ISRN Stroke The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . All rights reserved. A Low-Cost Biofeedback System for Electromyogram-Triggered Functional Electrical Stimulation Therapy: An Indo-German Feasibility Study Sun, 01 Jun 2014 11:34:23 +0000 Functional electrical stimulation (FES) facilitates ambulatory function after paralysis by activating the muscles of the lower extremities. The FES-assisted stepping can either be triggered by a heel-swich, or by an electromyogram-(EMG-) based gait event detector. A group of six chronic (>6 months poststroke) hemiplegic stroke survivors underwent transcutaneous FES-assisted training for 1 hour on stepping task with EMG biofeedback from paretic tibialis anterior (TA) and medial gastrocnemius (GM) muscles, where the stimulation of the paretic TA or GM was triggered with surface EMG from the same muscle. During the baseline, postintervention, and 2-day-postintervention assessments, a total of 5 minutes of surface EMG was recorded from paretic GM and TA muscles during volitional treadmill walking. Two-way ANOVA showed significant effects in terms of values for the 6 stroke subjects, 0.002, the 3 assessments, 0, and the interaction between subjects and assessments, . The study showed a significant improvement from baseline in paretic GM and TA muscles coordination during volitional treadmill walking. Moreover, it was found that the EMG-triggered FES-assisted therapy for stand-to-walk transition helped in convergence of the deviation in centroidal angular momentum from the normative value to a quasi-steady state during the double-support phase of the nonparetic. Also, the observational gait analysis showed improvement in ankle plantarflexion during late stance, knee flexion, and ground clearance of the foot during swing phase of the gait. Alakananda Banerjee, Bhawna Khattar, and Anirban Dutta Copyright © 2014 Alakananda Banerjee et al. All rights reserved. Knowledge and Perception of Stroke: A Population-Based Survey in Uganda Sun, 06 Apr 2014 11:25:37 +0000 Purpose. This study, designed to complement a large population survey on prevalence of stroke risk factors, assessed knowledge and perception of stroke and associated factors. Methods. A population survey was conducted in urban Nansana and rural Busukuma, Wakiso district, central Uganda. Adult participants selected by multistage stratified sampling were interviewed about selected aspects of stroke knowledge and perception in a pretested structured questionnaire. Results. There were 1616 participants (71.8% urban; 68.4% female; mean age: 39.6 years ± 15.3). Nearly 3/4 did not know any stroke risk factors and warning signs or recognize the brain as the organ affected. Going to hospital (85.2%) was their most preferred response to a stroke event. Visiting herbalists/traditional healers was preferred by less than 1%. At multivariable logistic regression, good knowledge of stroke warning signs and risk factors was associated with tertiary level of education (OR 4.29, 95% CI 2.13–8.62 and OR 5.96, 95% CI 2.94–12.06), resp.) and self-reported diabetes (OR 1.97, 95% CI 1.18–3.32 and OR 1.84, 95% CI 1.04–3.25), resp.). Conclusion. Knowledge about stroke in Uganda is poor although the planned response to a stroke event was adequate. Educational strategies to increase stroke knowledge are urgently needed as a prelude to developing preventive programmes. Jane Nakibuuka, Martha Sajatovic, Elly Katabira, Edward Ddumba, Jayne Byakika-Tusiime, and Anthony J. Furlan Copyright © 2014 Jane Nakibuuka et al. All rights reserved. Experiences of Thrombolytic Therapy for Ischemic Stroke in Tuzla Canton, Bosnia and Herzegovina Tue, 11 Mar 2014 06:32:54 +0000 Aim. To demonstrate our experiences of thrombolytic therapy in acute ischemic stroke. Subjects and Methods. Patients with ischemic stroke treated with rt-PA, admitted at the Department of Neurology, Tuzla, Bosnia and Herzegovina, in the period between April 1, 2008, and December 31, 2012, were included. Results. Between April 2008 and December 2012, intravenous rt-PA was given to 87 patients with acute ischemic stroke, which represents 3.2% of patients with acute ischemic stroke admitted to our department in that period. Hypertension was the leading stroke risk factor. The mean NIHSS score before thrombolysis was 12 (range 4–21). Large artery arteriosclerosis was the most common stroke etiology. The mean door-to-needle time was 72 minutes and onset-to-needle time 152 minutes. Half of patients (44/87) had a significant improvement within the first 24 hours. Parenchymal hemorrhage occurred in 5 patients (6%) and was fatal in two cases. At 3-month follow-up, 45% of patients (39/87) had good outcome (mRS 0 or 1). Sixteen patients were dead at 3 months, and mean baseline stroke severity was significantly higher in patients who died (NIHSS 16.5 versus 11, ). Conclusion. The number of patients with acute ischemic stroke treated using rt-PA in the Department of Neurology, Tuzla, is lower than in developed countries. Thrombolytic therapy is safe and leads to favorable outcome in half of the patients. Dževdet Smajlović, Denisa