stroke as a function of the following predictors: Age (20-49 years, 50-57 years) gender, occupational class, self-employment (yes; no), onset calendar year (1996, 1997, ..., 2006), diagnosis (subarachnoid haemorrhage; intracerebral haemorrhage; cerebral infarction; stroke, not specified as haemorrhage or infarction) and 'type of municipality' (the variable is set to 1 if the person lived in a municipality which had a brain injury rehabilitation centre at the time of the stroke. Otherwise it is set to 0). Municipalities will be treated as the subjects while individual observations within municipalities are treated as correlated repeated measurements. Discussion Since our follow-up is done through registers and all people in the target population are included, the study is free from sampling bias, recall bias and non-response bias. The study is also strengthened by its size. The major weakness of the study is that it does not contain any stroke severity measures. Thus, it cannot accurately predict whether a particular stroke patient will in fact return to work. The study is, however, quite useful from a public health perspective. It can be used to estimate the proportion of patients in a certain group that is expected to return to work, and thereby provide a comparison material, which e.g. municipalities can use to evaluate their success in returning their stroke patients to work. PMID:20958997

Recovery and rehabilitation after stroke.

PubMed

Brown, Allen W; Schultz, Billie A

2010-11-01

Most individuals survive stroke and age with its consequences. Rehabilitation becomes the dominant medical need soon after onset, and coordinated rehabilitation services using evidence-based interventions determined by patient need are of primary importance in affecting outcome and quality of life. This discussion will focus on the natural history of recovery after stroke and the changes in brain organization that support behavioral improvement during recovery, then review established and emerging therapeutic approaches directed at improving independent functional performance and quality of life. © Thieme Medical Publishers.

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.

Prehospital neurological deterioration in stroke.

PubMed

Slavin, Sabreena J; Sucharew, Heidi; Alwell, Kathleen; Moomaw, Charles J; Woo, Daniel; Adeoye, Opeolu; Flaherty, Matthew L; Ferioli, Simona; McMullan, Jason; Mackey, Jason; De Los Rios La Rosa, Felipe; Martini, Sharyl; Kissela, Brett M; Kleindorfer, Dawn O

2018-04-27

Patients with stroke can experience neurological deterioration in the prehospital setting. We evaluated patients with stroke to determine factors associated with prehospital neurological deterioration (PND). Among the Greater Cincinnati/Northern Kentucky region (population ~1.3 million), we screened all 15 local hospitals' admissions from 2010 for acute stroke and included patients aged ≥20. The GCS was compared between emergency medical services (EMS) arrival and hospital arrival, with decrease ≥2 points considered PND. Data obtained retrospectively included demographics, medical history and medication use, stroke subtype (eg, ischaemic stroke (IS), intracerebral haemorrhage (ICH), subarachnoid haemorrhage (SAH)) and IS subtype (eg, small vessel, large vessel, cardioembolic), seizure at onset, time intervals between symptom onset, EMS arrival and hospital arrival, EMS level of training, and blood pressure and serum glucose on EMS arrival. Of 2708 total patients who had a stroke, 1092 patients (median (IQR) age 74 (61-83) years; 56% women; 21% black) were analysed. PND occurred in 129 cases (12%), including 9% of IS, 24% of ICH and 16% of SAH. In multivariable analysis, black race, atrial fibrillation, haemorrhagic subtype and ALS level of transport were associated with PND. Haemorrhage and atrial fibrillation is associated with PND in stroke, and further investigation is needed to establish whether PND can be predicted. Further studies are also needed to assess whether preferential transport of patients with deterioration to hospitals equipped with higher levels of care is beneficial, identify why race is associated with deterioration and to test therapies targeting PND. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Alberta Stroke Program Early CT Score-Time Score Predicts Outcome after Endovascular Therapy in Patients with Acute Ischemic Stroke: A Retrospective Single-Center Study.

PubMed

Todo, Kenichi; Sakai, Nobuyuki; Kono, Tomoyuki; Hoshi, Taku; Imamura, Hirotoshi; Adachi, Hidemitsu; Yamagami, Hiroshi; Kohara, Nobuo

2018-04-01

Clinical outcomes after successful endovascular therapy in patients with acute ischemic stroke are associated with several factors including onset-to-reperfusion time (ORT), the National Institute of Health Stroke Scale (NIHSS) score, and the Alberta Stroke Program Early CT Score (ASPECTS). The NIHSS-time score, calculated as follows: [NIHSS score] × [onset-to-treatment time (h)] or [NIHSS score] × [ORT (h)], has been reported to predict clinical outcomes after intravenous recombinant tissue plasminogen activator therapy and endovascular therapy for acute stroke. The objective of the current study was to assess whether the combination of the ASPECTS and the ORT can predict the outcomes after endovascular therapy. The charts of 117 consecutive ischemic stroke patients with successful reperfusion after endovascular therapy were retrospectively reviewed. We analyzed the association of ORT, ASPECTS, and ASPECTS-time score with clinical outcome. ASPECTS-time score was calculated as follows: [11 - ASPECTS] × [ORT (h)]. Rates of good outcome for patients with ASPECTS-time scores of tertile values, scores 5.67 or less, scores greater than 5.67 to 10.40 or less, and scores greater than 10.40, were 66.7%, 56.4%, and 33.3%, respectively (P < .05). Ordinal logistic regression analysis showed that the ASPECTS-time score (per category increase) was an independent predictor for better outcome (common odds ratio: .374; 95% confidence interval: .150-0.930; P < .05). A lower ASPECTS-time score may predict better clinical outcomes after endovascular treatment. Copyright © 2018 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Patent foramen ovale closure versus medical therapy after cryptogenic stroke: An updated meta-analysis of all randomized clinical trials.

PubMed

Kheiri, Babikir; Abdalla, Ahmed; Osman, Mohammed; Ahmed, Sahar; Hassan, Mustafa; Bachuwa, Ghassan

2018-03-07

Cryptogenic strokes can be attributed to paradoxical emboli through patent foramen ovale (PFO). However, the effectiveness of PFO closure in preventing recurrent stroke is uncertain and the results of previous randomized clinical trials (RCTs) have been inconclusive. Hence, this study provides an updated meta-analysis of all RCTs comparing PFO closure with medical therapy for secondary prevention of cryptogenic stroke. All RCTs were identified by a comprehensive literature search of PubMed, Embase, the Cochrane Collaboration Central Register of Controlled Trials, Scopus, and Clinicaltrials.gov. The primary outcome was recurrent ischemic stroke and secondary outcomes were transient ischemic attack (TIA), all-cause mortality, new-onset atrial fibrillation (AF), serious adverse events, and major bleeding. 5 RCTs with 3440 participants were included in the present study (1829 patients underwent PFO closure and 1611 were treated medically). Pooled analysis showed a statistically significant reduction in the rate of recurrent stroke with PFO closure in comparison to medical therapy (OR 0.41; 95% CI 0.19-0.90; p = 0.03). However, there were no statistically significant reductions of recurrent TIAs (OR 0.77; 95% CI 0.51-1.14; p = 0.19) or all-cause mortality (OR 0.76; 95% CI 0.35-1.65; p = 0.48). The risk of developing new-onset AF was increased significantly with PFO closure (OR 4.74; 95% CI 2.33-9.61; p < 0.0001), but no significant differences in terms of serious adverse events or major bleeding between both groups. Patent foramen ovale closure in adults with recent cryptogenic stroke was associated with a lower rate of recurrent strokes in comparison with medical therapy alone.

Processes of care associated with acute stroke outcomes.

PubMed

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

2010-05-10

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

Pennsylvania comprehensive stroke center collaborative: Statement on the recently updated IV rt-PA prescriber information for acute ischemic stroke.

PubMed

Daou, Badih; Deprince, Maureen; D'Ambrosio, Robin; Tjoumakaris, Stavropoula; Rosenwasser, Robert H; Ackerman, Daniel J; Bell, Rodney; Tzeng, Diana L; Ghobrial, Michelle; Fernandez, Andres; Shah, Qaisar; Gzesh, Dan J; Murphy, Deborah; Castaldo, John E; Mathiesen, Claranne; Pineda, Maria Carissa; Jabbour, Pascal

2015-12-01

Recently, the FDA guidelines regarding the eligibility of patients with acute ischemic stroke to receive IV rt-PA have been modified and are not in complete accord with the latest AHA/ASA guidelines. The resultant differences may result in discrepancies in patient selection for intravenous thrombolysis. Several comprehensive stroke centers in the state of Pennsylvania have undertaken a collaborative effort to clarify and unify our own recommendations regarding how to reconcile these different guidelines. Seizure at onset of stroke, small previous strokes that are subacute or chronic, multilobar infarct involving more than one third of the middle cerebral artery territory on CT scan, hypoglycemia, minor or rapidly improving symptoms should not be considered as contraindications for intravenous thrombolysis. It is recommended to follow the AHA/ASA guidelines regarding blood pressure management and bleeding diathesis. Patients receiving factor Xa inhibitors and direct thrombin inhibitors within the preceding 48 h should be excluded from receiving IV rt-PA. CT angiography is effective in identifying candidates for endovascular therapy. Consultation with and/or transfer to a comprehensive stroke center should be an option where indicated. Patients should receive IV rt-PA up to 4.5h after the onset of stroke. The process of identifying patients who will benefit the most from IV rt-PA is still evolving. Considering the rapidity with which patients need to be evaluated and treated, it remains imperative that systems of care adopt protocols to quickly gather the necessary data and have access to expert consultation as necessary to facilitate best practices. Copyright © 2015 Elsevier B.V. All rights reserved.

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

PubMed

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

2013-07-04

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

Tissue hypoxia during ischemic stroke: adaptive clues from hypoxia-tolerant animal models.

PubMed

Nathaniel, Thomas I; Williams-Hernandez, Ashley; Hunter, Anan L; Liddy, Caroline; Peffley, Dennis M; Umesiri, Francis E; Imeh-Nathaniel, Adebobola

2015-05-01

The treatment and prevention of hypoxic/ischemic brain injury in stroke patients remain a severe and global medical issue. Numerous clinical studies have resulted in a failure to develop chemical neuroprotection for acute, ischemic stroke. Over 150 estimated clinical trials of ischemic stroke treatments have been done, and more than 200 drugs and combinations of drugs for ischemic and hemorrhagic strokes have been developed. Billions of dollars have been invested for new scientific breakthroughs with only limited success. The revascularization of occluded cerebral arteries such as anti-clot treatments of thrombolysis has proven effective, but it can only be used in a 3-4.5h time frame after the onset of a stroke, and not for every patient. This review is about novel insights on how to resist tissue hypoxia from unconventional animal models. Ability to resist tissue hypoxia is an extraordinary ability that is not common in many laboratory animals such as rat and mouse models. For example, we can learn from a naked mole-rat, Chrysemys picta, how to actively regulate brain metabolic activity to defend the brain against fluctuating oxygen tension and acute bouts of oxidative stress following the onset of a stroke. Additionally, a euthermic arctic ground squirrel can teach us how the brain of a stroke patient can remain well oxygenated during tissue hypoxia with no evidence of cellular stress. In this review, we discuss how these animals provide us with a system to gain insight into the possible mechanisms of tissue hypoxia/ischemia. This issue is of clinical significance to stroke patients. We describe specific physiological and molecular adaptations employed by different animals' models of hypoxia tolerance in aquatic and terrestrial environments. We highlight how these adaptations might provide potential clues on strategies to adapt for the clinical management of tissue hypoxia during conditions such as stroke where oxygen demand fails to match the supply. Copyright © 2015 Elsevier Inc. All rights reserved.

Ischemic Strokes Due to Large-Vessel Occlusions Contribute Disproportionately to Stroke-Related Dependence and Death: A Review.

PubMed

Malhotra, Konark; Gornbein, Jeffrey; Saver, Jeffrey L

2017-01-01

Since large-vessel occlusion (LVO)-related acute ischemic strokes (AIS) are associated with more severe deficits, we hypothesize that the endovascular thrombectomy (ET) may disproportionately benefit stroke-related dependence and death. To delineate LVO-AIS impact, systematic search identified studies measuring dependence or death [modified Rankin Scale (mRS) 3-6] or mortality following ischemic stroke among consecutive patients presenting with both LVO and non-LVO events within 24 h of symptom onset. Among 197 articles reviewed, 2 met inclusion criteria, collectively enrolling 1,467 patients. Rates of dependence or death (mRS 3-6) within 3-6 months were higher after LVO than non-LVO ischemic stroke, 64 vs. 24%, odds ratio (OR) 4.46 (CI: 3.53-5.63, p  < 0.0001). Mortality within 3-6 months was higher after LVO than non-LVO ischemic stroke, 26.2 vs. 1.3%, OR 4.09 (CI: 2.5-6.68), p  < 0.0001. Consequently, while LVO ischemic events accounted for 38.7% (CI: 21.8-55.7%) of all acutely presenting ischemic strokes, they accounted for 61.6% (CI: 41.8-81.3%) of poststroke dependence or death and 95.6% (CI: 89.0-98.8%) of poststroke mortality. Using literature-based projections of LVO cerebral ischemia patients treatable within 8 h of onset, ET can be used in 21.4% of acutely presenting patients with ischemic stroke, and these events account for 34% of poststroke dependence and death and 52.8% of poststroke mortality. LVOs cause a little more than one-third of acutely presenting AIS, but are responsible for three-fifths of dependency and more than nine-tenths of mortality after AIS. At the population level, ET has a disproportionate benefit in reducing severe stroke outcomes.

Telling the Story of Stroke When It's Hard to Talk

ERIC Educational Resources Information Center

Hinckley, Jacqueline J.

2015-01-01

Illness narratives may be told in various contexts and are reported to be associated with a variety of positive health outcomes, such as fewer doctors' office visits. The story of stroke onset can be highly varied among people without language impairments, seeming to reflect the way the individual is understanding and adapting to living with the…

Vision In Stroke cohort: Profile overview of visual impairment.

PubMed

Rowe, Fiona J

2017-11-01

To profile the full range of visual disorders from a large prospective observation study of stroke survivors referred by stroke multidisciplinary teams to orthoptic services with suspected visual problems. Multicenter prospective study undertaken in 20 acute Trust hospitals. Standardized screening/referral forms and investigation forms documented data on referral signs and symptoms plus type and extent of visual impairment. Of 1,345 patients referred with suspected visual impairment, 915 were recruited (59% men; mean age at stroke onset 69 years [SD 14]). Initial visual assessment was at median 22 days post stroke onset. Eight percent had normal visual assessment. Of 92% with confirmed visual impairment, 24% had reduced central visual acuity <0.3 logMAR and 13.5% <0.5 logMAR. Acquired strabismus was noted in 16% and acquired ocular motility disorders in 68%. Peripheral visual field loss was present in 52%, most commonly homonymous hemianopia. Fifteen percent had visual inattention and 4.6% had other visual perceptual disorders. Overall 84% were visually symptomatic with visual field loss the most common complaint followed by blurred vision, reading difficulty, and diplopia. Treatment options were provided to all with confirmed visual impairment. Targeted advice was most commonly provided along with refraction, prisms, and occlusion. There are a wide range of visual disorders that occur following stroke and, frequently, with visual symptoms. There are equally a wide variety of treatment options available for these individuals. All stroke survivors require screening for visual impairment and warrant referral for specialist assessment and targeted treatment specific to the type of visual impairment.

A collaborative system for endovascular treatment of acute ischaemic stroke: the Madrid Stroke Network experience.

PubMed

Alonso de Leciñana, M; Fuentes, B; Ximénez-Carrillo, Á; Vivancos, J; Masjuan, J; Gil-Nuñez, A; Martínez-Sánchez, P; Zapata-Wainberg, G; Cruz-Culebras, A; García-Pastor, A; Díaz-Otero, F; Fandiño, E; Frutos, R; Caniego, J-L; Méndez, J-C; Fernández-Prieto, A; Bárcena-Ruiz, E; Díez-Tejedor, E

2016-02-01

The complexity and expense of endovascular treatment (EVT) for acute ischaemic stroke (AIS) can present difficulties in bringing this approach closer to the patients. A collaborative node was implemented involving three stroke centres (SCs) within the Madrid Stroke Network to provide round-the-clock access to EVT for AIS. A weekly schedule was established to ensure that at least one SC was 'on-call' to provide EVT for all those with moderate to severe AIS due to large vessel occlusion, >4.5 h from symptom onset, or within this time-window but with contraindication to, or failure of, systemic thrombolysis. The time-window for treatment was 8 h for anterior circulation stroke and <24 h in posterior stroke. Outcomes measured were re-canalization rates, modified Rankin Scale (mRS) score at 3 months, mortality and symptomatic intra-cranial haemorrhage (SICH). Over a 2-year period (2012-2013), 303 candidate patients with AIS were considered for EVT as per protocol, and 196 (65%) received treatment. Reasons for non-treatment were significant improvement (14%), spontaneous re-canalization (26%), clinical worsening (9%) or radiological criteria of established infarction (31%). Re-canalization rate amongst treated patients was 80%. Median delay from symptom onset to re-canalization was 323 min (p25; p75 percentiles 255; 430). Mortality was 11%; independence (mRS 0-2) was 58%; SICH was 3%. Implementation of a collaborative network to provide EVT for AIS is feasible and effective. Results are good in terms of re-canalization rates and clinical outcomes. © 2015 EAN.

A Multimodal Communication Program for Aphasia during Inpatient Rehabilitation: A Case Study

PubMed Central

Wallace, Sarah E.; Purdy, Mary; Skidmore, Elizabeth

2014-01-01

BACKGROUND Communication is essential for successful rehabilitation, yet few aphasia treatments have been investigated during the acute stroke phase. Alternative modality use including gesturing, writing, or drawing has been shown to increase communicative effectiveness in people with chronic aphasia. Instruction in alternative modality use during acute stroke may increase patient communication and participation, therefore resulting in fewer adverse situations and improved rehabilitation outcomes. OBJECTIVE The study purpose was to explore a multimodal communication program for aphasia (MCPA) implemented during acute stroke rehabilitation. MCPA aims to improve communication modality production, and to facilitate switching among modalities to resolve communication breakdowns. METHODS Two adults with severe aphasia completed MCPA beginning at 2 and 3 weeks post onset a single left-hemisphere stroke. Probes completed during each session allowed for evaluation of modality production and modality switching accuracy. RESULTS Participants completed MCPA (10 and 14 treatment sessions respectively) and their performance on probes suggested increased accuracy in the production of various alternate communication modalities. However, increased switching to an alternate modality was noted for only one participant. CONCLUSIONS Further investigation of multimodal treatment during inpatient rehabilitation is warranted. In particular, comparisons between multimodal and standard treatments would help determine appropriate interventions for this setting. PMID:25227547

Paul Coverdell National Acute Stroke Registry Surveillance - four states, 2005-2007.

PubMed

George, Mary G; Tong, Xin; McGruder, Henraya; Yoon, Paula; Rosamond, Wayne; Winquist, Andrea; Hinchey, Judith; Wall, Hilary K; Pandey, Dilip K

2009-11-06

Each year, approximately 795,000 persons in the United States experience a new or recurrent stroke. Data from the prototype phase (2001-2004) of the Paul Coverdell National Acute Stroke Registry (PCNASR) suggested that numerous acute stroke patients did not receive treatment according to established guidelines. This report summarizes PCNASR data collected during 2005-2007 from Georgia, Illinois, Massachusetts, and North Carolina, the first states to have PCNASRs implemented in and led by state health departments. PCNASR was established by CDC in 2001 to track and improve the quality of hospital-based acute stroke care. The prototype phase (2001-2004) registries were led by CDC-funded clinical investigators in academic and medical institutions, whereas the full implementation of the 2005-2007 statewide registries was led by CDC-funded state health departments. Health departments in each state recruit hospitals to collect data. To be included in PCNASR, patients must be aged >or=18 years and have a clinical diagnosis of acute ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, or transient ischemic attack (TIA) or an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code indicative of a stroke or TIA. Data for patients who are already hospitalized at the time of stroke are not included. The following 10 performance measures of care, based on established guidelines for care of acute stroke patients, were developed by CDC in partnership with neurologists who specialize in stroke care: 1) received deep venous thrombosis prophylaxis, 2) received antithrombotic therapy at discharge, 3) received anticoagulation therapy for atrial fibrillation, 4) received tissue plasminogen activator (among eligible patients), 5) received antithrombotic therapy within 48 hours of admission or by the end of the second hospital day, 6) received lipid level testing, 7) received dysphagia screening, 8) received stroke education, 9) received smoking cessation counseling, and 10) received assessment for rehabilitation services. Adherence to these performance measures of care was calculated using predefined inclusion and exclusion criteria. A total of 195 hospitals from Georgia, Illinois, Massachusetts, and North Carolina contributed data to PCNASR during 2005-2007, representing 56,969 patients. Approximately half (53.3%) the cases of stroke in the registry occurred among females. A total of 2.5% of cases were among Hispanics; however, the proportion varied significantly by state. Cases among black patients ranged from 5.6% in Massachusetts to 35.8% in Georgia. The age at which patients experienced stroke varied significantly by state. On average, patients were oldest in Massachusetts (median age: 77 years) and youngest in Georgia (median age: 67 years). Overall, the clinical diagnosis for registry stroke cases was hemorrhagic stroke (13.8% of cases), ischemic stroke (56.2%), ill-defined stroke (i.e., medical record did not specify ischemic or hemorrhagic stroke; 7.3%), and TIA (21.6%). A total of 18.5% of patients with stroke symptoms arrived at the hospital within 2 hours of symptom onset; however, the time from onset of symptoms to hospital arrival was not recorded or was not known for the majority (57.8%) of patients. Of the 56,969 patients, 47.6% were transported by emergency medical services (EMS) from the scene of symptom onset, 11.1% were transferred by EMS from another hospital, and 39.4% used private or other transportation. Adherence to acute stroke care measures defined by PCNASR were as follows: received antithrombotic therapy at discharge (97.6%), received antithrombotic therapy within 48 hours of admission or by the end of the second hospital day (94.6%), assessed for rehabilitation services (90.1%), received deep venous thrombosis prophylaxis (85.5%), received anticoagulation therapy for atrial fibrillation (82.5%), received smoking cessation counseling (78.6%), received lipid level testing (69.9%), received stroke education (58.8%), received dysphagia screening (56.7%), and received tissue plasminogen activator (among eligible patients) (39.8%). Between 2001-2004 (prototype phase) and 2005-2007 (implementation by state health departments), substantial improvement occurred in dysphagia screening, lipid testing, smoking cessation counseling, and antithrombotic therapy prescribed at discharge. These initial improvements indicate that a surveillance system to track and improve the quality of hospital-based stroke care can be led successfully by state health departments, although further evaluations over time are needed. Despite these improvements, additional increases are needed in adherence to these and other performance measures. Nearly 40% of stroke patients did not use EMS services for transport to hospitals, and no change occurred in the proportion of patients who arrived at the hospital in time to receive thrombolytic therapy for ischemic stroke. Patients who are not promptly transported to hospitals after symptom onset are ineligible for thrombolytic therapy and other timely interventions for acute stroke. Results from PCNASR indicate the need for additional public health measures to inform the public of the need for timely activation of EMS services for signs and symptoms of stroke. In addition, low rates of adherence to certain measures of stroke care underscore the need for continuing coordinated programs to improve stroke quality of care. Additional analyses are needed to assess improvements in adherence to guidelines over time.

Outcomes after endovascular treatment for anterior circulation stroke presenting as wake-up strokes are not different than those with witnessed onset beyond 8 hours.

PubMed

Aghaebrahim, Amin; Leiva-Salinas, Carlos; Jadhav, Ashutosh P; Jankowitz, Brian; Zaidi, Syed; Jumaa, Mouhammad; Urra, Xabi; Amorim, Edilberto; Zhu, Guangming; Giurgiutiu, Dan-Victor; Horev, Anat; Reddy, Vivek; Hammer, Maxim; Wechsler, Lawrence; Wintermark, Max; Jovin, Tudor

2015-12-01

Previous studies have suggested that patients with wake-up stroke (WUS) may have superior outcomes compared with patients with a witnessed late time of onset after revascularization. We sought to test this hypothesis in patients with anterior circulation large vessel occlusion stroke (ACLVOS) treated with endovascular therapy beyond 8 h from time last seen well (TLSW). A single center retrospective review of a prospectively acquired database of consecutive patients was performed to identify patients presenting beyond 8 h of TLSW with radiographic evidence of ACLVOS, small core, and large penumbra who subsequently underwent endovascular treatment. We identified 206 patients. Patients were divided into two groups: (1) patients with WUS (38%, n=78) and (2) patients with witnessed onset beyond 8 h (62%, n=128). The groups were similar in age, baseline National Institutes of Health Stroke Scale score, TLSW to reperfusion, baseline infarct volume, and rate of successful recanalization. Rates of good outcome (modified Rankin Scale score of 0-2 at 90 days, 43% vs. 50%, p=0.3), parenchymal hematoma (9% vs. 5.5%, p=0.3), and final infarct volume (75.2 vs. 61.4 mL, p=0.6) were comparable. Multivariate analysis identified age (OR=0.95, 95% CI 0.91 to 0.99, p<0.042), successful recanalization (OR 6.0, 95% CI 1.5 to 23.5, p=0.009), and final infarct volume (OR 0.98, 95% CI 0.97 to 0.99, p<0.001) but not mode of presentation as predictors of favorable outcomes. Rates of good outcomes, parenchymal hematoma, and final infarct volumes following endovascular treatment may not be different in patients with WUS compared with patients with witnessed onset of symptoms beyond 8 h. 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/

Menopause and Stroke: An Epidemiologic Review

PubMed Central

Lisabeth, Lynda; Bushnell, Cheryl

2012-01-01

Although women have a lower risk of stroke during middle age, the menopausal transition is a time when many women develop cardiovascular risk factors. In addition, during the 10 years after menopause, the risk of stroke roughly doubles in women. Endogenous estrogen levels decline by 60% during the menopausal transition, leading to a relative androgen excess, which could contribute to the increased cardiovascular risk factors in women. Earlier onset of menopause may influence the risk of stroke, but the data are not clear. Because of the stroke risk associated with hormone therapy, this is only indicated for treatment of vasomotor symptoms, but some formulations may be safe than others. More research is needed to understand which women are at greatest stroke risk during midlife and to determine the safest formulation, dose, and duration of hormone therapy that will treat vasomotor symptoms without increasing the risk for stroke. PMID:22172623

Early blood pressure lowering treatment in acute stroke. Ordinal analysis of vascular events in the Scandinavian Candesartan Acute Stroke Trial (SCAST).

PubMed

Jusufovic, Mirza; Sandset, Else Charlotte; Bath, Philip M; Berge, Eivind

2016-08-01

Early blood pressure-lowering treatment appears to be beneficial in patients with acute intracerebral haemorrhage and potentially in ischaemic stroke. We used a new method for analysis of vascular events in the Scandinavian Candesartan Acute Stroke Trial to see if the effect was dependent on the timing of treatment. Scandinavian Candesartan Acute Stroke Trial was a randomized controlled and placebo-controlled trial of candesartan within 30 h of ischaemic or haemorrhagic stroke. Of 2029 patients, 231 (11.4%) had a vascular event (vascular death, nonfatal stroke or nonfatal myocardial infarction) during the first 6 months. The modified Rankin Scale (mRS) score following a vascular event was used to categorize vascular events in order of severity: no event (n = 1798), minor (mRS 0-2, n = 59), moderately severe (mRS 3-4, n = 57) and major event (mRS 5-6, n = 115). We used ordinal logistic regression for analysis and adjusted for predefined prognostic variables. Candesartan had no overall effect on vascular events (adjusted common odds ratio 1.11, 95% confidence interval 0.84-1.47, P = 0.48), and the effects were the same in ischaemic and haemorrhagic stroke. Among the patients treated within 6 h, the adjusted common odds ratio for vascular events was 0.37, 95% confidence interval 0.16-0.84, P = 0.02, and there was no heterogeneity of effect between ischaemic and haemorrhagic strokes. Ordinal analysis of vascular events showed no overall effect of candesartan in the subacute phase of stroke. The effect of treatment given within 6 h of stroke onset appears promising, and will be addressed in ongoing trials. Ordinal analysis of vascular events is feasible and can be used in future trials.

Color-coded fluid-attenuated inversion recovery images improve inter-rater reliability of fluid-attenuated inversion recovery signal changes within acute diffusion-weighted image lesions.

PubMed

Kim, Bum Joon; Kim, Yong-Hwan; Kim, Yeon-Jung; Ahn, Sung Ho; Lee, Deok Hee; Kwon, Sun U; Kim, Sang Joon; Kim, Jong S; Kang, Dong-Wha

2014-09-01

Diffusion-weighted image fluid-attenuated inversion recovery (FLAIR) mismatch has been considered to represent ischemic lesion age. However, the inter-rater agreement of diffusion-weighted image FLAIR mismatch is low. We hypothesized that color-coded images would increase its inter-rater agreement. Patients with ischemic stroke <24 hours of a clear onset were retrospectively studied. FLAIR signal change was rated as negative, subtle, or obvious on conventional and color-coded FLAIR images based on visual inspection. Inter-rater agreement was evaluated using κ and percent agreement. The predictive value of diffusion-weighted image FLAIR mismatch for identification of patients <4.5 hours of symptom onset was evaluated. One hundred and thirteen patients were enrolled. The inter-rater agreement of FLAIR signal change improved from 69.9% (k=0.538) with conventional images to 85.8% (k=0.754) with color-coded images (P=0.004). Discrepantly rated patients on conventional, but not on color-coded images, had a higher prevalence of cardioembolic stroke (P=0.02) and cortical infarction (P=0.04). The positive predictive value for patients <4.5 hours of onset was 85.3% and 71.9% with conventional and 95.7% and 82.1% with color-coded images, by each rater. Color-coded FLAIR images increased the inter-rater agreement of diffusion-weighted image FLAIR recovery mismatch and may ultimately help identify unknown-onset stroke patients appropriate for thrombolysis. © 2014 American Heart Association, Inc.

CT Angiography and Presentation NIH stroke Scale in Predicting TIA in Patients Presenting with Acute Stroke Symptoms.

PubMed

Karaman, Bedriye; Selph, James; Burdine, Joselyn; Graham, Cole Blease; Sen, Souvik

2013-11-08

Patient candidacy for acute stroke intervention, is currently assessed using brain computed tomography angiography (CTA) evidence of significant stenosis/occlusion (SSO) with a high National Institutes of Health Stroke Scale (NIHSS) (>6). This study examined the association between CTA without significant stenosis/occlusion (NSSO) and lower NIHSS (≤ 6) with transient ischemic attack (TIA) and other good clinical outcomes at discharge. Patients presenting <8 hours from stroke symptom onset, had an NIHSS assessment and brain CTA performed at presentation. Good clinical outcomes were defined as: discharge diagnosis of TIA, modified Rankin Score [mRS] ≤ 1, and home as the discharge disposition. Eighty-five patients received both an NIHSS at presentation and a CTA at 4.2 ± 2.2 hours from stroke symptom onset. Patients with NSSO on CTA as well as those with NIHSS≤6 had better outcomes at discharge (p<0.001). NIHSS ≤ 6 were more likely than NSSO (p=0.01) to have a discharge diagnosis of TIA (p<0.001). NSSO on CTA and NIHSS ≤ 6 also correlated with fewer deaths (p<0.001). Multivariable analyses showed NSSO on CTA (Adjusted OR: 5.8 95% CI: 1.2-27.0, p=0.03) independently predicted the discharge diagnosis of TIA. Addition of NIHSS ≤ 6 to NSSO on CTA proved to be a stronger independent predictor of TIA (Adjusted OR 18.7 95% CI: 3.5-98.9, p=0.001).

Effects of poststroke pyrexia on stroke outcome : a meta-analysis of studies in patients.

PubMed

Hajat, C; Hajat, S; Sharma, P

2000-02-01

The effect of pyrexia on cerebral ischemia has been extensively studied in animals. In humans, however, such studies are small and the results conflicting. We undertook a meta-analysis using all such published studies on the effect of hyperthermia on stroke outcome. Three databases were searched for all published studies that examined the relationship of raised temperature after stroke onset and eventual outcome. Combined probability values and odds ratios were obtained. A heterogeneity test was performed to ensure that the data were suitable for such an analysis. Morbidity and mortality were used as outcome measures. Nine studies were identified totaling 3790 patients, providing our study with 99% power to detect a 9% increase in morbidity and 84% power to detect a 1% increase in mortality for the pyrexial group. The combined odds ratio for mortality was 1.19 (95% CI, 0.99 to 1.43). A heterogeneity test was highly nonsignificant (P>0.05) for mortality, suggesting that the data were sufficiently similar to be meta-analyzed. Combined probability values were highly significant for both morbidity (P<0.0001) and mortality (P<0. 00000001). The results from this meta-analysis suggest that pyrexia after stroke onset is associated with a marked increase in morbidity and mortality. Measures should be taken to combat fever in the clinical setting to prevent stroke progression. The possible benefit of therapeutic hypothermia in the management of acute stroke should be further investigated.

National Institutes of Health Stroke Scale-Time Score Predicts Outcome after Endovascular Therapy in Acute Ischemic Stroke: A Retrospective Single-Center Study.

PubMed

Todo, Kenichi; Sakai, Nobuyuki; Kono, Tomoyuki; Hoshi, Taku; Imamura, Hirotoshi; Adachi, Hidemitsu; Kohara, Nobuo

2016-05-01

Outcomes after successful endovascular therapy in acute ischemic stroke are associated with onset-to-reperfusion time (ORT) and the National Institutes of Health Stroke Scale (NIHSS) score. In intravenous recombinant tissue plasminogen activator therapy, the NIHSS-time score, calculated by multiplying onset-to-treatment time with the NIHSS score, has been shown to predict clinical outcomes. In this study, we assessed whether a similar combination of the ORT and the NIHSS score can be applied to predict the outcomes after endovascular therapy. We retrospectively reviewed the charts of 128 consecutive ischemic stroke patients with successful reperfusion after endovascular therapy. We analyzed the association of the ORT, the NIHSS score, and the NIHSS-time score with good outcome (modified Rankin Scale score ≤ 2 at 3 months). Good outcome rates for patients with NIHSS-time scores of 84.7 or lower, scores higher than 84.7 up to 127.5 or lower, and scores higher than 127.5 were 72.1%, 44.2%, and 14.3%, respectively (P < .01). Multivariate logistic regression analysis revealed that the NIHSS-time score was an independent predictor of good outcomes (odds ratio, .372; 95% confidence interval, .175-.789) after adjusting for age, sex, internal carotid artery occlusion, plasma glucose level, ORT, and NIHSS score. The NIHSS-time score can predict good clinical outcomes after endovascular treatment. Copyright © 2016 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Early versus delayed rehabilitation treatment in hemiplegic patients with ischemic stroke: proprioceptive or cognitive approach?

PubMed

Morreale, Manuela; Marchione, Pasquale; Pili, Antonio; Lauta, Antonella; Castiglia, Stefano F; Spallone, Aldo; Pierelli, Francesco; Giacomini, Patrizia

2016-02-01

Early/intensive mobilization may improve functional recovery after stroke but it is not clear which kind of "mobilization" is more effective. Proprioceptive neuromuscular facilitation (PNF) and cognitive therapeutic exercise (CTE) are widespread applied in post-stroke rehabilitation but their efficacy and safety have not been systematically investigated. To compare PNF and CTE methods in a two different time setting (early versus standard approach) in order to evaluate different role of time and techniques in functional recovery after acute ischemic stroke. We designed a prospectical multicenter blinded interventional study of early versus standard approach with two different methods by means of both PNF and CTE. A discrete stroke-dedicated area for out-of-thrombolysis patients, connected with two different comprehensive stroke centres in two different catchment areas. Three hundred and forty consecutive stroke patient with first ever sub-cortical ischemic stroke in the mean cerebral artery (MCA) territory and contralateral hemiplegia admitted within 6 and 24 hours from symptoms onset. All patients were randomly assigned by means of a computer generated randomization sequence in blocks of 4 to one to the 4 interventional groups: early versus delayed rehabilitation programs with Kabat's schemes or Perfetti's technique. Patients in both delayed group underwent to a standard protocol in the acute phase. disability at 3-12 months. Disability measures: modified Rankin Score and Barthel Index. Safety outcome: immobility-related adverse events. Six-Minute Walking Test, Motricity Index, Mini-Mental State Examination, Beck Depression Inventory. Disability was not different between groups at 3 months but Barthel Index significantly changed between early versus delayed groups at 12 months (P=0.01). Six-Minute Walking Test (P=0.01) and Motricity Index in both upper (P=0.01) and lower limbs (P=0.001) increased in early versus delayed groups regardless rehabilitation schedule. A time-dependent effect of rehabilitation on post stroke motor recovery was observed, particularly in lower limb improvement. According to our results, rehabilitation technique seems not to affect long term motor recovery. These results show a significant effect of time but not of technique that may impact the decision making in the acute phase of care.

RACIAL DISPARITIES IN TPA TREATMENT RATE FOR STROKE: A POPULATION-BASED STUDY

PubMed Central

Hsia, Amie W.; Edwards, Dorothy F.; Morgenstern, Lewis B.; Wing, Jeffrey J.; Brown, Nina C.; Coles, Regina; Loftin, Sarah; Wein, Andrea; Koslosky, Sara S.; Fatima, Sabiha; Fokar, Ali; Gibbons, M. Chris; Jayam-Trouth, Annapurni; Kidwell, Chelsea S.

2011-01-01

Background Some prior studies have shown that racial disparities exist in intravenous tissue plasminogen activator (IV tPA) utilization for acute ischemic stroke. We sought to determine whether race was associated with tPA treatment for stroke in a predominantly black urban population. Methods Systematic chart abstraction was performed on consecutive hospitalized ischemic stroke patients from all seven acute care hospitals in the District of Columbia from Feb 1, 2008 to Jan 31, 2009. Results Of 1044 ischemic stroke patients, 74%% were black, 19% non-Hispanic white, 5% received IV tPA. Blacks were one third less likely than whites to receive IV tPA (3% vs. 10%, p<0.001). However, blacks were also less likely than whites to present within 3 hours of symptom onset (13% vs. 21%, p=0.004) and also less likely to be tPA-eligible (5% vs. 13%, p<0.001). Of those who presented within 3 hours, blacks were almost half as likely to be treated with IV tPA than whites (27% vs. 46%, p=0.023). The treatment rate for tPA-eligible patients was similar for blacks and whites (70% vs. 76%, p=0.62). Conclusions In this predominantly black urban population hospitalized for acute ischemic stroke, blacks were significantly less likely to be treated with IV tPA due to contraindications to treatment, delayed presentation, and stroke severity. Effective interventions designed to increase treatment in this population need to focus on culturally relevant education programs designed to address barriers specific to this population. PMID:21719765

Driving simulation for evaluation and rehabilitation of driving after stroke.

PubMed

Akinwuntan, Abiodun Emmanuel; Wachtel, Jerry; Rosen, Peter Newman

2012-08-01

Driving is an important activity of daily living. Loss of driving privileges can lead to depression, decreased access to medical care, and increased healthcare costs. The ability to drive is often affected after stroke. In approximately 30% of stroke survivors, it is clear from the onset that driving will no longer be possible. Approximately 33% of survivors will be able to return to driving with little or no retraining, and 35% will require driving-related rehabilitation before they can resume safe driving again. The ability to drive is not routinely evaluated after stroke, and there is no established rehabilitation program for poststroke driving. When driving evaluation does occur, it is not always clear which tests are the most salient for accurately assessing poststroke driving ability. Investigators have examined the efficacy of various methodologies to predict driving performance after stroke and have found mixed results, with each method having unique weaknesses, including poor predictive ability, poor face validity, poor sensitivity or specificity, and limited reliability. Here we review common models of driving to gain insight into why single-construct visual or cognitive off-road measures are inadequate for evaluating driving, a complex and dynamic activity that involves timely interaction of multiple motor, visual, cognitive, and perceptual skills. We also examine the potential for driving simulators to overcome the problems currently faced in the evaluation and rehabilitation of driving after stroke. Finally, we offer suggestions for the future direction of simulator-based poststroke driving evaluation and training. Copyright © 2012 National Stroke Association. Published by Elsevier Inc. All rights reserved.

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

PubMed Central

2014-01-01

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

Prespecified dose-response analysis for A Very Early Rehabilitation Trial (AVERT)

PubMed Central

Churilov, Leonid; Ellery, Fiona; Collier, Janice; Chamberlain, Jan; Langhorne, Peter; Lindley, Richard I.; Moodie, Marj; Dewey, Helen; Thrift, Amanda G.; Donnan, Geoff

2016-01-01

Objective: Our prespecified dose-response analyses of A Very Early Rehabilitation Trial (AVERT) aim to provide practical guidance for clinicians on the timing, frequency, and amount of mobilization following acute stroke. Methods: Eligible patients were aged ≥18 years, had confirmed first (or recurrent) stroke, and were admitted to a stroke unit within 24 hours of stroke onset. Patients were randomized to receive very early and frequent mobilization, commencing within 24 hours, or usual care. We used regression analyses and Classification and Regression Trees (CART) to investigate the effect of timing and dose of mobilization on efficacy and safety outcomes, irrespective of assigned treatment group. Results: A total of 2,104 patients were enrolled, of whom 2,083 (99.0%) were followed up at 3 months. We found a consistent pattern of improved odds of favorable outcome in efficacy and safety outcomes with increased daily frequency of out-of-bed sessions (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.09 to 1.18, p < 0.001), keeping time to first mobilization and mobilization amount constant. Increased amount (minutes per day) of mobilization reduced the odds of a good outcome (OR 0.94, 95% CI 0.91 to 0.97, p < 0.001). Session frequency was the most important variable in the CART analysis, after prognostic variables age and baseline stroke severity. Conclusion: These data suggest that shorter, more frequent mobilization early after acute stroke is associated with greater odds of favorable outcome at 3 months when controlling for age and stroke severity. Classification of evidence: This study provides Class III evidence that shorter, more frequent early mobilization improves the chance of regaining independence after stroke. PMID:26888985

SOS score: an optimized score to screen acute stroke patients for obstructive sleep apnea.

PubMed

Camilo, Millene R; Sander, Heidi H; Eckeli, Alan L; Fernandes, Regina M F; Dos Santos-Pontelli, Taiza E G; Leite, Joao P; Pontes-Neto, Octavio M

2014-09-01

Obstructive sleep apnea (OSA) is frequent in acute stroke patients, and has been associated with higher mortality and worse prognosis. Polysomnography (PSG) is the gold standard diagnostic method for OSA, but it is impracticable as a routine for all acute stroke patients. We evaluated the accuracy of two OSA screening tools, the Berlin Questionnaire (BQ), and the Epworth Sleepiness Scale (ESS) when administered to relatives of acute stroke patients; we also compared these tools against a combined screening score (SOS score). Ischemic stroke patients were submitted to a full PSG at the first night after onset of symptoms. OSA severity was measured by apnea-hypopnea index (AHI). BQ and ESS were administered to relatives of stroke patients before the PSG and compared to SOS score for accuracy and C-statistics. We prospectively studied 39 patients. OSA (AHI ≥10/h) was present in 76.9%. The SOS score [area under the curve (AUC): 0.812; P = 0.005] and ESS (AUC: 0.789; P = 0.009) had good predictive value for OSA. The SOS score was the only tool with significant predictive value (AUC: 0.686; P = 0.048) for severe OSA (AHI ≥30/h), when compared to ESS (P = 0.119) and BQ (P = 0.191). The threshold of SOS ≤10 showed high sensitivity (90%) and negative predictive value (96.2%) for OSA; SOS ≥20 showed high specificity (100%) and positive predictive value (92.5%) for severe OSA. The SOS score administered to relatives of stroke patients is a useful tool to screen for OSA and may decrease the need for PSG in acute stroke setting. Copyright © 2014 Elsevier B.V. All rights reserved.

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

PubMed

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

2010-01-01

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

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

PubMed Central

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

2012-01-01

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

Screening tests for aphasia in patients with stroke: a systematic review.

PubMed

El Hachioui, Hanane; Visch-Brink, Evy G; de Lau, Lonneke M L; van de Sandt-Koenderman, Mieke W M E; Nouwens, Femke; Koudstaal, Peter J; Dippel, Diederik W J

2017-02-01

Aphasia has a large impact on the quality of life and adds significantly to the costs of stroke care. Early recognition of aphasia in stroke patients is important for prognostication and well-timed treatment planning. We aimed to identify available screening tests for differentiating between aphasic and non-aphasic stroke patients, and to evaluate test accuracy, reliability, and feasibility. We searched PubMed, EMbase, Web of Science, and PsycINFO for published studies on screening tests aimed at assessing aphasia in stroke patients. The reference lists of the selected articles were scanned, and several experts were contacted to detect additional references. Of each screening test, we estimated the sensitivity, specificity, likelihood ratio of a positive test, likelihood ratio of a negative test, and diagnostic odds ratio (DOR), and rated the degree of bias of the validation method. We included ten studies evaluating eight screening tests. There was a large variation across studies regarding sample size, patient characteristics, and reference tests used for validation. Many papers failed to report on the consecutiveness of patient inclusion, time between aphasia onset and administration of the screening test, and blinding. Of the three studies that were rated as having an intermediate or low risk of bias, the DOR was highest for the Language Screening Test and ScreeLing. Several screening tools for aphasia in stroke are available, but many tests have not been verified properly. Methodologically sound validation studies of aphasia screening tests are needed to determine their usefulness in clinical practice.