Salihović, Omer Ć. Ibrahimagić, Zikrija Dostović, Leila Avdić, and Mirjana Vidović Copyright © 2014 Dževdet Smajlović et al. All rights reserved. Screening of Paroxysmal Atrial Fibrillation after Ischemic Stroke: 48-Hour Holter Monitoring versus Prolonged Intermittent ECG Recording Tue, 04 Mar 2014 07:45:48 +0000 Aims. Screening of paroxysmal atrial fibrillation (PAF) after ischemic stroke and TIA is important. The ideal method is not known and studies of intermittent screening methods in particular are lacking. In this retrospective study we compared a shorter continuous screening method with an intermittent screening method. Methods. Since early 2011 our stroke unit has used two different methods of screening: either a 48-hour continuous screening with Holter monitor or a 21-day twice daily intermittent screening with a hand-held ECG recorder. Through the Swedish National Stroke Registry and medical records reviewing all screening episodes between 2011-02-01 and 2013-01-31 were collected and analysed.   Results. Of 386 screenings, 26 screenings were excluded leaving 360 screenings for the final analysis of which 114 screenings were made with hand-held ECG recorder and 246 with Holter monitoring. No significant difference between the groups concerning basic characteristics was observed. In the hand-held ECG recorder group a total of 13 PAF screenings (11.4%) were detected compared with 7 (2,8%) in the Holter group (). Conclusions. A prolonged intermittent screening is a better method than a shorter continuous screening in terms of detecting PAF after ischemic stroke and TIA. Gustav Orrsjö, Björn Cederin, Eric Bertholds, Salmir Nasic, and Lennart Welin Copyright © 2014 Gustav Orrsjö et al. All rights reserved. Does Task-Oriented Practice Improve Upper Extremity Motor Recovery after Stroke? A Systematic Review Tue, 18 Feb 2014 14:06:24 +0000 Background. Stroke commonly affects upper extremity motor abilities, yet there has been very limited success in developing effective rehabilitation interventions to remediate motor impairments, particularly for the upper extremity. Objective. To determine if task-oriented practice administered soon after stroke is more effective than usual care in improving poststroke upper extremity motor recovery and to explore the optimal amount of practice. Methods. A systematic review of the literature was performed from 1950 to November 2012, to identify randomized controlled trials of task-oriented practice compared to usual care, or to different amounts of task-oriented practice to improve motor impairment and activity. Studies were excluded if specific types of interventions were used as comparators or if they were of poor methodological quality. Results. Six studies met the review criteria. Three of the six studies demonstrated a statistically significant effect of task-oriented practice. Study results could not be pooled because of a lack of homogeneity in populations and intervention. Conclusions. The results demonstrate that an increase in the amount of task-oriented practice after stroke may result in less upper extremity impairment; further research on both effect and required dosage is needed as results are inconsistent. Jackie Bosch, Martin J. O’Donnell, Susan Barreca, Lehana Thabane, and Laurie Wishart Copyright © 2014 Jackie Bosch et al. All rights reserved. The Severity of Ischemia Varies in Sprague-Dawley Rats from Different Vendors Sun, 09 Feb 2014 09:26:52 +0000 The purpose of this study was to compare acute cerebral perfusion measured by computed tomography, stroke lesion volume measured by magnetic resonance imaging, and motor function in Sprague-Dawley rats supplied by Charles River (Charles River, Quebec, Canada) and Harlan (Harlan, Michigan, USA). During the acute stages of ischemia (<3 hours), Sprague-Dawley rats supplied by Harlan had a greater reduction in blood flow (67%) than rats supplied by Charles River (37%). MRI at days 1 and 6 after ischemia showed larger lesions in the Charles River animals compared to Harlan animals () at both time points. Lesion volume decreased in both Charles River and Harlan rats at day 6 compared to day 1 () and corresponded to lesion size on histology. The Harlan animals had significant functional deficits () one day after surgery in postural hang reflex, forelimb placement, and tactile fraction first tests, whereas rats supplied by Charles River had no significant functional impairment as a result of surgery. The current study provides evidence that differences in response to ischemia between rats of the same strain supplied by different vendors should be an important consideration when animals are selected for the study of cerebral ischemia. Simona Nikolova, Ting-Yim Lee, and Robert Bartha Copyright © 2014 Simona Nikolova et al. All rights reserved. Young Women Stroke Survivors and Their Desire for Peer Support Thu, 02 Jan 2014 12:33:57 +0000 The concerns of young stroke survivors are not well known. The aim of this paper is to draw on data from a larger study to show that young women who survived a hemorrhagic stroke desire access to peer support, but there is not