Glycated hemoglobin independently predicts stroke recurrence within one year after acute first-ever non-cardioembolic strokes onset in A Chinese cohort study.

PubMed

Wu, Shuolin; Shi, Yuzhi; Wang, Chunxue; Jia, Qian; Zhang, Ning; Zhao, Xingquan; Liu, Gaifen; Wang, Yilong; Liu, Liping; Wang, Yongjun

2013-01-01

Hyperglycemia is related to stroke. Glycated hemoglobin (HbA1c) can reflect pre-stroke glycaemia status. However, the information on the direct association between HbA1c and recurrence after non-cardioembolic acute ischemic strokes is rare and there is no consistent conclusion. The ACROSS-China database comprised of 2186 consecutive first-ever acute ischemic stroke patients with baseline HbA1c values. After excluding patients who died from non-stroke recurrence and patients lost to follow up, 1817 and 1540 were eligible for 3-month and 1-year analyses, respectively. Multivariate Cox regression was performed to evaluate the associations between HbA1c and 3-month and 1-year stroke recurrence. The HbA1c values at admission were divided into 4 levels by quartiles: Q1 (<5.5%); Q2 (5.5 to <6.1%); Q3 (6.1% to <7.2%); and Q4 (≥ 7.2%). The cumulative recurrence rates were 8.3% and 11.0% for 3 months and 1 year, respectively. In multivariate analyses, when compared with Q1, the adjusted hazard ratios (AHRs) were 2.83 (95% confidence interval (CI) 1.28-6.26) in Q3 and 3.71(95% CI 1.68-8.21) in Q4 for 3-month stroke recurrence; 3.30 (95% CI 1.31-8.34) in Q3 and 3.35 (95% CI 1.36-8.21) in Q4 for 1-year stroke recurrence. Adding fasting plasma glucose in the multivariate analyses did not modify the association: AHRs were 2.75 (95% CI 1.24-6.11) in Q3 and 3.67 (95% CI 1.59-8.53) in Q4 for 3-month analysis; AHRs were 3.08 (95% CI 1.10-8.64) in Q3 and 3.31(95% CI 1.35-8.14) in Q4 for 1-year analysis. A higher "normal" HbA1c level reflecting pre-stroke glycaemia status independently predicts stroke recurrence within one year after non-cardioembolic acute ischemic stroke onset. HbA1c is recommended as a routine test in acute ischemic stroke patients.

CT scanning in stroke patients: meeting the challenge in the remote and rural district general hospital.

PubMed

Todd, A W; Anderson, E M

2009-05-01

National audit data allow crude comparison between centres and indicate that most Scottish hospitals fail to meet current guidelines for CT scanning of the brain in stroke patients. This study identifies some of the reasons for delay in performing CT scans in a largely rural population. This audit study assesses the delays from onset of symptoms, time of admission and request received to CT scan in stroke patients for three different in-patient groups as well as those managed in the community. The reasons for delay in CT scanning varied between different patient groups but for one group of in-patients, changes in booking procedure and introduction of a second CT scanner increased the proportion scanned within 48 hours of request from 65% to 96%. Further developments including the introduction of Saturday and Sunday routine CT scanning, radiologist reporting from home and additional CT scanners placed in remote hospitals may be expected to improve these figures further. Target times of three hours from onset of symptoms to scan to allow thrombolysis may however be impossible to meet for all stroke patients in rural areas.

International Practice in Care Provision for Post-stroke Visual Impairment.

PubMed

Rowe, Fiona J

2017-09-01

This study sought to explore the practice of orthoptists internationally in care provision for poststroke visual impairment. Survey questions were developed and piloted with clinicians, academics, and users. Questions addressed types of visual problems, how these were identified, treated, and followed up, care pathways in use, links with other professions, and referral options. The survey was approved by the institutional ethical committee. The survey was accessed via a web link that was circulated through the International Orthoptic Association member professional organisations to orthoptists. Completed electronic surveys were obtained from 299 individuals. About one-third (35.5%) of orthoptists saw patients within 2 weeks of stroke onset and over half (55.5%) by 1 month post stroke. Stroke survivors were routinely assessed by 87%; over three-quarters in eye clinics. Screening tools were used by 11%. Validated tests were used for assessment of visual acuity (76.5%), visual field (68.2%), eye movement (80.9%), binocular vision (77.9%), and visual function (55.8%). Visual problems suspected by family or professionals were high (86.6%). Typical overall follow-up period of vision care was less than 3 months. Designated care pathways for stroke survivors with visual problems were used by 56.9% of orthoptists. Information on visual impairment was provided by 85.9% of orthoptists. In international orthoptic practice, there is general agreement on assessment and management of visual impairment in stroke populations. More than half of orthoptists reported seeing stroke survivors within 1 month of the stroke onset, typically in eye clinics. There was a high use of validated tests of visual acuity, visual fields, ocular motility, and binocular vision. Similarly there was high use of established treatment options including prisms, occlusion, compensatory strategies, and oculomotor training, appropriately targeted at specific types of visual conditions/symptoms. This information can be used to inform choice of core outcome orthoptic measures in stroke practice.

Patent Foramen Ovale Closure for Secondary Prevention of Cryptogenic Stroke: Updated Meta-Analysis of Randomized Clinical Trials.

PubMed

Vaduganathan, Muthiah; Qamar, Arman; Gupta, Ankur; Bajaj, Navkaranbir; Golwala, Harsh B; Pandey, Ambarish; Bhatt, Deepak L

2018-05-01

Patent foramen ovale closure represents a potential secondary prevention strategy for cryptogenic stroke, but available trials have varied by size, device studied, and follow-up. We conducted a systematic search of published randomized clinical trials evaluating patent foramen ovale closure versus medical therapy in patients with recent stroke or transient ischemic attack using PubMED, EMBASE, and Cochrane through September 2017. Weighting was by random effects models. Of 480 studies screened, we included 5 randomized clinical trials in the meta-analysis in which 3440 patients were randomized to patent foramen ovale closure (n = 1829) or medical therapy (n = 1611) and followed for an average of 2.0 to 5.9 years. Index stroke/transient ischemic attack occurred within 6 to 9 months of randomization. The primary end point was composite stroke/transient ischemic attack and death (in 3 trials) or stroke alone (in 2 trials). Patent foramen ovale closure reduced the primary end point (0.70 vs 1.48 events per 100 patient-years; risk ratio [RR], 0.52 [0.29-0.91]; I 2  = 55.0%) and stroke/transient ischemic attack (1.04 vs 2.00 events per 100 patient-years; RR, 0.55 [0.37-0.82]; I 2  = 42.2%) with modest heterogeneity compared with medical therapy. Procedural bleeding was not different between study arms (1.8% vs 1.8%; RR, 0.94 [0.49-1.83]; I 2  = 29.2%), but new-onset atrial fibrillation/flutter was increased with patent foramen ovale closure (6.6% vs 0.7%; RR, 4.69 [2.17-10.12]; I 2  = 29.3%). In patients with recent cryptogenic stroke, patent foramen ovale closure reduces recurrent stroke/transient ischemic attack compared with medical therapy, but is associated with a higher risk of new-onset atrial fibrillation/flutter. Copyright © 2018 Elsevier Inc. All rights reserved.

Clinical Scales Do Not Reliably Identify Acute Ischemic Stroke Patients With Large-Artery Occlusion.

PubMed

Turc, Guillaume; Maïer, Benjamin; Naggara, Olivier; Seners, Pierre; Isabel, Clothilde; Tisserand, Marie; Raynouard, Igor; Edjlali, Myriam; Calvet, David; Baron, Jean-Claude; Mas, Jean-Louis; Oppenheim, Catherine

2016-06-01

It remains debated whether clinical scores can help identify acute ischemic stroke patients with large-artery occlusion and hence improve triage in the era of thrombectomy. We aimed to determine the accuracy of published clinical scores to predict large-artery occlusion. We assessed the performance of 13 clinical scores to predict large-artery occlusion in consecutive patients with acute ischemic stroke undergoing clinical examination and magnetic resonance or computed tomographic angiography ≤6 hours of symptom onset. When no cutoff was published, we used the cutoff maximizing the sum of sensitivity and specificity in our cohort. We also determined, for each score, the cutoff associated with a false-negative rate ≤10%. Of 1004 patients (median National Institute of Health Stroke Scale score, 7; range, 0-40), 328 (32.7%) had an occlusion of the internal carotid artery, M1 segment of the middle cerebral artery, or basilar artery. The highest accuracy (79%; 95% confidence interval, 77-82) was observed for National Institute of Health Stroke Scale score ≥11 and Rapid Arterial Occlusion Evaluation Scale score ≥5. However, these cutoffs were associated with false-negative rates >25%. Cutoffs associated with an false-negative rate ≤10% were 5, 1, and 0 for National Institute of Health Stroke Scale, Rapid Arterial Occlusion Evaluation Scale, and Cincinnati Prehospital Stroke Severity Scale, respectively. Using published cutoffs for triage would result in a loss of opportunity for ≥20% of patients with large-artery occlusion who would be inappropriately sent to a center lacking neurointerventional facilities. Conversely, using cutoffs reducing the false-negative rate to 10% would result in sending almost every patient to a comprehensive stroke center. Our findings, therefore, suggest that intracranial arterial imaging should be performed in all patients with acute ischemic stroke presenting within 6 hours of symptom onset. © 2016 American Heart Association, Inc.

Differing Patterns of Altered Slow-5 Oscillations in Healthy Aging and Ischemic Stroke.

PubMed

La, Christian; Mossahebi, Pouria; Nair, Veena A; Young, Brittany M; Stamm, Julie; Birn, Rasmus; Meyerand, Mary E; Prabhakaran, Vivek

2016-01-01

The 'default-mode' network (DMN) has been investigated in the presence of various disorders, such as Alzheimer's disease and Autism spectrum disorders. More recently, this investigation has expanded to include patients with ischemic injury. Here, we characterized the effects of ischemic injury in terms of its spectral distribution of resting-state low-frequency oscillations and further investigated whether those specific disruptions were unique to the DMN, or rather more general, affecting the global cortical system. With 43 young healthy adults, 42 older healthy adults, 14 stroke patients in their early stage (<7 days after stroke onset), and 16 stroke patients in their later stage (between 1 to 6 months after stroke onset), this study showed that patterns of cortical system disruption may differ between healthy aging and following the event of an ischemic stroke. The stroke group in the later stage demonstrated a global reduction in the amplitude of the slow-5 oscillations (0.01-0.027 Hz) in the DMN as well as in the primary visual and sensorimotor networks, two 'task-positive' networks. In comparison to the young healthy group, the older healthy subjects presented a decrease in the amplitude of the slow-5 oscillations specific to the components of the DMN, while exhibiting an increase in oscillation power in the task-positive networks. These two processes of a decrease DMN and an increase in 'task-positive' slow-5 oscillations may potentially be related, with a deficit in DMN inhibition, leading to an elevation of oscillations in non-DMN systems. These findings also suggest that disruptions of the slow-5 oscillations in healthy aging may be more specific to the DMN while the disruptions of those oscillations following a stroke through remote (diaschisis) effects may be more widespread, highlighting a non-specificity of disruption on the DMN in stroke population. The mechanisms underlying those differing modes of network disruption need to be further explored to better inform our understanding of brain function in healthy individuals and following injury.

Natural history and magnetic resonance imaging follow-up in 9 Sturge-Weber Syndrome patients and clinical correlation.

PubMed

Udani, Vrajesh; Pujar, Suresh; Munot, Pinki; Maheshwari, Shailendra; Mehta, Nirad

2007-04-01

The natural history of Sturge-Weber Syndrome is variable where some patients have refractory epilepsy and persistent neurologic deficits while others do well. Also, evolution of MRI abnormalities is largely unknown. This long-term follow-up study tries to address these two issues. This retrospective and later prospective study followed 9 children with confirmed SWS. Clinical details of seizures, stroke-like episodes, neurologic and developmental deficits were ascertained specifically. Patients were divided into those with onset below or after 6 months of age for analysis. Disease was classified as active or inactive and correlations were made with the use of aspirin. All past, as well as prospectively acquired imaging was reviewed by two independent blinded neuroradiologists and the images were analysed as ictal (temporally related to seizure/stroke-like event) or interictal. Degree and extent of leptomeningeal enhancement was specifically looked for. Four boys and five girls were followed up for a mean of 6.1 years. Disease activity subsided in 8/9. Early-onset patients had a severe early course with significant residual deficits while late-onset patients did uniformly well. In 6 patients where aspirin was used, a stable course ensued. There was a significant increase in degree/extent of leptomeningeal enhancement during an ictus which returned to the baseline in the interictal state in all 7 patients where both images were available. Focal cerebral atrophy worsened in early-onset cases. In conclusion, SWS patients with onset of seizures/stroke-like events before 6 months of age seem to do worse with a severe early course and persistent neurologic deficits. However the course stabilizes after 5 years of age in most. Late-onset SWS patients have a benign course. Aspirin use is associated with a stable course though further studies are needed. The leptomeningeal enhancement appears to increase during acute events before returning to baseline suggesting that extent of the disease is probably best judged during the interictal state.

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.

Recurrent Wernicke's aphasia: migraine and not stroke!

PubMed

Mishra, Nishant Kumar; Rossetti, Andrea O; Ménétrey, André; Carota, Antonio

2009-05-01

We report the clinical findings of a 40-year-old woman with recurrent migraine presenting with Wernicke's aphasia in accordance with the results of a standardized battery for language assessment (Boston Aphasia Diagnostic Examination). The patient had no evidence of parenchymal or vascular lesions on MRI and showed delta and theta slowing over the left posterior temporal leads on the EEG. Although the acute onset of a fluent aphasia suggested stroke as a likely etiology, the recurrence of aphasia as the initial symptom of migraine was related to cortical spreading depression and not to stroke.

Quick reference guide to apixaban.

PubMed

Hurst, Katherine Victoria; O'Callaghan, John Matthew; Handa, Ashok

2017-01-01

Direct oral anticoagulants (DOACs) are being increasingly used in the clinical setting for patients at risk of venous thromboembolism (VTE) and/or stroke. These medications offer valued benefits for long-term use, including a fast onset of anticoagulation, fixed anticoagulation profile (and consequent prescription of specified doses) and no requirement for routine monitoring. Apixaban is a selective factor Xa inhibitor, approved for use in the prevention of stroke in patients with nonvalvular atrial fibrillation and in the prevention and treatment of acute VTE. Like many of the DOACs, it has a fast onset of action and works to deliver predictable coagulation results. Multiple randomized controlled trials including ARISTOTLE and AMPLIFY have shown apixaban to be noninferior to vitamin K antagonists in the prevention of stroke and VTE, with a good safety profile. This article aims to review the use of apixaban for the prevention and treatment of thromboembolic disease, highlighting the key study results that have led to its current licensing and use.

Quick reference guide to apixaban

PubMed Central

Hurst, Katherine Victoria; O’Callaghan, John Matthew; Handa, Ashok

2017-01-01

Direct oral anticoagulants (DOACs) are being increasingly used in the clinical setting for patients at risk of venous thromboembolism (VTE) and/or stroke. These medications offer valued benefits for long-term use, including a fast onset of anticoagulation, fixed anticoagulation profile (and consequent prescription of specified doses) and no requirement for routine monitoring. Apixaban is a selective factor Xa inhibitor, approved for use in the prevention of stroke in patients with nonvalvular atrial fibrillation and in the prevention and treatment of acute VTE. Like many of the DOACs, it has a fast onset of action and works to deliver predictable coagulation results. Multiple randomized controlled trials including ARISTOTLE and AMPLIFY have shown apixaban to be noninferior to vitamin K antagonists in the prevention of stroke and VTE, with a good safety profile. This article aims to review the use of apixaban for the prevention and treatment of thromboembolic disease, highlighting the key study results that have led to its current licensing and use. PMID:28744136

Inflammatory pathways are central to posterior cerebrovascular artery remodelling prior to the onset of congenital hypertension.

PubMed

Walas, Dawid; Nowicki-Osuch, Karol; Alibhai, Dominic; von Linstow Roloff, Eva; Coghill, Jane; Waterfall, Christy; Paton, Julian Fr

2018-01-01

Cerebral artery hypoperfusion may provide the basis for linking ischemic stroke with hypertension. Brain hypoperfusion may induce hypertension that may serve as an auto-protective mechanism to prevent ischemic stroke. We hypothesised that hypertension is caused by remodelling of the cerebral arteries, which is triggered by inflammation. We used a congenital rat model of hypertension and examined age-related changes in gene expression of the cerebral arteries using RNA sequencing. Prior to hypertension, we found changes in signalling pathways associated with the immune system and fibrosis. Validation studies using second harmonics generation microscopy revealed upregulation of collagen type I and IV in both tunica externa and media. These changes in the extracellular matrix of cerebral arteries pre-empted hypertension accounting for their increased stiffness and resistance, both potentially conducive to stroke. These data indicate that inflammatory driven cerebral artery remodelling occurs prior to the onset of hypertension and may be a trigger elevating systemic blood pressure in genetically programmed hypertension.

A free radical scavenger edaravone suppresses systemic inflammatory responses in a rat transient focal ischemia model

PubMed Central

Fujiwara, Norio; Som, Angel T.; Pham, Loc-Duyen D.; Lee, Brian J.; Mandeville, Emiri T.; Lo, Eng H.; Arai, Ken

2017-01-01

A free radical scavenger edaravone is clinically used in Japan for acute stroke, and several basic researches have carefully examined the mechanisms of edaravone's protective effects. However, its actions on pro-inflammatory responses under stroke are still understudied. In this study, we subjected adult male Sprague-Dawley rats to 90-min middle cerebral artery (MCA) occlusion followed by reperfusion. Edaravone was treated twice via tail vein; after MCA occlusion and after reperfusion. As expected, edaravone-treated group showed less infarct volume and edema formation compared with control group at 24-hour after ischemic onset. Furthermore, edaravone reduced the levels of plasma interleukin (IL)-1β and matrix metalloproteinase-9 at 3-hour after ischemic onset. Several molecules besides IL-1β and MMP-9 are involved in inflammatory responses under stroke conditions. Therefore, we also examined whether edaravone treatment could decrease a wide range of pro-inflammatory cytokines/chemokines by testing rat plasma samples with a rat cytokine array. MCAO rats showed elevations in plasma levels of CINC-1, Fractalkine, IL-1α, IL-1ra, IL-6, IL-10, IP-10, MIG, MIP-1α, and MIP-3α, and all these increases were reduced by edaravone treatment. These data suggest that free radical scavengers may reduce systemic inflammatory responses under acute stroke conditions, and therefore, oxidative stress can be still a viable target for acute stroke therapy. PMID:27589890

Emergency department arrival times after acute ischemic stroke during the 1990s.

PubMed

Kleindorfer, Dawn O; Broderick, Joseph P; Khoury, Jane; Flaherty, Matthew L; Woo, Daniel; Alwell, Kathleen; Moomaw, Charles J; Pancioli, Arthur; Jauch, Edward; Miller, Rosie; Kissela, Brett M

2007-01-01

Only 8% of ischemic stroke (IS) patients are eligible for rt-PA, and the largest exclusion criterion is delayed time of presentation to the ED. We sought to investigate whether patients are arriving to the ED more quickly in 1999 than in 1993/94 within our large biracial population of 1.3 million. Using ICD-9 codes 430-436, we ascertained all stroke events that presented to a local ED within our population in 7/93-6/94 and again in 1999. Times were recorded as documented in the medical record. There were 1,792 IS patients that presented to an ED in 1993/94 and 1,973 in 1999. The percentage of patients with documented times arriving in under 3 h improved slightly in 1999 (26% vs. 23% in 93/94, P = 0.03), however, the percentage arriving in under 2 h did not. Blacks significantly improved in arrivals under 3 h: 26% in 1999 compared to 17% in 1993/94 (P = 0.01), while whites did not (26% vs. 25%, P = 0.29). In 1999, only 9% of patients arrived from 3-8 h after symptom onset, the large majority of times were either estimated, unknown, or >8 h. We found only marginal improvement in arrival times during the 1990s. In our population, blacks improved in early arrival after symptom onset, while whites did not. Very few patients arrive 3-8 h after onset; therefore expansion of the acute treatment time window to 8 h is unlikely to dramatically affect acute treatment of ischemic stroke.

Ambient air pollutants and acute case-fatality of cerebro-cardiovascular events: Takashima Stroke and AMI Registry, Japan (1988-2004).

PubMed

Turin, Tanvir Chowdhury; Kita, Yoshikuni; Rumana, Nahid; Nakamura, Yasuyuki; Ueda, Kayo; Takashima, Naoyuki; Sugihara, Hideki; Morita, Yutaka; Ichikawa, Masaharu; Hirose, Kunihiko; Nitta, Hiroshi; Okayama, Akira; Miura, Katsuyuki; Ueshima, Hirotsugu

2012-01-01

Apart from the conventional risk factors, cerebro-cardiovascular disease (CVD) are also reported to be associated with air pollution, thus lowering the level of exposure might contribute in prevention activities to reduce the associated adverse outcomes. Though few studies conducted in Japan have reported on the CVD mortality but none have explored the effect of air pollutant exposure on the acute case-fatality of CVD. We investigated the effects of air pollution exposure on acute case-fatality of stroke and acute myocardial infarction (AMI) in a setting where pollutant levels are rather low. We leveraged the data from the Takashima Stroke and AMI Registry, which covers a population of approximately 55,000 in Takashima County located in central Japan. The study period of 6,210 days (16 years, leap years also taken into account) were divided into quartiles of daily average pollutant concentration; suspended particulate matter (SPM), sulfur dioxide (SO(2)), nitrogen dioxide (NO(2)), and photochemical oxidants (Ox). The stroke and AMI events were categorized to corresponding quartiles based on the pollution levels of the onset day. To study the effects of air pollutants, we estimated the fatality rate ratio across quartiles of the pollutants where the lowest quartile served as the reference. There were 307 (men: 153 and women: 154) fatal stroke cases within 28 days of onset among the 2,038 first ever stroke during 1988-2004. In the same period, there were 142 (men: 94 and women: 54) fatal AMI cases within 28 days of onset among the 429 first ever AMI events. The mean of the measured pollutant levels were as follows: SPM 26.9 µg/m(3), SO(2) 3.9 ppb, NO(2) 16.0 ppb, and Ox 28.4 ppb. Among the pollutants, higher levels of NO(2) showed increased fatality risk. In multi-pollutant model, the highest quartile of NO(2) was associated with 60% higher stroke case-fatality risk in comparison to lowest quartile of NO(2). In the fully adjusted model the fatality-rate ratio was 1.65 (95% CI 1.06-2.57). This association was more prominent among stroke subtype of cerebral infarction. Other pollutant levels did not show any association with stroke or AMI case-fatality. We observed association between NO(2) levels, an index of traffic related air pollution, with the acute case-fatality of stroke, especially cerebral infarction in our study population. Further studies are needed in different regions to determine the association between ambient air pollutants and acute cardiovascular fatalities. Copyright © 2012 S. Karger AG, Basel.

A novel neuroimaging model to predict early neurological deterioration after acute ischemic stroke.

PubMed

Huang, Yen-Chu; Tsai, Yuan-Hsiung; Lee, Jiann-Der; Yang, Jen-Tsung; Pan, Yi-Ting

2018-05-16

In acute ischemic stroke, early neurological deterioration (END) may occur in up to one-third of patients. However, there is still no satisfying or comprehensive predictive model for all the stroke subtypes. We propose a practical model to predict END using magnetic resonance imaging (MRI). Patients with anterior circulation infarct were recruited and they underwent an MRI within 24 hours of stroke onset. END was defined as an elevation of ≥2 points on the National Institute of Health Stroke Scale (NIHSS) within 72 hours of stroke onset. We examined the relationships of END to individual END models, including: A, infarct swelling; B, small subcortical infarct; C, mismatch; and D, recurrence. There were 163 patients recruited and 43 (26.4%) of them had END. The END models A, B and C significantly predicted END respectively after adjusting for confounding factors (p=0.022, p=0.007 and p<0.001 respectively). In END model D, we examined all imaging predictors of Recurrence Risk Estimator (RRE) individually and only the "multiple acute infarcts" pattern was significantly associated with END (p=0.032). When applying END models A, B, C and D, they successfully predicted END (p<0.001; odds ratio: 17.5[95% confidence interval: 5.1-60.8]), with 93.0% sensitivity, 60.0% specificity, 45.5% positive predictive value and 96.0% negative predictive value. The results demonstrate that the proposed model could predict END in all stroke subtypes of anterior circulation infarction. It provides a practical model for clinical physicians to select high-risk patients for more aggressive treatment to prevent END. Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.org.

The Vienna Stroke Registry--objectives and methodology. The Vienna Stroke Study Group.

PubMed

2001-02-15

The Vienna Stroke Registry (VSR) comprises nine neurological departments of Vienna and was established in 1998. This article describes the objectives and methodology of the VSR. The goals of the VSR are as follows: (1) to document the quality (structure, process, outcome) of medical services and to construct a database which can be used for future adjustment of medical services in Vienna (early stroke intervention, concept of stroke units, rehabilitation services); (2) to guide educational programs; (3) to adjust or establish algorithms for clinical decision making and to analyze predictors of outcome; (4) to document changes in diagnostic and therapeutic strategies over time; (5) to formulate hypotheses about the etiology, pathophysiology, clinical course, and outcome of stroke. Since October 1998 all patients with the presumed diagnosis of a transitory ischemic attack (TIA) or stroke who had been admitted to one of the participating centers within 72 hours of the onset of symptoms were included in the VSR. All patients are prospectively documented according to standardized detailed protocols. The collected data refer to demographic parameters; medical, particularly, vascular history; vascular risk factors; laboratory and technical investigations (including cerebrovascular, cardiological, and neuroradiological findings); details of pharmacological and non-pharmacological treatment; factors influencing the time from the onset of symptoms to hospital admission and the start of therapy; clinical and etiological classification according to pre-specified criteria; neurological and functional impairment at specified time points; structured follow-up investigations at 3, 12, and 24 months after the event. Until September 2000, 2300 patients had been included in the VSR. The target number of 3500 patients will be achieved in the second half of 2001. A baseline description of the VSR population will be given separately.

Serum matrix metalloproteinase-9 levels and prognosis of acute ischemic stroke.

PubMed

Zhong, Chongke; Yang, Jingyuan; Xu, Tan; Xu, Tian; Peng, Yanbo; Wang, Aili; Wang, Jinchao; Peng, Hao; Li, Qunwei; Ju, Zhong; Geng, Deqin; Zhang, Yonghong; He, Jiang

2017-08-22

To examine the association between serum matrix metalloproteinases-9 (MMP-9) levels and prognosis of acute ischemic stroke. We measured serum MMP-9 levels in 3,186 participants (2,008 men and 1,178 women) from the China Antihypertensive Trial in Acute Ischemic Stroke (CATIS). Study outcome data on death, major disability (modified Rankin Scale score ≥3), and vascular disease were collected at 3 months after stroke onset. During 3 months of follow-up, 767 participants (24.6%) experienced major disability or died. Serum MMP-9 was significantly associated with an increased risk of death and major disability after adjustment for age, sex, time from onset to randomization, current smoking, alcohol drinking, admission NIH Stroke Scale score, diastolic blood pressure, plasma glucose, white blood cell counts, use of antihypertensive medications, and history of hypertension, coronary heart disease, and diabetes mellitus. For example, 1-SD (0.32 ng/mL) higher log-MMP-9 was associated with an odds ratio (95% confidence interval) of 1.16 (1.06-1.28) for the combined outcome of death and major disability, 1.12 (1.01-1.23) for major disability, and 1.29 (1.01-1.66) for death. The addition of serum MMP-9 to conventional risk factors improved risk prediction of the combined outcome of death or major disability (net reclassification index 9.1%, p = 0.033; integrated discrimination improvement 0.4%, p = 0.004). Higher serum MMP-9 levels in the acute phase of ischemic stroke were associated with increased risk of mortality and major disability, suggesting that serum MMP-9 could be an important prognostic factor for ischemic stroke. © 2017 American Academy of Neurology.

Risk profile and treatment options of acute ischemic in-hospital stroke.

PubMed

Schürmann, Kolja; Nikoubashman, Omid; Falkenburger, Björn; Tauber, Simone C; Wiesmann, Martin; Schulz, Jörg B; Reich, Arno

2016-03-01

Despite the potential immediate access to diagnosis and care, in-hospital stroke (IHS) is associated with delay in diagnosis, lower rates of reperfusion treatment, and unfavorable outcome. Endovascular reperfusion therapy has shown promising results in recent trials for community-onset strokes (COS) and is limited by less contraindications than systemic thrombolysis. Thus, endovascular approaches may offer additional acute treatment options for IHS. We performed a retrospective, observational monocentric analysis of patients with acute ischemic stroke between January 2010 and December 2014. Out of 3506 acute ischemic strokes, 331 (9.4%) were IHS. In-hospital mortality (31.4 vs. 8.0%) and duration of stay after stroke (19.5 vs. 12.1 days) were higher in IHS than in COS. Most IHS occurred in cardiologic and cardiosurgical patients after catheterization or surgery. In 111 cases (33.5%) the time of onset could not be established as a result of sedation or delayed referral resulting in delayed symptom recognition. 52 IHS (15.7%) and 828 COS (26.0%, p < 0.001) patients received any kind of reperfusion therapy, of which 59.6% (IHS) and 12.1% (COS) comprised isolated endovascular interventions (p < 0.001). Intra-hospital delays (time to brain imaging, systemic thrombolysis, and angiography) were longer and outcome parameters (mRS d90, in-hospital mortality, length of stay) were worse in IHS, whereas rates of procedural complications and intracranial hemorrhages were similar in both groups. The overall rate of reperfusion treatment is lower in IHS compared to COS, as IHS patients are less likely to be eligible for systemic thrombolysis. Interventional stroke treatment is a safe and feasible therapeutic option for patients who are not eligible for systemic thrombolysis and should be anticipated whenever IHS is diagnosed.

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

PubMed

Vibo, R; Kõrv, J; Roose, M

2007-04-01

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

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

PubMed

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

2015-08-01

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

The diagnosis and management of cerebrovascular disease in diabetes.

PubMed

Phipps, Michael S; Jastreboff, Ania M; Furie, Karen; Kernan, Walter N

2012-06-01

Cerebrovascular disease is a leading cause of morbidity and mortality in diabetes. Compared with nondiabetic patients, diabetic patients have at least twice the risk for stroke, earlier onset of symptoms, and worse functional outcomes. Approximately 20 % of diabetic patients will die from stroke, making it one of the leading causes of death in this population. Effective strategies for primary and secondary prevention of stroke have been developed in research cohorts that included both diabetic and nondiabetic patients. Nevertheless, prevention in diabetes has some specific considerations. In this paper, we summarize evidence to guide the diagnosis and management of stroke in diabetic patients. We propose that diabetic stroke patients should have a robust risk assessment to target interventions, like other patients with cerebrovascular disease, but with special attention to glycemic control and lifestyle modification.

The Chinese Stroke Association scientific statement: intravenous thrombolysis in acute ischaemic stroke

PubMed Central

Dong, Qiang; Dong, Yi; Liu, Liping; Xu, Anding; Zhang, Yusheng; Zheng, Huaguang; Wang, Yongjun

2017-01-01

The most effective medical treatment for acute ischaemic stroke (AIS) is to offer intravenous thrombolysis during the ultra-early period of time after the onset. Even based on the Consensus of Chinese Experts on Intravenous Thrombolysis for AIS in 2012 and 2014 Chinese Guidelines on the Diagnosis and Treatment of AIS, the rate of thrombolysis for AIS in China remained around 2.4%, and the rate of intravenous tissue plasminogen activator usage was only about 1.6% in real world. The indication of thrombolysis for AIS has been expanded, and contraindications have been reduced with recently published studies. In order to facilitate the standardisation of treating AIS, improve the rate of thrombolysis and benefit patients who had a stroke, Chinese Stroke Association has organised and developed this scientific statement. PMID:28989804

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

PubMed

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

2015-12-09

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

5A.01: CORONARY ATHEROSCLEROSIS AND ADVERSE OUTCOME IN HYPERTENSIVE PATIENTS WITH RECENT-ONSET ATRIAL FIBRILLATION AND TROPONIN RISE.

PubMed

Conti, A; Angeli, E; Trausi, F; Grifoni, C; Lazzeretti, D; Bianchi, S; Catarzi, S; Covelli, A; Perrotta, M E; Lencioni, A M; Pisani, N; Bertolini, L

2015-06-01

Atrial fibrillation (AF), the most common cardiac-arrhythmia in critical-care, has reached a high prevalence in hypertensive patients. Prevention of systemic-embolism is mandatory; unfortunately, evidence to support the treatment of comorbidities as coronary artery disease (CAD) that contribute to excess mortality is lacking, and the mechanism underlying the troponin-rise during AF without acute coronary syndrome (ACS) is unclear. This study investigates the relationship between CAD, stroke and outcomes in patients with troponin-rise and AF. Patients with a recent-onset AF and without severe comorbidities were enrolled. Baseline characteristics in those with troponin-rise versus those without were adjusted with propensity-score-matching for possible confounders. SPSS-software allowed estimation of the propensity-score using logistic-regression and specifying nearest-neighbor matching in prior-stroke, heart-rate, hypertension, TIMI-risk-score, GRACE-score, CHA2DS2Vasc-score. Patients with a troponin-rise or cardiovascular event (CVE) were considered for angiography. The primary endpoint was the composite of ACS, revascularization (with critical CAD>/ = 70%) and cardiac-death at the follow-up; the secondary endpoint was stroke. Out of 6203 AF patients without severe comorbidities, 3541 with recent-onset AF completed the study; 202(6%) showed a troponin-rise, 91(3%) a CVE. After matching no difference existed in baseline characteristics. On multivariate analysis, in the entire cohort, troponin-rise, know-CAD and hypertension were predictors of the endpoint, whereas only troponin-rise (Odd Ratio, OR: 10, Confidence Interval 95%, CI: 4-22, p < 0.001) and TIMI-score > 2 (OR 4, CI 2-9, p < 0.001) in the matching cohort, suggesting the role of CAD in poor outcomes. Patients with or without troponin-rise achieved the endpoint in 38(19%) and 43(1%), respectively (p < 0.001). Stroke occurred in 4(2%) and 20 (1%), respectively (p = 0.018). Critical CAD account for 23(12%) and 15(1%), respectively (p < 0,001). In the matching cohort, only stroke did not reach the statistical significance. Interestingly, the best cut/off troponin level for decision-making was 0.30 ng/L which, on Receiver Operator Curve analysis, was associated with 68% of sensitivity and 60% specificity; the value > 0.50 ng/L with 55% and 75%, respectively. Patients with a recent-onset AF and troponin-rise showed a high prevalence of CVE but not stroke, thus CAD might have a role in poor outcomes.

Performance of e-ASPECTS software in comparison to that of stroke physicians on assessing CT scans of acute ischemic stroke patients.

PubMed

Herweh, Christian; Ringleb, Peter A; Rauch, Geraldine; Gerry, Steven; Behrens, Lars; Möhlenbruch, Markus; Gottorf, Rebecca; Richter, Daniel; Schieber, Simon; Nagel, Simon

2016-06-01

The Alberta Stroke Program Early CT score (ASPECTS) is an established 10-point quantitative topographic computed tomography scan score to assess early ischemic changes. We compared the performance of the e-ASPECTS software with those of stroke physicians at different professional levels. The baseline computed tomography scans of acute stroke patients, in whom computed tomography and diffusion-weighted imaging scans were obtained less than two hours apart, were retrospectively scored by e-ASPECTS as well as by three stroke experts and three neurology trainees blinded to any clinical information. The ground truth was defined as the ASPECTS on diffusion-weighted imaging scored by another two non-blinded independent experts on consensus basis. Sensitivity and specificity in an ASPECTS region-based and an ASPECTS score-based analysis as well as receiver-operating characteristic curves, Bland-Altman plots with mean score error, and Matthews correlation coefficients were calculated. Comparisons were made between the human scorers and e-ASPECTS with diffusion-weighted imaging being the ground truth. Two methods for clustered data were used to estimate sensitivity and specificity in the region-based analysis. In total, 34 patients were included and 680 (34 × 20) ASPECTS regions were scored. Mean time from onset to computed tomography was 172 ± 135 min and mean time difference between computed tomographyand magnetic resonance imaging was 41 ± 31 min. The region-based sensitivity (46.46% [CI: 30.8;62.1]) of e-ASPECTS was better than three trainees and one expert (p ≤ 0.01) and not statistically different from another two experts. Specificity (94.15% [CI: 91.7;96.6]) was lower than one expert and one trainee (p < 0.01) and not statistically different to the other four physicians. e-ASPECTS had the best Matthews correlation coefficient of 0.44 (experts: 0.38 ± 0.08 and trainees: 0.19 ± 0.05) and the lowest mean score error of 0.56 (experts: 1.44 ± 1.79 and trainees: 1.97 ± 2.12). e-ASPECTS showed a similar performance to that of stroke experts in the assessment of brain computed tomographys of acute ischemic stroke patients with the Alberta Stroke Program Early CT score method. © 2016 World Stroke Organization.

A strategic plan to accelerate development of acute stroke treatments.

PubMed

Marler, John R

2012-09-01

In order to reenergize acute stroke research and accelerate the development of new treatments, we need to transform the usual design and conduct of clinical trials to test for small but significant improvements in effectiveness, and treat patients as soon as possible after stroke onset when treatment effects are most detectable. This requires trials that include thousands of acute stroke patients. A plan to make these trials possible is proposed. There are four components: (1) free access to the electronic medical record; (2) a large stroke emergency network and clinical trial coordinating center connected in real time to hundreds of emergency departments; (3) a clinical trial technology development center; and (4) strategic leadership to raise funds, motivate clinicians to participate, and interact with politicians, insurers, legislators, and other national and international organizations working to advance the quality of stroke care. © 2012 New York Academy of Sciences.

Berardinelli Seip syndrome with insulin-resistant diabetes mellitus and stroke in an infant

PubMed Central

Indumathi, C. K.; Lewin, S.; Ayyar, Vageesh

2011-01-01

Berardinelli Seip congenital lipodystrophy (BSCL) is a rare metabolic disorder characterized by severe generalized lipodystrophy, insulin resistance, and dyslipedemia since infancy, and onset of overt diabetes mellitus in adolescence. Here we report a 5-month-old infant with clinical and metabolic manifestations of Berardinelli Seip syndrome including overt diabetes mellitus and stroke, which are very rare at this age. PMID:21847459

Berardinelli Seip syndrome with insulin-resistant diabetes mellitus and stroke in an infant.

PubMed

Indumathi, C K; Lewin, S; Ayyar, Vageesh

2011-07-01

Berardinelli Seip congenital lipodystrophy (BSCL) is a rare metabolic disorder characterized by severe generalized lipodystrophy, insulin resistance, and dyslipedemia since infancy, and onset of overt diabetes mellitus in adolescence. Here we report a 5-month-old infant with clinical and metabolic manifestations of Berardinelli Seip syndrome including overt diabetes mellitus and stroke, which are very rare at this age.

Impact of General Anesthesia on Safety and Outcomes in the Endovascular Arm of Interventional Management of Stroke (IMS) III Trial.

PubMed

Abou-Chebl, Alex; Yeatts, Sharon D; Yan, Bernard; Cockroft, Kevin; Goyal, Mayank; Jovin, Tudor; Khatri, Pooja; Meyers, Phillip; Spilker, Judith; Sugg, Rebecca; Wartenberg, Katja E; Tomsick, Tom; Broderick, Joe; Hill, Michael D

2015-08-01

General anesthesia (GA) for endovascular therapy (EVT) of acute ischemic stroke may be associated with worse outcomes. The Interventional Management of Stroke III trial randomized patients within 3 hours of acute ischemic stroke onset to intravenous tissue-type plasminogen activator±EVT. GA use within 7 hours of stroke onset was recorded per protocol. Good outcome was defined as 90-day modified Rankin Scale ≤2. A multivariable analysis adjusting for dichotomized National Institutes of Health Stroke Scale (NIHSS; 8-19 versus ≥20), age, and time from onset to groin puncture was performed. Four hundred thirty-four patients were randomized to EVT, 269 (62%) were treated under local anesthesia and 147 (33.9%) under GA; 18 (4%) were undetermined. The 2 groups were comparable except for median baseline NIHSS (16 local anesthesia versus 18 GA; P<0.0001). The GA group was less likely to achieve a good outcome (adjusted relative risk, 0.68; confidence interval, 0.52-0.90; P=0.0056) and had increased in-hospital mortality (adjusted relative risk, 2.84; confidence interval, 1.65-4.91; P=0.0002). Those with medically indicated GA had worse outcomes (adjusted relative risk, 0.49; confidence interval, 0.30-0.81; P=0.005) and increased mortality (relative risk, 3.93; confidence interval, 2.18-7.10; P<0.0001) with a trend for higher mortality with routine GA. There was no significant difference in the adjusted risks of subarachnoid hemorrhage (P=0.32) or symptomatic intracerebral hemorrhage (P=0.37). GA was associated with worse neurological outcomes and increased mortality in the EVT arm; this was primarily true among patients with medical indications for GA. Relative risk estimates, though not statistically significant, suggest reduced risk for subarachnoid hemorrhage and symptomatic intracerebral hemorrhage under local anesthesia. Although the reasons for these associations are not clear, these data support the use of local anesthesia when possible during EVT. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00359424. © 2015 American Heart Association, Inc.

Ethnic disparities in incidence of stroke subtypes: Auckland Regional Community Stroke Study, 2002-2003.

PubMed

Feigin, Valery; Carter, Kristie; Hackett, Maree; Barber, P Alan; McNaughton, Harry; Dyall, Lorna; Chen, Mei-hua; Anderson, Craig

2006-02-01

Limited population-based data exist on differences in the incidence of major pathological stroke types and ischaemic stroke subtypes across ethnic groups. We aimed to provide such data within the large multi-ethnic population of Auckland, New Zealand. All first-ever cases of stroke (n=1423) in a population-based register in 940 000 residents (aged 15 years) in Auckland, New Zealand, for a 12-month period in 2002-2003, were classified into ischaemic stroke, primary intracerebral haemorrhage (PICH), subarachnoid haemorrhage, and undetermined stroke, according to standard definitions and results of neuroimaging/necropsy (in over 90% of cases). Ischaemic stroke was further classified into five subtypes. Ethnicity was self-identified and grouped as New Zealand (NZ)/European, Maori/Pacific, and Asian/other. Incidence rates were standardised to the WHO world population by the direct method, and differences in rates between ethnic groups expressed as rate ratios (RRs), with NZ/European as the reference group. In NZ/European people, ischaemic stroke comprised 73%, PICH 11%, and subarachnoid haemorrhage 6%, but PICH was higher in Maori/Pacific people (17%) and in Asian/other people (22%). Compared with NZ/European people, age-adjusted RRs for PICH were 2.7 (95% CI 1.8-4.0) and 2.3 (95% CI 1.4-3.7) among Maori/Pacific and Asian/other people, respectively. The corresponding RR for ischaemic stroke was greater for Maori/Pacific people (1.7 [95% CI 1.4-2.0]), particularly embolic stroke, and for Asian/other people (1.3 [95% CI 1.0-1.7]). The onset of stroke in Maori/Pacific and Asian/other people began at significantly younger ages (62 years and 64 years, respectively) than in NZ/Europeans (75 years; p<0.0001). There were ethnic differences in the risk factor profiles (such as age, sex, hypertension, cardiac disease, diabetes, hypercholesterolaemia, smoking status, overweight) for the stroke types and subtypes. Compared to NZ/Europeans, Maori/Pacific and Asian/other people are at higher risk of ischaemic stroke and PICH, whereas similar rates of subarachnoid haemorrhage were evident across ethnic groups. The ethnic disparities in the rates of stroke types could be due to substantial differences found in risk factor profiles between ethnic groups. This information should be considered when planning prevention and stroke-care services in multi-ethnic communities.

The Next Step in Understanding Impaired Reactive Balance Control in People With Stroke: The Role of Defective Early Automatic Postural Responses.

PubMed

de Kam, Digna; Roelofs, Jolanda M B; Bruijnes, Amber K B D; Geurts, Alexander C H; Weerdesteyn, Vivian

2017-08-01

Postural muscle responses are often impaired after stroke. We aimed to identify the contribution of deficits in very early postural responses to poorer reactive balance capacity, with a particular focus on reactive stepping as a key strategy for avoiding falls. A total of 34 chronic stroke survivors and 17 controls were subjected to translational balance perturbations in 4 directions. We identified the highest perturbation intensity that could be recovered without stepping (single stepping threshold [SST]) and with maximally 1 step (multiple stepping threshold [MST]). We determined onset latencies and response amplitudes of 7 leg muscles bilaterally and identified associations with balance capacity. People with stroke had a lower MST than controls in all directions. Side steps resulted in a higher lateral MST than crossover steps but were less common toward the paretic side. Postural responses were delayed and smaller in amplitude on the paretic side only. We observed the strongest associations between gluteus medius (GLUT) onset and amplitude and MST toward the paretic side ( R 2 = 0.33). Electromyographic variables were rather weakly associated with forward and backward MSTs ( R 2 = 0.10-0.22) and with SSTs ( R 2 = 0.08-0.15). Delayed and reduced paretic postural responses are associated with impaired reactive stepping after stroke. Particularly, fast and vigorous activity of the GLUT is imperative for overcoming large sideways perturbations, presumably because it facilitates the effective use of side steps. Because people with stroke often fall toward the paretic side, this finding indicates an important target for training.