widespread access to peer support. Open-ended interviews were conducted with an international sample of 28 women to learn about their poststroke experiences and were analyzed qualitatively for common issues and themes. A prominent theme across the interviews was the significance of age-similar peer support. Participants discussed feeling alone and misunderstood and wanting to have access to peer support. In conclusion, peer support may help to enhance psychological well-being, but the survivor’s own understanding of her peers must be centrally considered. Sharon-Dale Stone Copyright © 2014 Sharon-Dale Stone. All rights reserved. Computed Tomography Angiography before Intravenous Thrombolysis Does Not Increase the Risk of Renal Dysfunction Tue, 17 Dec 2013 10:12:24 +0000 Our aim is to determine whether computed tomography angiography (CTA) before intravenous thrombolysis (IVT) affects renal function in acute ischemic stroke (AIS) patients. We performed an observational analysis of AIS patients treated with IVT for three years. Patients were classified into 2 groups: those who underwent CTA (CTA-group) and those who did not (control-group). Differences in creatinine levels between baseline and 24–72 hours after IVT were calculated. Acute renal dysfunction (ARD) was defined as an increase in serum creatinine level of ≥0.5 mg/dL and/or ≥25% above baseline within 24–72 hours after IVT. 190 patients were treated with IVT. Renal function (before and after IVT) was assessed in 162 (115 in control-group; 47 in CTA-group). Nine patients (5.5%) developed ARD (2 (4.2%) in CTA-group and 7 (6.1%) in control-group; ). CTA was not associated with a higher risk of ARD and did not affect the efficacy or safety of IVT. Previous chronic renal insufficiency, baseline creatinine levels, and previous use of nonsteroidal anti-inflammatory drugs were associated with a significant increase in creatinine levels, independently of contrast use. In conclusion, CTA does not seem to increase the risk of renal dysfunction. This technique may be used safely without knowledge of baseline creatinine levels. Pilar Sobrino García, Andrés García Pastor, Juan Pablo Cuello, Silvia Gil Navarro, Gema Vicente Peracho, Pedro María Rodriguez Cruz, Javier Ricardo Pérez Sánchez, Fernando Díaz Otero, Pilar Vázquez Alen, Jose Antonio Villanueva Osorio, and Antonio Gil Nuñez Copyright © 2013 Pilar Sobrino García et al. All rights reserved. Hemorrhagic Transformation (HT) and Symptomatic Intracerebral Hemorrhage (sICH) Risk Prediction Models for Postthrombolytic Hemorrhage in the Stroke Belt Thu, 21 Nov 2013 10:58:29 +0000 Background. Symptomatic intracerebral hemorrhage (sICH) remains the most feared complication of intravenous tissue plasminogen activator (IV tPA) treatment. We aimed to investigate how previously validated scoring methodologies would perform in treated patients in two US Stroke Belt states. Methods and Results. We retrospectively reviewed consecutive patients from two centers in two Stroke Belt states who received IV tPA (2008–2011). We assessed the ability of three models to predict sICH. sICH was defined as a type 2 parenchymal hemorrhage with deterioration in National Institutes of Health Stroke Scale (NIHSS) score of ≥4 points or death. Among 457 IV tPA-treated patients, 19 (4.2%) had sICH (mean age 68, 26.3% Black, 63.2% female). The Cucchiara model was most predictive of sICH in the entire cohort (AUC: 0.6528) and most predictive of sICH among Blacks (OR = 6.03, 95% CI 1.07–34.1, ) when patients were dichotomized by score. Conclusions. In our small sample from the racially heterogeneous US Stroke Belt, the Cucchiara model outperformed the other models at predicting sICH. While predictive models should not be used to justify nontreatment with thrombolytics, those interested in understanding contributors to sICH may choose to use the Cucchiara model until a Stroke Belt model is developed for this region. James E. Siegler, Muhammad Alvi, Amelia K. Boehme, Michael J. Lyerly, Karen C. Albright, Reza Bavarsad Shahripour, Pawan V. Rawal, Niren Kapoor, April Sisson, J. Thomas Houston, Anne W. Alexandrov, Sheryl Martin-Schild, and Andrei V. Alexandrov Copyright © 2013 James E. Siegler et al. All rights reserved. Physical Activity after Stroke: A Systematic Review and Meta-Analysis Thu, 07 Nov 2013 11:55:00 +0000 Background and Purpose. Physical activity is beneficial after stroke, but it is unclear how active stroke survivors are. This systematic review and meta-analysis sought to determine levels of activity and factors predicting activity. Summary of Review: Methods. MEDLINE (1946 to present) and EMBASE (1980 to present) were systematically searched until July 2012. All studies quantifying whole-body-free living physical activity by objective and self-reported methods in a community dwelling population with stroke were included. A random effect meta-analysis was performed. Results. Twenty-six studies were included (), of which eleven () contained sufficient data for meta-analysis. There were heterogeneous designs, measurements, and procedures. The studies generally recruited small samples of high-functioning participants. Level of physical activity was generally low in quantity, duration and intensity. Poorer walking ability, specific sensorimotor functions, and low mood were correlates of low physical activity. Meta-analysis generated an estimate of 4355.2 steps/day (95% CI: 3210.4 to 5499.9) with no significant heterogeneity ( = 0). Conclusions. In high-functioning stroke survivors, physical activity including walking was generally low. Strategies are needed to promote and maintain physical activity in stroke survivors. Research is needed to establish reasons for low physical activity after stroke. Matthew J. Field, Nick Gebruers, Thavapriya Shanmuga Sundaram, Sarah Nicholson, and Gillian Mead Copyright © 2013 Matthew J. Field et al. All rights reserved. 24-Hour ICH Score Is a Better Predictor of Outcome than Admission ICH Score Tue, 22 Oct 2013 10:16:38 +0000 Background. The ICH score is a validated tool for predicting 30-day morbidity and mortality in patients with intracerebral hemorrhage. Aims and/or Hypothesis. The aim of this study is to determine if the ICH score calculated 24 hours after admission is a better predictor of mortality than the ICH score calculated on admission. Methods. Patients presenting to our center with ICH from 7/08–12/10 were retrospectively identified from our prospective stroke registry. ICH scores were calculated based on initial Glasgow coma scale (GCS) and emergent head computed tomography (CT) on initial presentation and were recalculated after 24 hours. Results. A total of 91 patients out of 121 had complete data for admission and 24-hour ICH score. The ICH score changed in 38% from baseline to 24 hours. After adjusting for age, NIHSS on admission, and glucose, ICH score at 24 hours was a significant, independent predictor of mortality (OR = 2.71, 95% CI 1–19–6.20, and ), but ICH score on admission was not (OR = 2.14, 95% CI 0.88–5.24, and ). Conclusion. Early determination of the ICH score may incorrectly estimate the severity and expected outcome after ICH. Calculations of the ICH score 24 hours after admission will better predict early outcomes. Aimee M. Aysenne, Karen C. Albright, Tiffany Mathias, Tiffany R. Chang, Amelia K. Boehme, T. Mark Beasley, and Sheryl Martin-Schild Copyright © 2013 Aimee M. Aysenne et al. All rights reserved. Social Participation after Stroke: One-Year Follow-Up of Stroke Survivors in Nigeria Mon, 21 Oct 2013 09:40:22 +0000 Background. Stroke may negatively affect social participation in survivors. Aims. This study assessed the pattern of social participation in a sample of Nigerian stroke survivors across the first 12 months after stroke. Methods. Stroke survivors were consecutively recruited while on admission at a tertiary health institution. The London handicap scale was used to assess social participation at 1, 3, 6, 9, and 12 months at the homes of the stroke survivors. Overall and domain-specific patterns of social participation were examined independently and also in relation to initial stroke severity. Results. Overall social participation significantly improved over 12 months (), while significant improvements were observed only in the mobility, physical independence, and work and leisure domains at P equals 0.04, 0.04, and 0.05, respectively. In spite of the improvement in the work and leisure domain, the domain recorded the lowest level of participation. Social participation also differed by initial stroke severity with severe stroke survivors having the lowest level of participation across 12 months after stroke. Conclusions. The poor outcome in the work and leisure domain of social participation and in individuals with initial severe stroke has implications for planning and provision of appropriate long-term stroke rehabilitation. Grace O. Vincent-Onabajo Copyright © 2013 Grace O. Vincent-Onabajo. All rights reserved. Hospital-Acquired Infection Underlies Poor Functional Outcome in Patients with Prolonged Length of Stay Sun, 15 Sep 2013 14:03:53 +0000 Introduction. Prolonged length of stay (pLOS) following ischemic stroke inflates cost, increases risk for hospital-acquired complications, and has been associated with worse prognosis. Methods. Acute ischemic stroke patients admitted between July 2008 and December 2010 were retrospectively analyzed for pLOS, defined as a patient stable for discharge hospitalized for an additional ≥24 hours. Results. Of 274 patients included, 106 (38.7%) had pLOS (median age 65 years, 60.6% female, 69.0% black). Patients with pLOS had higher admission NIHSS than patients without pLOS (9 versus 5, ). A larger proportion of patients with pLOS developed an infection (), and after adjusting for covariates, these patients had greater odds of poor short-term functional outcome (OR = 2.25, 95% CI 1.17–4.32, ). Adjusting for infection, the odds of patients with pLOS having poor short-term functional outcome were no longer significant (OR = 1.68, 95% CI 0.83–3.35, ). Conclusions. The contraction of a hospital-acquired infection was a significant predictor of pLOS and a contributor of poor short-term outcome following an ischemic