Reducing time-to-unit among patients referred to an outpatient stroke assessment unit with a novel triage process: a prospective cohort study.

PubMed

Bibok, Maximilian B; Votova, Kristine; Balshaw, Robert F; Lesperance, Mary L; Croteau, Nicole S; Trivedi, Anurag; Morrison, Jaclyn; Sedgwick, Colin; Penn, Andrew M

2018-02-27

To evaluate the performance of a novel triage system for Transient Ischemic Attack (TIA) units built upon an existent clinical prediction rule (CPR) to reduce time to unit arrival, relative to the time of symptom onset, for true TIA and minor stroke patients. Differentiating between true and false TIA/minor stroke cases (mimics) is necessary for effective triage as medical intervention for true TIA/minor stroke is time-sensitive and TIA unit spots are a finite resource. Prospective cohort study design utilizing patient referral data and TIA unit arrival times from a regional fast-track TIA unit on Vancouver Island, Canada, accepting referrals from emergency departments (ED) and general practice (GP). Historical referral cohort (N = 2942) from May 2013-Oct 2014 was triaged using the ABCD2 score; prospective referral cohort (N = 2929) from Nov 2014-Apr 2016 was triaged using the novel system. A retrospective survival curve analysis, censored at 28 days to unit arrival, was used to compare days to unit arrival from event date between cohort patients matched by low (0-3), moderate (4-5) and high (6-7) ABCD2 scores. Survival curve analysis indicated that using the novel triage system, prospectively referred TIA/minor stroke patients with low and moderate ABCD2 scores arrived at the unit 2 and 1 day earlier than matched historical patients, respectively. The novel triage process is associated with a reduction in time to unit arrival from symptom onset for referred true TIA/minor stroke patients with low and moderate ABCD2 scores.

No Relation between Body Temperature and Arterial Recanalization at Three Days in Patients with Acute Ischaemic Stroke

PubMed Central

Geurts, Marjolein; van der Worp, H. Bart; Horsch, Alexander D.; Kappelle, L. Jaap; Biessels, Geert J.; Velthuis, Birgitta K.

2015-01-01

Background Recanalization of an occluded intracranial artery is influenced by temperature-dependent enzymes, including alteplase. We assessed the relation between body temperature on admission and recanalization. Methods We included 278 patients with acute ischaemic stroke within nine hours after symptom onset, who had an intracranial arterial occlusion on admission CT angiography, in 13 participating centres. We calculated the relation per every 0.1°Celsius increase in admission body temperature and recanalization at three days. Results Recanalization occurred in 80% of occluded arteries. There was no relation between body temperature and recanalization at three days after adjustments for age, NIHSS score on admission and treatment with alteplase (adjusted odds ratio per 0.1°Celsius, 0.99; 95% confidence interval, 0.94–1.05; p = 0.70). Results for patients treated or not treated with alteplase were essentially the same. Conclusions Our findings suggest that in patients with acute ischaemic stroke there is no relation between body temperature on admission and recanalization of an occluded intracranial artery three days later, irrespective of treatment with alteplase. PMID:26473959

Ischemic stroke risk factors during Greek economic crisis.

PubMed

Katsanos, Aristeidis H; Fiolaki, Aidonio; Markou, Sofia; Markoula, Sofia; Kosmidou, Maria; Kyritsis, Athanassios P; Giannopoulos, Sotirios

2016-02-01

The impact of Greece's economic crisis on healthcare is of great concern. The aim of the present study was to assess the impact of economic crisis on the prevention of cerebral ischemic events. Retrospective analysis of patients with ischemic stroke (IS) or transient ischemic attack (TIA) admitted to a tertiary neurological department in northwestern Greece during the period 2008-2014. Using 2011 as the transitional year IS/TIA patients were dichotomized according to their admission date in two subgroups: the "before economic crisis" subgroup and the "after economic crisis" subgroup. Logistic regression analyses were performed to identify predictor variables of statin/antihypertensive pretreatment. Patients admitted after the economic crisis outbreak (mean age: 57.6 ± 13.5 years) were found to have lower waist periphery measurements (p = 0.001), lower incidence of diabetes (p = 0.028), hyperlipidemia (p = 0.002) and metabolic syndrome(p < 0.001), at stroke onset with lower rates of antilipidemic treatment prescription prior to stroke onset compared to those patients with cerebral ischemia that were hospitalized before the financial crisis (mean age: 59.6 ± 11.1 years). However, between the two subgroups were no significant differences in the rates of untreated patients with hyperlipidemia (p = 0.189) and/or hypertension (p = 0.313). Even though statin pretreatment prior to stroke onset was found to be reduced during economic crisis compared to the period before the crisis, (OR = 0.58, 95%CI: 0.34-0.95, p = 0.032), this association did not retain statistical significance in the multivariate logistic regression analysis (OR = 1.69, 95%CI = 0.83-3.42, p = 0.143). Our study supports that at present financial crisis has not significantly affected the prevention of cerebrovascular events in the citizens of a provincial city area. Data from other regions and time-periods are needed for the final verdict. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

International trends in clinical characteristics and oral anticoagulation treatment for patients with atrial fibrillation: Results from the GARFIELD-AF, ORBIT-AF I, and ORBIT-AF II registries.

PubMed

Steinberg, Benjamin A; Gao, Haiyan; Shrader, Peter; Pieper, Karen; Thomas, Laine; Camm, A John; Ezekowitz, Michael D; Fonarow, Gregg C; Gersh, Bernard J; Goldhaber, Samuel; Haas, Sylvia; Hacke, Werner; Kowey, Peter R; Ansell, Jack; Mahaffey, Kenneth W; Naccarelli, Gerald; Reiffel, James A; Turpie, Alexander; Verheugt, Freek; Piccini, Jonathan P; Kakkar, Ajay; Peterson, Eric D; Fox, Keith A A

2017-12-01

Atrial fibrillation (AF) is the most common cardiac arrhythmia in the world. We aimed to provide comprehensive data on international patterns of AF stroke prevention treatment. Demographics, comorbidities, and stroke risk of the patients in the GARFIELD-AF (n=51,270), ORBIT-AF I (n=10,132), and ORBIT-AF II (n=11,602) registries were compared (overall N=73,004 from 35 countries). Stroke prevention therapies were assessed among patients with new-onset AF (≤6 weeks). Patients from GARFIELD-AF were less likely to be white (63% vs 89% for ORBIT-AF I and 86% for ORBIT-AF II) or have coronary artery disease (19% vs 36% and 27%), but had similar stroke risk (85% CHA 2 DS 2 -VASc ≥2 vs 91% and 85%) and lower bleeding risk (11% with HAS-BLED ≥3 vs 24% and 15%). Oral anticoagulant use was 46% and 57% for patients with a CHA 2 DS 2 -VASc=0 and 69% and 87% for CHA 2 DS 2 -VASc ≥2 in GARFIELD-AF and ORBIT-AF II, respectively, but with substantial geographic heterogeneity in use of oral anticoagulant (range: 31%-93% [GARFIELD-AF] and 66%-100% [ORBIT-AF II]). Among patients with new-onset AF, non-vitamin K antagonist oral anticoagulant use increased over time to 43% in 2016 for GARFIELD-AF and 71% for ORBIT-AF II, whereas use of antiplatelet monotherapy decreased from 36% to 17% (GARFIELD-AF) and 18% to 8% (ORBIT-AF I and II). Among new-onset AF patients, non-vitamin K antagonist oral anticoagulant use has increased and antiplatelet monotherapy has decreased. However, anticoagulation is used frequently in low-risk patients and inconsistently in those at high risk of stroke. Significant geographic variability in anticoagulation persists and represents an opportunity for improvement. Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.

Endovascular ischemic stroke models of adult rhesus monkeys: a comparison of two endovascular methods.

PubMed

Wu, Di; Chen, Jian; Wang, Bincheng; Zhang, Mo; Shi, Jingfei; Ma, Yanhui; Zhu, Zixin; Yan, Feng; He, Xiaoduo; Li, Shengli; Dornbos Iii, David; Ding, Yuchuan; Ji, Xunming

2016-08-18

To further investigate and improve upon current stroke models in nonhuman primates, infarct size, neurologic function and survival were evaluated in two endovascular ischemic models in sixteen rhesus monkeys. The first method utilized a micro-catheter or an inflatable balloon to occlude the M1 segment in six monkeys. In the second model, an autologous clot was injected via a micro-catheter into the M1 segment in ten monkeys. MRI scanning was performed on all monkeys both at baseline and 3 hours after the onset of ischemia. Spetzler neurologic functions were assessed post-operatively, and selective perfusion deficits were confirmed by DSA and MRI in all monkeys. Animals undergoing micro-catheter or balloon occlusion demonstrated more profound hemiparesis, larger infarct sizes, lower Spetzler neurologic scores and increased mortality compared to the thrombus occlusion group. In animals injected with the clot, there was no evidence of dissolution, and the thrombus was either near the injection site (M1) or flushed into the superior division of the MCA (M2). All animals survived the M2 occlusion. M1 occlusion with thrombus generated 50% mortality. This study highlighted clinically important differences in these two models, providing a platform for further study of a translational thromboembolic model of acute ischemic stroke.

Pulmonary embolism in a stroke patient after systemic thrombolysis: clinical decisions and literature review.

PubMed

Pilato, Fabio; Calandrelli, Rosalinda; Profice, Paolo; Della Marca, Giacomo; Broccolini, Aldobrando; Bello, Giuseppe; Bocci, Maria Grazia; Distefano, Marisa; Colosimo, Cesare; Rossini, Paolo Maria

2013-11-01

Pulmonary embolism can be a catastrophic event that can result in early death or serious hemodynamic dysfunction. The dehydration, immobility, and infections occurring in acute stroke patients puts these patients at risk of developing deep vein thrombosis and pulmonary embolism. Recombinant tissue-type plasminogen activator (rt-PA) is the established therapy for acute ischemic stroke, and its prompt administration results in a better outcome in stroke patients. We describe a 73-year-old man who arrived at the emergency room within 2 hours of acute onset of left hemiparesis who was treated with rt-PA and suffered a pulmonary embolism 3 days after acute stroke therapy. rt-PA is also a current therapy for pulmonary embolism, but an ischemic stroke in the previous 3 months is an absolute contraindication to thrombolysis because of the high risk of intracranial hemorrhage. We discuss clinical and therapeutic decisions and review the current literature. Copyright © 2013 National Stroke Association. Published by Elsevier Inc. All rights reserved.

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

PubMed

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

2015-04-01

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

Safety and Time Course of Drip-and-Ship in Treatment of Acute Ischemic Stroke.

PubMed

Ishihara, Hideyuki; Oka, Fumiaki; Oku, Takayuki; Shinoyama, Mizuya; Suehiro, Eiichi; Sugimoto, Kazutaka; Suzuki, Michiyasu

2017-11-01

The drip-and-ship approach allows intravenous tissue plasminogen activator therapy and adjuvant endovascular treatment in acute ischemic stroke, even in rural areas. Here, we examined the safety and time course of the drip-and-ship approach. Fifty consecutive cases treated with the drip-and-ship approach (drip-and-ship group) in June 2009 to March 2016 were retrospectively examined. Changes in mean blood pressure, systemic complications, and neurological complications were compared according to method of transportation. Time courses were compared between drip-and-ship and direct admission groups during the same period. In the drip-and-ship group, 33 and 17 patients were transferred to hospital by ambulance and helicopter, respectively. One patient suffered hemorrhagic infarction during transportation by ambulance. Mean blood pressure change was lower in patients transferred by helicopter than ambulance (<5 mmHg versus 12.2 mmHg, respectively). The mean onset-to-door times in the drip-and-ship and direct admission groups were 71 and 64 minutes, respectively, and mean door-to-needle times were 70 and 47 minutes, respectively (P =.002). Although mean transportation time from the primary stroke hospital to our hospital was 32 minutes, the entry-to-exit time from the primary stroke hospital was 113 minutes. Thereafter, there was an average delay of 100 minutes until reperfusion compared with the direct admission group. Drip-and-ship was relatively safe in this small series. Transportation by helicopter was less stressful for acute ischemic stroke patients. It is important to reduce door-to-needle time and needle-to-departure time in the primary stroke hospital to minimize the time until treatment in cases of acute ischemic stroke. Copyright © 2017. Published by Elsevier Inc.

Intranasal Delivery of Apelin-13 Is Neuroprotective and Promotes Angiogenesis After Ischemic Stroke in Mice

PubMed Central

Chen, Dongdong; Lee, Jinhwan; Gu, Xiaohuan; Wei, Ling

2015-01-01

Apelin is a peptide originally isolated from bovine stomach tissue extracts and identified as an endogenous ligand of the APJ receptor; recent work showed that apelin ameliorates the ischemic injury in the heart and the brain. Being an analogue to the angiotensin II receptor, the apelin/APJ signaling may mediate angiogenesis process. We explored the noninvasive intranasal brain delivery method and investigated therapeutic effects of apelin-13 in a focal ischemic stroke model of mice. Intranasal administration of apelin-13 (4 mg/kg) was given 30 min after the onset of stroke and repeated once daily. Three days after stroke, mice received apelin-13 had significantly reduced infarct volume and less neuronal death in the penumbra. Western blot analyses showed upregulated levels of apelin, apelin receptor APLNR, and Bcl-2 and decreased caspase-3 activation in the apelin-13-treated brain. The proinflammatory cytokines tumor necrosis factor-alpha, interleukin-1β, and chemokine monocyte chemoattractant protein-1 mRNA increased in the ischemic brain, which were significantly attenuated by apelin-13. Apelin-13 remarkably reduced microglia recruitment and activation in the penumbra according to morphological features of Iba-1-positive cells 3 days after ischemia. Apelin-13 significantly increased the expression of angiogenic factor vascular endothelial growth factor and matrix metalloproteinase-9 14 days after stroke. Angiogenesis illustrated by collagen IV + /5-bromo-2′-deoxyuridin + colabeled cells was significantly increased by the apelin-13 treatment 21 days after stroke. Finally, apelin-13 promoted the local cerebral blood flow restoration and long-term functional recovery. This study demonstrates a noninvasive intranasal delivery of apelin-13 after stroke, suggesting that the reduced inflammatory activities, decreased cell death, and increased angiogenesis contribute to the therapeutic benefits of apelin-13. PMID:26391329

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

PubMed

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

2018-04-01

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

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

PubMed

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

2017-06-01

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

Recovery of slow-5 oscillations in a longitudinal study of ischemic stroke patients.

PubMed

La, C; Nair, V A; Mossahebi, P; Stamm, J; Birn, R; Meyerand, M E; Prabhakaran, V

2016-01-01

Functional networks in resting-state fMRI are identified by characteristics of their intrinsic low-frequency oscillations, more specifically in terms of their synchronicity. With advanced aging and in clinical populations, this synchronicity among functionally linked regions is known to decrease and become disrupted, which may be associated with observed cognitive and behavioral changes. Previous work from our group has revealed that oscillations within the slow-5 frequency range (0.01-0.027 Hz) are particularly susceptible to disruptions in aging and following a stroke. In this study, we characterized longitudinally the changes in the slow-5 oscillations in stroke patients across two different time-points. We followed a group of ischemic stroke patients (n = 20) and another group of healthy older adults (n = 14) over two visits separated by a minimum of three months (average of 9 months). For the stroke patients, one visit occurred in their subacute window (10 days to 6 months after stroke onset), the other took place in their chronic window (> 6 months after stroke). Using a mid-order group ICA method on 10-minutes eyes-closed resting-state fMRI data, we assessed the frequency distributions of a component's representative time-courses for differences in regards to slow-5 spectral power. First, our stroke patients, in their subacute stage, exhibited lower amplitude slow-5 oscillations in comparison to their healthy counterparts. Second, over time in their chronic stage, those same patients showed a recovery of those oscillations, reaching near equivalence to the healthy older adult group. Our results indicate the possibility of an eventual recovery of those initially disrupted network oscillations to a near-normal level, providing potentially a biomarker for stroke recovery of the cortical system. This finding opens new avenues in infra-slow oscillation research and could serve as a useful biomarker in future treatments aimed at recovery.

The Effect of Early Neuromuscular Electrical Stimulation Therapy in Acute/Subacute Ischemic Stroke Patients With Dysphagia

PubMed Central

Lee, Kyeong Woo; Kim, Sang Beom; Lee, Jong Hwa; Lee, Sook Joung; Park, Jin Gee

2014-01-01

Objective To compare the outcome of an early application of neuromuscular electrical stimulation (NMES) combined with traditional dysphagia therapy (TDT) versus traditional dysphagia therapy only in acute/subacute ischemic stroke patients with moderate to severe dysphagia by videofluoroscopic swallowing study (VFSS). Methods Fifty-seven dysphagic stroke patients were enrolled in a VFSS within 10 days after stroke onset. Patients were randomly assigned into two treatment groups. Thirty-one patients received NMES combined with TDT (NMES/TDT group) and 26 patients received TDT only (TDT group). Electrical stimulation with a maximal tolerable intensity was applied on both suprahyoid muscles for 30 minutes, 5 days per week during 3 weeks. The swallowing function was evaluated at baseline and 3, 6, and 12 weeks after baseline. Outcomes of the VFSS were assessed using the Functional Oral Intake Scale (FOIS). Results The mean ages were 63.5±11.4 years in the NMES/TDT group and 66.7±9.5 years in the TDT group. Both groups showed a significant improvement on the FOIS after treatment. The FOIS score was significantly more improved at 3 and 6 weeks after baseline in the NMES/TDT group than in the TDT group (p<0.05). Conclusion An early application of NMES combined with TDT showed a positive effect in acute/subacute ischemic stroke patients with dysphagia. These results indicated that the early application of NMES could be used as a supplementary treatment of TDT to help rehabilitate acute/subacute dysphagic stroke patients by improving their swallowing coordination. PMID:24855608

Customized Interactive Robotic Treatment for Stroke: EMG-Triggered Therapy

PubMed Central

Dipietro, Laura; Ferraro, Mark; Palazzolo, Jerome Joseph; Krebs, Hermano Igo; Volpe, Bruce T.; Hogan, Neville

2009-01-01

A system for electromyographic (EMG) triggering of robot-assisted therapy (dubbed the EMG game) for stroke patients is presented. The onset of a patient’s attempt to move is detected by monitoring EMG in selected muscles, whereupon the robot assists her or him to perform point-to-point movements in a horizontal plane. Besides delivering customized robot-assisted therapy, the system can record signals that may be useful to better understand the process of recovery from stroke. Preliminary experiments aimed at testing the proposed system and gaining insight into the potential of EMG-triggered, robot-assisted therapy are reported. PMID:16200756

[Understanding the reasons behind the low utilization of thrombolysis in hyperacute ischemic stroke].

PubMed

Zhang, Xiaoxue; Zhang, Jingfen; Li, Ruiming; Cheng, Guojuan; Chen, Qiang

2016-03-22

The study aimed to analyze the influencing factors of thrombolysis therapy in acute ischemic stroke patients with onset time less than 4.5 hours. We consecutively prospectively screened acute ischemic stroke patients with onset time less than 4.5 hours from emergency department, outpatients and inpatients of neurology department, and image center in our hospital over a 31-month time period (April 2012-November 2014). The rate of thrombolysis and the reasons for not receiving thrombolysis were analyzed. A total of 538 patients who met the inclusion criteria were included (68.2% males, mean age 67±13 years old). Only 104 (19.3%) patients received thrombolysis. The main reasons for the patients not receiving thrombolysis included minor symptoms (172 cases, 39.6%), rapidly improving symptoms and high possibility of transient ischemic attack (TIA) (59 cases, 13.6%), patients or families refusing thrombolysis (44, 10.1%), in-hospital delay (38, 8.8%), elderly people with age over than 80 years old (38, 8.8%). The thrombolysis rate within time window of acute ischemic stroke is remarkably higher than that of several years ago in China. The main reasons for not receiving thrombolysis are minor and rapidly improving symptoms, patients or families' refusal, in-hospital delay, elderly people with age over than 80 years old.

[Mobile stroke unit for prehospital stroke treatment].

PubMed

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

2016-01-01

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

Mechanism of metabolic stroke and spontaneous cerebral hemorrhage in glutaric aciduria type I

PubMed Central

2014-01-01

Background Metabolic stroke is the rapid onset of lasting central neurological deficit associated with decompensation of an underlying metabolic disorder. Glutaric aciduria type I (GA1) is an inherited disorder of lysine and tryptophan metabolism presenting with metabolic stroke in infancy. The clinical presentation includes bilateral striatal necrosis and spontaneous subdural and retinal hemorrhages, which has been frequently misdiagnosed as non-accidental head trauma. The mechanisms underlying metabolic stroke and spontaneous hemorrhage are poorly understood. Results Using a mouse model of GA1, we show that metabolic stroke progresses in the opposite sequence of ischemic stroke, with initial neuronal swelling and vacuole formation leading to cerebral capillary occlusion. Focal regions of cortical followed by striatal capillaries are occluded with shunting to larger non-exchange vessels leading to early filling and dilation of deep cerebral veins. Blood–brain barrier breakdown was associated with displacement of tight-junction protein Occludin. Conclusion Together the current findings illuminate the pathophysiology of metabolic stroke and vascular compromise in GA1, which may translate to other neurometabolic disorders presenting with stroke. PMID:24468193

Mechanism of metabolic stroke and spontaneous cerebral hemorrhage in glutaric aciduria type I.

PubMed

Zinnanti, William J; Lazovic, Jelena; Housman, Cathy; Antonetti, David A; Koeller, David M; Connor, James R; Steinman, Lawrence

2014-01-27

Metabolic stroke is the rapid onset of lasting central neurological deficit associated with decompensation of an underlying metabolic disorder. Glutaric aciduria type I (GA1) is an inherited disorder of lysine and tryptophan metabolism presenting with metabolic stroke in infancy. The clinical presentation includes bilateral striatal necrosis and spontaneous subdural and retinal hemorrhages, which has been frequently misdiagnosed as non-accidental head trauma. The mechanisms underlying metabolic stroke and spontaneous hemorrhage are poorly understood. Using a mouse model of GA1, we show that metabolic stroke progresses in the opposite sequence of ischemic stroke, with initial neuronal swelling and vacuole formation leading to cerebral capillary occlusion. Focal regions of cortical followed by striatal capillaries are occluded with shunting to larger non-exchange vessels leading to early filling and dilation of deep cerebral veins. Blood-brain barrier breakdown was associated with displacement of tight-junction protein Occludin. Together the current findings illuminate the pathophysiology of metabolic stroke and vascular compromise in GA1, which may translate to other neurometabolic disorders presenting with stroke.

Inverse relationship of baseline body temperature and outcome between ischemic stroke patients treated and not treated with thrombolysis: the Bergen stroke study.

PubMed

Naess, Halvor; Idicula, T; Lagallo, N; Brogger, J; Waje-Andreassen, U; Thomassen, L

2010-12-01

High body temperature may promote clot lysis whereas low body temperature is neuroprotective in patients with cerebral infarction. We hypothesized that high body temperature is associated with favorable outcome in patients treated with tissue plasminogen activator (tPA) and that low body temperature is associated with favorable outcome in patients not treated with tPA. Patients (n = 111) who were treated with tPA and patients (n = 139) who were not treated with tPA, but presented within 6 h of stroke onset were included. Patients with no temperature measurements within 6 h of stroke onset were excluded. National Institute of Health Stroke Scale (NIHSS) score was obtained on admission. Modified Rankin score (mRS) was obtained after 1 week. Favorable outcome was defined as mRS 0-2 and unfavorable outcome as mRS 3-6. On logistic regression analysis, high body temperature was independently associated with favorable outcome among patients treated with tPA (OR = 3.7, P = 0.009) and low body temperature was independently associated with favorable prognosis among patients not treated with tPA (OR = 2.0, P = 0.042). Our study suggests that the effect of high body temperature on clot lysis is more important than the neuroprotective effect of low body temperature in the early phase after cerebral infarction treated with tPA. Copyright © 2010 The Authors. Journal compilation © 2010 Blackwell Munksgaard.

A free radical scavenger edaravone suppresses systemic inflammatory responses in a rat transient focal ischemia model.

PubMed

Fujiwara, Norio; Som, Angel T; Pham, Loc-Duyen D; Lee, Brian J; Mandeville, Emiri T; Lo, Eng H; Arai, Ken

2016-10-28

A free radical scavenger edaravone is clinically used in Japan for acute stroke, and several basic researches have carefully examined the mechanisms of edaravone's protective effects. However, its actions on pro-inflammatory responses under stroke are still understudied. In this study, we subjected adult male Sprague-Dawley rats to 90-min middle cerebral artery (MCA) occlusion followed by reperfusion. Edaravone was treated twice via tail vein; after MCA occlusion and after reperfusion. As expected, edaravone-treated group showed less infarct volume and edema formation compared with control group at 24-h after an ischemic onset. Furthermore, edaravone reduced the levels of plasma interleukin (IL)-1β and matrix metalloproteinase-9 at 3-h after ischemic onset. Several molecules besides IL-1β and MMP-9 are involved in inflammatory responses under stroke conditions. Therefore, we also examined whether edaravone treatment could decrease a wide range of pro-inflammatory cytokines/chemokines by testing rat plasma samples with a rat cytokine array. MCAO rats showed elevations in plasma levels of CINC-1, Fractalkine, IL-1α, IL-1ra, IL-6, IL-10, IP-10, MIG, MIP-1α, and MIP-3α, and all these increases were reduced by edaravone treatment. These data suggest that free radical scavengers may reduce systemic inflammatory responses under acute stroke conditions, and therefore, oxidative stress can be still a viable target for acute stroke therapy. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Troponin elevation in acute ischemic stroke (TRELAS) - protocol of a prospective observational trial

PubMed Central

2011-01-01

Background Levels of the cardiac muscle regulatory protein troponin T (cTnT) are frequently elevated in patients with acute ischemic stroke and elevated cTnT predicts poor outcome and mortality. The pathomechanism of troponin release may relate to co-morbid coronary artery disease and myocardial ischemia or, alternatively, to neurogenic cardiac damage due to autonomic activation after acute ischemic stroke. Therefore, there is uncertainty about how acute ischemic stroke patients with increased cTnT levels should be managed regarding diagnostic and therapeutic workup. Methods/Design The primary objective of the prospective observational trial TRELAS (TRoponin ELevation in Acute ischemic Stroke) is to investigate the frequency and underlying pathomechanism of cTnT elevation in acute ischemic stroke patients in order to give guidance for clinical practice. All consecutive patients with acute ischemic stroke admitted within 72 hours after symptom onset to the Department of Neurology at the Campus Benjamin Franklin of the University Hospital Charité will be screened for cTnT elevations (i.e. >= 0.05 μg/l) on admission and again on the following day. Patients with increased cTnT will undergo coronary angiography within 72 hours. Diagnostic findings of coronary angiograms will be compared with age- and gender-matched patients presenting with Non-ST-Elevation myocardial infarction to the Department of Cardiology. The primary endpoint of the study will be the occurrence of culprit lesions in the coronary angiogram indicating underlying co-morbid obstructive coronary artery disease. Secondary endpoints will be the localization of stroke in the cerebral imaging and left ventriculographic findings of wall motion abnormalities suggestive of stroke-induced global cardiac dysfunction. Discussion TRELAS will prospectively determine the frequency and possible etiology of troponin elevation in a large cohort of ischemic stroke patients. The findings are expected to contribute to clarify pathophysiologic concepts of co-morbid cardiac damage in ischemic stroke patients and also to provide a basis for clinical recommendations for cardiac workup of such patients. Trial registration clinicaltrials.gov NCT01263964 PMID:21824425

Lifecourse social conditions and racial disparities in incidence of first stroke.

PubMed

Glymour, M Maria; Avendaño, Mauricio; Haas, Steven; Berkman, Lisa F

2008-12-01

Some previous studies found excess stroke rates among black subjects persisted after adjustment for socioeconomic status (SES), fueling speculation regarding racially patterned genetic predispositions to stroke. Previous research was hampered by incomplete SES assessments, without measures of childhood conditions or adult wealth. We assess the role of lifecourse SES in explaining stroke risk and stroke disparities. Health and Retirement Study participants age 50+ (n = 20,661) were followed on average 9.9 years for self- or proxy-reported first stroke (2175 events). Childhood social conditions (southern state of birth, parental SES, self-reported fair/poor childhood health, and attained height), adult SES (education, income, wealth, and occupational status) and traditional cardiovascular risk factors were used to predict first stroke onset using Cox proportional hazards models. Black subjects had a 48% greater risk of first stroke incidence than whites (95% confidence interval, 1.33-1.65). Childhood conditions predicted stroke risk in both blacks and whites, independently of adult SES. Adjustment for both childhood social conditions and adult SES measures attenuated racial differences to marginal significance (hazard ratio, 1.13; 95% CI, 1.00-1.28). Childhood social conditions predict stroke risk in black and White American adults. Additional adjustment for adult SES, in particular wealth, nearly eliminated the disparity in stroke risk between black and white subjects.

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

PubMed

Tripp, Florian; Krakow, Karsten

2014-05-01

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

Early mobilization after stroke: an example of an individual patient data meta-analysis of a complex intervention.

PubMed

Craig, Louise E; Bernhardt, Julie; Langhorne, Peter; Wu, Olivia

2010-11-01

Very early mobilization (VEM) is a distinctive characteristic of care in some stroke units; however, evidence of the effectiveness of this approach is limited. To date, only 2 phase II trials have compared VEM with standard care: A Very Early Rehabilitation Trial (AVERT) in Australia and the recently completed Very Early Rehabilitation or Intensive Telemetry after Stroke trial in the United Kingdom. The Very Early Rehabilitation or Intensive Telemetry after Stroke protocol was designed to complement that of AVERT in a number of key areas. The aim of this analysis was to investigate the impact of VEM on independence by pooling data from these 2 comparable trials. Individual data from the 2 trials were pooled. Overall, patients were between 27 and 97 years old, had first or recurring stroke, and were treated within 36 hours after stroke onset. The primary outcome was independence, defined as modified Rankin scale score of 0 to 2 at 3 months. The secondary outcomes included complications of immobility and activities of daily living. Logistic regression was used to assess the effect of VEM on outcome, adjusting for known confounders including age, baseline stroke severity, and premorbid modified Rankin scale score. Findings-All patients in AVERT and Very Early Rehabilitation or Intensive Telemetry after Stroke were included, resulting in 54 patients in the VEM group and 49 patients in the standard care group. The baseline characteristics of VEM patients were largely comparable with standard care patients. Time to first mobilization from symptom onset was significantly shorter among VEM patients (median, 21 hours; interquartile range, 15.8-27.8 hours) compared with standard care patients (median, 31 hours; interquartile range, 23.0-41.2 hours). VEM patients had significantly greater odds of independence compared with standard care patients (adjusted odds ratio, 3.11; 95% confidence interval, 1.03-9.33). Planned collaborations between stroke researchers to conduct trials with common protocols and outcome measures can help advance rehabilitation science. VEM was associated with improved independence at 3 months compared with standard care. However, both trials are limited by small sample sizes. Larger trials (such as AVERT phase III) are still needed in this field.

Post-Thalamic Stroke Movement Disorders: A Systematic Review.

PubMed

Gupta, Navnika; Pandey, Sanjay

2018-06-05

After a stroke, movement disorders are rare manifestations mainly affecting the deep structures of the brain like the basal ganglia (44%) and thalamus (37%), although there have been case studies of movement disorders in strokes affecting the cerebral cortex also. This review aims to delineate the various movement disorders seen in association with thalamic strokes and tries to identify the location of the nuclei affected in each of the described movement disorders. Cases were identified through a search of PubMed database using different search terms related to post-thalamic stroke movement disorders and a secondary search of references of identified articles. We reviewed 2,520 research articles and only 86 papers met the inclusion criteria. Cases were included if they met criteria for post-thalamic stroke movement disorders. Case-cohort studies were also reviewed and will be discussed further. Key Messages: The most common post-stroke abnormal movement disorder reported in our review was dystonia followed by hemiataxia. There was a higher association between ischaemic stroke and movement disorder. Acute onset movement disorders were more common than delayed. The posterolateral thalamus was most commonly involved in post-thalamic stroke movement disorders. © 2018 S. Karger AG, Basel.

Varied overground walking training versus body-weight-supported treadmill training in adults within 1 year of stroke: a randomized controlled trial.

PubMed

DePaul, Vincent G; Wishart, Laurie R; Richardson, Julie; Thabane, Lehana; Ma, Jinhui; Lee, Timothy D

2015-05-01

Although task-related walking training has been recommended after stroke, the theoretical basis, content, and impact of interventions vary across the literature. There is a need for a comparison of different approaches to task-related walking training after stroke. To compare the impact of a motor-learning-science-based overground walking training program with body-weight-supported treadmill training (BWSTT) in ambulatory, community-dwelling adults within 1 year of stroke onset. In this rater-blinded, 1:1 parallel, randomized controlled trial, participants were stratified by baseline gait speed. Participants assigned to the Motor Learning Walking Program (MLWP) practiced various overground walking tasks under the supervision of 1 physiotherapist. Cognitive effort was encouraged through random practice and limited provision of feedback and guidance. The BWSTT program emphasized repetition of the normal gait cycle while supported on a treadmill and assisted by 1 to 3 therapy staff. The primary outcome was comfortable gait speed at postintervention assessment (T2). In total, 71 individuals (mean age = 67.3; standard deviation = 11.6 years) with stroke (mean onset = 20.9 [14.1] weeks) were randomized (MLWP, n = 35; BWSTT, n = 36). There was no significant between-group difference in gait speed at T2 (0.002 m/s; 95% confidence interval [CI] = -0.11, 0.12; P > .05). The MLWP group improved by 0.14 m/s (95% CI = 0.09, 0.19), and the BWSTT group improved by 0.14 m/s (95% CI = 0.08, 0.20). In this sample of community-dwelling adults within 1 year of stroke, a 15-session program of varied overground walking-focused training was not superior to a BWSTT program of equal frequency, duration, and in-session step activity. © The Author(s) 2014.

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

PubMed

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

2014-04-01

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

Transcranial laser therapy in acute stroke treatment: results of neurothera effectiveness and safety trial 3, a phase III clinical end point device trial.

PubMed

Hacke, Werner; Schellinger, Peter D; Albers, Gregory W; Bornstein, Natan M; Dahlof, Bjorn L; Fulton, Rachael; Kasner, Scott E; Shuaib, Ashfaq; Richieri, Steven P; Dilly, Stephen G; Zivin, Justin; Lees, Kennedy R

2014-11-01

On the basis of phase II trials, we considered that transcranial laser therapy could have neuroprotective effects in patients with acute ischemic stroke. We studied transcranial laser therapy in a double-blind, sham-controlled randomized clinical trial intended to enroll 1000 patients with acute ischemic stroke treated ≤24 hours after stroke onset and who did not undergo thrombolytic therapy. The primary efficacy measure was the 90-day functional outcome as assessed by the modified Rankin Scale, with hierarchical Bayesian analysis incorporating relevant previous data. Interim analyses were planned after 300 and 600 patients included. The study was terminated on recommendation by the Data Monitoring Committee after a futility analysis of 566 completed patients found no difference in the primary end point (transcranial laser therapy 140/282 [49.6%] versus sham 140/284 [49.3%] for good functional outcome; modified Rankin Scale, 0-2). The results remained stable after inclusion of all 630 randomized patients (adjusted odds ratio, 1.024; 95% confidence interval, 0.705-1.488). Once the results of the interim futility analysis became available, all study support was immediately withdrawn by the capital firms behind PhotoThera, and the company was dissolved. Proper termination of the trial was difficult but was finally achieved through special efforts by former employees of PhotoThera, the CRO Parexel and members of the steering and the safety committees. We conclude that transcranial laser therapy does not have a measurable neuroprotective effect in patients with acute ischemic stroke when applied within 24 hours after stroke onset. http://www.clinicaltrials.gov. Unique identifier: NCT01120301. © 2014 American Heart Association, Inc.

Clinical Outcome After Mechanical Thrombectomy in Non-elderly Patients with Acute Ischemic Stroke in the Anterior Circulation: Primary Admission Versus Patients Referred from Remote Hospitals.

PubMed

Pfaff, J; Pham, M; Herweh, C; Wolf, M; Ringleb, P A; Schönenberger, S; Bendszus, M; Möhlenbruch, M

2017-06-01

Stroke networks have been installed to increase access to advanced stroke specific treatments like mechanical thrombectomy (MT). This concept often requires patients to be transferred to a comprehensive stroke center (CSC) offering MT. Do patient referral, transportation, and logistic effort translate into clinical outcomes comparable to patients admitted primarily to the CSC? We categorized 112 patients with acute ischemic stroke in the anterior circulation, who received MT at our institution, into primary admissions (A) and referrals from either local (B) or regional (C) hospitals, assessed the clinical outcome, and tested the impact of distance and delay of transportation from the referring remote hospital. The median time from symptom onset to initial CT was similar in all groups (p = 0,939). Patients who were transferred to the CSC had significantly increasing median time between initial CT and MT (in minutes (interquartile range [IQR]); A: 83 [68-120]; B: 174 [159-208]; C: 220 [181-235]; p < 0.001) and median time between onset to MT (in minutes [IQR]; A: 178 [150-210]; B: 274 [238-349]; C: 293 [256-329]; p < 0.001). After 90 days of MT there was no significant difference in clinical outcome (modified Rankin Scale ≤ 2) between primary admitted and referred patients (p = 0.502). Clinical outcome in patients who received MT after transfer from either local or regional remote hospitals was not significantly worse than in patients primarily admitted to the CSC. In the event of an acute ischemic stroke patients living in urban or rural areas should, despite a possible delay, have access to MT.

Effect of visuospatial neglect on spatial navigation and heading after stroke.

PubMed

Aravind, Gayatri; Lamontagne, Anouk

2017-06-09

Visuospatial neglect (VSN) impairs the control of locomotor heading in post-stroke individuals, which may affect their ability to safely avoid moving objects while walking. We aimed to compare VSN+ and VSN- stroke individuals in terms of changes in heading and head orientation in space while avoiding obstacles approaching from different directions and reorienting toward the final target. Stroke participants with VSN (VSN+) and without VSN (VSN-) walked in a virtual environment avoiding obstacles that approached contralesionally, head-on or ipsilesionally. Measures of obstacle avoidance (onset-of-heading change, maximum mediolateral deviation) and target alignment (heading and head-rotation errors with respect to target) were compared across groups and obstacle directions. In total, 26 participants with right-hemisphere stroke participated (13 VSN+ and 13 VSN-; 24 males; mean age 60.3 years, range 48 to 72 years). A larger proportion of VSN+ (75%) than VSN- (38%) participants collided with contralesional and head-on obstacles. For VSN- participants, deviating to the same side as the obstacle was a safe strategy to avoid diagonal obstacles and deviating to the opposite-side led to occasional collisions. VSN+ participants deviated ipsilesionally, displaying same-side and opposite-side strategies for ipsilesional and contralesional obstacles, respectively. Overall, VSN+ participants showed greater distances at onset-of-heading change, smaller maximum mediolateral deviation and larger errors in target alignment as compared with VSN- participants. The ipsilesional bias arising from VSN influences the modulation of heading in response to obstacles and, along with the adoption of the "riskier" strategies, contribute to the higher number colliders and poor goal-directed walking abilities in stroke survivors with VSN. Future research should focus on developing assessment and training tools for complex locomotor tasks such as obstacle avoidance in this population. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

Stroke thrombolysis: save a minute, save a day.

PubMed

Meretoja, Atte; Keshtkaran, Mahsa; Saver, Jeffrey L; Tatlisumak, Turgut; Parsons, Mark W; Kaste, Markku; Davis, Stephen M; Donnan, Geoffrey A; Churilov, Leonid

2014-04-01

Stroke thrombolysis is highly time-critical, but data on long-term effects of small reductions in treatment delays have not been available. Our objective was to quantify patient lifetime benefits gained from faster treatment. Observational prospective data of consecutive stroke patients treated with intravenous thrombolysis in Australian and Finnish centers (1998-2011; n=2258) provided distributions of age, sex, stroke severity, onset-to-treatment times, and 3-month modified Rankin Scale in daily clinical practice. Treatment effects derived from a pooled analysis of thrombolysis trials were used to model the shift in 3-month modified Rankin Scale distributions with reducing treatment delays, from which we derived the expected lifetime and level of long-term disability with faster treatment. Each minute of onset-to-treatment time saved granted on average 1.8 days of extra healthy life (95% prediction interval, 0.9-2.7). Benefit was observed in all groups: each minute provided 0.6 day in old severe (age, 80 years; National Institutes of Health Stroke Scale [NIHSS] score, 20) patients, 0.9 day in old mild (age, 80 years; NIHSS score, 4) patients, 2.7 days in young mild (age, 50 years; NIHSS score, 4) patients, and 3.5 days in young severe (age, 50 years; NIHSS score, 20) patients. Women gained slightly more than men over their longer lifetimes. In the whole cohort, each 15 minute decrease in treatment delay provided an average equivalent of 1 month of additional disability-free life. Realistically achievable small reductions in stroke thrombolysis delays would result in significant and robust average health benefits over patients' lifetimes. The awareness of concrete importance of speed could promote practice change.

Cost-effectiveness of thrombolysis within 4.5 hours of acute ischemic stroke: experience from Australian stroke center.

PubMed

Tan Tanny, Sharman P; Busija, Lucy; Liew, Danny; Teo, Sarah; Davis, Stephen M; Yan, Bernard

2013-08-01

Previous economic studies outside Australia have demonstrated that patients treated with tissue-type plasminogen activator (tPA) within 4.5 hours of stroke onset have lower healthcare costs than those not. We aim to perform cost-effectiveness analysis of intravenous tPA in an Australian setting. Data on clinical outcomes and costs were derived for 378 patients who received intravenous tPA within 4.5 hours of stroke onset at Royal Melbourne Hospital (Australia) between January 2003 and December 2011. To simulate clinical outcomes and costs for a hypothetical control group assumed not to have received tPA, we applied efficacy data from a meta-analysis of randomized trials to outcomes observed in the tPA group. During a 1-year time-horizon, net costs, years of life lived, and quality-adjusted life-years were compared and incremental cost-effectiveness ratios derived for tPA versus no tPA. In the study population, mean (SD) age was 68.2 (13.5) years and 206 (54.5%) were men. Median National Institutes of Health Stroke Scale score (interquartile range) at presentation was 12.5 (8-18). Compared with no tPA, we estimated that tPA would result in 0.02 life-years and 0.04 quality-adjusted life-years saved per person>1 year. The net cost of tPA was AUD $55.61 per patient. The incremental cost-effectiveness ratios were AUD $2377 per life-year saved and AUD $1478 per quality-adjusted life-years saved. Because the costs of tPA are incurred only once, the incremental cost-effectiveness ratios would decrease with increasing time-horizon. Uncertainty analyses indicated the results to be robust. Intravenous tPA within 4.5 hours represents a cost-effective intervention for acute ischemic stroke.

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

PubMed

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

2016-11-01

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

Single trial prediction of self-paced reaching directions from EEG signals.

PubMed

Lew, Eileen Y L; Chavarriaga, Ricardo; Silvoni, Stefano; Millán, José Del R

2014-01-01

Early detection of movement intention could possibly minimize the delays in the activation of neuroprosthetic devices. As yet, single trial analysis using non-invasive approaches for understanding such movement preparation remains a challenging task. We studied the feasibility of predicting movement directions in self-paced upper limb center-out reaching tasks, i.e., spontaneous movements executed without an external cue that can better reflect natural motor behavior in humans. We reported results of non-invasive electroencephalography (EEG) recorded from mild stroke patients and able-bodied participants. Previous studies have shown that low frequency EEG oscillations are modulated by the intent to move and therefore, can be decoded prior to the movement execution. Motivated by these results, we investigated whether slow cortical potentials (SCPs) preceding movement onset can be used to classify reaching directions and evaluated the performance using 5-fold cross-validation. For able-bodied subjects, we obtained an average decoding accuracy of 76% (chance level of 25%) at 62.5 ms before onset using the amplitude of on-going SCPs with above chance level performances between 875 to 437.5 ms prior to onset. The decoding accuracy for the stroke patients was on average 47% with their paretic arms. Comparison of the decoding accuracy across different frequency ranges (i.e., SCPs, delta, theta, alpha, and gamma) yielded the best accuracy using SCPs filtered between 0.1 to 1 Hz. Across all the subjects, including stroke subjects, the best selected features were obtained mostly from the fronto-parietal regions, hence consistent with previous neurophysiological studies on arm reaching tasks. In summary, we concluded that SCPs allow the possibility of single trial decoding of reaching directions at least 312.5 ms before onset of reach.

Acute stroke care at rural hospitals in Idaho: challenges in expediting stroke care.