stroke. Whether the cause or the consequence of pLOS, hospital-acquired infections are largely preventable and a target for reducing length of stay. Alexander J. George, Amelia K. Boehme, James E. Siegler, Dominique Monlezun, Bethena D. Fowler, Amir Shaban, Karen C. Albright, T. Mark Beasley, and Sheryl Martin-Schild Copyright © 2013 Alexander J. George et al. All rights reserved. The Impact of Left Ventricular Hypertrophy and Diastolic Dysfunction on Outcome in Intracerebral Hemorrhage Patients Mon, 19 Aug 2013 11:32:34 +0000 Background. The objective of this study was to determine the prevalence of LVH and DD in patients presenting with supratentorial deep ICH and to determine if the presence of LVH or DD was an independent predictor of initial ICH volume, hematoma expansion, or poor outcome. Methods. A cross-sectional study was performed on ICH patients who presented from 7/2008 to 12/2010. Cases were excluded if ICH was traumatic, lobar, infratentorial, secondary to elevated international normalized ratio, suspicious for underlying structural malformation, or where surgical evacuation was performed. Logistic and linear regressions were used to assess the ability of LVH to predict ICH imaging characteristics and patient outcomes. Results. After adjusting for use of hemostatic agents, LVH was not a significant independent predictor of initial ICH volume or 33% volume expansion . After adjusting for age, infectious complications, and use of hemostatic agents, LVH was not a significant independent predictor of poor functional outcome . Similar results were seen for DD. Conclusion. In our sample, patients with deep ICH and LVH were more likely to develop IVH, but LVH was not a significant independent predictor of initial ICH volume, hematoma expansion, or poor short-term outcome. Karen C. Albright, Joshua M. Burak, Tiffany R. Chang, Aimee Aysenne, James E. Siegler, Laurie Schluter, Sharyl R. Martini, Amelia K. Boehme, and Sheryl Martin-Schild Copyright © 2013 Karen C. Albright et al. All rights reserved. Delirium in Acute Stroke: A Survey of Screening and Diagnostic Practice in Scotland Tue, 13 Aug 2013 08:28:09 +0000 Aims. To survey the use of delirium screening and diagnostic tools in patients with acute stroke across Scotland and to establish whether doctors and nurses felt the tools used were suitable for stroke patients. Methods. An invitation to participate in a web-based survey was e-mailed to 217 doctors and nurses working in acute stroke across Scotland. Descriptive statistics were used to report nominal data, and content analysis was used to interpret free text responses. Results. Sixty-five responses were logged (30% return rate). 48% of the respondents reported that they routinely screened newly admitted patients for delirium. Following initial screening, 38% reported that they screened for delirium as the need arises. 43% reported using clinical judgment to diagnose delirium, and 32% stated that they combined clinical judgment with a standardised tool. 28% of the clinicians reported that they used the Confusion Assessment Method; however, only 13.5% felt that it was suitable for stroke patients. Conclusions. Screening for delirium is inconsistent in Scottish stroke services, and there is uncertainty regarding the suitability of screening tools with stroke patients. As the importance of early identification of delirium on stroke outcomes is articulated in recent publications, validating a screening tool to detect delirium in acute stroke is recommended. Gail Carin-Levy, Kath Nicol, Frederike van Wijck, and Gillian E. Mead Copyright © 2013 Gail Carin-Levy et al. All rights reserved. MicroRNA: Not Far from Clinical Application in Ischemic Stroke Mon, 05 Aug 2013 09:06:40 +0000 Ischemic stroke predominates in all types of stroke and none neuroprotective agents success in the clinical trial. MicroRNAs are small endogenous noncoding RNA molecules that act as negative or positive regulators of gene expressions by binding completely or partially to complementary target sequences in the mRNAs. The genes which could be modulated by microRNAs play a role in the etiology and pathophysiology ischemic stroke. Therefore, microRNAs may have function on ischemic stroke. A lot of previous studies have investigated the roles of microRNAs in the ischemic stroke. This mini review would highlight the recent progress of microRNAs on the ischemic stroke. Accumulating evidence demonstrated that microRNAs contributed to the etiology of ischemic stroke and modulated the pathophysiological process such as brain edema, local inflammation, and apoptosis in the brain tissues after stroke. And we also discussed the potential application of microRNAs in ischemic stroke such as a biomarker of stroke and drug target. In conclusion, microRNAs play an important role in stroke etiology, pathophysiology, diagnosis, and therapy for ischemic stroke. It needs further research to investigate the biological function in ischemic stroke before it enters the clinical practice. Yun Li, Yahong Liu, Zhaojun Wang, Huajuan Hou, Ying Lin, and Yongjun Jiang Copyright © 2013 Yun Li et al. All rights reserved. Effect of Telmisartan on Cerebral and Systemic Haemodynamics in Patients with Recent Ischaemic Stroke: A Randomised Controlled Trial Wed, 05 Jun 2013 15:50:46 +0000 High blood pressure (BP) is common in acute stroke and is independently associated with a poor outcome. Lowering BP might improve outcome if cerebral blood flow (CBF) is unaffected in the presence of dysfunctional autoregulation. We investigated the effect of telmisartan on systemic and cerebral haemodynamics in patients with recent stroke. Patients with ischaemic stroke (<5 days) were randomised to 90 days of telmisartan (80 mg) or placebo. CBF (primary outcome) was measured using xenon CT at baseline and 4 hours. BP and transcranial doppler (TCD) were performed at baseline, 4 hours after-treatment, and on days 4, 7, and 90. Cerebral perfusion pressure and zero filling pressure (ZFP) were calculated. Of a planned 24 patients, 17 were recruited. Telmisartan significantly accentuated the fall in systolic and diastolic BP over 90 days (treatment-time interaction , resp.) but did not alter BP at 4 hours after treatment (171/99 versus 167/87 mmHg), CBF, or CBF velocity. ZFP was significantly lower in the treatment group . Impairment at 7 days and dependency at 90 days did not differ between the groups. In this underpowered study, telmisartan did not significantly alter BP or CBF after the first dose. Telmisartan reduced BP over the subsequent 90 days and significantly lowered ZFP. This trial is registered with ISRCTN 41456162. Gillian M. Sare, Andrew Ghadami, Sandeep Ankolekar, Timothy England, Fiona Hammonds, Margaret Adrian, Judith Clarke, Lynn Stokes, Dorothee Auer, and Philip M. W. Bath Copyright © 2013 Gillian M. Sare et al. All rights reserved. Prognostic Value of Complete Blood Count and Electrolyte Panel during Emergency Department Evaluation for Acute Ischemic Stroke Wed, 22 May 2013 14:28:08 +0000 Objective. To determine whether routine laboratory parameters are predictors of early mortality after acute ischemic stroke (AIS). Methods. The cohort consisted of 522 consecutive patients with AIS presenting to the emergency department (ED) at a tertiary referral center during a 27-month period, residing within the surrounding ten counties. Serum laboratory values were obtained for all patients and categorized according to whether the levels were low, normal, or high. These laboratory results were evaluated as potential predictors of 90-day mortality using Cox proportional hazards models. The associations were summarized by calculating risk ratios (RRs) and 95% confidence intervals (CI). Results. The presence of elevated white blood cell count (RR 2.2, 95% CI 1.5–3.4), low bicarbonate (RR 4.2, 95% CI 2.6–6.7), low calcium (RR 2.9, 95% CI 1.4–5.9), and high glucose (RR 1.3, 95% 1.1–1.6) were each univariately associated with significantly higher mortality within the first 90 days. Based on fitting a multivariate Cox regression model, elevated white blood cell count, low bicarbonate, and high glucose were each identified as being jointly associated with early mortality (). Conclusion. Early leukocytosis, acidosis, and hyperglycemia and hypocalcemia in AIS appear to be associated with early mortality. Whether addressing these factors will impact survival remains to be investigated. Latha Ganti, Rachel M. Gilmore, Amy L. Weaver, and Robert D. Brown Jr. Copyright © 2013 Latha Ganti et al. All rights reserved. Prevalence, Comorbid Associations and Prognostic Value of the Hyperdense Middle Cerebral Artery Sign Sun, 28 Apr 2013 17:52:32 +0000 Background. The significance of the Hyperdense Middle Cerebral Artery Sign (HMCAS) is uncertain. Aims. This prospective study investigated the sensitivity, specificity, prevalence, prognosis, interobserver variability, and associated clinical features of HMCAS in acute ischemic stroke. Methods. Initial CT scans of 117 patients with acute ischemic stroke or transient ischemic attack (TIA) and 65 age-matched controls were reported independently by two neuroradiologists blinded to diagnosis. Details of initial stroke severity and comorbidities were collected, and outcome on the modified Rankin scale (mRS) was assessed at 3–6 months. Results. HMCAS was seen in 15% of all ischemic strokes and 25% of all middle cerebral artery (MCA) strokes; specificity was 100%. HMCAS was associated with more severe initial deficit and atrial fibrillation. Only 21% of patients with a first-ever MCA stroke and HMCAS had a good outcome () compared to 55% of those without the sign (). Interobserver agreement was only 0.747 (Kappa statistic). Conclusion. The prevalence, specificity, sensitivity, and clinical associations of HMCAS were similar to previous reports. This study confirmed prospectively that HMCAS was associated with a poorer outcome at 3 to 6 months and demonstrated interobserver variability in detection of the sign. Patrick Aouad, Andrew Hughes, Nishant Valecha, Yash Gawarikar, Kate Ahmad, Ross O'Neil, Murali Guduguntla, and Christian Lueck Copyright © 2013 Patrick Aouad et al. All rights reserved. Morphology of Middle Cerebral Artery Aneurysms: Impact on Surgical Strategy and on Postoperative Outcome Wed, 27 Mar 2013 18:13:15 +0000 The outcome of middle cerebral artery (MCA) aneurysm clipping depends on the presence of subarachnoid hemorrhage (SAH). Moreover, it is influenced by anatomical features of the aneurysm and its parent artery. We hypothesized that morphological characteristics of the aneurysm may be predictive for postoperative outcome. Therefore, we identified radiographic assessable details that predicted the surgical difficulty and the risk for new ischemia. The angiograms of 151 consecutive patients (82 presenting with SAH) were analyzed in a standardized fashion focusing on 12 defined morphological aspects. The results were correlated to intraoperative rupture and to postoperative ischemia. Aneurysms presenting with SAH were associated with irregular shape, larger maximum diameter, and larger dome-to-base distance (DBD) and were located more frequently on the M2 segment. Multivariate analysis revealed 6 independent predictors for intraoperative rupture: SAH, location on M2 segment, DBD, maximum diameter, diameter of the parent MCA, and the presence of branching vessel. Independent predictors of surgery-related ischemia were identified: SAH, irregular shape, location on M2 segment, DBD, and the neck-to-vessel ratio (NVR). In MCA aneurysms, independent predictors for the risk of rupture intraoperatively and for the postsurgical outcome were the presence of SAH, location on the M2-segment, size (DBD), and the broadness of the neck. Karl-Michael Schebesch, Martin Proescholdt, Kathrin Steib, Odo-Winfried Ullrich, Andreas Herbst, Janine Rennert, and Alexander Brawanski Copyright © 2013 Karl-Michael Schebesch et al. All rights reserved. Predictors of Emotional Distress and Wellbeing 2–5 Years After Stroke Mon, 04 Mar 2013 18:13:48 +0000 Objectives. To identify predictors of emotional distress and psychological wellbeing in stroke survivors 2–5 years after discharge from comprehensive rehabilitation. Material and Methods. The Hospital Anxiety and Depression Scale (HADS), the General Health Questionnaire (GHQ-30), and questions regarding life situations were mailed to former patients. Multiple regression analyses were performed. Results. The responses from 68 participants (37% women), of an average age of 58 years old, were used. Emotional distress (HADS > 10) was identified in 41%. Well-being (GHQ-30 < 6) was identified in 46%. Not surprisingly, there was a strongly negative association between well-being (GHQ-30 < 6) and emotional distress (HADS > 10) at follow up. Dependency in toileting during rehabilitation predicted emotional distress 2–5 years later. Finally, well-being at followup was predicted by age > 65 years, independent mobility, perceiving proxies as supportive, and being in employment. Conclusions. Dependence in the activities of daily living 3–6 months after-injury predicted emotional distress 2–5 years after-stroke. Being over 65 years, having an occupation, proxy support and being less dependent all predicted well-being. Emotional distress and well-being were clearly negatively associated. Gender, education, marital status, and type of stroke were not associated with the outcome measures. H. Bergersen, A.-K. Schanke, and K. S. Sunnerhagen Copyright © 2013 H. Bergersen et al. All rights reserved. Can Transient Drop in Blood Pressure in High-Risk Hypertensive Patients Cause Small Cerebral Infarcts? Thu, 14 Feb 2013 14:29:40 +0000 Background. Multiple, simultaneous, acute cerebral infarcts in different arterial territories are usually secondary to embolic occlusion of multiple cerebral arteries. We observed, however, that no cardiac or aortic source could be found in many of these patients. We therefore undertook this study to attempt to identify other factors that may be important in the causation of these infarcts. Materials and Methods. We performed a five-year retrospective review of all patients with multiple, near simultaneous, acute cerebral infarcts detected on diffusion-weighted MRI scans. Results. We identified 78 patients with acute infarcts, in different cerebral arterial territories. We found a cardiac embolic source in 15 (19 percent) patients. Forty-one patients (53%) had no obvious cause for their infarcts after detailed cardiovascular and hematological evaluation. In 16 of these patients (20% of all 78 patients), all with a history of chronic hypertension who had multiple, acute, small (<2 cms), deep subcortical or superficial cortical infarcts (and most, 93%, with extensive evidence of chronic small vessel disease on MRI FLAIR images), blood pressure was low or normal on initial presentation (mean arterial pressure, MAP: 85 ± 11.4 mm Hg). Analysis of the last prestroke blood pressure, within the previous 1 to 11 days available in 13 of 16 patients, revealed much higher BP (MAP: 113.6 ± 11.3 mm Hg), indicating a mean drop of 25.1 percent (range 11 to 44 percent). Two weeks after the stroke, blood pressure had risen again to greater than 160/100 mm Hg (MAP: 128.2 ± 14.3). Conclusion. Our study suggests that transient drop in blood pressure in high-risk