PubMed

Gebhardt, James G; Norris, Thomas E

2006-01-01

Thrombolytics are currently the most effective treatment for stroke. However, the National Institute for Neurological Disorders and Stroke criteria for initiation of thrombolytic therapy, most notably the 3-hour time limit from symptom onset, have proven challenging for many rural hospitals to achieve. To provide a snapshot of stroke care at rural hospitals in Idaho and to investigate the experiences of these hospitals in expediting stroke care. Using a standard questionnaire, a telephone survey of hospital staff at 21 rural hospitals in Idaho was performed. The survey focused on acute stroke care practices and strategies to expedite stroke care. The median number of stroke patients treated per year was 23.3. Patient delays were reported by 77.8% of hospitals, transport delays by 66.7%, in-hospital delays by 61.1%, equipment delays by 22.2%, and ancillary services delays by 61.1%. Approximately 67% of hospitals had implemented a clinical pathway for stroke and 80.0% had provided staff with stroke-specific training. No hospitals surveyed had a designated stroke team, and only 33.3% reported engaging in quality improvement efforts to expedite stroke care. Thrombolytics (tPA) were available and indicated for stroke at 55.6% of the hospitals surveyed. Rural hospitals in Idaho face many difficult challenges as they endeavor to meet the 3-hour deadline for thrombolytic therapy, including limited resources and experience in acute stroke care, and many different types of prehospital and in-hospital delays.

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.

Lesion site patterns in severe, nonverbal aphasia to predict outcome with a computer-assisted treatment program.

PubMed

Naeser, M A; Baker, E H; Palumbo, C L; Nicholas, M; Alexander, M P; Samaraweera, R; Prete, M N; Hodge, S M; Weissman, T

1998-11-01

To test whether lesion site patterns in patients with chronic, severe aphasia who have no meaningful spontaneous speech are predictive of outcome following treatment with a nonverbal, icon-based computer-assisted visual communication (C-ViC) program. Retrospective study in which computed tomographic scans performed 3 months after onset of stroke and aphasia test scores obtained before C-ViC therapy were reviewed for patients after receiving C-ViC treatment. A neurology department and speech pathology service of a Department of Veterans Affairs medical center and a university aphasia research center. Seventeen patients with stroke and severe aphasia who began treatment with C-ViC from 3 months to 10 years after onset of stroke. Level of ability to use C-ViC on a personal computer to communicate. All patients with bilateral lesions failed to learn C-ViC. For patients with unilateral left hemisphere lesion sites, statistical analyses accurately discriminated between those who could initiate communication with C-ViC from those who were only able to answer directed questions. The critical lesion areas involved temporal lobe structures (Wernicke cortical area and the subcortical temporal isthmus), supraventricular frontal lobe structures (supplementary motor area or cingulate gyrus 24), and the subcortical medial subcallosal fasciculus, deep to the Broca area. Specific lesion sites were also identified for appropriate candidacy for C-ViC. Lesion site patterns on computed tomographic scans are helpful to define candidacy for C-ViC training, and to predict outcome level. A practical method is presented for clinical application of these lesion site results in combination with aphasia test scores.

Cerebral Blood Volume ASPECTS Is the Best Predictor of Clinical Outcome in Acute Ischemic Stroke: A Retrospective, Combined Semi-Quantitative and Quantitative Assessment

PubMed Central

Padroni, Marina; Bernardoni, Andrea; Tamborino, Carmine; Roversi, Gloria; Borrelli, Massimo; Saletti, Andrea; De Vito, Alessandro; Azzini, Cristiano; Borgatti, Luca; Marcello, Onofrio; d’Esterre, Christopher; Ceruti, Stefano; Casetta, Ilaria; Lee, Ting-Yim; Fainardi, Enrico

2016-01-01

Introduction The capability of CT perfusion (CTP) Alberta Stroke Program Early CT Score (ASPECTS) to predict outcome and identify ischemia severity in acute ischemic stroke (AIS) patients is still questioned. Methods 62 patients with AIS were imaged within 8 hours of symptom onset by non-contrast CT, CT angiography and CTP scans at admission and 24 hours. CTP ASPECTS was calculated on the affected hemisphere using cerebral blood flow (CBF), cerebral blood volume (CBV) and mean transit time (MTT) maps by subtracting 1 point for any abnormalities visually detected or measured within multiple cortical circular regions of interest according to previously established thresholds. MTT-CBV ASPECTS was considered as CTP ASPECTS mismatch. Hemorrhagic transformation (HT), recanalization status and reperfusion grade at 24 hours, final infarct volume at 7 days and modified Rankin scale (mRS) at 3 months after onset were recorded. Results Semi-quantitative and quantitative CTP ASPECTS were highly correlated (p<0.00001). CBF, CBV and MTT ASPECTS were higher in patients with no HT and mRS≤2 and inversely associated with final infarct volume and mRS (p values: from p<0.05 to p<0.00001). CTP ASPECTS mismatch was slightly associated with radiological and clinical outcomes (p values: from p<0.05 to p<0.02) only if evaluated quantitatively. A CBV ASPECTS of 9 was the optimal semi-quantitative value for predicting outcome. Conclusions Our findings suggest that visual inspection of CTP ASPECTS recognizes infarct and ischemic absolute values. Semi-quantitative CBV ASPECTS, but not CTP ASPECTS mismatch, represents a strong prognostic indicator, implying that core extent is the main determinant of outcome, irrespective of penumbra size. PMID:26824672

Impact of Bilingualism on Cognitive Outcome After Stroke.

PubMed

Alladi, Suvarna; Bak, Thomas H; Mekala, Shailaja; Rajan, Amulya; Chaudhuri, Jaydip Ray; Mioshi, Eneida; Krovvidi, Rajesh; Surampudi, Bapiraju; Duggirala, Vasanta; Kaul, Subhash

2016-01-01

Bilingualism has been associated with slower cognitive aging and a later onset of dementia. In this study, we aimed to determine whether bilingualism also influences cognitive outcome after stroke. We examined 608 patients with ischemic stroke from a large stroke registry and studied the role of bilingualism in predicting poststroke cognitive impairment in the absence of dementia. A larger proportion of bilinguals had normal cognition compared with monolinguals (40.5% versus 19.6%; P<0.0001), whereas the reverse was noted in patients with cognitive impairment, including vascular dementia and vascular mild cognitive impairment (monolinguals 77.7% versus bilinguals 49.0%; P<0.0009). There were no differences in the frequency of aphasia (monolinguals 11.8% versus bilinguals 10.5%; P=0.354). Bilingualism was found to be an independent predictor of poststroke cognitive impairment. Our results suggest that bilingualism leads to a better cognitive outcome after stroke, possibly by enhancing cognitive reserve. © 2015 American Heart Association, Inc.

[MELAS syndrome as a differential diagnosis of ischemic stroke].

PubMed

Finsterer, J

2009-01-01

Mitochondrial encephalomyopathy, lactacidosis and stroke-like episode (MELAS) syndrome is a phenotypically and genetically heterogeneous mitochondrial disorder with a clinical onset between the first and third decade. The clinical hallmark is the stroke-like-episode, which mimicks ischemic stroke but is usually transient and non-disabling in nature. The morphological equivalent on MRI is a T2-hyperintensity, predominantly over the temporo-parieto-occipital region, not confined to a vascular territory, which is also hyperintense on diffusion weighted imaging and on apparent diffusion coefficient sequences (vasogenic edema, stroke-like lesion). Additional features include seizures, cognitive decline, psychosis, lactic acidosis, migraine, visual impairment, hearing loss, short stature, diabetes, or myopathy. Muscle biopsy typically shows ragged-red fibers, COX-negative fibers, SDH hyperreactivity, and abnormally shaped mitochondria with paracristalline inclusions. The diagnosis is confirmed by demonstration of a biochemical respiratory chain defect or one of the disease-causing mutations, of which 80 % affect the mitochondrial tRNALeu gene.

Recovery of motor function after stroke.

PubMed

Sharma, Nikhil; Cohen, Leonardo G

2012-04-01

The human brain possesses a remarkable ability to adapt in response to changing anatomical (e.g., aging) or environmental modifications. This form of neuroplasticity is important at all stages of life but is critical in neurological disorders such as amblyopia and stroke. This review focuses upon our new understanding of possible mechanisms underlying functional deficits evidenced after adult-onset stroke. We review the functional interactions between different brain regions that may contribute to motor disability after stroke and, based on this information, possible interventional approaches to motor stroke disability. New information now points to the involvement of non-primary motor areas and their interaction with the primary motor cortex as areas of interest. The emergence of this new information is likely to impact new efforts to develop more effective neurorehabilitative interventions using transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS) that may be relevant to other neurological disorders such as amblyopia. Copyright © 2010 Wiley Periodicals, Inc.

Recovery of Motor Function After Stroke

PubMed Central

Sharma, Nikhil; Cohen, Leonardo G.

2016-01-01

The human brain possesses a remarkable ability to adapt in response to changing anatomical (e.g., aging) or environmental modifications. This form of neuroplasticity is important at all stages of life but is critical in neurological disorders such as amblyopia and stroke. This review focuses upon our new understanding of possible mechanisms underlying functional deficits evidenced after adult-onset stroke. We review the functional interactions between different brain regions that may contribute to motor disability after stroke and, based on this information, possible interventional approaches to motor stroke disability. New information now points to the involvement of non-primary motor areas and their interaction with the primary motor cortex as areas of interest. The emergence of this new information is likely to impact new efforts to develop more effective neurorehabilitative interventions using transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS) that may be relevant to other neurological disorders such as amblyopia. PMID:22415914

Cheyne-Stokes Respiration in Patients with First-Ever Lacunar Stroke

PubMed Central

Bonnin-Vilaplana, Marc; Arboix, Adrià; Parra, Olga; García-Eroles, Luis; Montserrat, Josep M.; Massons, Joan

2012-01-01

The aim of this single-center prospective study was to assess the presence of Cheyne-Stokes respiration (CSR) and CSR-related variables in 68 consecutive patients with radiologically proven first-ever lacunar stroke undergoing a respiratory sleep study using a portable respiratory polygraph within the first 48 hours of stroke onset. CSR was diagnosed in 14 patients (20.6%). Patients with CSR as compared with those without CSR showed a significantly higher mean (standard deviation, SD) apnea-hypopnea index (AHI) (34.9 (21.7) versus 18.5 (14.4), P = 0.001) and central apnea index (13.1 (13.8) versus 1.8 (3.4), P = 0.0001) as well as higher scores of the Barthel index and the Canadian Neurological scale as a measure of stroke severity, and longer hospital stay. CSR was present in one of each five patients with lacunar stroke. The presence of CSR was associated with a trend towards a higher functional stroke severity and worse prognosis. PMID:23471518

Human Data Supporting Glyburide in Ischemic Stroke

PubMed Central

Sheth, Kevin N.; Simard, J. Marc; Elm, Jordan; Kronenberg, Golo; Kunte, Hagen; Kimberly, W. Taylor

2016-01-01

The SUR1-TRPM4 channel is a critical determinant of edema and hemorrhagic transformation after focal ischemia. Blockade of this channel by the small molecule glyburide results in improved survival and neurological outcome in multiple preclinical models of ischemic stroke. A robust, compelling body of evidence suggests that an intravenous (IV) formulation of glyburide, RP-1127, can prevent swelling and improve outcome in patients with stroke. Retrospective studies of diabetic stroke patients show improved outcomes in patients who are continued on sulfonylureas after stroke onset. Early phase II study of MRI and plasma biomarkers support the conclusion that RP-1127 may decrease swelling and hemorrhagic transformation. Finally, the ongoing phase II RP-1127 development program has demonstrated continued safety as well as feasibility of enrollment and tolerability of the intervention. Continued efforts to complete the ongoing phase IIb study and definitive efficacy studies are urgently needed to bring a candidate pharmacotherapy to a population of severe stroke patients that currently have no alternative. PMID:26463916

Human Data Supporting Glyburide in Ischemic Stroke.

PubMed

Sheth, Kevin N; Simard, J Marc; Elm, Jordan; Kronenberg, Golo; Kunte, Hagen; Kimberly, W Taylor

2016-01-01

The SUR1-TRPM4 channel is a critical determinant of edema and hemorrhagic transformation after focal ischemia. Blockade of this channel by the small molecule glyburide results in improved survival and neurological outcome in multiple preclinical models of ischemic stroke. A robust, compelling body of evidence suggests that an intravenous formulation of glyburide, RP-1127, can prevent swelling and improve outcome in patients with stroke. Retrospective studies of diabetic stroke patients show improved outcomes in patients who are continued on sulfonylureas after stroke onset. An early phase II study using magnetic resonance imaging and plasma biomarkers supports the conclusion that RP-1127 may decrease swelling and hemorrhagic transformation. Finally, the ongoing phase II RP-1127 development program has demonstrated continued safety as well as feasibility of enrollment and tolerability of the intervention. Continued efforts to complete the ongoing phase II study and definitive efficacy studies are needed to bring a candidate pharmacotherapy to a population of severe stroke patients that currently have no alternative.

PATIENT REFUSAL OF THROMBOLYTIC THERAPY FOR SUSPECTED ACUTE ISCHEMIC STROKE

PubMed Central

FS, Vahidy; MH, Rahbar; AP, Lal; JC, Grotta; SI, Savitz

2012-01-01

Objective To determine factors associated with patients refusing IV t-PA for suspected acute ischemic stroke (AIS), and to compare the outcomes of patients who refused t-PA (RT) with those treated with t-PA. Methods Patients who were treated with and refused t-PA at our stroke center were identified retrospectively. Demographics, clinical presentation, and outcome measures were collected and compared. Clinical outcome was defined as excellent (mRS: 0–1), good (mRS: 0–2), and poor (mRS: 3–6). Results Over 7.5 years, thirty (4.2%) patients refused t-PA. There were no demographic differences between the treated and RT groups. The rate of RT decreased over time (OR 0.63, 95% CI 0.50 – 0.79). Factors associated with refusal included a later symptom onset to emergency department presentation time (OR 1.02, 95% CI 1.01 – 1.03), lower NIHSS (OR 1.11, 95% CI 1.03 – 1.18), a higher proportion of stroke mimics (OR 17.61, 95% CI 6.20 – 50.02) and shorter hospital stay (OR 1.32, 95% CI 1.09 – 1.61). Among patients who were subsequently diagnosed with ischemic stroke, only length of stay was significantly shorter for refusal patients (OR 1.37, 95% CI 1.06 – 1.78). After controlling for mild strokes and stroke mimics, clinical outcome was not different between the groups (OR 1.61, 95% CI 0.69 – 3.73). Conclusion The incidence of patients refusing t-PA has decreased over time, yet it may be a cause for t-PA under-utilization. Patients with milder symptoms were more likely to refuse t-PA. Refusal patients presented later to the hospital and had shorter hospital stays. One out six refusal patients (16.6%) had a stroke mimic. PMID:23227830

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.

Stroke treatment outcomes in hospitals with and without Stroke Units.

PubMed

Masjuan, J; Gállego Culleré, J; Ignacio García, E; Mira Solves, J J; Ollero Ortiz, A; Vidal de Francisco, D; López-Mesonero, L; Bestué, M; Albertí, O; Acebrón, F; Navarro Soler, I M

2017-10-23

Organisational capacity in terms of resources and care circuits to shorten response times in new stroke cases is key to obtaining positive outcomes. This study compares therapeutic approaches and treatment outcomes between traditional care centres (with stroke teams and no stroke unit) and centres with stroke units. We conducted a prospective, quasi-experimental study (without randomisation of the units analysed) to draw comparisons between 2 centres with stroke units and 4 centres providing traditional care through the neurology department, analysing a selection of agreed indicators for monitoring quality of stroke care. A total of 225 patients participated in the study. In addition, self-administered questionnaires were used to collect patients' evaluations of the service and healthcare received. Centres with stroke units showed shorter response times after symptom onset, both in the time taken to arrive at the centre and in the time elapsed from patient's arrival at the hospital to diagnostic imaging. Hospitals with stroke units had greater capacity to respond through the application of intravenous thrombolysis than centres delivering traditional neurological care. Centres with stroke units showed a better fit to the reference standards for stroke response time, as calculated in the Quick study, than centres providing traditional care through the neurology department. Copyright © 2017 Sociedad Española de Neurología. Publicado por Elsevier España, S.L.U. All rights reserved.

The Effects of Various Weather Conditions as a Potential Ischemic Stroke Trigger in Dogs

PubMed Central

Silver, Gena M.

2017-01-01

Stroke is the fifth leading cause of death in the United States, and is the leading cause of serious, long-term disability worldwide. There are at least 795,000 new or recurrent strokes each year, and approximately 85% of all stroke occurrences are ischemic. Unfortunately, companion animals are also at risk for ischemic stroke. Although the exact incidence of ischemic stroke in companion animals is unknown, some studies, and the veterinary information network (VIN), report that approximately 3% of neurological case referrals are due to a stroke. There is a long list of predisposing factors associated with the risk of ischemic stroke in both humans and canines; however, these factors do not explain why a stroke happens at a particular time on a particular day. Our understanding of these potential stroke “triggers” is limited, and the effect of transient environmental exposures may be one such “trigger”. The present study investigated the extent to which the natural occurrence of canine ischemic stroke was related to the weather conditions in the time-period immediately preceding the onset of stroke. The results of the present study demonstrated that the change in weather conditions could be a potential stroke trigger, with the strokes evaluated occurring after periods of rapid, large fluctuations in weather conditions. There are currently no epidemiological data on the seasonal variability of ischemic stroke in dogs, and determining whether canine stroke parallels human stroke would further validate the use of companion dogs as an appropriate naturally occurring model. PMID:29144407

Predictors of intensive care unit admission and mortality in patients with ischemic stroke: investigating the effects of a pulmonary rehabilitation program.

PubMed

Güngen, Belma Doğan; Tunç, Abdulkadir; Aras, Yeşim Güzey; Gündoğdu, Aslı Aksoy; Güngen, Adil Can; Bal, Serdar

2017-07-11

The aim of this study was to investigate the predictors of intensive care unit (ICU) admission and mortality among stroke patients and the effects of a pulmonary rehabilitation program on stroke patients. This prospective study enrolled 181 acute ischemic stroke patients aged between 40 and 90 years. Demographical characteristics, laboratory tests, diffusion-weighed magnetic resonance imaging (DWI-MRI) time, nutritional status, vascular risk factors, National Institute of Health Stroke Scale (NIHSS) scores and modified Rankin scale (MRS) scores were recorded for all patients. One-hundred patients participated in the pulmonary rehabilitation program, 81 of whom served as a control group. Statistically, one- and three-month mortality was associated with NIHSS and MRS scores at admission and three months (p<0.001; r=0.440, r=0.432, r=0.339 and r=0.410, respectively). One and three months mortality- ICU admission had a statistically significant relationship with parenteral nutrition (p<0.001; r=0.346, r=0.300, respectively; r=0.294 and r=0.294, respectively). Similarly, there was also a statistically significant relationship between pneumonia onset and one- and three-month mortality- ICU admission (p<0.05; r=0.217, r=0.127, r=0.185 and r=0.185, respectively). A regression analysis showed that parenteral nutrition (odds ratio [OR] =13.434, 95% confidence interval [CI] =1.148-157.265, p=0.038) was a significant predictor of ICU admission. The relationship between pulmonary physiotherapy (PPT) and ICU admission- pneumonia onset at the end of three months was statistically significant (p=0.04 and p=0.043, respectively). This study showed that PPT improved the prognosis of ischemic stroke patients. We believe that a pulmonary rehabilitation program, in addition to general stroke rehabilitation programs, can play a critical role in improving survival and functional outcomes. NCT03195907 . Trial registration date: 21.06.2017 'Retrospectively registered'.

A zero-footprint 3D visualization system utilizing mobile display technology for timely evaluation of stroke patients

NASA Astrophysics Data System (ADS)

Park, Young Woo; Guo, Bing; Mogensen, Monique; Wang, Kevin; Law, Meng; Liu, Brent

2010-03-01

When a patient is accepted in the emergency room suspected of stroke, time is of the utmost importance. The infarct brain area suffers irreparable damage as soon as three hours after the onset of stroke symptoms. A CT scan is one of standard first line of investigations with imaging and is crucial to identify and properly triage stroke cases. The availability of an expert Radiologist in the emergency environment to diagnose the stroke patient in a timely manner only increases the challenges within the clinical workflow. Therefore, a truly zero-footprint web-based system with powerful advanced visualization tools for volumetric imaging including 2D. MIP/MPR, 3D display can greatly facilitate this dynamic clinical workflow for stroke patients. Together with mobile technology, the proper visualization tools can be delivered at the point of decision anywhere and anytime. We will present a small pilot project to evaluate the use of mobile technologies using devices such as iPhones in evaluating stroke patients. The results of the evaluation as well as any challenges in setting up the system will also be discussed.

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.

Aortic stiffness predicts functional outcome in patients after ischemic stroke.

PubMed

Gasecki, Dariusz; Rojek, Agnieszka; Kwarciany, Mariusz; Kubach, Marlena; Boutouyrie, Pierre; Nyka, Walenty; Laurent, Stephane; Narkiewicz, Krzysztof

2012-02-01

Increased aortic stiffness (measured by carotid-femoral pulse wave velocity) and central augmentation index have been shown to independently predict cardiovascular events, including stroke. We studied whether pulse wave velocity and central augmentation index predict functional outcome after ischemic stroke. In a prospective study, we enrolled 99 patients with acute ischemic stroke (age 63.7 ± 12.4 years, admission National Institutes of Health Stroke Scale score 6.6 ± 6.6, mean ± SD). Carotid-femoral pulse wave velocity and central augmentation index (SphygmoCor) were measured 1 week after stroke onset. Functional outcome was evaluated 90 days after stroke using the modified Rankin Scale with modified Rankin Scale score of 0 to 1 considered an excellent outcome. In univariate analysis, low carotid-femoral pulse wave velocity (P=0.000001) and low central augmentation index (P=0.028) were significantly associated with excellent stroke outcome. Age, severity of stroke, presence of previous stroke, diabetes, heart rate, and peripheral pressures also predicted stroke functional outcome. In multivariate analysis, the predictive value of carotid-femoral pulse wave velocity (<9.4 m/s) remained significant (OR, 0.21; 95% CI, 0.06-0.79; P=0.02) after adjustment for age, National Institutes of Health Stroke Scale score on admission, and presence of previous stroke. By contrast, central augmentation index had no significant predictive value after adjustment. This study indicates that aortic stiffness is an independent predictor of functional outcome in patients with acute ischemic stroke.

Life satisfaction two-years after stroke onset: the effects of gender, sex occupational status, memory function and quality of life among stroke patients (Newsqol) and their family caregivers (Whoqol-bref) in Luxembourg.

PubMed

Baumann, Michèle; Couffignal, Sophie; Le Bihan, Etienne; Chau, Nearkasen

2012-09-25

Life satisfaction (LS) of cerebrovascular disease survivors and their family caregivers may relate to socioeconomic factors, impaired functions, health-related quality of life (QoL), but their respective influences remain unclear. This study assessed, two years post-stroke onset, the effects of these factors on patients' LS and family caregivers' LS in Luxembourg. All stroke patients admitted to all hospitals in Luxembourg were identified by the 'Inspection Général de la Sécurité Sociale' using the only national system database for care expenditure reimbursement. Their diagnosis was confirmed by medical investigator. The sample included ninety four patients living at home having given consent (mean age 65.5 years) and sixty two main caregivers (mean age 59.3 years). Questionnaires were completed during face-to-face interviews. LS was assessed via European single question (range 1-10), survivors' QoL via Newsqol (11 dimensions), and caregivers' QoL via Whoqol-bref (4 domains) (range 0-100). Data were analysed using multiple regression models. Two years after stroke onset, 44.7% of patients suffered from impaired sensory function, 35.1% from impaired motor function, and 31.9% from impaired memory function. Mean patient' LS was 7.1/10 (SD 1.9). It was higher in women (+12.4) and lower among unemployed socioeconomically active patients (-13.1, vs. retired people). Adjusted for sex, occupation, impaired motor and memory functions, LS positively correlated with scores of Newsqol feelings, sleep, emotion, cognition and pain dimensions (slopes 0.20 to 0.31), but did not correlate with those of caregivers' Whoqol-bref domains. Family caregiver' LS was 7.2 (SD 1.7). It was lower in those with patients suffering from impaired memory function (-12.8) as well as from feelings and emotion issues (slopes 0.22). It was associated with all caregivers' Whoqol-bref domains (physical health, psychological health, environment, and social relationships) (slopes 0.53 to 0.68). Two-year post-cerebrovascular disease patient' LS was associated with gender, occupation, and impaired memory function. It correlated with feelings, sleep, emotion, cognition, and pain issues. Family caregivers of patients with impaired memory function had lower LS. Family caregiver' LS correlated with dimensions of patients' feelings (less independent, yourself, life changed, depressed, useless, less control because of stroke) and emotion (get more emotional, fear of another stroke or to become dependent on others), and with their own QoL. LS, Newsqol, and Whoqol appeared to be appropriate tools. Our findings may be useful for policy makers in relation to family and medical-social issues of stroke home-based rehabilitation.

Time to treatment with intravenous alteplase and outcome in stroke: an updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials.

PubMed

Lees, Kennedy R; Bluhmki, Erich; von Kummer, Rüdiger; Brott, Thomas G; Toni, Danilo; Grotta, James C; Albers, Gregory W; Kaste, Markku; Marler, John R; Hamilton, Scott A; Tilley, Barbara C; Davis, Stephen M; Donnan, Geoffrey A; Hacke, Werner; Allen, Kathryn; Mau, Jochen; Meier, Dieter; del Zoppo, Gregory; De Silva, D A; Butcher, K S; Parsons, M W; Barber, P A; Levi, C; Bladin, C; Byrnes, G

2010-05-15

Early administration of intravenous recombinant tissue plasminogen activator (rt-PA) after ischaemic stroke improves outcome. Previous analysis of combined data from individual patients suggested potential benefit beyond 3 h from stroke onset. We re-examined the effect of time to treatment with intravenous rt-PA (alteplase) on therapeutic benefit and clinical risk by adding recent trial data to the analysis. We added data from ECASS III (821 patients) and EPITHET (100 patients) to a pool of common data elements from six other trials of alteplase for acute stroke (2775 patients). We used multivariate logistic regression to assess the relation of stroke onset to start of treatment (OTT) with treatment on favourable 3-month outcome (defined as modified Rankin score 0-1), mortality, and occurrence and outcome of clinically relevant parenchymal haemorrhage. The presence of an arterial occlusion was inferred from the patient's symptoms and absence of haemorrhage or other causes of ischaemic stroke. Vascular imaging was not a requirement in the trials. All patients with confirmed OTT within 360 min were included in the analysis. Treatment was started within 360 min of stroke onset in 3670 patients randomly allocated to alteplase (n=1850) or to placebo (n=1820). Odds of a favourable 3-month outcome increased as OTT decreased (p=0.0269) and no benefit of alteplase treatment was seen after around 270 min. Adjusted odds of a favourable 3-month outcome were 2.55 (95% CI 1.44-4.52) for 0-90 min, 1.64 (1.12-2.40) for 91-180 min, 1.34 (1.06-1.68) for 181-270 min, and 1.22 (0.92-1.61) for 271-360 min in favour of the alteplase group. Large parenchymal haemorrhage was seen in 96 (5.2%) of 1850 patients assigned to alteplase and 18 (1.0%) of 1820 controls, with no clear relation to OTT (p=0.4140). Adjusted odds of mortality increased with OTT (p=0.0444) and were 0.78 (0.41-1.48) for 0-90 min, 1.13 (0.70-1.82) for 91-180 min, 1.22 (0.87-1.71) for 181-270 min, and 1.49 (1.00-2.21) for 271-360 min. Patients with ischaemic stroke selected by clinical symptoms and CT benefit from intravenous alteplase when treated up to 4.5 h. To increase benefit to a maximum, every effort should be taken to shorten delay in initiation of treatment. Beyond 4.5 h, risk might outweigh benefit. None. Copyright 2010 Elsevier Ltd. All rights reserved.

Neuroprotection by post-stroke administration of an oral formulation of angiotensin-(1-7) in ischaemic stroke.

PubMed

Bennion, Douglas M; Jones, Chad H; Donnangelo, Lauren L; Graham, Justin T; Isenberg, Jacob D; Dang, Alex N; Rodriguez, Vermali; Sinisterra, Ruben D M; Sousa, Frederico B; Santos, Robson A S; Sumners, Colin

2018-06-01

What is the central question of this study? Angiotensin-(1-7) decreases cerebral infarct volume and improves neurological function when delivered centrally before and during ischaemic stroke. Here, we assessed the neuroprotective effects of angiotensin-(1-7) when delivered orally post-stroke. What is the main finding and its importance? We show that oral delivery of angiotensin-(1-7) attenuates cerebral damage induced by middle cerebral artery occlusion in rats, without affecting blood pressure or cerebral blood flow. Importantly, these treatments begin post-stroke at times coincident with the treatment window for tissue plasminogen activator, providing supporting evidence for clinical translation of this new therapeutic strategy. As a target for stroke therapies, the angiotensin-converting enzyme 2-angiotensin-(1-7)-Mas [ACE2/Ang-(1-7)/Mas] axis of the renin-angiotensin system can be activated chronically to induce neuroprotective effects, in opposition to the deleterious effects of angiotensin II via its type 1 receptor. However, more clinically relevant treatment protocols with Ang-(1-7) that involve its systemic administration beginning after the onset of ischaemia have not been tested. In this study, we tested systemic post-stroke treatments using a molecule where Ang-(1-7) is included within hydroxypropyl-β-cyclodextrin [HPβCD-Ang-(1-7)] as an orally bioavailable treatment. In three separate protocols, HPβCD-Ang-(1-7) was administered orally to Sprague-Dawley rats after induction of ischaemic stroke by endothelin-1-induced middle cerebral artery occlusion: (i) to assess its effects on cerebral damage and behavioural deficits; (ii) to determine its effects on cardiovascular parameters; and (iii) to determine whether it altered cerebral blood flow. The results indicate that post-stroke oral administration of HPβCD-Ang-(1-7) resulted in 25% reductions in cerebral infarct volumes and improvement in neurological functions (P < 0.05), without inducing any alterations in blood pressure, heart rate or cerebral blood flow. In conclusion, Ang-(1-7) treatment using an oral formulation after the onset of ischaemia induces significant neuroprotection in stroke and might represent a viable approach for taking advantage of the protective ACE2/Ang-(1-7)/Mas axis in this disease. © 2018 The Authors. Experimental Physiology © 2018 The Physiological Society.

Timing of oral anticoagulant therapy in acute ischemic stroke with atrial fibrillation: study protocol for a registry-based randomised controlled trial.

PubMed

Åsberg, Signild; Hijazi, Ziad; Norrving, Bo; Terént, Andreas; Öhagen, Patrik; Oldgren, Jonas

2017-12-02

Oral anticoagulation therapy is recommended for the prevention of recurrent ischemic stroke in patients with atrial fibrillation (AF). Current guidelines do not provide evidence-based recommendations on optimal time-point to start anticoagulation therapy after an acute ischemic stroke. Non-vitamin K antagonist oral anticoagulants (NOACs) may offer advantages compared to warfarin because of faster and more predictable onset of action and potentially a lower risk of intracerebral haemorrhage also in the acute phase after an ischemic stroke. The TIMING study aims to establish the efficacy and safety of early vs delayed initiation of NOACs in patients with acute ischemic stroke and AF. The TIMING study is a national, investigator-led, registry-based, multicentre, open-label, randomised controlled study. The Swedish Stroke Register is used for enrolment, randomisation and follow-up of 3000 patients, who are randomised (1:1) within 72 h from ischemic stroke onset to either early (≤ 4 days) or delayed (≥ 5-10 days) start of NOAC therapy. The primary outcome is the composite of recurrent ischemic stroke, symptomatic intracerebral haemorrhage, or all-cause mortality within 90 days after randomisation. Secondary outcomes include: individual components of the primary outcome at 90 and 365 days; major haemorrhagic events; functional outcome by the modified Rankin Scale at 90 days; and health economics. In an optional biomarker sub-study, blood samples will be collected after randomisation from approximately half of the patients for central analysis of cardiovascular biomarkers after study completion. The study is funded by the Swedish Medical Research Council. Enrolment of patients started in April 2017. The TIMING study addresses the ongoing clinical dilemma of when to start NOAC after an acute ischemic stroke in patients with AF. By the inclusion of a randomisation module within the Swedish Stroke Register, the advantages of a prospective randomised study design are combined with the strengths of a national clinical quality register in allowing simplified enrolment and follow-up of study patients. In addition, the register adds the possibility of directly assessing the external validity of the study findings. ClinicalTrials.gov, NCT02961348 . Registered on 8 November 2016.

Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.

PubMed

Jauch, Edward C; Saver, Jeffrey L; Adams, Harold P; Bruno, Askiel; Connors, J J Buddy; Demaerschalk, Bart M; Khatri, Pooja; McMullan, Paul W; Qureshi, Adnan I; Rosenfield, Kenneth; Scott, Phillip A; Summers, Debbie R; Wang, David Z; Wintermark, Max; Yonas, Howard

2013-03-01

The authors present an overview of the current evidence and management recommendations for evaluation and treatment of adults with acute ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators responsible for the care of acute ischemic stroke patients within the first 48 hours from stroke onset. These guidelines supersede the prior 2007 guidelines and 2009 updates. Members of the writing committee were appointed by the American Stroke Association Stroke Council's Scientific Statement Oversight Committee, representing various areas of medical expertise. Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process. Panel members were assigned topics relevant to their areas of expertise, reviewed the stroke literature with emphasis on publications since the prior guidelines, and drafted recommendations in accordance with the American Heart Association Stroke Council's Level of Evidence grading algorithm. The goal of these guidelines is to limit the morbidity and mortality associated with stroke. The guidelines support the overarching concept of stroke systems of care and detail aspects of stroke care from patient recognition; emergency medical services activation, transport, and triage; through the initial hours in the emergency department and stroke unit. The guideline discusses early stroke evaluation and general medical care, as well as ischemic stroke, specific interventions such as reperfusion strategies, and general physiological optimization for cerebral resuscitation. Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke remains urgently needed.

Four-year follow-up of transient ischemic attacks, strokes, and mimics: a retrospective transient ischemic attack clinic cohort study.

PubMed

Dutta, Dipankar; Bowen, Emily; Foy, Chris

2015-05-01

There is limited information on outcomes from rapid access transient ischemic attack (TIA) clinics. We present 4-year outcomes of TIAs, strokes, and mimics from a UK TIA clinic database. All patients referred between April 2010 and May 2012 were retrospectively identified and outcomes determined. End points were stroke, myocardial infarction, any vascular event (TIA, stroke, or myocardial infarction), and all-cause death. Data were analyzed by survival analysis. Of 1067 patients, 31.6% were TIAs, 18% strokes, and 50.4% mimics. Median assessment time was 4.5 days from onset and follow-up was for 34.9 months. Subsequent strokes occurred in 7.1% of patients with TIA, 10.9% of patients with stroke, and 2.0% of mimics at the end of follow-up. Stroke risk at 90 days was 1.3% for patients diagnosed as TIA or stroke. Compared with mimics, hazard ratios for subsequent stroke were 3.88 (1.90-7.91) for TIA and 5.84 (2.81-12.11) for stroke. Hazard ratio for any subsequent vascular event was 2.91 (1.97-4.30) for TIA and 2.83 (1.81-4.41) for stroke. Hazard ratio for death was 1.68 (1.10-2.56) for TIA and 2.19 (1.38-3.46) for stroke. Our results show a lower 90-day stroke incidence after TIA or minor stroke than in earlier studies, suggesting that rapid access daily TIA clinics may be having a significant effect on reducing strokes. © 2015 American Heart Association, Inc.

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.

The association between high on-treatment platelet reactivity and early recurrence of ischemic events after minor stroke or TIA.

PubMed

Rao, Zilong; Zheng, Huaguang; Wang, Fei; Wang, Anxin; Liu, Liping; Dong, Kehui; Zhao, Xingquan; Wang, Yilong; Cao, Yibin

2017-08-01

To evaluate the role of HTPR in predicting early recurrence of ischemic events in patients with minor ischemic stroke or high-risk TIA. From January 2014 to September 2014, a single center continuously enrolled patients with minor ischemic stroke or high-risk TIA and gave them antiplatelet therapy consisting of aspirin with clopidogrel. HTPR was assessed by TEG after 7 days of antiplatelet therapy and detected CYP2C19 genotype. The incidence of recurrent ischemic events was assessed 3 months after onset. The incidence of recurrent ischemic events was compared between the HTPR and NTPR groups with the Kaplan-Meier method, and multivariate Cox proportional hazards models were used to determine the risk factors associated with recurrent ischemic events. We enrolled 278 eligible patients with minor ischemic stroke or high-risk TIA. Through TEG testing, patients with HTPR were 22.7%, and carriers were not associated with HTPR to ADP by TEG-ADP(%) (p = 0.193). A total of 265 patients completed 3 months of follow-up, and Kaplan-Meier analysis showed that patients with HTPR had a higher percentage of recurrent ischemic events compared with patients with NTPR (p = 0.002). In multivariate Cox proportional hazards models, history of ischemic stroke or TIA (HR 4.45, 95% CI 1.77-11.16, p = 0.001) and HTPR (HR 3.34, 95% CI 1.41-7.91, p = 0.006) was independently associated with recurrent ischemic events. In patients with minor stroke or TIA, the prevalence of HTPR was 22.7%, and HTPR was independently associated with recurrent ischemic events.

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

Neuroanatomic correlates of stroke-related myocardial injury.

PubMed

Ay, H; Koroshetz, W J; Benner, T; Vangel, M G; Melinosky, C; Arsava, E M; Ayata, C; Zhu, M; Schwamm, L H; Sorensen, A G

2006-05-09

Myocardial injury can occur after ischemic stroke in the absence of primary cardiac causes. The neuroanatomic basis of stroke-related myocardial injury is not well understood. To identify regions of brain infarction associated with myocardial injury using a method free of the bias of an a priori hypothesis as to any specific location. Of 738 consecutive patients with acute ischemic stroke, the authors identified 50 patients in whom serum cardiac troponin T (cTnT) elevation occurred in the absence of any apparent cause within 3 days of symptom onset. Fifty randomly selected, age- and sex-matched patients with ischemic stroke without cTnT elevation served as controls. Diffusion-weighted images with outlines of infarction were co-registered to a template, averaged, and then subtracted to find voxels that differed between the two groups. Voxel-wise p values were determined using a nonparametric permutation test to identify specific regions of infarction that were associated with cTnT elevation. The study groups were well balanced with respect to stroke risk factors, history of coronary artery disease, infarction volume, and frequency of right and left middle cerebral artery territory involvement. Brain regions that were a priori associated with cTnT elevation included the right posterior, superior, and medial insula and the right inferior parietal lobule. Among patients with right middle cerebral artery infarction, the insular cluster was involved in 88% of patients with and 33% without cTnT elevation (odds ratio: 15.00; 95% CI: 2.65 to 84.79). Infarctions in specific brain regions including the right insula are associated with elevated serum cardiac troponin T level indicative of myocardial injury.

Post-stroke visual neglect affects goal-directed locomotion in different perceptuo-cognitive conditions and on a wide visual spectrum.

PubMed

Ogourtsova, Tatiana; Archambault, Philippe S; Lamontagne, Anouk

2018-01-01

Unilateral spatial neglect (USN), a highly prevalent and disabling post-stroke deficit, has been shown to affect the recovery of locomotion. However, our current understanding of USN role in goal-directed locomotion control, and this, in different cognitive/perceptual conditions tapping into daily life demands, is limited. To examine goal-directed locomotion abilities in individuals with and without post-stroke USN vs. healthy controls. Participants (n = 45, n = 15 per group) performed goal-directed locomotion trials to actual, remembered and shifting targets located 7 m away at 0° and 15° right/left while immersed in a 3-D virtual environment. Greater end-point mediolateral displacement and heading errors (end-point accuracy measures) were found for the actual and the remembered left and right targets among those with post-stroke USN compared to the two other groups (p <  0.05). A delayed onset of reorientation to the left and right shifting targets was also observed in USN+ participants vs. the other two groups (p <  0.05). Results on clinical near space USN assessment and walking speed explained only a third of the variance in goal-directed walking performance. Post-stroke USN was found to affect goal-directed locomotion in different perceptuo-cognitive conditions, both to contralesional and ipsilesional targets, demonstrating the presence of lateralized and non-lateralized deficits. Beyond neglect severity and walking capacity, other factors related to attention, executive functioning and higher-order visual perceptual abilities (e.g. optic flow perception) may account for the goal-directed walking deficits observed in post-stroke USN+. Goal-directed locomotion can be explored in the design of future VR-based evaluation and training tools for USN to improve the currently used conventional methods.

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.

Stroke Laterality Bias in the Management of Acute Ischemic Stroke.

PubMed

McCluskey, Gavin; Wade, Carrie; McKee, Jacqueline; McCarron, Peter; McVerry, Ferghal; McCarron, Mark O

2016-11-01

Little is known of the impact of stroke laterality on the management process and outcome of patients with acute ischemic stroke (AIS). Consecutive patients admitted to a general hospital over 1 year with supratentorial AIS were eligible for inclusion in the study. Baseline characteristics and risk factors, delays in hospital admission, imaging, intrahospital transfer to an acute stoke unit, stroke severity and classification, length of hospital admission, as well as 10-year mortality were measured and compared among right and left hemisphere AIS patients. There were 141 patients (77 men, 64 women; median age 73 [interquartile range 63-79] years), There were 71 patients with left hemisphere AIS and 70 with right hemisphere AIS. Delays to hospital admission from stroke onset to neuroimaging were similar among right and left hemisphere AIS patients. Delay in transfer to an acute stroke unit (ASU) following hospital admission was on average 14 hours more for right hemisphere compared to left hemisphere AIS patients (P = .01). Laterality was not associated with any difference in 10-year survival. Patients with mild and nondominant AIS merit particular attention to minimize their intrahospital transfer time to an ASU. Copyright © 2016 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Perinatal stroke and the risk of developing childhood epilepsy

PubMed Central

Golomb, Meredith R.; Garg, Bhuwan P.; Carvalho, Karen S.; Johnson, Cynthia S.; Williams, Linda S.

2008-01-01

Objectives To describe the prevalence of epilepsy after 6 months-of-age in children with perinatal stroke and examine whether perinatal data predict epilepsy onset and resolution. Study design A retrospective review of 64 children with perinatal stroke. In children with at least 6 months of follow-up data, Kaplan-Meier curves, univariate log-rank tests, and Cox proportional hazards models were used to examine predictors of time to development of seizures, and time to resolution of seizures in children with epilepsy. The association of risk factors with the presence of epilepsy at any time after 6 months-of-age was examined using Fisher’s exact test. Results Forty-one of the 61 children with at least 6 months of follow-up data (67%) had epilepsy between 6 months-of-age and last follow-up, but in 13 of 41 seizures eventually resolved and anticonvulsants were discontinued. Infarct on prenatal ultrasound (p=0.0065) and family history of epilepsy (p=0.0093) were significantly associated with time to development of seizures after 6 months-of-age in the univariate analysis. No assessed variables were associated with time to resolution of epilepsy or with the presence of epilepsy after 6 months-of-age. Conclusions Childhood epilepsy is frequent after perinatal stroke. Evidence of infarction on prenatal ultrasound and a family history of epilepsy predict earlier onset of active seizures. PMID:17889079

Views of physiatrists and physical therapists on the use of gait-training robots for stroke patients

PubMed Central

Kang, Chang Gu; Chun, Min Ho; Chang, Min Cheol; Kim, Won; Hee Do, Kyung

2016-01-01

[Purpose] Gait-training robots have been developed for stroke patients with gait disturbance. It is important to survey the views of physiatrists and physical therapists on the characteristics of these devices during their development. [Subjects and Methods] A total of 100 physiatrists and 100 physical therapists from 38 hospitals participated in our questionnaire survey. [Results] The most common answers about the merits of gait-training robots concern improving the treatment effects (28.5%), followed by standardizing treatment (19%), motivating patients about treatment (17%), and improving patients’ self-esteem (14%). The subacute period (1–3 months post-stroke onset) was most often chosen as the ideal period (47.3%) for the use of these devices, and a functional ambulation classification of 0–2 was the most selected response for the optimal patient status (27%). The preferred model was the treadmill type (47.5%) over the overground walking type (40%). The most favored commercial price was $50,000–$100,000 (38.3%). The most selected optimal duration for robot-assisted gait therapy was 30–45 min (47%), followed by 15–30 min (29%), 45–60 min (18%), ≥ 60 min (5%), and < 15 min (1%). [Conclusion] Our study findings could guide the future designs of more effective gait-training robots for stroke patients. PMID:26957758

Neurological complication after low-voltage electric injury: a case report.

PubMed

Kim, Ha Min; Ko, Yeong-A; Kim, Joon Sung; Lim, Seong Hoon; Hong, Bo Young

2014-04-01

Electrical shock can result in neurological complications, involving both peripheral and central nervous systems, which may present immediately or later on. However, delayed neurological complications caused by low-voltage electric shock are rarely reported. Here, a case of a man suffering from weakness and aphasia due to the delayed-onset of the peripheral nerve injury and ischemic stroke following an electrical shock is presented. Possible mechanisms underlying the neurological complications include thermal injury to perineural tissue, overactivity of the sympathetic nervous system, vascular injury, and histological or electrophysiological changes. Moreover, vasospasms caused by low-voltage alternating current may predispose individuals to ischemic stroke. Therefore, clinicians should consider the possibility of neurological complications, even if the onset of the symptoms is delayed, and should perform diagnostic tests, such as electrophysiology or imaging, when patients present with weakness following an electric injury.