hypertensive patients with severe, small vessel disease may sometimes result in small, cerebral infarcts. More research is needed to further clarify and confirm this possibility. Satyakam Bhagavati and Jai Choi Copyright © 2013 Satyakam Bhagavati and Jai Choi. All rights reserved. Anaesthesia during Carotid Endarterectomy and Urinary Neopterin Wed, 17 Oct 2012 08:12:02 +0000 Recent systematic reviews of randomized controlled trials show that the rate of postoperative complications after carotid endarterectomy (CEA) was not significantly different between operations performed under general anesthesia (GA) or local anesthesia (LA). However, these studies were not large enough to draw meaningful conclusions about any difference in mortality. This study therefore aimed to compare a surrogate endpoint of postoperative mortality between GA and LA by using urinary neopterin. 68 consecutive patients admitted electively for CEA were studied. Urinary neopterin levels were assayed preoperatively, immediately postoperatively (PO), 4, 6, 12, and 24 hrs PO. This study compared the level of urinary neopterin between GA and LA. Of the 68 CEAs, 48 operations were performed under GA. Urinary neopterin concentration in LA group increased PO and reached a peak at 6 hrs PO. At this point, the urinary neopterin levels in the GA group (85.3 μmol/mol creatinine) were significantly lower than those under the LA group (123.4 μmol/mol creatinine) (). We found that the level of urinary neopterin level after operation in LA was significantly higher than those under GA. More studies are needed. K. Rerkasem and C. P. Shearman Copyright © 2012 K. Rerkasem and C. P. Shearman. All rights reserved. Quantifying the Contribution of Risk Factors for Ischemic Stroke in Patients with a History of TIA Fri, 28 Sep 2012 23:01:29 +0000 Background. Patients with a history of transient ischemic attack (TIA) are known to be at higher risk for a stroke. We sought to investigate predictors of individual risk for an ischemic stroke within 30 days of a TIA. Methods and Results. A retrospective analysis of 57,585 TIA admissions was collected from 155 United States hospitals. Data describing each admission included demographic and clinical data, and information about the admitting hospital. Cerebrovascular disease was the primary readmission reason (19% of readmissions) in the TIA patient population. The prevalence of 30-day ischemic stroke readmissions was 11 per 1,000 TIA admissions; however, 53% of stroke readmissions occurred within one week. Hierarchal regression models suggested that peripheral vascular disease and hypertensive chronic kidney disease were significant individual stroke risk factors, whereas history of myocardial infarction, essential hypertension, and diabetes mellitus was not associated with significant stroke risk. Certified stroke centers were not associated with significantly lower stroke readmission rates. Conclusions. The results suggest that cardiovascular comorbidities confer the most significant risk for an ischemic stroke within 30 days of a TIA. Interestingly, certified stroke centers do not appear to be associated with significantly lower stroke-readmission rates, highlighting the challenges managing this patient population. Duncan C. Ramsey, Mark G. Burnett, and Matthew C. Cowperthwaite Copyright © 2012 Duncan C. Ramsey et al. All rights reserved. Poststroke Fatigue Is Still a Neglected Issue: Findings from an Internet-Based Study on the Need for Information and Treatment in The Netherlands Sun, 24 Jun 2012 11:14:36 +0000 Objective. To evaluate the need for information and treatment of poststroke fatigue (PSF) in community-dwelling patients with stroke in The Netherlands. Methods. Data were obtained from a Dutch internet-based questionnaire. The amount of information received about PSF, self-management and other treatment options, and the perceived need for treatment were scored. PSF was assessed with two Visual Numerical Scales of fatigue severity (VNSF), the Fatigue Severity Scale (FSS7), and by scoring the nature (physical versus mental) and onset time of PSF. Results. Data were available of 538 stroke survivors (mean age 52 years, 45% men, and mean time since onset 2.7 years). Severe fatigue (both VNSF items ≥7; 48%) and severe fatigue impact (FSS7 > 5; 68%) were frequent. Most participants (57%) experienced both physical and mental fatigue. Only 17% of the respondents indicated to have had received sufficient information about PSF and 7% about treatment options, whereas 56% expressed a substantial need for treatment. The need for treatment was moderately associated with fatigue severity and fatigue impact, whereas information status was not related to any demographical, fatigue, or stroke characteristic. Conclusions. PSF is a significant symptom after stroke requiring medical attention and treatment. The results of this survey indicate that patients do not receive adequate information on PSF. Aglaia M. E. E. Zedlitz, Michelle van Eijk, Roy P. C. Kessels, Alexander C. H. Geurts, and Luciano Fasotti Copyright © 2012 Aglaia M. E. E. Zedlitz et al. All rights reserved.