Animal models of ischemic stroke and their application in clinical research.

PubMed

Fluri, Felix; Schuhmann, Michael K; Kleinschnitz, Christoph

2015-01-01

This review outlines the most frequently used rodent stroke models and discusses their strengths and shortcomings. Mimicking all aspects of human stroke in one animal model is not feasible because ischemic stroke in humans is a heterogeneous disorder with a complex pathophysiology. The transient or permanent middle cerebral artery occlusion (MCAo) model is one of the models that most closely simulate human ischemic stroke. Furthermore, this model is characterized by reliable and well-reproducible infarcts. Therefore, the MCAo model has been involved in the majority of studies that address pathophysiological processes or neuroprotective agents. Another model uses thromboembolic clots and thus is more convenient for investigating thrombolytic agents and pathophysiological processes after thrombolysis. However, for many reasons, preclinical stroke research has a low translational success rate. One factor might be the choice of stroke model. Whereas the therapeutic responsiveness of permanent focal stroke in humans declines significantly within 3 hours after stroke onset, the therapeutic window in animal models with prompt reperfusion is up to 12 hours, resulting in a much longer action time of the investigated agent. Another major problem of animal stroke models is that studies are mostly conducted in young animals without any comorbidity. These models differ from human stroke, which particularly affects elderly people who have various cerebrovascular risk factors. Choosing the most appropriate stroke model and optimizing the study design of preclinical trials might increase the translational potential of animal stroke models.

Animal models of ischemic stroke and their application in clinical research

PubMed Central

Fluri, Felix; Schuhmann, Michael K; Kleinschnitz, Christoph

2015-01-01

This review outlines the most frequently used rodent stroke models and discusses their strengths and shortcomings. Mimicking all aspects of human stroke in one animal model is not feasible because ischemic stroke in humans is a heterogeneous disorder with a complex pathophysiology. The transient or permanent middle cerebral artery occlusion (MCAo) model is one of the models that most closely simulate human ischemic stroke. Furthermore, this model is characterized by reliable and well-reproducible infarcts. Therefore, the MCAo model has been involved in the majority of studies that address pathophysiological processes or neuroprotective agents. Another model uses thromboembolic clots and thus is more convenient for investigating thrombolytic agents and pathophysiological processes after thrombolysis. However, for many reasons, preclinical stroke research has a low translational success rate. One factor might be the choice of stroke model. Whereas the therapeutic responsiveness of permanent focal stroke in humans declines significantly within 3 hours after stroke onset, the therapeutic window in animal models with prompt reperfusion is up to 12 hours, resulting in a much longer action time of the investigated agent. Another major problem of animal stroke models is that studies are mostly conducted in young animals without any comorbidity. These models differ from human stroke, which particularly affects elderly people who have various cerebrovascular risk factors. Choosing the most appropriate stroke model and optimizing the study design of preclinical trials might increase the translational potential of animal stroke models. PMID:26170628

Poor stroke risk perception despite moderate public stroke awareness: insight from a cross-sectional national survey in Greece.

PubMed

Ntaios, George; Melikoki, Vasiliki; Perifanos, George; Perlepe, Kalliopi; Gioulekas, Fotios; Karagiannaki, Anastasia; Tsantzali, Ioanna; Lazarou, Chrysanthi; Beradze, Nikolaos; Poulianiti, Evdoxia; Poulikakou, Matina; Palantzas, Theofanis; Kaditi, Stavrina; Perlepe, Fay; Sidiropoulos, George; Papageorgiou, Kyriaki; Papavasileiou, Vasileios; Vemmos, Konstantinos; Makaritsis, Konstantinos; Dalekos, George N

2015-04-01

Although stroke is the fourth cause of death in Western societies, public stroke awareness remains suboptimal. The aim of this study was to estimate stroke risk perception and stroke awareness in Greece through a cross-sectional telephone survey. A trained interview team conducted this cross-sectional telephone survey between February and April 2014 using an online structured questionnaire. Participants were selected using random digit dialing of landline and mobile telephone numbers with quota sampling weighted for geographical region based on the most recent General Population Census (2011). Between February and April 2014, 723 individuals (418 women [58%], 47.4 ± 17.8 years) agreed to respond. Among all respondents, 642 (88.8%) were able to provide at least 1 stroke risk factor; 673 respondents (93.08%) were able to provide correctly at least 1 stroke symptom or sign. When asked what would they do in case of acute onset of stroke symptoms, 497 (68.7%) responded that they would either call the ambulance or visit the closest emergency department. Only 35.3%, 18.9%, 17.2%, 20.7%, and 15.0% of respondents with atrial fibrillation, arterial hypertension, dyslipidemia, diabetes mellitus, and current smoking, respectively, considered themselves as being in high risk for stroke. Stroke risk perception in Greece is low despite moderate public stroke awareness. Copyright © 2015 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Increased Risk of Stroke in Patients of Concussion: A Nationwide Cohort Study.

PubMed

Liu, Shih-Wei; Huang, Liang-Chung; Chung, Wu-Fu; Chang, Hsuan-Kan; Wu, Jau-Ching; Chen, Li-Fu; Chen, Yu-Chun; Huang, Wen-Cheng; Cheng, Henrich; Lo, Su-Shun

2017-02-25

Long-term morbidities can develop after traumatic brain injury (TBI). Some studies have suggested that the risk of stroke is higher after TBI, but the association between concussion and stroke remains unclear. Using a national cohort, the authors analyzed the incidence of both hemorrhagic and ischemic strokes in patients with previous concussion. A representative cohort of approximately one million people was followed up for four years. Patients with new-onset concussion were identified ( n = 13,652) as the concussion group. Subsequently, the incidence rates of later stroke events in the concussion group were compared to a sex-, age- and propensity score-matched comparison group ( n = 13,652). The overall incidence rate of stroke in the concussion group was higher than that of the comparison group (9.63 versus 6.52 per 1000 person-years, p < 0.001). Significantly higher stroke risk was observed in the concussion group than in the comparison group (crude hazard ratio 1.48, p < 0.001; adjusted HR 1.65, p < 0.001). In the concussion group, the cumulative incidence rates of both ischemic stroke and hemorrhagic stroke were higher than those of the comparison group (8.9% vs. 5.8% and 2.7% vs. 1.6%, respectively, both p < 0.001). Concussion is an independent risk factor for both ischemic and hemorrhagic strokes. Prevention and monitoring strategies of stroke are therefore suggested for patients who have experienced concussion.

[Frequency and characteristics of strokes involving the perforating arteries in the Department of Neurology at the Befelatanana General Hospital, Antananarivo].

PubMed

Rasaholiarison, Nomena Finiavana; Randrianasolo, Rahamefy Odilon; Rajaonarison, Lala Andriamasinavalona; Rakotomanana, Jenny Larissa; Razafimahefa, Julien; Tehindrazanarivelo, Alain Djacoba

2017-01-01

Strokes of the perforating arteries are mainly arteriolopathies. They result in dementia and stroke recurrence. This study aimed to evaluate the frequency and characteristics of these strokes to better prevent these complications. We conducted a descriptive, retrospective study in the department of neurology at the Befelatanana general hospital, Antananarivo over the period 01 March-25 September 2015. All patients with abrupt neurological deficit and deep brain involvement on brain scanner were included in the study. The features of strokes involving the perforating arteries were collected. Data were processed with SPSS 20 software. Out of 172 patients with a stroke, 83(48.25%) had stroke involving the perforating arteries. Stroke involving the perforating arteries affected young people (65.06%) aged less than 65 years and preferentially the male population (61.44%). Haemorrhagic forms accounted for 67.46%. Thirty-one patients (37.34%) had stroke recurrences and, among them, almost a quarter had 2 recurrences (38.70%) in less than a year. All patients with recurrence had dysexecutive disorder (p < 0.0001) and poor antihypertensive medication adherence. Mortality accounted for only 6.02% in patients with onset of these strokes during hospitalization. Specific neurologic follow-up is necessary after a first stroke involving perforating arteries in order to make an early diagnosis of dementia and to prevent recurrences.

Aberrant left subclavian artery occlusion in right-sided aortic artery associated with left cerebral infarction: A case report.

PubMed

Tempaku, Akira; Kuroiwa, Terumasa; Nishio, Akimasa

2018-06-01

Purpose Right-sided aortic arch is a rare vessel anomaly with an incidence of 0.1% worldwide. Supra-aortic branches form a mirror image of the left-sided aortic arch or an aberrant left subclavian artery associated with Kommerell diverticulum. Most patients are diagnosed by a difference in blood pressure in each upper extremity or by the presence of left subclavian steal syndrome in their younger age. The diagnosis of onset of ischemic stroke in middle age is rare. Methods We present the case of a female patient who presented with an ischemic stroke in the left posterior circulation area. She had no history of congenital heart malformation. We performed head magnetic resonance imaging, cerebral angiography, and enhanced computed tomography of the aortic arch and major branches. Results The patient had a right-sided aortic arch and an aberrant left subclavian artery. The left subclavian artery was occluded at the proximal portion with a fibrous string. Collateral flow in the anterior cervical subcutaneous area supported left limb perfusion. Conclusion An atheromatous change reduced shunt flow via collateral networks at the anterior cervical region. Congenital subclavian steal supported the ischemic stroke.

Soluble TNF receptor 1-secreting ex vivo-derived dendritic cells reduce injury after stroke.

PubMed

Works, Melissa G; Koenig, Jenny B; Sapolsky, Robert M

2013-09-01

Inflammation is a major factor in the progression of damage after stroke and in the clinic, current therapies treat the clot, not the resulting damage. We have developed a novel method of protein delivery that exploits the migration ability of leukocytes after ischemic stroke (transient middle cerebral artery occlusion; tMCAO). In our studies, ex vivo-derived dendritic cells (exDCs) migrate to the inflamed rat brain soon after tMCAO onset and the number of cells that remain in the brain after injection is significantly correlated with the amount of local inflammation at the injury site. In addition, exDCs transduced to overexpress soluble tumor necrosis factor (TNF) receptor1 (sTNFR1) produce functional cargo that is secreted and that blocks TNF-α bioavailability in vitro. When delivered at 6 hours post-tMCAO reperfusion, sTNFR1-exDC-treated rats show significantly smaller infarct size and decreased inflammation compared with animals treated with exDCs transduced with GFP lentivirus. These studies indicate that cell-mediated delivery of proteins may be a promising new approach to reduce brain damage after acute neurologic insult.

Moyamoya vasculopathy - Patient demographics and characteristics in the Finnish population.

PubMed

Saarela, Marika; Mustanoja, Satu; Pekkola, Johanna; Tyni, Tiina; Hernesniemi, Juha; Kivipelto, Leena; Tatlisumak, Turgut

2017-01-01

Background and purpose Moyamoya vasculopathy, a rare steno-occlusive progressive cerebrovascular disorder, has not been thoroughly studied in Caucasian populations. We established a registry of Finnish patients treated at the Helsinki University Hospital, to collect and report demographic and clinical data. Methods We collected data both retrospectively and prospectively from all the patients with a moyamoya vasculopathy referred to our hospital between January 1987 and December 2014. All patients underwent a neurological outpatient clinic visit. Results We diagnosed 61 patients (50 females, 10 children) with moyamoya vasculopathy. The mean age at the disease-onset was 31.5 ± 17.9 years. The two most common presenting symptoms were ischemic stroke (n = 31) and hemorrhage (n = 8). Forty-four percent underwent revascularization surgery, and 70% were prescribed antithrombotic treatment. Conclusions The results support in part the Western phenotype of the disease considering the later presentation and larger female predominance compared to the Asian moyamoya vasculopathy reports. However, the proportion of ischemic strokes and hemorrhagic strokes is closer to Japanese population than German population. The absence of familial cases points to a different genetic profile in the Finnish patients.

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

PubMed

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

2016-06-01

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

Interhospital Transfer Before Thrombectomy Is Associated With Delayed Treatment and Worse Outcome in the STRATIS Registry (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke)

PubMed Central

Saver, Jeffrey L.; Zaidat, Osama O.; Jahan, Reza; Aziz-Sultan, Mohammad Ali; Klucznik, Richard P.; Haussen, Diogo C.; Hellinger, Frank R.; Yavagal, Dileep R.; Yao, Tom L.; Liebeskind, David S.; Jadhav, Ashutosh P.; Gupta, Rishi; Hassan, Ameer E.; Martin, Coleman O.; Bozorgchami, Hormozd; Kaushal, Ritesh; Nogueira, Raul G.; Gandhi, Ravi H.; Peterson, Eric C.; Dashti, Shervin R.; Given, Curtis A.; Mehta, Brijesh P.; Deshmukh, Vivek; Starkman, Sidney; Linfante, Italo; McPherson, Scott H.; Kvamme, Peter; Grobelny, Thomas J.; Hussain, Muhammad S.; Thacker, Ike; Vora, Nirav; Chen, Peng Roc; Monteith, Stephen J.; Ecker, Robert D.; Schirmer, Clemens M.; Sauvageau, Eric; Abou-Chebl, Alex; Derdeyn, Colin P.; Maidan, Lucian; Badruddin, Aamir; Siddiqui, Adnan H.; Dumont, Travis M.; Alhajeri, Abdulnasser; Taqi, M. Asif; Asi, Khaled; Carpenter, Jeffrey; Boulos, Alan; Jindal, Gaurav; Puri, Ajit S.; Chitale, Rohan; Deshaies, Eric M.; Robinson, David H.; Kallmes, David F.; Baxter, Blaise W.; Jumaa, Mouhammad A.; Sunenshine, Peter; Majjhoo, Aniel; English, Joey D.; Suzuki, Shuichi; Fessler, Richard D.; Delgado Almandoz, Josser E.; Martin, Jerry C.; Mueller-Kronast, Nils H.

2017-01-01

Background: Endovascular treatment with mechanical thrombectomy (MT) is beneficial for patients with acute stroke suffering a large-vessel occlusion, although treatment efficacy is highly time-dependent. We hypothesized that interhospital transfer to endovascular-capable centers would result in treatment delays and worse clinical outcomes compared with direct presentation. Methods: STRATIS (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke) was a prospective, multicenter, observational, single-arm study of real-world MT for acute stroke because of anterior-circulation large-vessel occlusion performed at 55 sites over 2 years, including 1000 patients with severe stroke and treated within 8 hours. Patients underwent MT with or without intravenous tissue plasminogen activator and were admitted to endovascular-capable centers via either interhospital transfer or direct presentation. The primary clinical outcome was functional independence (modified Rankin Score 0–2) at 90 days. We assessed (1) real-world time metrics of stroke care delivery, (2) outcome differences between direct and transfer patients undergoing MT, and (3) the potential impact of local hospital bypass. Results: A total of 984 patients were analyzed. Median onset-to-revascularization time was 202.0 minutes for direct versus 311.5 minutes for transfer patients (P<0.001). Clinical outcomes were better in the direct group, with 60.0% (299/498) achieving functional independence compared with 52.2% (213/408) in the transfer group (odds ratio, 1.38; 95% confidence interval, 1.06–1.79; P=0.02). Likewise, excellent outcome (modified Rankin Score 0–1) was achieved in 47.4% (236/498) of direct patients versus 38.0% (155/408) of transfer patients (odds ratio, 1.47; 95% confidence interval, 1.13–1.92; P=0.005). Mortality did not differ between the 2 groups (15.1% for direct, 13.7% for transfer; P=0.55). Intravenous tissue plasminogen activator did not impact outcomes. Hypothetical bypass modeling for all transferred patients suggested that intravenous tissue plasminogen activator would be delayed by 12 minutes, but MT would be performed 91 minutes sooner if patients were routed directly to endovascular-capable centers. If bypass is limited to a 20-mile radius from onset, then intravenous tissue plasminogen activator would be delayed by 7 minutes and MT performed 94 minutes earlier. Conclusions: In this large, real-world study, interhospital transfer was associated with significant treatment delays and lower chance of good outcome. Strategies to facilitate more rapid identification of large-vessel occlusion and direct routing to endovascular-capable centers for patients with severe stroke may improve outcomes. Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02239640. PMID:28943516

Relative Risks of Contributing Factors to Morbidity and Mortality in Adults With Craniopharyngioma on Growth Hormone Replacement.

PubMed

Yuen, Kevin C J; Mattsson, Anders F; Burman, Pia; Erfurth, Eva-Marie; Camacho-Hubner, Cecilia; Fox, Janet L; Verhelst, Johan; Geffner, Mitchell E; Abs, Roger

2018-02-01

In adults, craniopharyngioma (CP) of either childhood-onset (CO-CP) or adult-onset (AO-CP) is associated with increased morbidity and mortality, but data on the relative risks (RRs) of contributing factors are lacking. To assess the RRs of factors contributing to morbidity and mortality in adults with CO-CP and AO-CP. Data on 1669 patients with CP from KIMS (Pfizer International Metabolic Database) were analyzed using univariate and multiple Poisson and Cox regression methods. When CO-CP and AO-CP groups were combined, history of stroke and hyperlipidemia increased cardiovascular risk, higher body mass index (BMI) and radiotherapy increased cerebrovascular risk, and increased waist circumference increased the risk of developing diabetes mellitus (DM). Compared with patients with CO-CP, patients with AO-CP had a threefold higher risk of tumor recurrence, whereas being female and previous radiotherapy exposure conferred lower risks. Radiotherapy and older age with every 10 years from disease onset conferred a 2.3- to 3.5-fold risk for developing new intracranial tumors, whereas older age, greater and/or increasing BMI, history of stroke, and lower insulinlike growth factor I (IGF-I) standard deviation score measured at last sampling before death were related to increased all-cause mortality. Compared with the general population, adults with CP had 9.3-, 8.1-, and 2.2-fold risks of developing DM, new intracranial tumors, and early death, respectively. Conventional factors that increase the risks of cardio- and cerebrovascular diseases and DM and risks for developing new intracranial tumors contributed to excess morbidity and mortality. In addition, lower serum IGF-I level measured from the last sample before death was inversely associated with mortality risk in patients with CP. Copyright © 2017 Endocrine Society

Only White Matter Hyperintensities Predicts Post-Stroke Cognitive Performances Among Cerebral Small Vessel Disease Markers: Results from the TABASCO Study.

PubMed

Molad, Jeremy; Kliper, Efrat; Korczyn, Amos D; Ben Assayag, Einor; Ben Bashat, Dafna; Shenhar-Tsarfaty, Shani; Aizenstein, Orna; Shopin, Ludmila; Bornstein, Natan M; Auriel, Eitan

2017-01-01

White matter hyperintensities (WMH) were shown to predict cognitive decline following stroke or transient ischemic attack (TIA). However, WMH are only one among other radiological markers of cerebral small vessel disease (SVD). The aim of this study was to determine whether adding other SVD markers to WMH improves prediction of post-stroke cognitive performances. Consecutive first-ever stroke or TIA patients (n = 266) from the Tel Aviv Acute Brain Stroke Cohort (TABASCO) study were enrolled. MRI scans were performed within seven days of stroke onset. We evaluated the relationship between cognitive performances one year following stroke, and previously suggested total SVD burden score including WMH, lacunes, cerebral microbleeds (CMB), and perivascular spaces (PVS). Significant negative associations were found between WMH and cognition (p < 0.05). Adding other SVD markers (lacunes, CMB, PVS) to WMH did not improve predication of post-stroke cognitive performances. Negative correlations between SVD burden score and cognitive scores were observed for global cognitive, memory, and visual spatial scores (all p < 0.05). However, following an adjustment for confounders, no associations remained significant. WMH score was associated with poor post-stroke cognitive performance. Adding other SVD markers or SVD burden score, however, did not improve prediction.

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

PubMed

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

2003-05-01

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

RAAS and stress markers in acute ischemic stroke: preliminary findings.

PubMed

Back, C; Thiesen, K L; Skovgaard, K; Edvinsson, L; Jensen, L T; Larsen, V A; Iversen, H K

2015-02-01

Angiotensin II type 1 receptor blockade has neuroprotective effects in animal stroke models, but no effects in clinical stroke trials. We evaluated cerebral and peripheral changes in the renin angiotensin aldosterone system (RAAS) and stress responses in acute ischemic stroke patients. Blood from a jugular and cubital vein was collected within 48 h of stroke onset, after 24 and 48 h, and renin, angiotensin I, angiotensin II, aldosterone, norepinephrine, epinephrine, and cortisol were measured. Post-stroke cubital vein samples were collected after 8 (4.7-10) months. The acute systolic blood pressure was significantly increased, 148 (141-168) vs 140 (130-147) mmHg post-stroke. Angiotensin I, renin and aldosterone levels were significantly lower, angiotensin II was unchanged, and ACE activity was higher in the acute phase compared to post-stroke. No differences in RAAS were detected between jugular and cubital plasma levels. Jugular venous plasma levels of epinephrine and cortisol were elevated in the acute phase compared to cubital levels (P < 0.05). Increased epinephrine and cortisol levels in the jugular vein blood may reflect a higher peripheral turnover. The observed changes in RAAS in the acute stroke phase are consistent with responses to increased blood pressure. © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

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.

Risk factors for ischemic stroke and its subtypes in Chinese vs. Caucasians: Systematic review and meta-analysis.

PubMed

Tsai, Chung-Fen; Anderson, Niall; Thomas, Brenda; Sudlow, Cathie L M

2015-06-01

Chinese populations are reported to have a different distribution of ischemic stroke subtypes compared with Caucasians. To understand this better, we aimed to evaluate the differences in prevalence of risk factors in ischemic stroke and their distributions among ischemic stroke subtypes in Chinese vs. Caucasians. We systematically sought studies conducted since 1990 with data on frequency of risk factors among ischemic stroke subtypes in Chinese or Caucasians. For each risk factor, we calculated study-specific and random effects pooled estimates in Chinese and Caucasians separately for: prevalence among ischemic stroke; odds ratios, comparing prevalence for each ischemic stroke subtype vs. all others. We included seven studies among 16,199 Chinese, and eleven among 16,189 Caucasian ischemic stroke patients. Risk factors studied were hypertension, diabetes, atrial fibrillation, ischemic heart disease, hypercholesterolemia, smoking and alcohol. Chinese ischemic stroke patients had younger onset of stroke than Caucasians, similar prevalence of hypertension, diabetes, smoking and alcohol, and significantly lower prevalence of atrial fibrillation, ischemic heart disease and hypercholesterolemia. Risk factor associations with ischemic stroke subtypes were mostly similar among Chinese and Caucasian ischemic stroke patients. Compared with all other ischemic subtypes, diabetes was more common in large artery stroke, atrial fibrillation and ischemic heart disease in cardioembolic stroke, and hypertension and diabetes in lacunar stroke. Our study showed a lower prevalence of atrial fibrillation, ischemic heart disease and hypercholesterolemia in Chinese, and mostly similar risk factor associations in Chinese and Caucasian ischemic stroke patients. Further analyses of individual patient data to allow adjustment for confounders are needed to confirm and extend these findings. © 2015 World Stroke Organization.

A novel animal model of dysphagia following stroke.

PubMed

Sugiyama, Naoto; Nishiyama, Eiji; Nishikawa, Yukitoshi; Sasamura, Takashi; Nakade, Shinji; Okawa, Katsumasa; Nagasawa, Tadashi; Yuki, Akane

2014-02-01

Patients who have an ischemic stroke are at high risk of swallowing disorders. Aspiration due to swallowing disorders, specifically delayed trigger of the pharyngeal stage of swallowing, predisposes such patients to pneumonia. In the present study, we evaluated swallowing reflex in a rat model of transient middle cerebral artery occlusion (tMCAO), which is one of the most common experimental animal models of cerebral ischemia, in order to develop a novel animal model of dysphagia following ischemic stroke. A swallowing reflex was elicited by a 10-s infusion of distilled water (DW) to the pharyngolaryngeal region in the tMCAO rat model. Swallowing reflex was estimated using the electromyographic activity of the mylohyoid muscle from 1 to 3 weeks after surgery. Two weeks after tMCAO, the number of swallows significantly decreased and the onset latency of the first swallow was prolonged compared with that of the sham group. The number of swallows in rats significantly increased by infusions of 10 mM citric acid and 0.6 μM capsaicin to the pharyngolaryngeal region compared with the number from infusion of DW. It has been reported that sensory stimulation of the pharyngolaryngeal region with citric acid, capsaicin, and L-menthol ameliorates hypofunction of pharyngeal-stage swallowing in dysphagia patients. Therefore, the tMCAO rat model may show some of the symptoms of pharyngeal-stage swallowing disorders, similar to those in patients with ischemic stroke. This rat tMCAO model has the potential to become a novel animal model of dysphagia following stroke that is useful for development of therapeutic methods and drugs.

MR OEF imaging in MELAS.

PubMed

Xie, Sheng

2014-01-01

Oxygen extraction fraction (OEF) is defined as the ratio of blood oxygen that a tissue takes from the blood flow to maintain function and morphological integrity. OEF reflects the efficiency of oxygen utilization by the tissue and, therefore, is a hemodynamic measure in brain ischemia. Mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) is a common mitochondrial disorder. It is characterized by neurological remissions and relapses and associated with progressive neurocognitive deficits. Because of abnormalities of mitochondrial function in MELAS, defects in the oxidative metabolic pathways of energy production decrease the cerebral oxygen utilization and lead to the reduction of OEF. Quantification of OEF can reflect the functional status of cerebral mitochondria and provide insight into the pathophysiological changes in the brain in MELAS. In light of recent advances in MRI, the discovery of the blood-oxygen level-dependent signal has allowed development of MRI methods targeted toward quantitative OEF imaging. A new MR sequence, termed the gradient-echo sampling of spin echo, was successfully developed to enable quantitative assessment of the OEF in the brain tissue. MR OEF imaging in patients with MELAS detects extensive OEF reduction in the stroke-like lesions, as well as in the normal-appearing brain regions. More severe dysfunction of the mitochondria in the stroke-like lesions was implied at the onset of the stroke-like episode. Determination of OEF throughout the episode demonstrated a chronological change in mitochondrial function in individual cases. Such neuroimaging findings might provide some clues in the investigation of the underlying mechanisms of stroke-like episodes.

Angiographic Features, Collaterals, and Infarct Topography of Symptomatic Occlusive Radiation Vasculopathy

PubMed Central

Zou, Winnie X.Y.; Leung, Thomas W.; Yu, Simon C.H.; Wong, Edward H.C.; Leung, S.F.; Soo, Yannie O.Y.; Ip, Vincent H.L.; Chan, Anne Y.Y.; Lam, Wynnie W.M.; Siu, Deyond Y.W.; Abrigo, Jill; Lee, Kwok Tung; Liebeskind, David S.; Wong, Ka Sing

2014-01-01

Background and Purpose Occlusive radiation vasculopathy (ORV) predisposes head-and-neck cancer survivors to ischemic strokes. Methods We analyzed the digital subtraction angiography acquired in 96 patients who had first-ever transient ischemic attack or ischemic strokes attributed to ORV. Another age-matched 115 patients who had no radiotherapy but symptomatic high-grade (>70%) carotid stenoses were enrolled as referent subjects. Digital subtraction angiography was performed within 2 months from stroke onset and delineated carotid and vertebrobasilar circulations from aortic arch up to intracranial branches. Two reviewers blinded to group assignment recorded all vascular lesions, collateral status, and infarct pattern. Results ORV patients had less atherosclerotic risk factors at presentation. In referent patients, high-grade stenoses were mostly focal at the proximal internal carotid artery. In contrast, high-grade ORV lesions diffusely involved the common carotid artery and internal carotid artery and were more frequently bilateral (54% versus 22%), tandem (23% versus 10%), associated with complete occlusion in one or both carotid arteries (30% versus 9%), vertebral artery (VA) steno-occlusions (28% versus 16%), and external carotid artery stenosis (19% versus 5%) (all P<0.05). With comparable rates of vascular anomaly, ORV patients showed more established collateral circulations through leptomeningeal arteries, anterior communicating artery, posterior communicating artery, suboccipital/costocervical artery, and retrograde flow in ophthalmic artery. In terms of infarct topography, the frequencies of cortical or subcortical watershed infarcts were similar in both groups. Conclusions ORV angiographic features and corresponding collaterals are distinct from atherosclerotic patterns at initial stroke presentation. Clinical decompensation, despite more extensive collateralization, may precipitate stroke in ORV. PMID:23306321

75 FR 62487 - Compassionate Allowances for Cardiovascular Disease and Multiple Organ Transplants, Office of the...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-10-12

... hearings concerned rare diseases, cancers, traumatic brain injury and stroke, early-onset Alzheimer's... held five hearings since December 2007. These hearings were on rare diseases, cancers, traumatic brain...

Feasibility and Efficacy of Nurse-Driven Acute Stroke Care.

PubMed

Mainali, Shraddha; Stutzman, Sonja; Sengupta, Samarpita; Dirickson, Amanda; Riise, Laura; Jones, Donald; Yang, Julian; Olson, DaiWai M

2017-05-01

Acute stroke care requires rapid assessment and intervention. Replacing traditional sequential algorithms in stroke care with parallel processing using telestroke consultation could be useful in the management of acute stroke patients. The purpose of this study was to assess the feasibility of a nurse-driven acute stroke protocol using a parallel processing model. This is a prospective, nonrandomized, feasibility study of a quality improvement initiative. Stroke team members had a 1-month training phase, and then the protocol was implemented for 6 months and data were collected on a "run-sheet." The primary outcome of this study was to determine if a nurse-driven acute stroke protocol is feasible and assists in decreasing door to needle (intravenous tissue plasminogen activator [IV-tPA]) times. Of the 153 stroke patients seen during the protocol implementation phase, 57 were designated as "level 1" (symptom onset <4.5 hours) strokes requiring acute stroke management. Among these strokes, 78% were nurse-driven, and 75% of the telestroke encounters were also nurse-driven. The average door to computerized tomography time was significantly reduced in nurse-driven codes (38.9 minutes versus 24.4 minutes; P < .04). The use of a nurse-driven protocol is feasible and effective. When used in conjunction with a telestroke specialist, it may be of value in improving patient outcomes by decreasing the time for door to decision for IV-tPA. Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Knowledge, attitude, and practice of stroke among high school students in Nepal.

PubMed

Thapa, Lekhjung; Sharma, Nooma; Poudel, Ramesh Sharma; Bhandari, Tirtha Raj; Bhagat, Riwaz; Shrestha, Ashis; Shrestha, Shakti; Khatiwada, Dipendra; Caplan, Louis R

2016-01-01

Baseline stroke knowledge in a targeted population is indispensable to promote the effective stroke education. We report the baseline knowledge, attitude, and practice (KAP) of high school students with respect to stroke from Nepal. A self-structured questionnaire survey regarding KAP about stroke was conducted in high school students of 33 schools of Bharatpur, Nepal. Descriptive statistics including Chi-square test was used, and the significant variables were subjected to binary logistic regression. Among 1360 participants, 71.1% had heard or read about stroke; 30.2% knew someone with stroke. 39.3% identified brain as the organ affected. Sudden onset limb/s weakness/numbness (72%) and hypertension (74%) were common warning symptom and risk factor identified. 88.9% would take stroke patients to a hospital. Almost half participants (55.5%) felt ayurvedic treatment be effective. 44.8% felt stroke as a hindrance to a happy life and 86.3% believed that family care was helpful for early recovery. Students who identified at least one risk factor were 3.924 times ( P < 0.001, confidence interval [CI] = 1.867-8.247) or those who identified at least one warning symptom were 2.833 times ( P ≤ 0.023, CI = 1.156-6.944) more likely to take stroke patients to a hospital. KAP of high school Nepalese students regarding stroke was satisfactory, and the students having knowledge about the risk factors and warning symptoms were more likely to take stroke patients to a hospital. However, a few misconceptions persisted.

Temporal trends in stroke incidence in South Asian, Chinese and white patients: A population based analysis.

PubMed

Khan, Nadia A; McAlister, Finlay A; Pilote, Louise; Palepu, Anita; Quan, Hude; Hill, Michael D; Fang, Jiming; Kapral, Moira K

2017-01-01

Little is known about potential ethnic differences in stroke incidence. We compared incidence and time trends of ischemic stroke and primary intracerebral hemorrhage in South Asian, Chinese and white persons in a population-based study. Population based census and administrative data analysis in the provinces of Ontario and British Columbia, Canada using validated ICD 9/ICD 10 coding for acute ischemic and hemorrhagic stroke (1997-2010). There were 3290 South Asians, 4444 Chinese and 160944 white patients with acute ischemic stroke and 535 South Asian, 1376 Chinese and 21842 white patients with intracerebral hemorrhage. South Asians were younger than whites at onset of stroke (70 vs. 74 years for ischemic and 67 vs. 71 years for hemorrhagic stroke). Age and sex adjusted ischemic stroke incidence in 2010 was 43% lower in Chinese and 63% lower in South Asian than in White patients. Age and sex adjusted intracerebral hemorrhage incidence was 18% higher in Chinese patients, and 66% lower in South Asian relative to white patients. Stroke incidence declined in all ethnic groups (relative reduction 69% in South Asians, 25% in Chinese, and 34% in white patients for ischemic stroke and for intracerebral hemorrhage, 79% for South Asians, 51% for Chinese and 30% in white patients). Although stroke rates declined across all ethnic groups, these rates differed significantly by ethnicity. Further study is needed to understand mechanisms underlying the higher ischemic stroke incidence in white patients and intracerebral hemorrhage in Chinese patients.

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

PubMed Central

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

2008-01-01

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

Polysomnographic Characteristics of Sleep in Stroke: A Systematic Review and Meta-Analysis

PubMed Central

Baglioni, Chiara; Nissen, Christoph; Schweinoch, Adrian; Riemann, Dieter; Spiegelhalder, Kai; Berger, Mathias; Weiller, Cornelius; Sterr, Annette

2016-01-01

Background Research on sleep after stroke has focused mainly on sleep disordered breathing. However, the extend to which sleep physiology is altered in stroke survivors, how these alterations compare to healthy volunteers, and how sleep changes might affect recovery as well as physical and mental health has yet to be fully researched. Motivated by the view that a deeper understanding of sleep in stroke is needed to account for its role in health and well-being as well as its relevance for recovery and rehabilitation, we conducted a systematic review and meta-analysis of polysomnographic studies comparing stroke to control populations. Method Medline and PsycInfo databases were searched using "stroke" and words capturing polysomnographic parameters as search terms. This yielded 1692 abstracts for screening, with 15 meeting the criteria for systematic review and 9 for meta-analysis. Prisma best practice guidelines were followed for the systematic review; the Comprehensive Meta-Analysis software was used for random effects modelling. Results The meta-analysis revealed that patients with stroke have poorer sleep than controls. Patients had lower sleep efficiency (mean 75% vs 84%), shorter total-sleep-time (309.4 vs 340.3 min) and more wake-after-sleep-onset (97.2 vs 53.8 min). Patients also spend more time in stage 1 (13% vs 10%) and less time in stage 2 sleep (36% vs 45%) and slow-wave-sleep (10% vs 12%). No group differences were identified for REM sleep. The systematic review revealed a strong bias towards studies in the early recovery phase of stroke, with no study reporting specifically on patients in the chronic state. Moreover, participants in the control groups included community samples as well as other patients groups. Conclusions These results indicate poorer sleep in patients with stroke than controls. While strongly suggestive in nature, the evidence base is limited and methodologically diverse, and hands a clear mandate for further research. A particular need regards polysomnographic studies in chronic community-dwelling patients compared to age-matched individuals. PMID:26949966

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.

How is the patient’s nutrition after a stroke?

PubMed

Ballesteros Pomar, María D; Palazuelo Amez, Laura

2017-05-08

Neurological conditions usually cause altered levels of consciousness or swallowing mechanisms which make artificial nutritional support necessary. International guidelines recommend nutritional screening to detect malnutrition in patients with neurological diseases. Dysphagia is a common problem after a stroke, however, it is a treatable pathology, and swallowing rehabilitation allows for improving patients’ nutritional status. Awareness of this problem is required among healthcare professionals both for its diagnosis and for the implementation of nutritional intervention measures. Patients should be tested for dysphagia within the first 24 hours of the stroke onset; this swallowing assessment as well as malnutrition screening should never be delayed by more than 72 hours. The present study addresses diagnostic and therapeutic approaches, the indications of the different nutritional treatments available and the transition to oral feeding in patients who have had a stroke episode.

Holistic concerns of Chinese stroke survivors during hospitalization and in transition to home.

PubMed

Yeung, Siu Ming; Wong, Frances Kam Yuet; Mok, Esther

2011-11-01

This article is a report of a study conducted to explore the phenomenon of concerns as experienced by Chinese stroke survivors during hospitalization and in transition to home. Stroke is characterized by its sudden onset and prolonged residual problems, which affect survivors' holistic well-being. Many studies have focused on stroke consequences and their correlates with psychosocial outcomes. Very little is known about holistic concerns of stroke survivors, particularly in the transition from hospital to home. We used purposive sampling of 15 stroke survivors who participated in semi-structured interviews after being discharged from stroke wards of a general hospital in Hong Kong from November 2008 to February 2009. The interviews were transcribed verbatim and analysed using Giorgi's phenomenological techniques. Stroke survivors' physical, psychological, socio-cultural and spiritual concerns in hospital and transition to home emerged from the data analysis. The four major themes identified were: (a) dynamic interplay of holistic concerns, (b) cultural expression of illness experiences, (c) social support 'paradox' and (d) caring gaps in clinical management. Understanding the interwoven holistic concerns for the stroke survivors in hospital and after discharged home can help nurses to identify their health needs and plan for appropriate nursing interventions. The findings provide guidance for the development of culture-sensitive holistic care interventions with family involvement in Chinese stroke populations. © 2011 The Authors. Journal of Advanced Nursing © 2011 Blackwell Publishing Ltd.

Atrial fibrillation and risk of stroke in dialysis patients.

PubMed

Wetmore, James B; Ellerbeck, Edward F; Mahnken, Jonathan D; Phadnis, Milind; Rigler, Sally K; Mukhopadhyay, Purna; Spertus, John A; Zhou, Xinhua; Hou, Qingjiang; Shireman, Theresa I

2013-03-01

Both stroke and chronic atrial fibrillation (AF) are common in dialysis patients, but uncertainty exists in the incidence of new strokes and the risk conferred by chronic AF. A cohort of dually eligible (Medicare and Medicaid) incident dialysis patients was constructed. Medicare claims were used to determine the onset of chronic AF, which was specifically treated as a time-dependent covariate. Cox proportional hazards models were used to model time to stroke. Of 56,734 patients studied, 5629 (9.9%) developed chronic AF. There were 22.8 ischemic and 5.0 hemorrhagic strokes per 1000 patient-years, a ratio of approximately 4.5:1. Chronic AF was independently associated with time to ischemic (hazard ratio [HR], 1.26; 99% confidence interval [CI], 1.06-1.49; P = .0005), but not hemorrhagic, stroke. Race was strongly associated with hemorrhagic stroke: African Americans (HR, 1.46; 99% CI, 1.08-1.96), Hispanics (HR, 1.64; 99% CI, 1.16-2.31), and others (HR, 1.76; 99% CI, 1.16-2.78) had higher rates than did Caucasians (all P < .001). Chronic AF has a significant, but modest, association with ischemic stroke. Race/ethnicity is strongly associated with hemorrhagic strokes. The proportion of strokes owing to hemorrhage is much higher than in the general population. Copyright © 2013 Elsevier Inc. All rights reserved.

White matter injury induced by diabetes in acute stroke is clinically relevant: A preliminary study.

PubMed

Yu, Xinfeng; Song, Ruirui; Jiaerken, Yerfan; Yuan, Lixia; Huang, Peiyu; Lou, Min; Jiang, Quan; Zhang, Minming

2017-01-01

The importance of white matter injury induced by diabetes in stroke severity and prognosis is largely unknown. We aimed to investigate the relationship between diabetes-related white matter injury beyond stroke lesions with acute neurological deficits and clinical outcome after stroke. In total, 36 stroke patients within 3-7 days after onset were enrolled. Neurological deficits on admission were assessed by National Institute of Health Stroke Score, and poor outcome at 3 months was defined as modified Rankin score >2. White matter tracts were compared between patients with diabetic and non-diabetic stroke using fractional anisotropy from diffusion tensor imaging. Regional white matter abnormality with decreased fractional anisotropy was observed in diabetic patients (n = 18) when compared to non-diabetic patients (n = 18). Decreased fractional anisotropy in ipsilesional distal corticospinal tract was independently associated with higher National Institute of Health Stroke Score motor component score (β = -0.444, p = 0.005), and decreased fractional anisotropy in contralesional superior longitudinal fasciculus I was independently related to poor outcome (odds ratio, 0.900; p = 0.033). Our findings suggested that only white matter injury induced by diabetes in specific tracts like corticospinal tract and superior longitudinal fasciculus beyond stroke lesions has clinically relevant, providing insight into the mechanism of stroke recovery under the diabetic condition. © The Author(s) 2016.

Current status of stroke epidemiology in Greece: a panorama.

PubMed

Vasiliadis, Angelo V; Zikić, Milorad

2014-01-01

Although strokes have been documented since about 3 millennia, they remain today as one of the leading causes of mortality, as well as of subsequent serious long-term physical and mental morbidity, among patients in many different countries all over the world. Greece presents an increase in mortality rates according to World Health Organization, and this fact underlines the need for early diagnosis and treatment, as well as, the need to implement effective prevention strategies for strokes. This review makes an effort to describe the current status of stroke epidemiological features, as well as to present the risk factors prevalent in Greece. The incidence rate is 261-319/100,000 based on the recent population based registry. Stroke appears to be more prevalent in men than in women, and the mean age of stroke onset in Greece is at 70 years of age. Hypertension, atrial fibrillation, dyslipidaemia and diabetes mellitus are the major risk factors of stroke in the Greek population, while smoking is the most commonly documented modifiable risk factor in young adults with ischemic stroke. Similar to other parts of the world, ischemic stroke is the most common stroke type. The 28-day case fatality rate for men and women was 26.5%. The mean in-hospital cost per stroke patient was 3624.9 € and the mean rehabilitation cost of outpatients with stroke was 5553.3 €, while the cost proportion of hemorrhagic stroke is higher when compared to ischemic stroke. Stroke is a devastating condition with recognized challenges in identifying effective prevention programs. In Greece, limited data exists regarding the epidemiology of strokes. As a result, the need to conduct new studies and researches across the country is well documented. Copyright © 2014 Polish Neurological Society. Published by Elsevier Urban & Partner Sp. z o.o. All rights reserved.

Preferential location for arterial dissection presenting as golf-related stroke.

PubMed

Choi, M H; Hong, J M; Lee, J S; Shin, D H; Choi, H A; Lee, K

2014-02-01

Golf-related stroke has not been systematically reviewed. The purpose of our study was to describe in detail this particular stroke syndrome. Seven patients were analyzed at a university hospital and 7 patients were reviewed from MEDLINE literature. General demographics, symptom onset, neurologic signs, radiologic findings, and outcome were investigated. A total of 14 patients including 7 patients from the MEDLINE search were analyzed; all were men, with a mean age of 46.9 ± 12.8 years. Symptom onset was classified as during the golf swing (n = 9), unknown (n = 3), and after playing golf (n = 2). Most patients (n = 12) showed involvement of the vertebral artery and 2 patients showed involvement of the internal carotid artery (P = .008). Nine dissections were found on the right side, 3 on the left side, and 2 were bilateral (P = .046). Twelve patients had extracranial involvement and 2 patients had intracranial involvement (P = .008). Seven patients returned to normal, 5 returned to independence, 1 had unknown status, and 1 died. The anatomic preference of golf-related craniocervical arterial dissection is associated with the extracranial and vertebrobasilar system with a right-sided tendency as the result of stereotypical rotational movement during a golf swing.

Association between atherogenic dyslipidemia and recurrent stroke risk in patients with different subtypes of ischemic stroke.

PubMed

Zhao, Lu; Wang, Ruihao; Song, Bo; Tan, Song; Gao, Yuan; Fang, Hui; Lu, Jie; Xu, Yuming

2015-07-01

The association between atherogenic dyslipidemia and stroke recurrence remains unclear, and may be influenced by different subtypes of ischemic stroke. We aimed to investigate whether atherogenic dyslipidemia contributed to stroke recurrence in ischemic stroke patients and in those with certain subtypes of ischemic stroke. We conducted a prospective hospital-based study enrolling patients with acute ischemic stroke. Atherogenic dyslipidemia was defined as high-density lipoprotein cholesterol <40 mg/dl and triglycerides ≥200 mg/dl. Ischemic stroke subtypes were classified according to the Trial of Org 10172 in Acute Stroke Treatment criteria. The patients were followed up at 3, 6, 12 and 24 months after stroke onset. The association between atherogenic dyslipidemia and stroke recurrence was analyzed by using multivariable Cox regression model. In the 510 ischemic stroke patients, 64 patients (12·5%) had atherogenic dyslipidemia, and 66 patients (12·9%) experienced stroke recurrence events within 24 months. Kaplan-Meier analysis revealed that stroke recurrence rate was significantly higher in patients with atherogenic dyslipidemia than those without in all the stroke patients (20·3% vs. 11·9%; P = 0·048), and more evident in those of large-artery atherosclerosis subtype (31·0% vs. 14·1%; P = 0·014), but not in the other subtypes. Multivariable Cox regression analysis revealed that atherogenic dyslipidemia was associated with higher stroke recurrence risk among stroke patients of large-artery atherosclerosis subtype (hazard ratio, 2·79; 95% confidence interval, 1·24-6·28), but not significant in all the stroke patients (hazard ratio, 1·69; 95% confidence interval, 0·85-3·37). Atherogenic dyslipidemia is associated with higher risk of stroke recurrence in ischemic stroke patients. Such association might be more pronounced in large-artery atherosclerosis subtype and needs further investigation to establish such relationship. © 2015 World Stroke Organization.

A Mitochondrial Disorder in a Middle Age Iranian Patient: Report of a Rare Case

PubMed Central

Almasi, Mostafa; Motamed, Mohammad Reza; Mehrpour, Masoud; Haghi-Ashtiani, Bahram; Haji Akhondi, Fahimeh; Nilipour, Yalda; Fereshtehnejad, Seyed-Mohammad

2017-01-01

Introduction: Mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) can involve multiple systems and cause stroke-like episodes and status epilepticus. Case Presentation: A 48-year-old female with history of early fatigability, migraine-type headaches, and bilateral sensory-neural hearing loss presented 3 episodes of serial seizures. On admission she was affected by Wernicke aphasia and, then, right hemiparesis. Investigations showed elevated arterial lactate and ragged red fibers on muscle biopsy. Conclusion: Though more commonly diagnosed during childhood, some cases of adult-onset MELAS syndrome are reported. This syndrome should be considered in patients with stroke-like events in adults without cerebrovascular risk factors and difficult-to-treat seizures. PMID:29158884

Poststroke delusions: What about the neuroanatomical and neurofunctional basis?

PubMed

Torrisi, Michele; De Luca, Rosaria; Pollicino, Patrizia; Leonardi, Simona; Marino, Silvia; Maresca, Giuseppa; Maggio, Maria Grazia; Piccolo, Adriana; Bramanti, Placido; Calabrò, Rocco Salvatore

2018-01-19

Delusion is a belief about yourself, people, or events that has no accordance with reality. Although it is known that stroke could cause various psychiatric and psychological effects, including depression, anxiety, and aggressiveness, psychotic symptoms, especially delusions, are rather uncommon. The most investigated poststroke delusions are paranoid type, nihilistic, and Fregoli syndrome. We will describe two patients showing delusion symptoms (Cotard-like and erotomanic ones) that occurred after a stroke involving the right temporal lobe, the basal ganglia and insular region, persisting for a long period after the stroke onset. We have, therefore, supposed that the simultaneous involvement of these brain areas could be involved in the neuroanatomical basis of delusions, as also demonstrated by the neurofunctional evaluation.

Thyroid storm with multiple organ failure, disseminated intravascular coagulation, and stroke with a normal serum FT3 level.

PubMed

Harada, Yuko; Akiyama, Hisanao; Yoshimoto, Tatsuji; Urao, Yasuko; Ryuzaki, Munekazu; Handa, Michiko

2012-01-01

Thyroid storm is a rare disorder with a sudden onset, rapid progression and high mortality. We experienced a case of thyroid storm which had a devastating course, including multiple organ failure (MOF), severe hypoglycemia, disseminated intravascular coagulation (DIC), and stroke. It was difficult to make a diagnosis of thyroid storm in the present patient, because she did not have a history of thyroid disease and her serum FT3 level was normal. Clinicians should be aware that thyroid storm can occur even when there is an almost normal level of thyroid hormones, and that intensive anticoagulation is required for patients with atrial fibrillation to prevent stroke after thyroid storm.

Antithrombotic and Thrombolytic Therapy for Ischemic Stroke

PubMed Central

Lansberg, Maarten G.; O’Donnell, Martin J.; Khatri, Pooja; Lang, Eddy S.; Nguyen-Huynh, Mai N.; Schwartz, Neil E.; Sonnenberg, Frank A.; Schulman, Sam; Vandvik, Per Olav; Spencer, Frederick A.; Alonso-Coello, Pablo; Guyatt, Gordon H.

2012-01-01

Objectives: This article provides recommendations on the use of antithrombotic therapy in patients with stroke or transient ischemic attack (TIA). Methods: We generated treatment recommendations (Grade 1) and suggestions (Grade 2) based on high (A), moderate (B), and low (C) quality evidence. Results: In patients with acute ischemic stroke, we recommend IV recombinant tissue plasminogen activator (r-tPA) if treatment can be initiated within 3 h (Grade 1A) or 4.5 h (Grade 2C) of symptom onset; we suggest intraarterial r-tPA in patients ineligible for IV tPA if treatment can be initiated within 6 h (Grade 2C); we suggest against the use of mechanical thrombectomy (Grade 2C) although carefully selected patients may choose this intervention; and we recommend early aspirin therapy at a dose of 160 to 325 mg (Grade 1A). In patients with acute stroke and restricted mobility, we suggest the use of prophylactic-dose heparin or intermittent pneumatic compression devices (Grade 2B) and suggest against the use of elastic compression stockings (Grade 2B). In patients with a history of noncardioembolic ischemic stroke or TIA, we recommend long-term treatment with aspirin (75-100 mg once daily), clopidogrel (75 mg once daily), aspirin/extended release dipyridamole (25 mg/200 mg bid), or cilostazol (100 mg bid) over no antiplatelet therapy (Grade 1A), oral anticoagulants (Grade 1B), the combination of clopidogrel plus aspirin (Grade 1B), or triflusal (Grade 2B). Of the recommended antiplatelet regimens, we suggest clopidogrel or aspirin/extended-release dipyridamole over aspirin (Grade 2B) or cilostazol (Grade 2C). In patients with a history of stroke or TIA and atrial fibrillation we recommend oral anticoagulation over no antithrombotic therapy, aspirin, and combination therapy with aspirin and clopidogrel (Grade 1B). Conclusions: These recommendations can help clinicians make evidence-based treatment decisions with their patients who have had strokes. PMID:22315273

Autologous intravenous bone marrow mononuclear cell therapy for patients with subacute ischaemic stroke: A pilot study

PubMed Central

Prasad, Kameshwar; Mohanty, Sujata; Bhatia, Rohit; Srivastava, M.V.P.; Garg, Ajay; Srivastava, Achal; Goyal, Vinay; Tripathi, Manjari; Kumar, Amit; Bal, Chandrashekar; Vij, Aarti; Mishra, Nalini Kant

2012-01-01

Background & objectives: Bone marrow mononuclear cell therapy has emerged as one of the option for the treatment of Stroke. Several preclinical studies have shown that the treatment with mononuclear cell (MNCs) can reduce the infarct size and improve the functional outcome. We evaluated the feasibility, safety and clinical outcome of administering bone marrow mononuclear cell (MNCs) intravenously to patients with subacute ischaemic stroke. Methods: In a non-randomized phase-I clinical study, 11 consecutive, eligible and consenting patients, aged 30-70 yr with ischaemic stroke involving anterior circulation within 7 to 30 days of onset of stroke were included. Bone marrow was aspirated from iliac crest and the harvested mononuclear cells were infused into antecubital vein. Outcomes measured for safety included immediate reactions after cell infusion and evidence of tumour formation at one year in whole body PET scan. Patients were followed at week 1, 4-6, 24 and 52 to determine clinical progress using National Institute of Health Stroke Scale (NIHSS), Barthel Index (BI), modified Rankin Scale (mRS), MRI, EEG and PET. Feasibility outcomes included target-dose feasibility. Favourable clinical outcome was defined as mRS score of 2 or less or BI score of 75 to 100 at six months after stem cell therapy. Results: Between September 2006 and April 2007, 11 patients were infused with bone-marrow mononuclear cells (mean 80 million with CD-34+ mean 0.92 million). Protocol was target-dose feasible in 9 patients (82%). FDG-PET scan at 24 and 52 wk in nine patients did not reveal evidence of tumour formation. Seven patients had favourable clinical outcome. Interpretation & conclusions: Intravenous bone marrow mononuclear cell therapy appears feasible and safe in patients with subacute ischaemic stroke. Further, a randomized controlled trial to examine its efficacy is being conducted. PMID:22960888

Feedback-controlled robotics-assisted treadmill exercise to assess and influence aerobic capacity early after stroke: a proof-of-concept study.

PubMed

Stoller, Oliver; Schindelholz, Matthias; Bichsel, Lukas; Schuster, Corina; de Bie, Rob A; de Bruin, Eling D; Hunt, Kenneth J

2014-07-01

The majority of post-stroke individuals suffer from low exercise capacity as a secondary reaction to immobility. The aim of this study was to prove the concept of feedback-controlled robotics-assisted treadmill exercise (RATE) to assess aerobic capacity and guide cardiovascular exercise in severely impaired individuals early after stroke. Subjects underwent constant load and incremental exercise testing using a human-in-the-loop feedback system within a robotics-assisted exoskeleton (Lokomat, Hocoma AG, CH). Inclusion criteria were: stroke onset ≤8 weeks, stable medical condition, non-ambulatory status, moderate motor control of the lower limbs and appropriate cognitive function. Outcome measures included oxygen uptake kinetics, peak oxygen uptake (VO2peak), gas exchange threshold (GET), peak heart rate (HRpeak), peak work rate (Ppeak) and accuracy of reaching target work rate (P-RMSE). Three subjects (18-42 d post-stroke) were included. Oxygen uptake kinetics during constant load ranged from 42.0 to 60.2 s. Incremental exercise testing showed: VO2peak range 19.7-28.8 ml/min/kg, GET range 11.6-12.7 ml/min/kg, and HRpeak range 115-161 bpm. Ppeak range was 55.2-110.9 W and P-RMSE range was 3.8-7.5 W. The concept of feedback-controlled RATE for assessment of aerobic capacity and guidance of cardiovascular exercise is feasible. Further research is warranted to validate the method on a larger scale. Aerobic capacity is seriously reduced in post-stroke individuals as a secondary reaction to immobility. Robotics-assisted walking devices may have substantial clinical relevance regarding assessment and improvement of aerobic capacity early after stroke. Feedback-controlled robotics-assisted treadmill exercise represents a new concept for cardiovascular assessment and intervention protocols for severely impaired individuals.

Association of Elevated High Sensitivity Cardiac Troponin T(hs-cTnT) Levels with Hemorrhagic Transformation and 3-Month Mortality in Acute Ischemic Stroke Patients with Rheumatic Heart Disease in China

PubMed Central

Xiong, Yao; Liu, Bian; Hao, Zilong; Tao, Wendan; Liu, Ming

2016-01-01

Background and Objective Elevated levels of high sensitivity cardiac troponin T (hs-cTnT) occur in a substantial proportion of patients with acute ischemic stroke (AIS) and can predict poor outcome and mortality after stroke. Whether elevated hs-cTnT levels can also predict hemorrhagic transformation (HT) or prognosis in AIS patients with rheumatic heart disease (RHD) remains unclear. Methods Data from the Chengdu Stroke Registry on consecutive AIS patients with RHD admitted to West China Hospital within1 month of stroke onset from October 2011 to February 2014 were examined. Clinico-demographic characteristics, HT, functional outcomes and stroke recurrence were compared between patients with elevated hs-cTnT levels(≥14ng/L) and patients with normal hs-cTnT levels (<14ng/L). Results The final analysis involved 84 patients (31 males; mean age, 61.6±12.2years), of whom serum hs-cTnT levels were elevated in 58.3%. Renal impairment was independently associated with elevated hs-cTnT levels (OR 4.184, 95%CI 1.17 to 15.01, P = 0.028), and patients with elevated hs-cTnT levels were at significantly higher risk of HT, 3-month mortality and 3-month disability/mortality (all P≤0.029). After controlling for age, sex, hypertension, renal impairment and National Institutes of Health Stroke Scale score on admission, the risk of HT and 3-month mortality was, respectively, 4.0- and 5.5-fold higher in patients with elevated hs-cTnT levels than in patients with normal hs-cTnT levels. Conclusion Elevated hs-cTnT levels are independently associated with HT and 3-month mortality in AIS patients with RHD. These results with a small cohort should be verified and extended in large studies. PMID:26849554

Post-stroke social networks, depressive symptoms, and disability in Tanzania: A prospective study.

PubMed

Saadi, Altaf; Okeng'o, Kigocha; Biseko, Maijo R; Shayo, Agness F; Mmbando, Theoflo N; Grundy, Sara J; Xu, Ai; Parker, Robert A; Wibecan, Leah; Iyer, Geetha; Onesmo, Peter M; Kapina, Boniphace N; Regenhardt, Robert W; Mateen, Farrah J

2018-01-01

Background Evidence suggests that social networks improve functional recovery after stroke, but this work has not been extended to low- and middle-income countries (LMICs). Post-stroke depression interferes with functional outcome but is understudied in LMICs. Aims To determine the relationships between social networks, disability, and depressive symptoms in patients surviving 90-days post-stroke in Dar es Salaam, Tanzania. Methods Participants ≥ 18 years, admitted ≤ 14 days of stroke onset, were enrolled. Disability was measured using the modified Rankin Scale, social networks by the Berkman-Syme social network index, and depressive symptoms by the Patient Health Questionnaire-9 (PHQ-9) by telephone interview at 90 days. A Kruskal-Wallis test or Spearman's correlation coefficient was used to assess the associations between social networks, depressive symptoms, and disability. Results Of 176 participants, 43% (n = 75) died, with an additional 11% (n = 20) lost to follow-up by 90 days. Among 81 survivors, 94% (n = 76, 57% male, average age 54 years) had complete information on all scales (mean and median follow-up time of 101 and 88 days). Thirty percent (n = 23, 41.9%, 95% confidence interval 20.2) had at least mild depressive symptoms (PHQ-9 ≥ 5 points). Nearly two-thirds (n = 46, 61%) reported ≥ 3 close friends. A higher social network index score was associated with fewer depressive symptoms (p < 0.0001) and showed a trend towards significance with lower disability (p = 0.061). Higher depressive symptom burden was correlated with higher disability (r = 0.52, p < 0.0001). Conclusion Post-stroke social isolation is associated with more depressive symptoms in Tanzania. Understanding social networks and the associated mechanisms of recovery in stroke is especially relevant in the context of limited resources.

The Field Assessment Stroke Triage for Emergency Destination (FAST-ED): a Simple and Accurate Pre-Hospital Scale to Detect Large Vessel Occlusion Strokes

PubMed Central

Lima, Fabricio O.; Silva, Gisele S.; Furie, Karen L.; Frankel, Michael R.; Lev, Michael H.; Camargo, Érica CS; Haussen, Diogo C.; Singhal, Aneesh B.; Koroshetz, Walter J.; Smith, Wade S.; Nogueira, Raul G.

2016-01-01

Background and Purpose Patients with large vessel occlusion strokes (LVOS) may be better served by direct transfer to endovascular capable centers avoiding hazardous delays between primary and comprehensive stroke centers. However, accurate stroke field triage remains challenging. We aimed to develop a simple field scale to identify LVOS. Methods The FAST-ED scale was based on items of the NIHSS with higher predictive value for LVOS and tested in the STOPStroke cohort, in which patients underwent CT angiography within the first 24 hours of stroke onset. LVOS were defined by total occlusions involving the intracranial-ICA, MCA-M1, MCA-2, or basilar arteries. Patients with partial, bi-hemispheric, and/or anterior + posterior circulation occlusions were excluded. Receiver operating characteristic (ROC) curve, sensitivity, specificity, positive (PPV) and negative predictive values (NPV) of FAST-ED were compared with the NIHSS, Rapid Arterial oCclusion Evaluation (RACE) scale and Cincinnati Prehospital Stroke Severity Scale (CPSSS). Results LVO was detected in 240 of the 727 qualifying patients (33%). FAST-ED had comparable accuracy to predict LVO to the NIHSS and higher accuracy than RACE and CPSS (area under the ROC curve: FAST-ED=0.81 as reference; NIHSS=0.80, p=0.28; RACE=0.77, p=0.02; and CPSS=0.75, p=0.002). A FAST-ED ≥4 had sensitivity of 0.60, specificity 0.89, PPV 0.72, and NPV 0.82 versus RACE ≥5 of 0.55, 0.87, 0.68, 0.79 and CPSS ≥2 of 0.56, 0.85, 0.65, 0.78, respectively. Conclusions FAST-ED is a simple scale that if successfully validated in the field may be used by medical emergency professionals to identify LVOS in the pre-hospital setting enabling rapid triage of patients. PMID:27364531

Protocol for a prospective interventional trial to develop a diagnostic index test for stroke as a cause of vertigo, dizziness and imbalance in the emergency room (EMVERT study)

PubMed Central

Bardins, Stanislavs; Müller, Hans-Helge; Jahn, Klaus; Zwergal, Andreas

2017-01-01

Introduction Identifying stroke as a cause of acute vertigo, dizziness and imbalance in the emergency room is still a clinical challenge. Many patients are admitted to stroke units, but only a minority will have strokes. This imposes a heavy financial burden on the healthcare system. The aim of this study is to develop a diagnostic index test to identify patients with a high risk of having a stroke as the cause of acute vertigo and imbalance. Methods and analysis Patients with acute onset of vertigo, dizziness, postural imbalance or double vision within the last 24 hours lasting for at least 10 min are eligible to be included in the study. Patients with clinically proven peripheral or central aetiology will be excluded. In the emergency room, all enrolled patients will undergo standardised neuro-ophthalmological/physiological testing (including video-oculography, mobile posturography, measurement of subjective visual vertical) (EMVERT block 1). Within 10 days, standardised MRI will be performed as a reference test to identify stroke (EMVERT block 2). Data from EMVERT block 2 will be compared with results from block 1 in order to devise a diagnostic index test with a high specificity and sensitivity to predict the risk of stroke in the emergency room. Ethics and dissemination The study was approved by the ethics committee of the University of Munich and will be conducted according to the Guideline for Good Clinical Practice, the Federal Data Protecting Act and the Helsinki Declaration of the World Medical Association in its recent version. Study results are expected to be published in international peer-reviewed journals and will be presented at international conferences. Trial registration number German Clinical Trial Register: DRKS00008992; Universal trial number: U1111-1172-8719); pre-results. PMID:29018076

Is Technologist Review of Raw Data Necessary after Home Studies for Sleep Apnea?

PubMed Central

Brown, Devin L.; Chervin, Ronald D.; Hegeman, Garnett; Smith, Melinda A.; Garcia, Nelda M.; Morgenstern, Lewis B.; Lisabeth, Lynda D.

2014-01-01

Study Objectives: As the importance of portable monitors for detection of sleep apnea increases, efficient and cost-minimizing methods for data interpretation are needed. We sought to compare in stroke patients, for whom portable studies often have particular advantages, results from a cardiopulmonary monitoring device with and without manual edits by a polysomnographic technologist. Methods: Participants in an ongoing stroke surveillance study in Corpus Christi, Texas, underwent sleep apnea assessments with the ApneaLink Plus device within 45 days of stroke onset. Recordings were analyzed by the device's software unedited, and again after edits were made to the raw data by a registered polysomnographic technologist. Sensitivity and specificity were calculated, with the edited data as the reference standard. Sleep apnea was defined by 3 different apnea-hypopnea index (AHI) thresholds: ≥ 5, ≥ 10, and ≥ 15. Results: Among 327 subjects, 54% were male, 59% were Hispanic, and the median age was 65 years (interquartile range: 57, 77). The median AHI for the unedited data was 9 (4, 22), and for the edited data was 13 (6, 27) (p < 0.01). Specificity was above 98% for each AHI cutoff, while sensitivity was 81% to 82%. For each cutoff threshold, the edited data yielded a higher proportion of positive sleep apnea screens (p < 0.01) by approximately 10% in each group. Conclusions: For stroke patients assessed with a cardiopulmonary monitoring device, manual editing by a technologist appears likely to improve sensitivity, whereas specificity of unedited data is already excellent. Citation: Brown DL; Chervin RD; Hegeman G; Smith MA; Garcia NM; Morgenstern LB; Lisabeth LD. Is technologist review of raw data necessary after home studies for sleep apnea? J Clin Sleep Med 2014;10(4):371-375. PMID:24733981

Evaluation of acute ischemic stroke using quantitative EEG: a comparison with conventional EEG and CT scan.

PubMed

Murri, L; Gori, S; Massetani, R; Bonanni, E; Marcella, F; Milani, S

1998-06-01

The sensitivity of quantitative electroencephalogram (EEG) was compared with that of conventional EEG in patients with acute ischaemic stroke. In addition, a correlation between quantitative EEG data and computerized tomography (CT) scan findings was carried out for all the areas of lesion in order to reassess the actual role of EEG in the evaluation of stroke. Sixty-five patients were tested with conventional and quantitative EEG within 24 h from the onset of neurological symptoms, whereas CT scan was performed within 4 days from the onset of stroke. EEG was recorded from 19 electrodes placed upon the scalp according to the International 10-20 System. Spectral analysis was carried out on 30 artefact-free 4-sec epochs. For each channel absolute and relative power were calculated for the delta, theta, alpha and beta frequency bands and such data were successively represented in colour-coded maps. Ten patients with extensive lesions documented by CT scan were excluded. The results indicated that conventional EEG revealed abnormalities in 40 of 55 cases, while EEG mapping showed abnormalities in 46 of 55 cases: it showed focal abnormalities in five cases and nonfocal abnormalities in one of six cases which had appeared to be normal according to visual inspection of EEG. In a further 11 cases, where the conventional EEG revealed abnormalities in one hemisphere, the quantitative EEG and maps allowed to further localize abnormal activity in a more localized way. The sensitivity of both methods was higher for frontocentral, temporal and parieto-occipital cortical-subcortical infarctions than for basal ganglia and internal capsule lesions; however, quantitative EEG was more efficient for all areas of lesion in detecting cases that had appeared normal by visual inspection and was clearly superior in revealing focal abnormalities. When we considered the electrode related to which the maximum power of the delta frequency band is recorded, a fairly close correlation was found between the localization of the maximum delta power and the position of lesions documented by CT scan for all areas of lesion excepting those located in the striatocapsular area.

Brain activation during a linguistic task in conduction aphasia.

PubMed

Demeurisse, G; Capon, A

1991-06-01

In order to investigate functional cortical reorganization during recovery from conduction aphasia, regional cerebral blood flows (rCBF) were measured by the two-dimensional 133 Xenon inhalation method in ten stroke patients. rCBF measurements were performed at rest and during the performance of a linguistic task, one month and three months after onset. The analysis of flow changes from rest to test condition indicates an increasing contribution of the right hemisphere as time goes on. The absence of flow increase in Broca's region suggests that this region is definitively disconnected from posterior language "centers" by the arcuate fasciculus lesion.

Nursing care for stroke patients: A survey of current practice in 11 European countries.

PubMed

Tulek, Zeliha; Poulsen, Ingrid; Gillis, Katrin; Jönsson, Ann-Cathrin

2018-02-01

To conduct a survey of the clinical nursing practice in European countries in accordance with the European Stroke Strategies 2006 and to examine to what extent the European Stroke Strategies have been implemented in stroke care nursing in Europe. Stroke is a leading cause of death and disability globally. Optimal organisation of interdisciplinary stroke care is expected to ameliorate outcome after stroke. Consequently, universal access to stroke care based on evidence-based guidelines is a priority. This study is a descriptive cross-sectional survey. A questionnaire comprising 61 questions based on the European Stroke Strategies and scientific evidence in nursing practice was distributed to representatives of the European Association of Neuroscience Nurses, who sent the questionnaire to nurses active in stroke care. The questionnaire covered the following areas of stroke care: organisation of stroke services, management of acute stroke and prevention including basic care and nursing, and secondary prevention. Ninety-two nurses in stroke care in 11 European countries participated in the survey. Within the first 48 hr after stroke onset, 95% monitor patients regularly, 94% start mobilisation after 24 hr when patients are stable, and 89% assess patients' ability to swallow. Change of position for immobile patients is followed by 73%, and postvoid residual urine volume is measured by 85%. Some aspects needed improvement, for example, staff education (70%), education for patients/families/carers (55%) and individual care plans in secondary prevention (62%). The participating European countries comply well with the European Stroke Strategies guidelines, particularly in the acute stroke care, but not all stroke units have reached optimal development in all aspects of stroke care nursing. Our study may provide clinical administrators and nurses in stroke care with information that may contribute to improved compliance with the European Stroke Strategies and evidence-based guidelines. © 2017 John Wiley & Sons Ltd.

Coronary atherosclerosis and adverse outcomes in patients with recent-onset atrial fibrillation and troponin rise.

PubMed

Conti, Alberto; Angeli, Elena; Scorpiniti, Margherita; Alesi, Andrea; Trausi, Federica; Lazzeretti, Delia; Padeletti, Luigi; Gensini, Gian Franco

2015-10-01

The relationship between troponin and atrial fibrillation (AF) without acute coronary syndrome is still unclear. We sought to investigate the presence of coronary atherosclerosis and adverse outcomes in patients with AF. Consecutive patients with recent-onset AF and without severe comorbidities were enrolled between 2004 and 2013. Patients with a troponin rise or with adverse outcomes were considered for coronary angiography and revascularization when "critical" stenosis (≥70%) was recognized. Propensity score matching was performed to adjust for baseline characteristics; after matching, no differences existed between the groups of patients with or without troponin rise. The primary end point was the composite of acute coronary syndrome, revascularization, and cardiac death at 1- and 12-month follow-ups. Of 3627 patients enrolled, 3541 completed the study; 202 (6%) showed troponin rise; and 91 (3%), an adverse outcome. In the entire cohort, on multivariate analysis, the odds ratio for the occurrence of the primary end point of troponin rise was 14 (95% confidence interval [CI], 10-23; P<.001), and that of known coronary artery disease was 3 (CI, 2-5; P=.001). In the matching cohort, the odds ratio of troponin rise was 10 (CI, 4-22; P<.001), and that of TIMI score greater than 2 was 4 (CI, 2-9; P≤.001). In the entire cohort, patients with or without troponin rise achieved the primary end point in 38 (19%) and 43 (1%) patients, respectively (P<.001). Stroke occurred in 4 (2%) and 20 (1%), respectively (P=.018). Critical stenosis and revascularization account for 23 (12%) and 15 (1%), respectively (P<.001). In the matching cohort, results were confirmed, but incidence of stroke was comparable. Patients with recent-onset AF and troponin rise showed higher prevalence of coronary atherosclerosis and adverse cardiac events. Stroke per se did not succeed in justifying the high morbidity. Thus, beyond stroke, coronary atherosclerosis might have a pivotal role in poor outcomes. Copyright © 2015 Elsevier Inc. All rights reserved.

A Decision Analysis of Percutaneous Left Atrial Appendage Occlusion Relative to Novel and Traditional Oral Anticoagulation for Stroke Prevention in Patients with New-Onset Atrial Fibrillation.

PubMed

Micieli, Andrew; Wijeysundera, Harindra C; Qiu, Feng; Atzema, Clare L; Singh, Sheldon M

2016-04-01

Percutaneous left atrial appendage occlusion (LAAO) is a nonpharmacologic approach for stroke prevention in nonvalvular atrial fibrillation (NVAF). No direct comparisons to novel oral anticoagulants (OACs) exists, limiting decision making on the optimal strategy for stroke prevention in NVAF patients. Addressing this gap in knowledge is timely given the recent debate by the US Food and Drug Administration regarding the effectiveness of LAAO. To assess the cost-effectiveness of LAAO and novel OACs relative to warfarin in patients with new-onset NVAF without contraindications to OAC. A cost-utility analysis using a patient-level Markov micro-simulation decision analytic model was undertaken to determine the lifetime costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER) of LAAO and all novel OACs relative to warfarin. Effectiveness and utility data were obtained from the published literature and cost from the Ontario Drug Benefits Formulary and Case Costing Initiative. Warfarin had the lowest discounted QALY (5.13 QALYs), followed by dabigatran (5.18 QALYs), rivaroxaban and LAAO (5.21 QALYs), and apixaban (5.25 QALYs). The average discounted lifetime costs were $15 776 for warfarin, $18 280 for rivaroxaban, $19 156 for apixaban, $20 794 for dabigatran, and $21 789 for LAAO. Apixaban dominated dabigatran and LAAO and demonstrated extended dominance over rivaroxaban. The ICER for apixaban relative to warfarin was $28 167/QALY. Apixaban was preferred in 40.2% of simulations at a willingness-to-pay threshold of $50 000/QALY. Assumptions regarding clinical and methodological differences between published studies of each therapy were minimized. Apixaban is the most cost-effective therapy for stroke prevention in patients with new-onset NVAF without contraindications to OAC. Uncertainty around this conclusion exists, highlighting the need for further research. © The Author(s) 2015.

Amino acid transmitters in patients with headache during the acute phase of cerebrovascular ischemic disease.

PubMed

Castillo, J; Martínez, F; Corredera, E; Aldrey, J M; Noya, M

1995-11-01

The pathophysiology of headache occurring at stroke onset is unknown. Migraine and ischemia share an excessive release of neuroexcitatory amino acids. Inhibitory amino acids also may be implicated in both diseases. We investigated whether fluctuations of these amino acids occur in headache accompanying cerebral infarction. We studied 100 patients with infarction in the territory of the middle cerebral artery. Neurological impairment was assessed using the Canadian Neurological Scale and Barthel Index. Size of infarction was determined with CT. Twenty-eight patients developed headache. Glutamate, aspartate, and taurine were quantified in blood and cerebrospinal fluid (CSF) within 24 hours of stroke onset with cationic exchange chromatography. Stroke subtypes, size of infarct on CT, and clinical scales were similar in patients with and without headache. Plasma glutamate level was 321.14 +/- 149.53 mumol/L in patients with headache and 233 +/- 107.23 mumol/L in those without headache (P < .005). Glutamate in CSF was higher in patients with headache (4.6 +/- 1.49 mumol/L) than in patients without headache (3.11 +/- 1.18 mumol/L) (P < .001). Aspartate concentrations in plasma and CSF were similar in both groups. Taurine concentrations in plasma were 103.10 +/- 52.82 mumol/L and 177.49 +/- 90.92 mumol/L in headache and nonheadache patients, respectively (P < .001). Taurine levels in CSF were 5.42 +/- 2.42 mumol/L in patients with headache and 9.27 +/- 5.31 mumol/L in those without headache (P < .001). No significant correlation was found between amino acid levels in plasma or CSF and size of infarction. Amino acid neurotransmitters play a role in the pathophysiology of headache that occurs at the onset of stroke. The ischemic penumbral area, more than the infarction itself, may cause a state of cortical hyperexcitability that would be responsible for the cortical release of amino acids and the induction of headache by altering pain perception mechanisms.

Co-morbid conditions in use of recombinant tissue plasminogen activator (rt-PA) for the treatment of acute ischaemic stroke.

PubMed

Nathaniel, Thomas I; Cochran, Thomas; Chaves, Jose; Fulmer, Eric; Sosa, Crystal; Yi, Sara; Fredwall, Megan; Sternberg, Shannon; Blackhurst, Dawn; Nelson, Alfred; Leacock, Rodney

2016-01-01

The objective of this study was to characterize the comorbidities in a population of patients with an acute ischaemic stroke, comparing patients that received recombinant tissue plasminogen activator (rt-PA) to those that did not receive rt-PA. In a retrospective sample of 663 patients admitted for acute ischaemic stroke, this study analysed the effects of co-morbid conditions in the use of rt-PA. It determined non-cerebrovascular risk factors (comorbidities) that differentiate patients who received rt-PA from those who did not receive rt-PA. Patients with a history of carotid stenosis, CHF and previous strokes are significantly (p < 0.05) associated with high risk of not receiving rt-PA. A significant number of patients with a history of hypertension and smoking received rt-PA (p < 0.05). The findings indicate that certain risk factors including carotid stenosis, CHF and previous stroke history impact the treatment of patients with acute ischaemic stroke, specifically the decision to administer rt-PA. Treatment with rt-PA is dependent on stroke severity and onset to treatment time, but the findings suggest that rt-PA use may also depend on patient comorbidities.

An investigation of the use of acupuncture in stroke patients in Taiwan: a national cohort study.

PubMed

Weng, Shu-Wen; Chen, Ta-Liang; Yeh, Chun-Chieh; Liao, Chien-Chang; Lane, Hsin-Long; Lin, Jaung-Geng; Shih, Chun-Chuan

2016-08-26

Acupuncture is considered a complementary and alternative medicine in many countries. The purpose of this study was to report the pattern of acupuncture use and associated factors in patients with stroke. We used claims data from Taiwan's National Health Insurance Research Database and identified 285001 new-onset stroke patients in 2000-2008 from 23 million people allover Taiwan. The use of acupuncture treatment after stroke within one year was identified. We compared sociodemographics, coexisting medical conditions, and stroke characteristics between stroke patients who did and did not receive acupuncture treatment. The use of acupuncture in stroke patients increased from 2000 to 2008. Female gender, younger age, white-collar employee status, higher income, and residence in areas with more traditional Chinese medicine (TCM) physicians were factors associated with acupuncture use in stroke patients. Ischemic stroke (odds ratio [OR] 1.21, 95 % confidence interval [CI] 1.15-1.28), having no renal dialysis (OR 2.76, 95 % CI 2.45-3.13), receiving rehabilitation (OR 3.20, 95 % CI 3.13-3.27) and longer hospitalization (OR 1.23, 95 % CI 1.19-1.27) were also associated with acupuncture use. Stroke patients using rehabilitation services were more likely to have more acupuncture visits and a higher expenditure on acupuncture compared with stroke patients who did not receive rehabilitation services. The application of acupuncture in stroke patients is well accepted and increasing in Taiwan. The use of acupuncture in stroke patients is associated with sociodemographic factors and clinical characteristics.

Serum Uric Acid Levels and Onset of Cardiovascular Diseases: a CALIBER Study

ClinicalTrials.gov

2018-02-06

Stable Angina; Unstable Angina; Myocardial Infarction; Unheralded Coronary Heart Disease Death; Heart Failure; Cardiac Arrest; Transient Ischaemic Attack; Ischemic Stroke; Subarachnoid Hemorrhage; Intracerebral Hemorrhage; Peripheral Arterial Disease; Abdominal Aortic Aneurysm; Atrial Fibrillation

[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.

Association of deep venous thrombosis with calf vein diameter in acute hemorrhagic stroke.

PubMed

Ogata, Toshiyasu; Yasaka, Masahiro; Wakugawa, Yoshiyuki; Kitazono, Takanari; Okada, Yasushi

2013-10-01

We investigated the association between the development of deep venous thrombosis (DVT) and calf vein diameter in patients with acute hemorrhagic stroke. We measured the maximum diameter of paralytic side posttibial veins (PTVs) and peroneal veins (PVs) in 49 patients with intracerebral hemorrhage on admission and at 2 weeks after stroke onset by ultrasonography. We also examined for the presence or absence of DVT, and then analyzed the association of DVT with the maximum vein diameter. At 2 weeks after stroke, DVTs were detected in PTVs in 7 patients and in PVs in 6 patients. The maximum calf vein diameters at 2 weeks were significantly greater in patients with DVT compared with those without DVT (PTV, P = .033; PV, P = .015). Although calf vein diameter at admission did not influence the future incidence of DVT in patients with intracerebral hemorrhage, the presence of DVT was associated with calf vein dilatation. Copyright © 2013 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Lesion segmentation from multimodal MRI using random forest following ischemic stroke.

PubMed

Mitra, Jhimli; Bourgeat, Pierrick; Fripp, Jurgen; Ghose, Soumya; Rose, Stephen; Salvado, Olivier; Connelly, Alan; Campbell, Bruce; Palmer, Susan; Sharma, Gagan; Christensen, Soren; Carey, Leeanne

2014-09-01

Understanding structure-function relationships in the brain after stroke is reliant not only on the accurate anatomical delineation of the focal ischemic lesion, but also on previous infarcts, remote changes and the presence of white matter hyperintensities. The robust definition of primary stroke boundaries and secondary brain lesions will have significant impact on investigation of brain-behavior relationships and lesion volume correlations with clinical measures after stroke. Here we present an automated approach to identify chronic ischemic infarcts in addition to other white matter pathologies, that may be used to aid the development of post-stroke management strategies. Our approach uses Bayesian-Markov Random Field (MRF) classification to segment probable lesion volumes present on fluid attenuated inversion recovery (FLAIR) MRI. Thereafter, a random forest classification of the information from multimodal (T1-weighted, T2-weighted, FLAIR, and apparent diffusion coefficient (ADC)) MRI images and other context-aware features (within the probable lesion areas) was used to extract areas with high likelihood of being classified as lesions. The final segmentation of the lesion was obtained by thresholding the random forest probabilistic maps. The accuracy of the automated lesion delineation method was assessed in a total of 36 patients (24 male, 12 female, mean age: 64.57±14.23yrs) at 3months after stroke onset and compared with manually segmented lesion volumes by an expert. Accuracy assessment of the automated lesion identification method was performed using the commonly used evaluation metrics. The mean sensitivity of segmentation was measured to be 0.53±0.13 with a mean positive predictive value of 0.75±0.18. The mean lesion volume difference was observed to be 32.32%±21.643% with a high Pearson's correlation of r=0.76 (p<0.0001). The lesion overlap accuracy was measured in terms of Dice similarity coefficient with a mean of 0.60±0.12, while the contour accuracy was observed with a mean surface distance of 3.06mm±3.17mm. The results signify that our method was successful in identifying most of the lesion areas in FLAIR with a low false positive rate. Copyright © 2014 Elsevier Inc. All rights reserved.

Lack of association between stroke symptom knowledge and intent to call 911: a population-based survey.

PubMed

Fussman, Chris; Rafferty, Ann P; Lyon-Callo, Sarah; Morgenstern, Lewis B; Reeves, Mathew J

2010-07-01

Excessive prehospital delay between acute stroke onset and hospital arrival is an ongoing problem. Translating knowledge of stroke warning signs into appropriate action is critical to decrease prehospital delay. Our objectives were to estimate the proportion of Michigan adults who would react appropriately by calling 911 when presented with hypothetical stroke-related scenarios and to examine the association between knowledge of warning signs and calling 911. In 2004, questions regarding initial response to health-related scenarios were added to the Michigan Behavioral Risk Factor Survey, a population-based telephone survey of adults. We calculated the proportion of respondents who would call 911 in response to 3 stroke-related scenarios and examined the association between stroke warning sign knowledge and 911 activation. Among 4841 adults, 27.6% (95% CI, 26.2 to 29.0) had adequate knowledge of stroke warning signs (defined as reporting 3 correct warning signs), and 14.0% (95% CI, 12.9 to 15.1) reported they would call 911 for all 3 stroke-related scenarios. Knowledge of specific stroke warning signs was only modestly associated with calling 911 in response to medical scenarios that involved the same stroke symptom (OR, 1.17 to 1.39). Even among those with adequate knowledge of stroke warning signs, only 17.6% (95% CI, 15.5 to 20.0) would call 911 for all 3 stroke scenarios. In this population-based survey, stroke symptom knowledge was not associated with the intent to call 911 for stroke. This study emphasizes the critical role of motivation in addition to symptom knowledge to reducing delay time to hospital arrival for stroke.

Air Pollution Is Associated With Ischemic Stroke via Cardiogenic Embolism.

PubMed

Chung, Jong-Won; Bang, Oh Young; Ahn, Kangmo; Park, Sang-Soon; Park, Tai Hwan; Kim, Jae Guk; Ko, Youngchai; Lee, SooJoo; Lee, Kyung Bok; Lee, Jun; Kang, Kyusik; Park, Jong-Moo; Cho, Yong-Jin; Hong, Keun-Sik; Nah, Hyun-Wook; Kim, Dae-Hyun; Cha, Jae-Kwan; Ryu, Wi-Sun; Kim, Dong-Eog; Kim, Joon-Tae; Choi, Jay Chol; Oh, Mi-Sun; Yu, Kyung-Ho; Lee, Byung-Chul; Lee, Ji Sung; Lee, Juneyoung; Park, Hong-Kyun; Kim, Beom Joon; Han, Moon-Ku; Bae, Hee-Joon

2017-01-01

The aim of the study was to assessed the impact of short-term exposure to air pollution on ischemic stroke subtype, while focusing on stroke caused via cardioembolism. From a nationwide, multicenter, prospective, stroke registry database, 13 535 patients with acute ischemic stroke hospitalized to 12 participating centers were enrolled in this study. Data on the hourly concentrations of particulate matter <10 μm, nitrogen dioxide (NO 2 ), sulfur dioxide (SO 2 ), ozone (O 3 ), and carbon monoxide (CO) were collected from 181 nationwide air pollution surveillance stations. The average values of these air pollutants over the 7 days before stroke onset from nearest air quality monitoring station in each patient were used to determine association with stroke subtype. The primary outcome was stroke subtype, including large artery atherosclerosis, small-vessel occlusion, cardioembolism, and stroke of other or undetermined cause. Particulate matter <10 μm and SO 2 concentrations were independently associated with an increased risk of cardioembolic stroke, as compared with large artery atherosclerosis and noncardioembolic stroke. In stratified analyses, the proportion of cases of cardioembolic stroke was positively correlated with the particulate matter <10 μm, NO 2 , and SO 2 quintiles. Moreover, seasonal and geographic factors were related to an increased proportion of cardioembolic stroke, which may be attributed to the high levels of air pollution. Our findings suggest that the short-term exposure to air pollutants is associated with cardioembolic stroke, and greater care should be taken for those susceptible to cerebral embolism during peak pollution periods. Public and environmental health policies to reduce air pollution could help slow down global increasing trends of cardioembolic stroke. © 2016 American Heart Association, Inc.

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.

Acute kidney injury and edaravone in acute ischemic stroke: the Fukuoka Stroke Registry.

PubMed

Kamouchi, Masahiro; Sakai, Hironori; Kiyohara, Yutaka; Minematsu, Kazuo; Hayashi, Kunihiko; Kitazono, Takanari

2013-11-01

A free radical scavenger, edaravone, which has been used for the treatment of ischemic stroke, was reported to cause acute kidney injury (AKI) as a fatal adverse event. The aim of the present study was to clarify whether edaravone is associated with AKI in patients with acute ischemic stroke. From the Fukuoka Stroke Registry database, 5689 consecutive patients with acute ischemic stroke who were hospitalized within 24 hours of the onset of symptoms were included in this study. A logistic regression analysis for the Fukuoka Stroke Registry cohort was done to identify the predictors for AKI. A propensity score-matched nested case-control study was also performed to elucidate any association between AKI and edaravone. Acute kidney injury occurred in 128 of 5689 patients (2.2%) with acute ischemic stroke. A multivariate analysis revealed that the stroke subtype, the basal serum creatinine level, and the presence of infectious complications on admission were each predictors of developing AKI. In contrast, a free radical scavenger, edaravone, reduced the risk of developing AKI (multivariate-adjusted odds ratio [OR] .45, 95% confidence interval [CI] .30-.67). Propensity score-matched case-control study confirmed that edaravone use was negatively associated with AKI (propensity score-adjusted OR .46, 95% CI .29-.74). Although AKI has a significant impact on the clinical outcome of hospital inpatients, edaravone has a protective effect against the development of AKI in patients with acute ischemic stroke. Copyright © 2013 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Neuroprotective effects of AT1 receptor antagonists after experimental ischemic stroke: what is important?

PubMed

Culman, Juraj; Jacob, Toni; Schuster, Sven O; Brolund-Spaether, Kjell; Brolund, Leonie; Cascorbi, Ingolf; Zhao, Yi; Gohlke, Peter

2017-09-01

The present study conducted in rats defines the requirements for neuroprotective effects of systemically administered AT1 receptor blockers (ARBs) in acute ischaemic stroke. The inhibition of central effects to angiotensin II (ANG II) after intravenous (i.v.) treatment with candesartan (0.3 and 3 mg/kg) or irbesartan and losartan (3 and 30 mg/kg) was employed to study the penetration of these ARBs across the blood-brain barrier. Verapamil and probenecid were used to assess the role of the transporters, P-glycoprotein and the multidrug resistance-related protein 2, in the entry of losartan and irbesartan into the brain. Neuroprotective effects of i.v. treatment with the ARBs were investigated after transient middle cerebral artery occlusion (MCAO) for 90 min. The treatment with the ARBs was initiated 3 h after the onset of MCAO and continued for two consecutive days. Blood pressure was continuously recorded before and during MCAO until 5.5 h after the onset of reperfusion. The higher dose of candesartan completely abolished, and the lower dose of candesartan and higher doses of irbesartan and losartan partially inhibited the drinking response to intracerebroventricular ANG II. Only 0.3 mg/kg candesartan improved the recovery from ischaemic stroke, and 3 mg/kg candesartan did not exert neuroprotective effects due to marked blood pressure reduction during reperfusion. Both doses of irbesartan and losartan had not any effect on the stroke outcome. An effective, long-lasting blockade of brain AT1 receptors after systemic treatment with ARBs without extensive blood pressure reductions is the prerequisite for neuroprotective effects in ischaemic stroke.

Comparative study of ipsilesional and contralesional repetitive transcranial magnetic stimulations for acute infarction.

PubMed

Watanabe, Kosuke; Kudo, Yosuke; Sugawara, Eriko; Nakamizo, Tomoki; Amari, Kazumitsu; Takahashi, Koji; Tanaka, Osamu; Endo, Miho; Hayakawa, Yuko; Johkura, Ken

2018-01-15

Repetitive transcranial magnetic stimulation (rTMS) is reported to improve chronic post-stoke hemiparesis. However, application of rTMS during the acute phase of post-stroke has not fully been investigated. We investigated the safety and the efficacy of intermittent theta-burst stimulation (iTBS) of the affected motor cortex and 1-Hz stimulation of the unaffected hemisphere during the acute phase in patients with hemiparesis due to capsular infarction. Twenty one patients who met the study criteria were randomly assigned to receive, starting within 7days after stroke onset and for a period of 10days, iTBS of the affected motor cortex hand area (n=8), 1-Hz stimulation of the unaffected motor cortex hand area (n=7), or sham stimulation (n=6). Upper limb motor function was evaluated before rTMS and 12weeks after onset of the stroke. Evaluation was based on the Fugl-Meyer Assessment (FMA), Stroke Impairment Assessment Set (SIAS), Modified Ashworth Scale (MAS), grip strength, and motor evoked potential (MEP) amplitude in the first dorsal interosseous (FDI) muscle. Both iTBS applied to the affected motor cortex hand area and 1-Hz stimulation applied to the unaffected motor cortex hand area enhanced motor recovery. In comparison to sham stimulation, iTBS increased the SIAS finger-function test score, and 1-Hz stimulation decreased the MAS wrist and finger score. Ipsilesional iTBS and contralesional 1-Hz stimulation applied during the acute phase of stroke have different effects: ipsilesional iTBS improves movement of the affected limb, whereas contralesional 1-Hz stimulation reduces spasticity of the affected limb. Copyright © 2017 Elsevier B.V. All rights reserved.

Early and late mortality of spontaneous hemorrhagic transformation of ischemic stroke.

PubMed

D'Amelio, Marco; Terruso, Valeria; Famoso, Giorgia; Di Benedetto, Norma; Realmuto, Sabrina; Valentino, Francesca; Ragonese, Paolo; Savettieri, Giovanni; Aridon, Paolo

2014-04-01

Hemorrhagic transformation (HT), a complication of ischemic stroke (IS), might influence patient's prognosis. Our aim is to evaluate, in a hospital-based series of patients not treated with thrombolysis, the relationship between HT and mortality. We compared mortality of individuals with spontaneous HT with that of individuals without. Medical records of patients diagnosed with anterior IS were retrospectively reviewed. Outcome measures were 30- and 90-day survival after IS onset. Kaplan-Meier estimates were used to construct survival curves. Cox proportional hazards model was used to estimate hazard ratio (HR) for the main outcome measure (death). HT was stratified in hemorrhagic infarction and parenchymal hematoma (PH). We also evaluated the relationship between HT and the main mortality risk factors (gender, age, premorbid status, severity of stroke, and radiological features). Thirty days from stroke onset, 8.1% (19 of 233) of patients died. At multivariate analysis, PH (HR: 7.7, 95% confidence interval [CI]: 2.1, 27.8) and low level of consciousness at admission (HR: 5.0, 95% CI: 1.3, 18.6) were significantly associated with death. At 3-month follow-up, mortality rate was 12.1% (28 of 232). At multivariate analysis, large infarct size (HR: 2.7, 95% CI: 1.2, 6.0) and HT (HR: 2.3, 95% CI: 1.0, 5.4) were independent risk factors for mortality. Parenchymal hematoma was, however, the strongest predictor of late mortality (HR: 7.9, 95% CI: 2.9, 21.4). Neurological status and infarct size play a significant role, respectively, in early and late mortality after IS. Parenchymal hematoma independently predicts both early and late mortality. Copyright © 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.

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

PubMed

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

2015-10-01

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

The Predictive Value of Motor-Evoked Potentials and the Silent Period on Patient Outcome after Acute Cerebral Infarction.

PubMed

Zhang, Xueqing; Ji, Wenzhen; Li, Lancui; Yu, Changshen; Wang, Wanjun; Liu, Shoufeng; Gao, Chunlin; Qiu, Lina; Tong, Xiaoguang; Wang, Jinhuan; Wu, Jialing

2016-07-01

The predictive value of neurophysiologic assessment on patients' outcome after acute cerebral infarction is poorly understood. The aim of this study was to investigate the prognostic value of motor-evoked potentials (MEPs) and the silent period (SP) on clinical outcome. A total of 202 patients with acute cerebral infarction were prospectively recruited. MEP and SP were recorded from the abductor pollicis brevis of the affected side within 10 days after stroke onset. Patient outcome was measured as the dependency rate. Cortical MEP was induced in 78 patients whereas it was absent in 82 patients. The initial NIHSS (National Institutes of Health Stroke Scale) score was significantly lower in patients with MEP than in those without MEP (P < .001). Regression analysis demonstrated that a left-sided lesion (OR = .391, 95% CI .178-.858, P = .019), NIHSS at admission (OR = .826, 95% CI .744-.917, P < .001), and presence of MEP (OR = 3.918, 95% CI 1.770-8.672, P < .001) were independent predictors of outcome 3 months after stroke. Among patients with MEP, only the contralateral cortical SP value was significantly shorter in the good outcome subgroup (t = 2.541, P = .013). Receiver operating characteristic curve analysis demonstrated that SP was able to predict patients at higher risk of unfavorable outcome 3 months after stroke onset (area under the curve .721, 95% CI .58-.86, P = .008). These data suggested that MEP and SP were useful tools to predict patients' acute outcomes following cerebral infarction. Copyright © 2016 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Screening patients with stroke for rehabilitation needs: validation of the post-stroke rehabilitation guidelines.

PubMed

Edwards, Dorothy F; Hahn, Michele G; Baum, Carolyn M; Perlmutter, Monica S; Sheedy, Catherine; Dromerick, Alexander W

2006-03-01

The authors assessed patients with acute stroke to determine whether the systematic use of brief screening measures would more efficiently detect cognitive and sensory impairment than standard clinical practice. Fifty-three patients admitted to an acute stroke unit were assessed within 10 days of stroke onset. Performance on the screening measures was compared to information obtained from review of the patient's chart at discharge. Cognition, language, visual acuity, visual-spatial neglect, hearing, and depression were evaluated. Formal screening detected significantly more impairments than were noted in patient charts in every domain. Only 3 patients had no impairments identified on screening; all remaining patients had at least 1 impairment detected by screening that was not documented in the chart. Thirty-five percent had 3 or more undetected impairments. Memory impairment was most likely to be noted in the chart; for all other domains tested, undocumented impairment ranged from 61% (neglect) to 97% (anomia). Many acute stroke patients had cognitive and perceptual deficits that were not documented in their charts. These data support the Post-Stroke Rehabilitation Guidelines for systematic assessment even when deficits are not immediately apparent. Systematic screening may improve discharge planning, rehabilitation treatment, and long-term outcome of persons with stroke.

Serum magnesium but not calcium was associated with hemorrhagic transformation in stroke overall and stroke subtypes: a case-control study in China.

PubMed

Tan, Ge; Yuan, Ruozhen; Wei, ChenChen; Xu, Mangmang; Liu, Ming

2018-05-26

Association between serum calcium and magnesium versus hemorrhagic transformation (HT) remains to be identified. A total of 1212 non-thrombolysis patients with serum calcium and magnesium collected within 24 h from stroke onset were enrolled. Backward stepwise multivariate logistic regression analysis was conducted to investigate association between calcium and magnesium versus HT. Calcium and magnesium were entered into logistic regression analysis in two models, separately: model 1, as continuous variable (per 1-mmol/L increase), and model 2, as four-categorized variable (being collapsed into quartiles). HT occurred in 140 patients (11.6%). Serum calcium was slightly lower in patients with HT than in patient without HT (P = 0.273). But serum magnesium was significantly lower in patients with HT than in patients without HT (P = 0.007). In logistic regression analysis, calcium displayed no association with HT. Magnesium, as either continuous or four-categorized variable, was independently and inversely associated with HT in stroke overall and stroke of large-artery atherosclerosis (LAA). The results demonstrated that serum calcium had no association with HT in patients without thrombolysis after acute ischemic stroke. Serum magnesium in low level was independently associated with increasing HT in stroke overall and particularly in stroke of LAA.

[Descriptive study of cerebrovascular accidents in Douala, Cameroon].

PubMed

Chiasseu, Mbeumi M T; Mbahe, S

2011-10-01

A cerebrovascular accident or stroke is a sudden-onset cerebral deficit of vascular origin lasting more than 24 hours. These events represent the second leading cause of death in the world and take a particularly heavy toll in third world countries. The purpose of this study was to describe cerebrovascular lesions (type, location, size) as well as patient age and gender in Cameroon. Brain CT-scan and MRI findings from 50 stroke patients admitted to two health centers in Douala were reviewed. Data showed that 74% of patients were over 50 years of age, the 51-60 year group being the most affected. Patients were male in 64% of cases. Ischemic stroke accounted for 60% of cases versus 40% for hemorrhagic stroke. The most affected sites were the sylvian territory site in ischemic stroke and the temporal lobe in hemorrhagic stroke, acconting for 43.3% and 35% of cases respectively. The median size of ischemic and hemorrhagic lesions were 2.81 cm3, and 26.98 cm3 respectively. Hemorrhagic stroke and lacunar infarcts were more common in this sample. Discrepancies between results at the two hospitals may be due to the use of different imaging techniques. Indeed, MRI is known to be more sensitive than CT-scan for acute detection of stroke lesions.

Rehabilitation therapy services for stroke patients living at home: systematic review of randomised trials.

PubMed

Legg, L; Langhorne, P

2004-01-31

Stroke-unit care can be valuable for stroke patients in hospital, but effectiveness of outpatient care is less certain. We aimed to assess the effects of therapy-based rehabilitation services targeted at stroke patients resident in the community within 1 year of stroke onset or discharge from hospital. We did a systematic review of randomised trials of outpatient services, including physiotherapy, occupational therapy, and multidisciplinary teams. We used Cochrane collaboration methodology. We identified a heterogeneous group of 14 trials (1617 patients). Therapy-based rehabilitation services for stroke patients living at home reduced the odds of deteriorating in personal activities of daily living (odds ratio 0.72 [95% CI 0.57-0.92], p=0.009) and increased ability of patients to do personal activities of daily living (standardised mean difference 0.14 [95% CI 0.02-0.25], p=0.02). For every 100 stroke patients resident in the community receiving therapy-based rehabilitation services, seven (95% CI 2-11) would not deteriorate. Therapy-based rehabilitation services targeted at selected patients resident in the community after stroke improve ability to undertake personal activities of daily living and reduce risk of deterioration in ability. These findings should be considered in future service planning.

Prevalence of sleep-disordered breathing in acute ischemic stroke as determined using a portable sleep apnea monitoring device in Korean subjects.

PubMed

Joo, Byung-Euk; Seok, Hung Youl; Yu, Sung-Wook; Kim, Byung-Jo; Park, Kun-Woo; Lee, Dae-Hie; Jung, Ki-Young

2011-01-01

It has been suggested that there is a strong association between sleep-disordered breathing (SDB) and stroke. However, this connection has not been studied in Korean subjects. Sixty-one patients with acute cerebral infarction (ACI) and 13 patients with transient ischemic attack (TIA) were consecutively enrolled. SDB was evaluated within 48 h of stroke or TIA onset using a portable screening device, which allowed incidents of apnea, hypopnea, and snoring to be automatically analyzed. Clinical and sleep-related variables, including body mass indices (BMI), cardiovascular risk factors, stroke severity and disability, and Epworth sleepiness scale, Stanford sleepiness scale, and Berlin questionnaire scores were assessed. Sixty-four age-matched patient's spouses or family members with no history of physician-diagnosed stroke were enrolled as controls. Mean apnea-hypopnea index (AHI) was significantly higher in TIA (14.6 ± 10.4) and ACI (15.6 ± 14.7) patients than in the controls (7.8 ± 7.0; p = 0.001). The prevalences of SDB were 69.2% in TIA and 50.8% in ACI patients and 32.8% in controls. BMI and systolic blood pressure (SBP) were significantly higher in patients with SDB than in patients without SDB. Sleep-related stroke onset occurred in 17 patients (22.9%), and these patients had significantly higher AHIs. Multiple logistic regression analysis showed that BMI (odds ratio, 1.293; p = 0.027) and SBP (odds ratio, 1.030; p = 0.004) were found to independently predict SDB in patients with TIA or ACI. SDB is prevalent during the 48 h following ACI or TIA in Korean subjects. The authors recommend that SDB be evaluated after an ACI or TIA, especially in those with a high BMI and an elevated SBP.

Magnetic Resonance Imaging-DRAGON score: 3-month outcome prediction after intravenous thrombolysis for anterior circulation stroke.

PubMed

Turc, Guillaume; Apoil, Marion; Naggara, Olivier; Calvet, David; Lamy, Catherine; Tataru, Alina M; Méder, Jean-François; Mas, Jean-Louis; Baron, Jean-Claude; Oppenheim, Catherine; Touzé, Emmanuel

2013-05-01

The DRAGON score, which includes clinical and computed tomographic scan parameters, showed a high specificity to predict 3-month outcome in patients with acute ischemic stroke treated by intravenous tissue plasminogen activator. We adapted the score for patients undergoing MRI as the first-line diagnostic tool. We reviewed patients with consecutive anterior circulation ischemic stroke treated ≤ 4.5 hour by intravenous tissue plasminogen activator between 2003 and 2012 in our center, where MRI is systematically implemented as first-line diagnostic work-up. We derived the MRI-DRAGON score keeping all clinical parameters of computed tomography-DRAGON (age, initial National Institutes of Health Stroke Scale and glucose level, prestroke handicap, onset to treatment time), and considering the following radiological variables: proximal middle cerebral artery occlusion on MR angiography instead of hyperdense middle cerebral artery sign, and diffusion-weighted imaging Alberta Stroke Program Early Computed Tomography Score (DWI ASPECTS) ≤ 5 instead of early infarct signs on computed tomography. Poor 3-month outcome was defined as modified Rankin scale >2. We calculated c-statistics as a measure of predictive ability and performed an internal cross-validation. Two hundred twenty-eight patients were included. Poor outcome was observed in 98 (43%) patients and was significantly associated with all parameters of the MRI-DRAGON score in multivariate analysis, except for onset to treatment time (nonsignificant trend). The c-statistic was 0.83 (95% confidence interval, 0.78-0.88) for poor outcome prediction. All patients with a MRI-DRAGON score ≤ 2 (n=22) had a good outcome, whereas all patients with a score ≥ 8 (n=11) had a poor outcome. The MRI-DRAGON score is a simple tool to predict 3-month outcome in acute stroke patients screened by MRI then treated by intravenous tissue plasminogen activator and may help for therapeutic decision.

Satisfaction with rehabilitation in relation to self-perceived quality of life and function among patients with stroke - a 12 month follow-up.

PubMed

Hansson, Eva Ekvall; Beckman, Anders; Wihlborg, Anna; Persson, Sylvia; Troein, Margareta

2013-06-01

Stroke causes complex disability and function, and perceived quality of life has been shown to correlate with satisfaction with care as well as with life in general among stroke patients. The aim of this study was to study the relation of satisfaction with how rehabilitation was provided with self-perceived quality of life, self-perceived function and rehabilitation received, 12 months after the incidence. The subjects were assessed 12 months after the onset of stroke. The Barthel index was used to measure function, and the EuroQol-5D to measure quality of life. To measure satisfaction with how rehabilitation was provided, a questionnaire from the Swedish Stroke Register was used. Two hundred and eighty-three patients participated in the follow-up, 137 women and 146 men, aged between 42 and 95 years (mean age 75.2, SD 11.8). For the majority of patients rehabilitation was initiated at in-hospital care (directly after onset). One hundred and sixty-eight patients considered that rehabilitation was well provided for. Sixty-six regarded that the rehabilitation was only partly provided for and 35 that it was not provided for at all. High value on Barthel Index was associated with satisfaction with how rehabilitation was provided for (OR 2.81). Also, rehabilitation on three or more levels was negatively associated with satisfaction with rehabilitation provision (OR 0.24) and so was being male (OR 0.49). In this study, patients with higher values on Barthel Index were more satisfied with how rehabilitation was provided for. However, male patients and patients who received rehabilitation on three or more levels of care were less satisfied. Given the assumption that patients with more severe dysfunction after stroke are being rehabilitated on more levels, this might imply that it is not the amount of rehabilitation that gives satisfaction but the patients self-perceived function after rehabilitation. © 2012 Nordic College of Caring Science.

Tenacity of Collateral Perfusion in Proximal Cerebral Arterial Occlusions 6-12 h after Onset.

PubMed

Kim, Beom Joon; Kim, Hyeran; Jeong, Han-Gil; Yang, Mi Hwa; Jung, Cheol Kyu; Han, Moon-Ku; Kim, Jae Hyoung; Demchuk, Andrew M; Bae, Hee-Joon

2018-06-07

Clinical trials have shown that benefits of endovascular recanalization (EVT) for acute ischemic stroke patients with sizable penumbral tissues seems plausible even beyond 6 h after their last seen normal (LSN). Persistency of ischemic penumbra remains unclear in delayed periods. From a prospective stroke registry database, we identified 111 acute ischemic stroke patients who had internal carotid artery or middle cerebral artery occlusion with baseline National Institutes of Health Stroke Scale scores ≥6 points and arrived 6-12 h after LSN. Baseline information and functional outcomes were prospectively collected as a clinical registry. Attending physicians made treatment decisions for EVT based on the current guidelines and institutional protocols. MR image parameters, including the volume of diffusion-restricted lesions and mapping of the -hypoperfused area, were quantified using automated commercial software. Binary logistic regression analysis models, with modified Rankin Scale (mRS) scores of 0-1 at 3 months after stroke included as a dependent variable, were constructed. Between 6 and 12 h after onset, 58% had a mismatch ratio of ≥1.8 at baseline and 42% had favorable imaging profiles as determined by DEFUSE 2 study. After 9 h, there was a mismatch ratio of ≥1.8 in 47 and 38% favorable profiles. EVT was performed in 54% of cases. A 3-month mRS score of 0-1 was found in 19% (25% in EVT and 12% in medical treatment groups) of cases. EVT was associated with an increased OR of having a mRS score of 0-1 at 3 months after stroke (adjusted OR 7.59 [95% CI 1.28-61.60]). Penumbral tissues were persistent in a substantial proportion of anterior circulation occlusion cases 6-12 h after LSN. EVT at 6-12 h in a predominantly Asian cohort resulted in better outcomes. © 2018 S. Karger AG, Basel.

The ratio of D-dimer to brain natriuretic peptide may help to differentiate between cerebral infarction with and without acute aortic dissection.

PubMed

Okazaki, Toshiyuki; Yamamoto, Yoko; Yoda, Keishi; Nagahiro, Shinji

2014-05-15

Previous studies reported that the plasma d-dimer level reflects the activity of thrombus formation in the left atrium of patients with acute cerebral infarction and acute aortic dissection (AAD). Brain natriuretic peptide (BNP) is considered to be a marker of chronic heart failure. The differential diagnosis in the emergency room between stroke due to cardioembolism and AAD is difficult but important for early treatment especially in patients requiring intravenous thrombolysis with a recombinant tissue-type plasminogen activator. We aimed to investigate the association between the plasma d-dimer and BNP levels in patients with cerebral infarction and AAD. We identified 115 consecutive patients with ischemic stroke who were admitted within 72 h of symptom onset and 15 consecutive patients with AAD and measured the level of plasma d-dimer and BNP and the d-dimer:BNP ratio. In patients with AAD the d-dimer level was significantly higher than that in patients with any other stroke subtypes and their BNP level was significantly lower than that in patients with cardioembolic stroke. The d-dimer:BNP ratio was significantly higher in patients with AAD than in those with any other stroke subtype. Compared to patients with a cardioembolic stroke subtype they manifested significantly higher d-dimer levels and d-dimer:BNP ratios suggesting that this ratio may help to diagnose cerebral infarction due to AAD (sensitivity 80%, specificity 93.5%, cut-off 0.074). When the population was limited to patients within 6h of onset, the ratio had higher sensitivity and specificity at the same cut-off value (sensitivity 81.8%, specificity 96.4%). We found that the d-dimer:BNP ratio may be helpful in distinguishing between cerebral infarction with and without AAD. Copyright © 2014 Elsevier B.V. All rights reserved.

Paediatric-onset coronary artery anomalies in pregnancy: a single-centre experience and systematic literature review.

PubMed

Keir, Michelle; Bhagra, Catriona; Vatenmakher, Debra; Arancibia-Galilea, Francisca; Jansen, Katrijn; Toh, Norihisa; Silversides, Candice K; Colman, Jack; Siu, Samuel C; Sermer, Mathew; Crean, Andrew M; Wald, Rachel M

2017-10-01

Individuals with childhood-onset coronary artery anomalies are at increased risk of lifelong complications. Although pregnancy is thought to confer additional risk, a few data are available regarding outcomes in this group of women. We sought to define outcomes of pregnancy in this unique population. We performed a retrospective survey of women with paediatric-onset coronary anomalies and pregnancy in our institution, combined with a systematic review of published cases. We defined paediatric-onset coronary artery anomalies as congenital coronary anomalies and inflammatory arteriopathies of childhood that cause coronary aneurysms. Major cardiovascular events were defined as pulmonary oedema, sustained arrhythmia requiring treatment, stroke, myocardial infarction, cardiac arrest, or death. A total of 25 surveys were mailed, and 20 were returned (80% response rate). We included 46 articles from the literature, which described cardiovascular outcomes in 82 women (138 pregnancies). These data were amalgamated for a total of 102 women and 194 pregnancies; 59% of women were known to have paediatric-onset coronary artery anomalies before pregnancy. In 23%, the anomaly was unmasked during or shortly after pregnancy. The remainder, 18%, was diagnosed later in life. Major cardiovascular events occurred in 14 women (14%) and included heart failure (n=5, 5%), myocardial infarction (n=7, 7%), maternal death (n=2, 2%), cardiac arrest secondary to ventricular fibrillation (n=1, 1%), and stroke (n=1, 1%). The majority of maternal events (13/14, 93%) occurred in women with no previous diagnosis of coronary disease. Women with paediatric-onset coronary artery anomalies have a 14% risk of adverse cardiovascular events in pregnancy, indicating the need for careful assessment and close follow-up. Prospective, multicentre studies are required to better define risk and predictors of complications during pregnancy.

Sleep modifications in acute transient global amnesia.

PubMed

Della Marca, Giacomo; Mazza, Marianna; Losurdo, Anna; Testani, Elisa; Broccolini, Aldobrando; Frisullo, Giovanni; Marano, Giuseppe; Morosetti, Roberta; Pilato, Fabio; Profice, Paolo; Vollono, Catello; Di Lazzaro, Vincenzo

2013-09-15

Transient global amnesia (TGA) is a temporary memory loss characterized by an abrupt onset of antero-grade and retrograde amnesia, totally reversible. Since sleep plays a major role in memory consolidation, and in the storage of memory-related traces into the brain cortex, the aims of the present study were: (1) to evaluate changes in sleep macro-structure in TGA; (2) to assess modifications in sleep micro-structure in TGA, with particular reference to the arousal EEG and to cyclic alternating pattern (CAP); (3) to compare sleep parameters in TGA patients with a control group of patients with acute ischemic events ("minor stroke" or transient ischemic attack [TIA]) clinically and neuroradiologically "similar" to the TGA. TGA GROUP: 17 patients, (8 men and 9 women, 60.2 ± 12.5 years). Stroke or TIA (SoT) group: 17 patients hospitalized in the Stroke Unit for recent onset of minor stroke or TIA with hemispheric localization; healthy controls (HC) group: 17 healthy volunteers, matched for age and sex. Patients and controls underwent full-night polysomnography. In the multivariate analysis (conditions TGA, SoT, and HC) a significant effect of the condition was observed for sleep efficiency index, number of awakenings longer 1 min, REM latency, CAP time, and CAP rate. TGA and SoT differed only for CAP time and CAP rate, which were lower in the TGA group. Microstructural modification associated with tga could be consequent to: (1) hippocampal dysfunction and memory impairment; (2) impairment of arousal-related structures (in particular, cholinergic pathways); (3) emotional distress.

Alteration of mean platelet volume in the pathogenesis of acute ischemic stroke: cause or consequence?

PubMed

Ayas, Zeynep Özözen; Can, Ufuk

2018-01-30

Platelets have a crucial role on vascular disease which are involved in pathogenesis of ischemic stroke. Platelet size is measured as mean platelet volume (MPV) and is a marker of platelet activity. Platelets contain more dense granules as the size increases and produce more serotonin and tromboglobulin (b-TG) than small platelets. In this study, the alteration of MPV values were investigated in patients with acute stroke, who had MPV values before stroke, during acute ischemic stroke and 7 days after the stroke. The relationship between this alteration and risk factors, etiology and localization of ischemic stroke were also investigated. Sixty-seven patients with clinically and radiologically established diagnoses of ischemic stroke were enrolled into the study and stroke etiology was classified by modified Trial of Org 10 172 in Acute Stroke Treatment (TOAST) classification and, modified Bamford classification was used for localization and stroke risk factors were also evaluated. The platelet counts and MPV values from patient files in patients who had values before stroke (at examination for another diseases), within 24 hours of symptom onset and after 7 further days were analysed. MPV values increased after stroke (10.59±2.26) compared with acute stroke values (9.84±1.64) and the values before stroke (9.59±1.72) (p<0.0001); this alteration of MPV values occured 7 days after stroke (p<0.016). There was a positive correlation between age and MPV values during acute stroke (r=0.270; p<0.05). Patients with atrial fibrillation had higher alteration in the time of MPV compared with patients without atrial fibrillation (p>0.006). We assessed for gender, men (n=38) had a higher alteration in the time of MPV compared with women (n=29) (p=0.013). Although there was no alteration of platelet counts, MPV values were increased 7 days after stroke in patients with acute ischemic stroke.

Hip Hop Stroke: Study Protocol for a Randomized Controlled Trial to Address Stroke Literacy.

PubMed

Williams, Olajide; Leighton-Herrmann, Ellyn; DeSorbo, Alexandra; Hecht, Mindy; Hedmann, Monique; Huq, Saima; Gerin, William; Chinchilli, Vernon; Ogedegbe, Gbenga; Noble, James

2015-10-01

Stroke is the fifth leading cause of death and the leading cause of serious long-term adult disability in the US. Acute stroke treatments with intravenous thrombolysis and endovascular therapy are proven to reduce disability, however a critical limitation on their effectiveness is the narrow time window for administration, which is 4.5 hours and 6 hours respectively from the onset of symptoms. Our overarching goal is to reduce pre-hospital delays to acute stroke treatments in economically disadvantaged minority communities where the greatest delays exist, using Hip Hop Stroke. Hip Hop Stroke (HHS) is a school-based, child-mediated, culturally-tailored stroke communication multimedia intervention developed using validated models of behavior change and designed to improve stroke literacy (knowledge of stroke symptoms, the urgent need to call 911, and prevention measures) of 4 th , 5 th and 6 th grade students and their parents residing in poor urban communities. Children in the intervention arm will receive the HHS intervention, while those in the attentional control arm will receive standardized nutrition education based on the USDA's MyPyramid program. Children will be trained and motivated to share stroke information with their parents or other adult caregiver. Both children and parents will complete a stroke knowledge assessment at baseline, immediately following the program, and at 3-months post-program. The primary outcome is the effect of the child mediation on parental stroke literacy. Stroke literate children, a captive audience in school systems, may represent a viable channel for spreading stroke information into households of poor urban communities where mass media stroke campaigns have shown the lowest penetration. These children may also call 911 when witnessing a stroke in their homes or communities. The HHS program may highlight the potential role of children in the chain of stroke recovery as a strategy for reducing prehospital delays to acute stroke treatment.

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.

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.

[Outcomes of open endovascular operations on the internal carotid artery in acute stage of ischaemic stroke].

PubMed

Khripun, A I; Priamikov, A D; Mironkov, A B; Tiurin, I N; Asratian, S A; Suriakhin, V S; Simonov, O V; Sazhina, O A; Mikhaĭlenko, V P

The authors share their experience in diagnosis and treatment of patients with acute ischaemic stroke. The study included a total of 33 patients. Of these, 20 patients (Study Group) were operated on at terms ranging from 2 to 7 days after onset of acute cerebral circulatory impairment. The Control Group was composed of 13 patients with ischaemic stroke, having refused surgical prevention of recurrent stroke. Both groups were matched by age, gender, level of neurological deficiency and size of cerebral ischaemic foci. Surgical management in the Study Group consisted in either carotid endarterectomy (n=15) or stenting of the internal carotid artery (n=5). Depending on the severity of coronary artery lesion and the presence of accompanying therapeutic pathology, options of operative treatment with various anaesthesiological support were offered. At discharge, neurological deficit in the Study Group patients was lower - 1.2 points by the NIH Stroke Scale versus 2.7 points in the Control Group, however, this difference was not statistically significant (p=0.45). In the Study Group there were two complications: haematoma of the postoperative injury requiring its revision and a transient ischaemic attack during stenting of the internal carotid artery, having disappeared on the operation table after the distal cerebral protection device was removed. Significantly better results were obtained by the following parameters: in the Study Group the number of patients discharged with no neurological deficit (scoring 0 by the NIHSS scale) was significantly higher compared with the Control Group; 50% vs 7.7% (p<0.001). There were no lethal outcomes in either group. One patient (7.7%) from the Study Group developed recurrent ischaemic stroke, whereas neither intra- nor postoperative stroke was registered in the Control Group patients (p<0.001). In carefully selected patients with ischaemic stroke (neurological deficit not exceeding 3 points by the Rankin scale and not more than 11 points by the NIHSS, with the size of the ischaemic focus not exceeding 4 cm), surgical prevention of recurrent stroke within 7 days after the onset of an ischaemic event may be performed effectively and safely. Early operation effectively prevents relapsing ischaemic events at the in-hospital stage. Besides, reconstruction of brachiocephalic arteries during an acute stage of stroke in operated patients improves the neurological status in the postoperative period, decreases the degree of motor and sensory disorders and makes it possible in half of patients to completely eliminate neurological deficit present at admission.

Population-based study of ischemic stroke risk after trauma in children and young adults.

PubMed

Fox, Christine K; Hills, Nancy K; Vinson, David R; Numis, Adam L; Dicker, Rochelle A; Sidney, Stephen; Fullerton, Heather J

2017-12-05

To quantify the incidence, timing, and risk of ischemic stroke after trauma in a population-based young cohort. We electronically identified trauma patients (<50 years old) from a population enrolled in a Northern Californian integrated health care delivery system (1997-2011). Within this cohort, we identified cases of arterial ischemic stroke within 4 weeks of trauma and 3 controls per case. A physician panel reviewed medical records, confirmed cases, and adjudicated whether the stroke was related to trauma. We calculated the 4-week stroke incidence and estimated stroke odds ratios (OR) by injury location using logistic regression. From 1,308,009 trauma encounters, we confirmed 52 trauma-related ischemic strokes. The 4-week stroke incidence was 4.0 per 100,000 encounters (95% confidence interval [CI] 3.0-5.2). Trauma was multisystem in 26 (50%). In 19 (37%), the stroke occurred on the day of trauma, and all occurred within 15 days. In 7/28 cases with cerebrovascular angiography at the time of trauma, no abnormalities were detected. In unadjusted analyses, head, neck, chest, back, and abdominal injuries increased stroke risk. Only head (OR 4.1, CI 1.1-14.9) and neck (OR 5.6, CI 1.03-30.9) injuries remained associated with stroke after adjusting for demographics and trauma severity markers (multisystem trauma, motor vehicle collision, arrival by ambulance, intubation). Stroke risk is elevated for 2 weeks after trauma. Onset is frequently delayed, providing an opportunity for stroke prevention during this period. However, in one-quarter of stroke cases with cerebrovascular angiography at the time of trauma, no vascular abnormality was detected. © 2017 American Academy of Neurology.

Sensitivity and responsiveness of the health-related quality of life in stroke patients-40 (HRQOLISP-40) scale.

PubMed

Vincent-Onabajo, Grace O; Owolabi, Mayowa O; Hamzat, Talhatu K

2014-01-01

To investigate the sensitivity and responsiveness of the Health-Related Quality of Life in Stroke Patients-40 (HRQOLISP-40) scale in evaluating stroke patients from onset to 12 months. Fifty-five patients with first-incidence stroke were followed-up for 12 months. The HRQOLISP-40 scale was used to assess health-related quality of life (HRQOL) while stroke severity was assessed with the Stroke Levity Scale. Sensitivity to change was assessed by analyzing changes in the HRQOLISP-40 scores between pairs of months with paired samples t-test. Standardized effect size (SES) and standardized response mean (SRM) were used to express responsiveness. Overall HRQOL and domains in the physical sphere of the HRQOLISP-40 were sensitive to change at different time intervals in the first 12 months post-stroke. Marked responsiveness (SES and SRM >0.7) was demonstrated by the overall scale, and the physical, psycho-emotional and cognitive domains at varying time intervals. For instance, SRM was greater than 0.7 between 1 and 6, 3 and 12, 1 and 9, and 1 and 12 months for both the physical and psycho-emotional domains. The HRQOLISP-40 is a sensitive and responsive stroke-specific quality of life measure that can be used to evaluate the outcome of stroke rehabilitation. Enhancing the health-related quality of life (HRQOL) of stroke survivors can be regarded as the ultimate goal of stroke rehabilitation. Sensitive and responsive stroke-specific HRQOL measures are required for use in evaluative studies, and clinical trials and practice. The Health-Related Quality of Life in Stroke Patients-40 (HRQOLISP-40) is a sensitive and responsive stroke-specific scale.

Regional variation in acute stroke care organisation.

PubMed

Muñoz Venturelli, Paula; Robinson, Thompson; Lavados, Pablo M; Olavarría, Verónica V; Arima, Hisatomi; Billot, Laurent; Hackett, Maree L; Lim, Joyce Y; Middleton, Sandy; Pontes-Neto, Octavio; Peng, Bin; Cui, Liying; Song, Lily; Mead, Gillian; Watkins, Caroline; Lin, Ruey-Tay; Lee, Tsong-Hai; Pandian, Jeyaraj; de Silva, H Asita; Anderson, Craig S

2016-12-15

Few studies have assessed regional variation in the organisation of stroke services, particularly health care resourcing, presence of protocols and discharge planning. Our aim was to compare stroke care organisation within middle- (MIC) and high-income country (HIC) hospitals participating in the Head Position in Stroke Trial (HeadPoST). HeadPoST is an on-going international multicenter crossover cluster-randomized trial of 'sitting-up' versus 'lying-flat' head positioning in acute stroke. As part of the start-up phase, one stroke care organisation questionnaire was completed at each hospital. The World Bank gross national income per capita criteria were used for classification. 94 hospitals from 9 countries completed the questionnaire, 51 corresponding to MIC and 43 to HIC. Most participating hospitals had a dedicated stroke care unit/ward, with access to diagnostic services and expert stroke physicians, and offering intravenous thrombolysis. There was no difference for the presence of a dedicated multidisciplinary stroke team, although greater access to a broad spectrum of rehabilitation therapists in HIC compared to MIC hospitals was observed. Significantly more patients arrived within a 4-h window of symptoms onset in HIC hospitals (41 vs. 13%; P<0.001), and a significantly higher proportion of acute ischemic stroke patients received intravenous thrombolysis (10 vs. 5%; P=0.002) compared to MIC hospitals. Although all hospitals provided advanced care for people with stroke, differences were found in stroke care organisation and treatment. Future multilevel analyses aims to determine the influence of specific organisational factors on patient outcomes. Copyright © 2016 Elsevier B.V. All rights reserved.

Pre-stroke seizures: A nationwide register-based investigation.

PubMed

Zelano, Johan; Larsson, David; Kumlien, Eva; Åsberg, Signild

2017-07-01

The relationship between cerebrovascular disease and seizures is clearly illustrated by poststroke epilepsy. Seizures can also be the first manifestation of cerebrovascular disease and case-control studies have demonstrated that seizures carry an increased risk of subsequent stroke. Thus, seizures could serve as a marker for vascular risk that merits intervention, but more data is needed before proper trials can be conducted. The occurrence of pre-stroke seizures has not been assessed on a national scale. We asked what proportion of strokes in middle-aged and elderly patients was preceded by seizures. All patients over 60 years of age with first-ever stroke in 2005-2010 (n=92,596) were identified in the Swedish stroke register (Riksstroke) and cross-sectional data on a history of a first seizure or epilepsy diagnosis in the ten years preceding stroke were collected from national patient registers with mandatory reporting. 1372 patients (1.48%) had a first seizure or epilepsy diagnosis registered less than ten years prior to the index stroke. The mean latency between seizure and stroke was 1474days (SD 1029 days). Seizures or epilepsy preceded 1.48% of strokes in patients >60years of age. Based on recent national incidence figures, 5-20% of incident cases of seizures or epilepsy after 60 years of age could herald stroke, depending on age group. These proportions are of a magnitude that merit further study on how to reduce the risk of stroke in patients with late-onset seizures or epilepsy. Copyright © 2017 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.

Incidence of seizures following initial ischemic stroke in a community-based cohort: The Framingham Heart Study.

PubMed

Stefanidou, Maria; Das, Rohit R; Beiser, Alexa S; Sundar, Banu; Kelly-Hayes, Margaret; Kase, Carlos S; Devinsky, Orrin; Seshadri, Sudha; Friedman, Daniel

2017-04-01

We examined the incidence of seizures following ischemic stroke in a community-based sample. All subjects with incident ischemic strokes in the Framingham Original and Offspring cohorts between 1982 and 2003 were identified and followed for up to 20 years to determine incidence of seizures. Seizure-type was based on the 2010 International League Against Epilepsy (ILAE) classification. Disability was stratified into mild/none, moderate and severe, based on post-stroke neurological deficit documentation according to the Framingham Heart Study (FHS) protocol and functional status was determined using the Barthel Index. An initial ischemic stroke occurred in 469 subjects in the cohort and seizures occurred in 25 (5.3%) of these subjects. Seizure incidence was similar in both large artery atherosclerosis (LAA) (6.8%) and cardio-embolic (CE) (6.2%) strokes. No seizures occurred following lacunar strokes. The predominant seizure type was focal seizure with or without evolution to bilateral convulsive seizure. One third of participants had seizures within the first 24h from stroke onset and half of all seizures occurred within the first 30days. On multivariate analysis, moderate and severe disability following stroke was associated with increased risk of incident seizure. Seizures occurred in approximately 5% of subjects after an ischemic stroke. One third of these seizures occurred in the first 24h after stroke and none followed lacunar strokes. Focal seizures with or without evolution in bilateral convulsive seizures were the most common seizure type. Moderate and severe disability was predictive of incident seizures. Copyright © 2017 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.

Relapse of Takayasu arteritis as a cause of suicidal poisoning and subsequent major ischemic stroke successfully treated with thrombolytic therapy.

PubMed

Komatina, Neneal; Lepić, Toplica; Labović, Boban; Stevović, Tatjana; Petronijević, Milan; Radovinović-Tasić, Sanja; Obradović, Dragana

2016-08-01

Takayasu arteritis (TA) is a rare large vessel arteritis, affecting primarily aorta and its major branches. Its clinical manifestations can vary significantly - from asymptomatic to serious vascular events. Acute neurological complications are frequent at the onset of the disease and in relapses. Anxiety and depression are more frequent in TA patients than in general population as well as during relapses. Prevalence of transient ischemic attack or ischemic stroke in TA patients is approximately 10-20%. We presented a patient with TA that began with a depressive episode resulting in attempted suicide by bromazepame poisoning. This was subsequently followed by major ischemic stroke caused by thrombosis of the left middle cerebral artery (probably due to aortic arch embolism) successfully treated with intravenous thrombolysis. Intravenous thrombolysis appears to be safe and effective in patients with TA and stroke.

[Moyamoya disease as a rare cause of ischaemic stroke--case report].

PubMed

Kułakowska, Alina; Kapica-Topczewska, Katarzyna; Borowik, Helena; Drozdowski, Wiesław

2009-10-01

Moyamoya disease is a rare, progressive disease of the vessels diagnosed according to characteristic abnormalities of brain arteries in the angiography. The incidence of moyamoya disease in Europe is lower than in Asia and its clinical course in European population is probably different from Asiatic (older age of onset and rare incidence of hemorrhagic strokes). Two young patients were diagnosed as moyamoya disease on the basis of clinical symptoms (ischaemic stroke) and results of brain vessels' angiography, which documented an occlusion of both internal carotid arteries above branching-off the ocular arteries in the first patient and stenosis of distal internal carotid arteries and proximal medial and anterior cerebral arteries in the second one. Both patients are under control of the Neurological Outpatient Department and their neurological state is stable. Despite that moyamoya disease is a rare cause of ischaemic stroke, it should be always considered as one of etiologic factors, especially in young patients.

Thrombolysis for stroke in pregnancy at 39 weeks gestation with a subsequent normal delivery.

PubMed

Ritchie, Joanne; Lokman, Mariam; Panikkar, Jane

2015-08-11

Stroke during pregnancy is fortunately a rare event, however, it can have severe consequences, with 9.5% of all maternal deaths being related to stroke. The most common presentation is an ischaemic stroke. There has been much debate as to the correct treatment for such cases' and whether thrombolysis can be used safely in pregnancy. Our case describes a 28-year-old woman with a previous normal vaginal delivery presenting in her third trimester with a sudden onset of dense left hemiparesis. She was successfully treated with alteplase, an intravenous recombinant tissue-type plasminogen activator, and made a full recovery after normal delivery of a healthy infant. This case report highlights one of the first documented successful outcomes from thrombolysis for this condition in the UK and may help inform future management of these women. 2015 BMJ Publishing Group Ltd.

Holmes' tremor as a delayed complication of thalamic stroke.

PubMed

Martins, William Alves; Marrone, Luiz Carlos Porcello; Fussiger, Helena; Vedana, Viviane Maria; Cristovam, Rafael do Amaral; Taietti, Marjorye Z; Marrone, Antonio Carlos Huf

2016-04-01

Movement disorders are not commonly associated with stroke. Accordingly, thalamic strokes have rarely been associated with tremor, pseudo-athetosis and dystonic postures. We present a 75-year-old man who developed a disabling tremor 1 year after a posterolateral thalamic stroke. This tremor had low frequency (3-4 Hz), did not disappear on focus and was exacerbated by maintaining a static posture and on target pursuit, which made it very difficult to perform basic functions. MRI demonstrated an old ischemic lesion at the left posterolateral thalamus. Treatment with levodopa led to symptom control. Lesions in the midbrain, cerebellum and thalamus may cause Holmes' tremor. Delayed onset of symptoms is usually seen, sometimes appearing 2 years after the original injury. This may be due to maturation of a complex neuronal network, leading to slow dopaminergic denervation. Further studies are needed to improve our understanding of this unique disconnection syndrome. Copyright © 2015 Elsevier Ltd. All rights reserved.

Endovascular therapy for acute ischaemic stroke: the Pragmatic Ischaemic Stroke Thrombectomy Evaluation (PISTE) randomised, controlled trial

PubMed Central

Muir, Keith W; Ford, Gary A; Messow, Claudia-Martina; Ford, Ian; Murray, Alicia; Clifton, Andrew; Brown, Martin M; Madigan, Jeremy; Lenthall, Rob; Robertson, Fergus; Dixit, Anand; Cloud, Geoffrey C; Wardlaw, Joanna; Freeman, Janet; White, Philip

2017-01-01

Objective The Pragmatic Ischaemic Thrombectomy Evaluation (PISTE) trial was a multicentre, randomised, controlled clinical trial comparing intravenous thrombolysis (IVT) alone with IVT and adjunctive intra-arterial mechanical thrombectomy (MT) in patients who had acute ischaemic stroke with large artery occlusive anterior circulation stroke confirmed on CT angiography (CTA). Design Eligible patients had IVT started within 4.5 hours of stroke symptom onset. Those randomised to additional MT underwent thrombectomy using any Conformité Européene (CE)-marked device, with target interval times for IVT start to arterial puncture of <90 min. The primary outcome was the proportion of patients achieving independence defined by a modified Rankin Scale (mRS) score of 0–2 at day 90. Results Ten UK centres enrolled 65 patients between April 2013 and April 2015. Median National Institutes of Health Stroke Scale score was 16 (IQR 13–21). Median stroke onset to IVT start was 120 min. In the intention-to-treat analysis, there was no significant difference in disability-free survival at day 90 with MT (absolute difference 11%, adjusted OR 2.12, 95% CI 0.65 to 6.94, p=0.20). Secondary analyses showed significantly greater likelihood of full neurological recovery (mRS 0–1) at day 90 (OR 7.6, 95% CI 1.6 to 37.2, p=0.010). In the per-protocol population (n=58), the primary and most secondary clinical outcomes significantly favoured MT (absolute difference in mRS 0–2 of 22% and adjusted OR 4.9, 95% CI 1.2 to 19.7, p=0.021). Conclusions The trial did not find a significant difference between treatment groups for the primary end point. However, the effect size was consistent with published data and across primary and secondary end points. Proceeding as fast as possible to MT after CTA confirmation of large artery occlusion on a background of intravenous alteplase is safe, improves excellent clinical outcomes and, in the per-protocol population, improves disability-free survival. Trial registration number NCT01745692; Results. PMID:27756804

Altered steering strategies for goal-directed locomotion in stroke

PubMed Central

2013-01-01

Background Individuals who have sustained a stroke can manifest altered locomotor steering behaviors when exposed to optic flows expanding from different locations. Whether these alterations persist in the presence of a visible goal and whether they can be explained by the presence of a perceptuo-motor disorder remain unknown. The purpose of this study was to compare stroke participants and healthy participants on their ability to control heading while exposed to changing optic flows and target locations. Methods Ten participants with stroke (55.6 ± 9.3 yrs) and ten healthy controls (57.0 ± 11.5 yrs) participated in a mouse-driven steering task (perceptuo-motor task) while seated and in a walking steering task. In the seated steering task, participants were instructed to head or ‘walk’ toward a target in the virtual environment by using a mouse while wearing a helmet-mounted display (HMD). In the walking task, participants performed a similar steering task in the same virtual environment while walking overground at their comfortable speed. For both experiments, the target and/or the focus of expansion (FOE) of the optic flow shifted to the side (±20°) or remained centered. The main outcome measure was net heading errors (NHE). Secondary outcomes included mediolateral displacement, horizontal head orientation, and onsets of heading and head reorientation. Results In the walking steering task, the presence of FOE shifts modulated the extent and timing of mediolateral displacement and head rotation changes, as well as NHE magnitudes. Participants overshot and undershot their net heading, respectively, in response to ipsilateral and contralateral FOE and target shifts. Stroke participants made larger NHEs, especially when the FOE was shifted towards the non-paretic side. In the seated steering task, similar NHEs were observed between stroke and healthy participants. Conclusions The findings highlight the fine coordination between rotational and translational steering mechanisms in presence of targets and FOE shifts. The altered performance of stroke participants in walking but not in the seated steering task suggests that an altered perceptuo-motor processing of optic flow is not a main contributing factor and that other stroke-related sensorimotor deficits are involved. PMID:23875969

Development of an education campaign to reduce delays in pre-hospital response to stroke.

PubMed

Caminiti, Caterina; Schulz, Peter; Marcomini, Barbara; Iezzi, Elisa; Riva, Silvia; Scoditti, Umberto; Zini, Andrea; Malferrari, Giovanni; Zedde, Maria Luisa; Guidetti, Donata; Montanari, Enrico; Baratti, Mario; Denti, Licia

2017-06-24

Systematic reviews call for well-designed trials with clearly described intervention components to support the effectiveness of educational campaigns to reduce patient delay in stroke presentation. We herein describe the systematic development process of a campaign aimed to increase stroke awareness and preparedness. Campaign development followed Intervention Mapping (IM), a theory- and evidence-based tool, and was articulated in two phases: needs assessment and intervention development. In phase 1, two cross-sectional surveys were performed, one aiming to measure stroke awareness in the target population and the other to analyze the behavioral determinants of prehospital delay. In phase 2, a matrix of proximal program objectives was developed, theory-based intervention methods and practical strategies were selected and program components and materials produced. In phase 1, the survey on 202 citizens highlighted underestimation of symptom severity, as in only 44% of stroke situations respondents would choose to call the emergency service (EMS). In the survey on 393 consecutive patients, 55% presented over 2 hours after symptom onset; major determinants were deciding to call the general practitioner first and the reaction of the first person the patient called. In phase 2, adult individuals were identified as the target of the intervention, both as potential "patients" and witnesses of stroke. The low educational level found in the patient survey called for a narrative approach in cartoon form. The family setting was chosen for the message because 42% of patients who presented within 2 hours had been advised by a family member to call EMS. To act on people's tendency to view stroke as an untreatable disease, it was decided to avoid fear-arousal appeals and use a positive message providing instructions and hope. Focus groups were used to test educational products and identify the most suitable sites for message dissemination. The IM approach allowed to develop a stroke campaign integrating theories, scientific evidence and information collected from the target population, and enabled to provide clear explanations for the reasons behind key decisions during the intervention development process. NCT01881152 . Retrospectively registered June 7 2013.

Green and black tea consumption and risk of stroke: a meta-analysis.

PubMed

Arab, Lenore; Liu, Weiqing; Elashoff, David

2009-05-01

Experimental models of stroke provide consistent evidence of smaller stroke volumes in animals ingesting tea components or tea extracts. To assess whether a similar association of black or green tea consumption with reduced risk is evident in human populations, we sought to identify and summarize all human clinical and observational data on tea and stroke. We searched PubMed and Web of Science for all studies on stroke and tea consumption in humans with original data, including estimation or measurement of tea consumption and outcomes of fatal or nonfatal stroke. Data from 9 studies involving 4378 strokes among 194 965 individuals were pooled. The main outcome was the occurrence of fatal or nonfatal stroke. We tested for heterogeneity and calculated the summary effect estimate associated with consumption of >or=3 cups of tea (green or black) per day using random-effects and fixed-effects models for the homogeneous studies. Publication bias was also evaluated. Regardless of their country of origin, individuals consuming >or=3 cups of tea per day had a 21% lower risk of stroke than those consuming <1 cup per day (absolute risk reduction, 0.79; CI, 0.73 to 0.85). The proportion of heterogeneity not explained by chance alone was 23.8%. Although a randomized clinical trial would be necessary to confirm the effect, this meta-analysis suggests that daily consumption of either green or black tea equaling 3 cups per day could prevent the onset of ischemic stroke.

Arterial stiffness and stroke: de-stiffening strategy, a therapeutic target for stroke

PubMed Central

Chen, Yajing; Shen, Fanxia; Liu, Jianrong; Yang, Guo-Yuan

2017-01-01

Stroke is the second leading cause of mortality and morbidity worldwide. Early intervention is of great importance in reducing disease burden. Since the conventional risk factors cannot fully account for the pathogenesis of stroke, it is extremely important to detect useful biomarkers of the vascular disorder for appropriate intervention. Arterial stiffness, a newly recognised reliable feature of arterial structure and function, is demonstrated to be associated with stroke onset and serve as an independent predictor of stroke incidence and poststroke functional outcomes. In this review article, different measurements of arterial stiffness, especially pressure wave velocity, were discussed. We explained the association between arterial stiffness and stroke occurrence by discussing the secondary haemodynamic changes. We reviewed clinical data that support the prediction role of arterial stiffness on stroke. Despite the lack of long-term randomised double-blind controlled therapeutic trials, it is high potential to reduce stroke prevalence through a significant reduction of arterial stiffness (which is called de-stiffening therapy). Pharmacological interventions or lifestyle modification that can influence blood pressure, arterial function or structure in either the short or long term are promising de-stiffening therapies. Here, we summarised different de-stiffening strategies including antihypertension drugs, antihyperlipidaemic agents, chemicals that target arterial remodelling and exercise training. Large and well-designed clinical trials on de-stiffening strategy are needed to testify the prevention effect for stroke. Novel techniques such as modern microscopic imaging and reliable animal models would facilitate the mechanistic analyses in pathophysiology, pharmacology and therapeutics. PMID:28959494

CHHIPS (Controlling Hypertension and Hypotension Immediately Post-Stroke) Pilot Trial: rationale and design.

PubMed

Potter, J; Robinson, T; Ford, G; James, M; Jenkins, D; Mistri, A; Bulpitt, C; Drummond, A; Jagger, C; Knight, J; Markus, H; Beevers, G; Dewey, M; Lees, K; Moore, A; Paul, S

2005-03-01

High and low blood pressure (BP) levels are common following acute stroke, with up to 60% of patients being hypertensive (SBP > 160 mmHg) and nearly 20% having relative hypotension (SBP < or = 140 mmHg), within the first few hours of ictus, both conditions being associated with an adverse prognosis. At present, the optimum management of blood pressure in the immediate post-stroke period is unclear. The primary aim of the Controlling Hypertension and Hypotension Immediately Post-Stroke (CHHIPS) Pilot Trial is to assess whether hypertension and relative hypotension, manipulated therapeutically in the first 24 h following acute stroke, affects short-term outcome measures. The CHHIPS Pilot Trial is a UK based multi-centre, randomized, double-blind, placebo-controlled, titrated dose trial. Acute stroke and medical units in teaching and district general hospitals, in the UK. The CHHIPS Pilot Study aims to recruit 2050 patients, with clinically suspected stroke, confirmed by brain imaging, who have no compelling indication or contraindication for BP manipulation. The primary outcome measure will be the effects of acute pressor therapy (initiated < or = 12 h from stroke onset) or depressor therapy (started < or = 24 h post-ictus) on death and dependency at 14 days post-stroke. Secondary outcome measures will include the influence of therapy on early neurological deterioration, the effectiveness of treatment in manipulating BP levels, the influence of time to treatment and stroke type on response and a cost-effectiveness analysis.

Post-stroke hemiparesis: Does chronicity, etiology, and lesion side are associated with gait pattern?

PubMed

Gama, Gabriela Lopes; Larissa, Coutinho de Lucena; Brasileiro, Ana Carolina de Azevedo Lima; Silva, Emília Márcia Gomes de Souza; Galvão, Élida Rayanne Viana Pinheiro; Maciel, Álvaro Cavalcanti; Lindquist, Ana Raquel Rodrigues

2017-07-01

Studies that evaluate gait rehabilitation programs for individuals with stroke often consider time since stroke of more than six months. In addition, most of these studies do not use lesion etiology or affected cerebral hemisphere as study factors. However, it is unknown whether these factors are associated with post-stroke motor performance after the spontaneous recovery period. To investigate whether time since stroke onset, etiology, and lesion side is associated with spatiotemporal and angular gait parameters of individuals with chronic stroke. Fifty individuals with chronic hemiparesis (20 women) were evaluated. The sample was stratified according to time since stroke (between 6 and 12 months, between 13 and 36 months, and over 36 months), affected cerebral hemisphere (left or right) and lesion etiology (ischemic and hemorrhagic). The participants were evaluated during overground walking at self-selected gait speed, and spatiotemporal and angular gait parameters were calculated. Results Differences between gait speed, stride length, hip flexion, and knee flexion were observed in subgroups stratified based on lesion etiology. Survivors of a hemorrhagic stroke exhibited more severe gait impairment. Subgroups stratified based on time since stroke only showed intergroup differences for stride length, and subgroups stratified based on affected cerebral hemisphere displayed between-group differences for swing time symmetry ratio. In order to recruit a more homogeneous sample, more accurate results were obtained and an appropriate rehabilitation program was offered, researchers and clinicians should consider that gait pattern might be associated with time since stroke, affected cerebral hemisphere and lesion etiology.

Ventilatory and circulatory responses at the onset of exercise in man following heart or heart-lung transplantation.

PubMed Central

Banner, N; Guz, A; Heaton, R; Innes, J A; Murphy, K; Yacoub, M

1988-01-01

1. Ventilatory and cardiovascular responses to the onset of voluntary and electrically induced leg exercise were studied in six patients following heart transplantation and five following heart-lung transplantation; the results were compared between the patient groups and also with responses from a group of normal subjects. 2. Oxygen consumption, carbon dioxide production and ventilation and its components were measured over two 30 s periods prior to, and two 30 s periods following, the onset of exercise. Relative changes in stroke volume and cardiac output were derived from ensemble-averaged Doppler measurements of ascending aortic blood velocity over the same 30 s periods. 3. None of the groups of subjects showed any significant differences in responses to voluntary exercise compared to electrically induced exercise of similar work pattern and intensity. 4. Compared to normal controls, the transplanted subjects showed higher resting heart rates which did not increase at the onset of exercise; stroke volume increased, but less than in the normal subjects. The resulting cardiac output increases in the transplanted subjects were minimal compared to the normal subjects. 5. Ventilation and oxygen uptake increased immediately and with similar magnitude in all three groups. 6. These results show that in the same individual it is possible to have an appropriate ventilatory response to the onset of exercise in the presumed absence of a normal corticospinal input to the exercising muscles (electrically induced exercise) and afferent neural information from the lungs and heart, and in the absence of a normal circulatory response to exercise. The mechanisms underlying this ventilatory response remain undetermined. PMID:3136247

Cost-Effectiveness of Thrombolysis within 4.5 Hours of Acute Ischemic Stroke in China

PubMed Central

Zhao, Xingquan; Liao, Xiaoling; Wang, Chunjuan; Du, Wanliang; Liu, Gaifen; Liu, Liping; Wang, Chunxue; Wang, Yilong; Wang, Yongjun

2014-01-01

Background Previous economic studies conducted in developed countries showed intravenous tissue-type plasminogen activator (tPA) is cost-effective for acute ischemic stroke. The present study aimed to determine the cost-effectiveness of tPA treatment in China, the largest developing country. Methods A combination of decision tree and Markov model was developed to determine the cost-effectiveness of tPA treatment versus non-tPA treatment within 4.5 hours after stroke onset. Outcomes and costs data were derived from the database of Thrombolysis Implementation and Monitor of acute ischemic Stroke in China (TIMS-China) study. Efficacy data were derived from a pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials. Costs and quality-adjusted life-years (QALYs) were compared in both short term (2 years) and long term (30 years). One-way and probabilistic sensitivity analyses were performed to test the robustness of the results. Results Comparing to non-tPA treatment, tPA treatment within 4.5 hours led to a short-term gain of 0.101 QALYs at an additional cost of CNY 9,520 (US$ 1,460), yielding an incremental cost-effectiveness ratio (ICER) of CNY 94,300 (US$ 14,500) per QALY gained in 2 years; and to a long-term gain of 0.422 QALYs at an additional cost of CNY 6,530 (US$ 1,000), yielding an ICER of CNY 15,500 (US$ 2,380) per QALY gained in 30 years. Probabilistic sensitivity analysis showed that tPA treatment is cost-effective in 98.7% of the simulations at a willingness-to-pay threshold of CNY 105,000 (US$ 16,200) per QALY. Conclusions Intravenous tPA treatment within 4.5 hours is highly cost-effective for acute ischemic strokes in China. PMID:25329637

Prospective, Multi-Centre, Single-Arm Study of Mechanical Thrombectomy using Solitaire FR in Acute Ischemic Stroke-STAR

PubMed Central

Pereira, Vitor M; Gralla, Jan; Davalos, Antoni; Bonafé, Alain; Castaño, Carlos; Chapot, Rene; Liebeskind, David S; Nogueira, Raul G; Arnold, Marcel; Sztajzel, Roman; Liebig, Thomas; Goyal, Mayank; Besselmann, Michael; Moreno, Alfredo; Schroth, Gerhard

2013-01-01

Background and Purpose Mechanical thrombectomy using stent retriever devices have been advocated to increase revascularization in intracranial vessel occlusion. We present the results of a large prospective study on the use of the Solitaire FR in patients with acute ischemic stroke. Methods STAR was an international, multicenter, prospective, single-arm study of Solitaire FR thrombectomy in patients with large vessel anterior circulation strokes treated within 8 hours of symptom onset. Strict criteria for site selection were applied. The primary endpoint was the revascularization rate (3TICI 2b) of the occluded vessel as determined by an independent core lab. The secondary endpoint was the rate of good functional outcome (defined as 90-day modified Rankin scale (mRS) 0–2). Results A total of 202 patients were enrolled across 14 comprehensive stroke centers in Europe, Canada and Australia. The median age was 72 years, 60% were female patients. The median National Institute of Health Stroke Scale (NIHSS) was 17. Most proximal intracranial occlusion was the internal carotid artery in 18%, the middle cerebral artery in 82%. Successful revascularization was achieved in 79.2% of patients. Device and/or procedure related severe adverse events were found in 7.4%. Favorable neurological outcome was found in 57.9%. The mortality rate was 6.9%. Any intracranial hemorrhagic transformation was found in 18.8% of patients, 1.5% were symptomatic. Conclusions In this single arm study, treatment with the Solitaire™ FR device in intracranial anterior circulation occlusions results in high rates of revascularization, low risk of clinically relevant procedural complications, and good clinical outcomes in combination with low mortality at 90 days. Clinical Trial Registration This study is registered with ClinicalTrials.gov, number NCT01327989. PMID:23908066

Effect of vitamin C supplementation on stroke recovery: A case-control study

PubMed Central

Rabadi, Meheroz H; Kristal, Bruce S

2007-01-01

Background and purpose: Epidemiological studies have associated increased dietary intake of antioxidants (vitamin C, E, and β-carotene) in preventing and decreasing the extent of ischemic brain injury. The effect of vitamin C supplementation on functional recovery after stroke has not been studied. Method: In this retrospective, case-control study of 23 patients with ischemic stroke taking vitamin C were identified and matched for age, sex, onset to admission, and admission total functional independence measure (TFIM) with 23 patients with ischemic stroke not taking Vitamin C supplementation. Vitamin C 1000 mg daily was prescribed on admission to our unit mainly to patients who were undernourished (defined as significant weight loss and/or 90% or less ideal body weight for age and sex) and those with pressure sores. The outcome measures were: change in the TFIM, FIM-Cognition (FIM-Cog), and FIM-Motor sub-scores, discharge disposition, and length of stay (LOS). Results: The change in TFIM (20 ± 13 standard deviation [SD] vs. 26 ± 6, p = 0.20), FIM-Cog (3 ± 3 SD vs. 4 ± 5, p = 0.41), FIM-Motor (15 ± 11 SD vs. 20 ± 13, p = 0.21) sub-scores were less in the vitamin C treated group, but these differences did not reach statistical significance. Similarly, no significant differences were found in LOS (21 ± 9 SD vs. 23 ± 9, p = 0.59), and discharge disposition (home/institution) (9/10 vs. 13/9, p = 0.60) between the vitamin C and the control groups. Conclusion: This study suggests vitamin C supplementation did not enhance functional recovery in undernourished ischemic stroke patients. PMID:18044087

"Stops walking when talking" as a predictor of falls in people with stroke living in the community

PubMed Central

Hyndman, D; Ashburn, A

2004-01-01

Objective: To test "Stops walking when talking" (SWWT) as a predictor of falls among people with stroke living in the community. Methods: People with stroke were identified through hospital records. Mobility, ADL (activites of daily living) ability, mental state, mood, and SWWT were assessed in a single session. Participants were followed prospectively for six months, using falls diaries and regular telephone calls. Results: Sixty three participants (36 men, 27 women; mean (SD) age 68.4 (10.6)) were recruited. Four subjects had a brainstem lesion, 30 had right hemisphere, and 29 left hemisphere infarctions. Mean time since onset of stroke was 20 months (range 2–72). Twenty six subjects stopped walking when a conversation was started and 16 of them fell during the six month follow up period (11 experienced repeated falls). For all fallers (⩾1) the positive predictive value of SWWT was 62% (16/26), the negative predictive value 62% (23/37), specificity 70% (23/33) and sensitivity 53% (16/30). For repeat fallers (⩾2) the positive predictive value of SWWT was 42% (11/26), the negative predictive value 89% (33/37), specificity 69% (33/48) and sensitivity 73% (11/15). Those who stopped walking were significantly more disabled (p<0.001)—that is, they were more dependent in activities of daily living, had worse gross function as well as worse upper and lower limb function, and had depression (p = 0.012). Conclusions: The specificity of the SWWT test was lower but sensitivity was higher than previously reported. Although the SWWT test was easy to use, its clinical usefulness as a single indicator of fall risk in identifying those community dwelling people with stroke most at risk of falls and in need of therapeutic intervention is questionable. PMID:15201358

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

Fjetland, Lars, E-mail: lars.fjetland@lyse.net; Roy, Sumit; Kurz, Kathinka D.

Purpose: To evaluate the safety and efficacy of neurointerventional procedures in acute stroke patients performed by a team of vascular interventional radiologists in close cooperation with diagnostic neuroradiologists and stroke neurologists and to compare the results with those of previous reports from centres with specialised interventional neuroradiologists. Material and Methods: A total of 39 patients with acute ischemic stroke due to large-vessel occlusion not responding to or not eligible for intravenous thrombolysis were treated with either intra-arterial thrombolysis or mechanical thrombectomy (Penumbra System or solitaire FR thrombectomy system, respectively) and included in our prospective study. Outcomes were measured using themore » modified Rankin scale after 90 days, and recanalization was assessed by thrombolysis using the myocardial infarction score. Results: Mean patient age was 68.3 {+-} 14.2 years; the average National Institutes of Health Stroke Scale score at hospital admission was 17.2 (SD = 6.2 [n = 38]). Successful recanalization was achieved in 74.4 % of patients. Median time from clinical onset to recanalization was 5 h 11 min. Procedure-related complications occurred in 5 % of patients, and 7.5 % had a symptomatic intracerebral hemorrhage. Of the patients, 22.5 % died within the first 90 postprocedural days, 5 % of these from cerebral causes. Patients who were successfully recanalized had a clinical better outcome at follow-up than those in whom treatment failed. Of the patients, 35.9 % had an mRS score {<=}2 after 90 days. Conclusion: Our results are in line with those in the published literature and show that a treatment strategy with general interventional radiologists performing neurointerventional procedures in acute stroke patients with large vessel occlusions can be achieved to the benefit of patients.« less

A cost-effectiveness analysis of screening for silent atrial fibrillation after ischaemic stroke.

PubMed

Levin, Lars-Åke; Husberg, Magnus; Sobocinski, Piotr Doliwa; Kull, Viveka Frykman; Friberg, Leif; Rosenqvist, Mårten; Davidson, Thomas

2015-02-01

The purpose of this study was to estimate the cost-effectiveness of two screening methods for detection of silent AF, intermittent electrocardiogram (ECG) recordings using a handheld recording device, at regular time intervals for 30 days, and short-term 24 h continuous Holter ECG, in comparison with a no-screening alternative in 75-year-old patients with a recent ischaemic stroke. The long-term (20-year) costs and effects of all alternatives were estimated with a decision analytic model combining the result of a clinical study and epidemiological data from Sweden. The structure of a cost-effectiveness analysis was used in this study. The short-term decision tree model analysed the screening procedure until the onset of anticoagulant treatment. The second part of the decision model followed a Markov design, simulating the patients' health states for 20 years. Continuous 24 h ECG recording was inferior to intermittent ECG in terms of cost-effectiveness, due to both lower sensitivity and higher costs. The base-case analysis compared intermittent ECG screening with no screening of patients with recent stroke. The implementation of the screening programme on 1000 patients resulted over a 20-year period in 11 avoided strokes and the gain of 29 life-years, or 23 quality-adjusted life years, and cost savings of €55 400. Screening of silent AF by intermittent ECG recordings in patients with a recent ischaemic stroke is a cost-effective use of health care resources saving costs and lives and improving the quality of life. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2014. For permissions please email: journals.permissions@oup.com.

Stroke management: Informal caregivers' burdens and strians of caring for stroke survivors.

PubMed

Gbiri, Caleb Ademola; Olawale, Olajide Ayinla; Isaac, Sarah Oghenekewe

2015-04-01

Stroke survivors live with varied degrees of disabilities and cares are provided largely by the informal caregivers. This study investigated informal caregivers' burden and strains of caring for stroke patients. This study involved 157 (81 males and 76 females) informal caregivers of stroke survivors receiving care in all secondary and tertiary health institutions with physiotherapy services in Lagos State, Nigeria. Information was collected through self-administered questionnaire during clinic-hours. Data was analyzed using Spearman's Rank Correlation Coefficient. The patients' age ranged between 20 and 79 (mean=59.6 ± 14.6 years). Sixty-one had haemorrhagic stroke while 96 had ischaemic stroke. The informal caregivers' age was 39.2 ± 12.8 years (range: 17-36 years). More (60.8%) participants reported moderate objective while 79.2% had mild subjective burdens. The following factors significantly increased (P<0.05) the level of burden and strains experienced by the informal caregivers: closer intimacy with the stroke survivors, fewer number of caregivers for the stroke patient, longer duration since the onset of stroke and more hours of caregiving per day. Caregiving had negative significant influence (P<0.05) on the social, emotional, health and financial well-beings of the informal caregivers. Caring for stroke survivors put social, emotional, health and financial burdens and strains on the informal caregivers. These burdens and strains increase with duration of stroke, intimacy, smaller number of caregivers and length of daily caregiving. Therefore, informal caregivers should be involved in the rehabilitation plan for stroke patients and their well-being should also be given adequate attention. Copyright © 2015 Elsevier Masson SAS. All rights reserved.

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.

Effect of Statin Intensity on the Risk of Epilepsy After Ischaemic Stroke: Real-World Evidence from Population-Based Health Claims.

PubMed

Lin, Fang-Ju; Lin, Hung-Wei; Ho, Yunn-Fang

2018-04-01

Statins possess neuroprotective effects. However, real-world evidence supporting their utility in post-stroke epilepsy (PSE) prevention is limited. The association between statin use, including timing of prescribing (pre-stroke vs post-stroke), type (lipophilicity, intensity of therapy) and dose intensity, and risk of developing PSE were investigated by studying Taiwanese health claims (2003-2013). Patients with new-onset ischaemic stroke were identified. The main outcome was a diagnosis of epilepsy after ischaemic stroke. According to pre-stroke statin use, groups of current users, former users, and non-users were compared using ANOVA. An extended Cox regression model was utilized to estimate the hazard ratio (HR) of PSE, with post-stroke statin use and certain comedications as time-dependent variables. Serial sensitivity analyses were performed to ensure study robustness. Of the 20,858 ischaemic stroke patients, 954 (4.6%) developed PSE. Post-stroke statin use (adjusted HR (aHR) 0.55; 95% confidence interval 0.46-0.67, p < 0.001), but not pre-stroke statin use was associated with a significantly reduced risk of developing PSE. A dose-response correlation was also observed between PSE risk reduction and quartiles of the statin cumulative defined daily dose (cDDD) (aHR 0.84, 0.67, 0.53, and 0.50 for the lowest, second, third, and highest quartiles of cDDD, respectively). Risk predictors and protectors against PSE were also characterized. The post-stroke use of statins after ischaemic stroke was associated with PSE risk reduction in a cDDD-dependent manner. Further clinical studies on the potential applications of statins for PSE prophylaxis, particularly among at-risk patients, are warranted.

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

PubMed

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

2014-07-08

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

Maternal death from stroke: a thirty year national retrospective review.

PubMed

Foo, Lin; Bewley, Susan; Rudd, Anthony

2013-12-01

In the United Kingdom (UK), the maternal mortality rate from stroke is reported at 0.3/100,000 deliveries, but only antenatal data have previously been reviewed. We hypothesise that the true rate is much higher due to a propensity for stroke occurring in the post-partum period, and that the rate will rise in parallel with trends of increasing maternal age and medical co-morbidities. Our objectives are to investigate the UK stroke mortality rate in pregnancy and the puerperium, and to examine temporal changes in fatal maternal strokes over a 30 year period. Retrospective review of stroke-related maternal deaths reported to the UK confidential enquiries into maternal death between 1979 and 2008, encompassing 21,514,457 maternities. In accordance with the ICD.10 classification, cases were divided into direct or indirect deaths. Late and coincidental deaths were not included in analyses. Lessons from sub-standard care associated with maternal death from stroke were collated. In 1979-2008 there were 347 maternal deaths from stroke: 139 cases were direct deaths, i.e. the fatal stroke was a direct result of pregnancy. The incidence of fatal stroke is relatively constant at 1.61/100,000 maternities, with a 13.9% (95% CI 12.6-15.3) proportional mortality rate. Intracranial haemorrhage was the single greatest cause of maternal death from stroke. This is the largest UK study examining the incidence of fatal maternal stroke in pregnancy and the puerperium. Our results highlight the high proportion of women who die from stroke in the puerperium. Sub-standard care featured especially in regard to management of dangerously high systolic blood pressure levels. These deaths highlight the importance of education in managing rapid-onset hypertension and superimposed coagulopathies. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Associations between quality of life and socioeconomic factors, functional impairments and dissatisfaction with received information and home-care services among survivors living at home two years after stroke onset.

PubMed

Baumann, Michèle; Le Bihan, Etienne; Chau, Kénora; Chau, Nearkasen

2014-04-28

Quality of life (QoL) assessment is important when monitoring over time the recovery of stroke-survivors living at home. This study explores the associations between QoL and socioeconomic factors, functional impairments and self-reported dissatisfaction with received information and home-care services among survivors two years after stroke onset. This problem remains partially addressed though optimal information and services may improve survivors' QoL. Stroke-survivors admitted to all hospitals in Luxembourg 18 months or more previously were identified using the only care-expenditure-reimbursement national system database. The clinical diagnosis was confirmed. Ninety four patients aged 65 years and living at home were interviewed to gather socioeconomic characteristics, functional impairments, dissatisfaction with information and home-care services, and QoL (using the Newcastle Stroke-Specific QoL, newsqol) assessing 11 domains. Data were analyzed using multiple linear regression models. About 50% of survivors had low education and lower income. Functional impairments were common: sensory (45%), motor (35%), memory (32%), language (31%), and vision (20%). Survivors with education (<12th grade) or lower income had low values for most newsqol domains (sex-age-adjusted regression coefficient saRC, i.e. mean difference, between -23 and -8). Patients who were working had better values for pain, mental feelings and sleep domains than did retired people (saRC between -3.9 and 4.2). Various functional impairments were associated with markedly low values of nearly all domains (saRC between -33.5 and -7.5) and motor, language, memory and sensory impairments had the highest impact. The survivors' perceived QoL was markedly low, especially for the domains of interpersonal relationship, sleep, cognition, mental feelings, and pain. Various QoL domains were strongly related to dissatisfaction with information about stroke and its consequences/changes over time, accuracy of information obtained, help received, coordination between services, and the possibility of receiving help when necessary (saRC reaching -30). Stroke-survivors had major alterations in QoL that reflected depressive symptoms, which should be appropriately treated. These findings may help with the development of public policies aiming at improving QoL among stroke survivors. The newsqol could be used routinely to measure the recovery of survivors over time and their needs in terms of information, help and care services.

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.

Abnormal blood pressure circadian rhythm in acute ischaemic stroke: are lacunar strokes really different?

PubMed

Castilla-Guerra, L; Espino-Montoro, A; Fernández-Moreno, M C; López-Chozas, J M

2009-08-01

A pathologically reduced or abolished circadian blood pressure variation has been described in acute stroke. However, studies on alterations of circadian blood pressure patterns after stroke and stroke subtypes are scarce. The objective of this study was to evaluate the changes in circadian blood pressure patterns in patients with acute ischaemic stroke and their relation to the stroke subtype. We studied 98 consecutive patients who were admitted within 24 h after ischaemic stroke onset. All patients had a detailed clinical examination, laboratory studies and a CT scan study of the brain on admission. To study the circadian rhythm of blood pressure, a continuous blood pressure monitor (Spacelab 90217) was used. Patients were classified according to the percentage fall in the mean systolic blood pressure or diastolic blood pressure at night compared with during the day as: dippers (fall> or =10-20%); extreme dippers (> or =20%); nondipper (<10%); and reverse dippers (<0%, that is, an increase in the mean nocturnal blood pressure compared with the mean daytime blood pressure). Data were separated and analysed in two groups: lacunar and nonlacunar infarctions. Statistical testing was conducted using the SSPS 12.0. Methods We studied 60 males and 38 females, mean age: 70.5+/-11 years. The patient population consisted of 62 (63.2%) lacunar strokes and 36 (36.8%) nonlacunar strokes. Hypertension was the most common risk factor (67 patients, 68.3%). Other risk factors included hypercholesterolaemia (44 patients, 44.8%), diabetes mellitus (38 patients, 38.7%), smoking (24 patients, 24.8%) and atrial fibrillation (19 patients, 19.3%). The patients with lacunar strokes were predominantly men (P=0.037) and had a lower frequency of atrial fibrillation (P=0.016) as compared with nonlacunar stroke patients. In the acute phase, the mean systolic blood pressure was 136+/-20 mmHg and diastolic blood pressure was 78.7+/-11.8. Comparing stroke subtypes, there were no differences in 24-h systolic blood pressure and 24-h diastolic blood pressure between patients with lacunar and nonlacunar infarction. However, patients with lacunar infarction showed a mean decline in day-night systolic blood pressure and diastolic blood pressure of approximately 4 mmHg [systolic blood pressure: 3.9 (SD 10) mmHg, P=0.003; diastolic blood pressure 3.7 (SD 7) mmHg, P=0.0001] compared with nonlacunar strokes. Nonlacunar strokes showed a lack of 24-h nocturnal systolic blood pressure and diastolic blood pressure fall. The normal diurnal variation in systolic blood pressure was abolished in 87 (88.9%) patients, and the variation in diastolic blood pressure was abolished in 76 (77.5%) patients. On comparing lacunar and nonlacunar strokes, we found that the normal diurnal variation in systolic blood pressure was abolished in 53 (85.4%) lacunar strokes and in 34 (94.4%) nonlacunar strokes (P=nonsignificant). In terms of diurnal variation in diastolic blood pressure, it was abolished in 43 (69.3%) lacunar strokes and in 33 (91.6%) nonlacunar strokes (P=0.026). Our results show clear differences in the blood pressure circadian rhythm of acute ischaemic stroke between lacunar and nonlacunar infarctions by means of 24-h blood pressure monitoring. The magnitude of nocturnal systolic and diastolic blood pressure dip was significantly higher in lacunar strokes. Besides, patients with lacunar strokes presented a higher percentage of dipping patterns in the diastolic blood pressure circadian rhythm. Therefore, one should consider the ischaemic stroke subtype when deciding on the management of blood pressure in acute stroke.

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.

Genetic Architecture of Lacunar Stroke.

PubMed

Traylor, Matthew; Bevan, Steve; Baron, Jean-Claude; Hassan, Ahamad; Lewis, Cathryn M; Markus, Hugh S

2015-09-01

Lacunar strokes comprise ≈20% of all strokes. Despite this frequency, their pathogenesis is poorly understood. Previous genome-wide association studies in lacunar stroke have been disappointing, which may be because of phenotypic heterogeneity. Pathological and radiological studies suggest that there may be different pathologies underlying lacunar strokes. This has led to the suggestion of 2 subtypes: isolated lacunar infarcts and multiple lacunar infarcts and leukoaraiosis. We performed genome-wide analyses in a magnetic resonance imaging-verified cohort of 1012 younger onset lacunar stroke cases and 964 controls. Using these data, we first estimated the heritability of lacunar stroke and its 2 hypothesized subtypes, and secondly, we determined whether this is enriched for regulatory regions in the genome, as defined by data from Encyclopedia of DNA Elements (ENCODE) and other sources. Finally, we determine the evidence for a polygenic contribution from rare variation to lacunar stroke and its subtypes. Our results indicate a substantial heritable component to magnetic resonance imaging-verified lacunar stroke (20%-25%) and its 2 subtypes (isolated lacunar infarct, 15%-18%; multiple lacunar infarcts/leukoaraiosis, 23%-28%). This heritable component is significantly enriched for sites affecting expression of genes. In addition, we show that the risk of the 2 subtypes of lacunar stroke in isolation, but not in combination, is associated with rare variation in the genome. Lacunar stroke, when defined on magnetic resonance imaging, is a highly heritable complex disease. Much of this heritability arises from regions of the genome affecting gene regulation. Rare variation affects 2 subtypes of lacunar in isolation, suggesting that they may have distinct genetic susceptibility factors. © 2015 The Authors.

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

High pro-BNP levels predict the occurrence of atrial fibrillation after cryptogenic stroke.

PubMed

Rodríguez-Yáñez, Manuel; Arias-Rivas, Susana; Santamaría-Cadavid, María; Sobrino, Tomás; Castillo, José; Blanco, Miguel

2013-07-30

Antiplatelets are recommended for secondary prevention in patients with cryptogenic stroke; however, some patients may present with a cardioembolic source that has not been detected, which may modify the treatment. Because high pro-brain natriuretic peptide (BNP) levels are associated with cardioembolic stroke, our objective was to determine whether pro-BNP levels in the acute phase of stroke predict the development of atrial fibrillation (AF) in patients with cryptogenic stroke. A prospective study including patients with cryptogenic stroke was conducted. Demographic data, medical history, and stroke characteristics were assessed at admission. A blood sample was obtained within the first 24 hours from stroke onset to determine pro-BNP levels. Patients were followed by a neurologist at 3 and 6 months and later by a primary care physician for 2 years to evaluate the development of AF. One thousand fifty patients with ischemic stroke were evaluated. Three hundred seventy-two patients (35%) had cryptogenic stroke. One hundred eight patients were excluded from the study, so 264 patients were valid for the analysis. AF was detected in 15 patients (5.6%) during the follow-up. Patients who developed AF were older, had hypertension more frequently, and showed higher levels of pro-BNP. In the logistic regression model, we found that pro-BNP ≥360 pg/mL was the only variable independently associated with the risk of developing AF (odds ratio 5.70, 95% confidence interval 1.11-29.29, p = 0.037). Pro-BNP ≥360 pg/mL increases by 5-fold the possibility of detecting AF during follow-up in patients with cryptogenic stroke.

Targeted mini-strokes produce changes in interhemispheric sensory signal processing that are indicative of disinhibition within minutes.

PubMed

Mohajerani, Majid H; Aminoltejari, Khatereh; Murphy, Timothy H

2011-05-31

Most processing of sensation involves the cortical hemisphere opposite (contralateral) to the stimulated limb. Stroke patients can exhibit changes in the interhemispheric balance of sensory signal processing. It is unclear whether these changes are the result of poststroke rewiring and experience, or whether they could result from the immediate effect of circuit loss. We evaluated the effect of mini-strokes over short timescales (<2 h) where cortical rewiring is unlikely by monitoring sensory-evoked activity throughout much of both cortical hemispheres using voltage-sensitive dye imaging. Blockade of a single pial arteriole within the C57BL6J mouse forelimb somatosensory cortex reduced the response evoked by stimulation of the limb contralateral to the stroke. However, after stroke, the ipsilateral (uncrossed) forelimb response within the unaffected hemisphere was spared and became independent of the contralateral forelimb cortex. Within the unaffected hemisphere, mini-strokes in the opposite hemisphere significantly enhanced sensory responses produced by stimulation of either contralateral or ipsilateral pathways within 30-50 min of stroke onset. Stroke-induced enhancement of responses within the spared hemisphere was not reproduced by inhibition of either cortex or thalamus using pharmacological agents in nonischemic animals. I/LnJ acallosal mice showed similar rapid interhemispheric redistribution of sensory processing after stroke, suggesting that subcortical connections and not transcallosal projections were mediating the novel activation patterns. Thalamic inactivation before stroke prevented the bilateral rearrangement of sensory responses. These findings suggest that acute stroke, and not merely loss of activity, activates unique pathways that can rapidly redistribute function within the spared cortical hemisphere.

Efficiency and effectiveness of stroke rehabilitation after first stroke.

PubMed

Lin, J H; Chang, C M; Liu, C K; Huang, M H; Lin, Y T

2000-06-01

To investigate predictive variables of rehabilitation efficiency and achievement of rehabilitation potential following stroke rehabilitation. We prospectively studied 110 first-stroke patients consecutively admitted to the inpatient rehabilitation department of our university hospital from 1 January to 31 December 1997. Functional recovery was measured as improvement in the ability to perform the Functional Independence Measure (FIM) instrument. Major medical (side of paralysis, stroke etiology, risk factors, Brunnstrom motor recovery stage, etc.), rehabilitative (initial FIM subscore, interval from stroke onset to rehabilitation commencement, rehabilitation stay, etc.), and demographic (age, years of education, occupation, marital and living status, care-giver, etc.) variables were examined. The mean FIM score was 57.7 +/- 24.5 at admission and 77.3 +/- 26.3 at discharge. The mean rehabilitation efficiency (0.7 +/- 0.7) and effectiveness (30.6 +/- 24.0%) of stroke rehabilitation were determined. Rehabilitation efficiency and rehabilitation effectiveness were significantly predicted by length of stay and arm motor recovery stage, and by age and arm motor recovery stage, respectively. The variance explained only 21% of the rehabilitation efficiency and 24% of the achievement of rehabilitation potential. The results of this study suggest that the large proportion of the unexplained variance in rehabilitation efficiency and effectiveness is due to nonmedical factors influencing the selection of patients for rehabilitation.

Induction and imaging of photothrombotic stroke in conscious and freely moving rats

NASA Astrophysics Data System (ADS)

Lu, Hongyang; Li, Yao; Yuan, Lu; Li, Hangdao; Lu, Xiaodan; Tong, Shanbao

2014-09-01

In experimental stroke research, anesthesia is common and serves as a major reason for translational failure. Real-time cerebral blood flow (CBF) monitoring during stroke onset can provide important information for the prediction of brain injury; however, this is difficult to achieve in clinical practice due to various technical problems. We created a photothrombotic focal ischemic stroke model utilizing our self-developed miniature headstage in conscious and freely moving rats. In this model, a high spatiotemporal resolution imager using laser speckle contrast imaging technology was integrated to acquire real-time two-dimensional CBF information during thrombosis. The feasibility, stability, and reliability of the system were tested in terms of CBF, behavior, and T2-weighted magnetic resonance imaging (MRI) findings. After completion of occlusion, the CBF in the targeted cortex of the stroke group was reduced to 16±9% of the baseline value. The mean infarct volume measured by MRI 24 h postmodeling was 77±11 mm3 and correlated well with CBF (R2=0.74). This rodent model of focal cerebral ischemia and real-time blood flow imaging opens the possibility of performing various fundamental and translational studies on stroke without the influence of anesthetics.

ABCD3-I score and the risk of early or 3-month stroke recurrence in tissue- and time-based definitions of TIA and minor stroke.

PubMed

Mayer, Lukas; Ferrari, Julia; Krebs, Stefan; Boehme, Christian; Toell, Thomas; Matosevic, Benjamin; Tinchon, Alexander; Brainin, Michael; Gattringer, Thomas; Sommer, Peter; Thun, Peter; Willeit, Johann; Lang, Wilfried; Kiechl, Stefan; Knoflach, Michael

2018-03-01

Changing definition of TIA from time to a tissue basis questions the validity of the well-established ABCD3-I risk score for recurrent ischemic cerebrovascular events. We analyzed patients with ischemic stroke with mild neurological symptoms arriving < 24 h after symptom onset in a phase where it is unclear, if the event turns out to be a TIA or minor stroke, in the prospective multi-center Austrian Stroke Unit Registry. Patients were retrospectively categorized according to a time-based (symptom duration below/above 24 h) and tissue-based (without/with corresponding brain lesion on CT or MRI) definition of TIA or minor stroke. Outcome parameters were early stroke during stroke unit stay and 3-month ischemic stroke. Of the 5237 TIA and minor stroke patients with prospectively documented ABCD3-I score, 2755 (52.6%) had a TIA by the time-based and 2183 (41.7%) by the tissue-based definition. Of the 2457 (46.9%) patients with complete 3-month followup, corresponding numbers were 1195 (48.3%) for the time- and 971 (39.5%) for the tissue-based definition of TIA. Early and 3-month ischemic stroke occurred in 1.1 and 2.5% of time-based TIA, 3.8 and 5.9% of time-based minor stroke, 1.2 and 2.3% of tissue-based TIA as well as in 3.1 and 5.5% of tissue-based minor stroke patients. Irrespective of the definition of TIA and minor stroke, the risk of early and 3-month ischemic stroke steadily increased with increasing ABCD3-I score points. The ABCD3-I score performs equally in TIA patients in tissue- as well as time-based definition and the same is true for minor stroke patients.

Sleep Modifications in Acute Transient Global Amnesia

PubMed Central

Della Marca, Giacomo; Mazza, Marianna; Losurdo, Anna; Testani, Elisa; Broccolini, Aldobrando; Frisullo, Giovanni; Marano, Giuseppe; Morosetti, Roberta; Pilato, Fabio; Profice, Paolo; Vollono, Catello; Di Lazzaro, Vincenzo

2013-01-01

Study Objective: Transient global amnesia (TGA) is a temporary memory loss characterized by an abrupt onset of antero-grade and retrograde amnesia, totally reversible. Since sleep plays a major role in memory consolidation, and in the storage of memory-related traces into the brain cortex, the aims of the present study were: (1) to evaluate changes in sleep macro-structure in TGA; (2) to assess modifications in sleep micro-structure in TGA, with particular reference to the arousal EEG and to cyclic alternating pattern (CAP); (3) to compare sleep parameters in TGA patients with a control group of patients with acute ischemic events (“minor stroke” or transient ischemic attack [TIA]) clinically and neuroradiologically “similar” to the TGA. Methods: TGA group: 17 patients, (8 men and 9 women, 60.2 ± 12.5 years). Stroke or TIA (SoT) group: 17 patients hospitalized in the Stroke Unit for recent onset of minor stroke or TIA with hemispheric localization; healthy controls (HC) group: 17 healthy volunteers, matched for age and sex. Patients and controls underwent full-night polysomnography. Results: In the multivariate analysis (conditions TGA, SoT, and HC) a significant effect of the condition was observed for sleep efficiency index, number of awakenings longer 1 min, REM latency, CAP time, and CAP rate. TGA and SoT differed only for CAP time and CAP rate, which were lower in the TGA group. Conclusions: Microstructural modification associated with TGA could be consequent to: (1) hippocampal dysfunction and memory impairment; (2) impairment of arousal-related structures (in particular, cholinergic pathways); (3) emotional distress. Citation: Della Marca G; Mazza M; Losurdo A; Testani E; Broccolini A; Frisullo G; Marano G; Morosetti R; Pilato F; Profice P; Vollono C; Di Lazzaro V. Sleep modifications in acute transient global amnesia. J Clin Sleep Med 2013;9(9):921-927. PMID:23997704