Stroke Research and Treatment The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Protocol Variations and Six-Minute Walk Test Performance in Stroke Survivors: A Systematic Review with Meta-Analysis Tue, 20 Jan 2015 13:44:16 +0000 Objective. To investigate the use of the six-minute walk test (6MWT) for stroke survivors, including adherence to 6MWT protocol guidelines and distances achieved. Methods. A systematic search was conducted from inception to March 2014. Included studies reported a baseline (intervention studies) or first instance (observational studies) measure for the 6MWT performed by stroke survivors regardless of time after stroke.  Results. Of 127 studies (participants n = 6,012) that met the inclusion criteria, 64 were also suitable for meta-analysis. Only 25 studies made reference to the American Thoracic Society (ATS) standards for the 6MWT, and 28 reported using the protocol standard 30 m walkway. Thirty-nine studies modified the protocol walkway, while 60 studies did not specify the walkway used. On average, stroke survivors walked 284 ± 107 m during the 6MWT, which is substantially less than healthy age-matched individuals. The meta-analysis identified that changes to the ATS protocol walkway are associated with reductions in walking distances achieved. Conclusion. The 6MWT is now widely used in stroke studies. The distances achieved by stroke patients indicate substantially compromised walking ability. Variations to the standard 30 m walkway for the 6MWT are common and caution should be used when comparing the values achieved from studies using different walkway lengths. A. Dunn, D. L. Marsden, E. Nugent, P. Van Vliet, N. J. Spratt, J. Attia, and R. Callister Copyright © 2015 A. Dunn et al. All rights reserved. Outcome Determinants of Stroke in a Brazilian Primary Stroke Center Thu, 11 Dec 2014 10:45:41 +0000 Background. Stroke mortality in Brazil is one of the highest among Western countries. Nonetheless, stroke outcome determinants are still poorly known in this country. In this study we evaluate outcome determinants of stroke in a primary stroke center in São Paulo, Brazil. Methods. We evaluated demographic, clinical, and outcome data of patients with ischemic stroke (IS), transient ischemic attack (TIA), and intracerebral hemorrhage (ICH) admitted at “Hospital Paulistano,” São Paulo, Brazil. In-hospital mortality and functional outcome determinants were assessed. Univariate and binary logistic regression analysis were performed. Results. Three hundred forty-one patients were included in the study, 52.2% being male with years. The stroke type distribution was IS: 59.2%, TIA: 29.6%, and ICH: 11.1%. ICH was associated with greater severity and poorer functional outcome. The determinants of poorer functional outcome were higher NIHSS, lower Glasgow score, and lower oxygen saturation level. The most important mortality determinant was the presence of visual symptoms. Conclusions. The stroke mortality and stroke outcome determinants found in the present study do not remarkably differ from studies carried out in developed countries. Stroke prognosis studies are crucial to better understand the high burden of stroke in Brazil. Gustavo W. Kuster, Lívia A. Dutra, Israel P. Brasil, Evelyn P. Pacheco, Márcio A. C. Arruda, Cristiane Volcov, and Renan B. Domingues Copyright © 2014 Gustavo W. Kuster et al. All rights reserved. Elevated Cardiac Troponin in Acute Stroke without Acute Coronary Syndrome Predicts Long-Term Adverse Cardiovascular Outcomes Tue, 04 Nov 2014 08:31:02 +0000 Background. Elevated cardiac troponin in acute stroke in absence of acute coronary syndrome (ACS) has unclear long-term outcomes. Methods. Retrospective analysis of 566 patients admitted to Temple University Hospital from 2008 to 2010 for acute stroke was performed. Patients were included if cardiac troponin I was measured and had no evidence of ACS and an echocardiogram was performed. Of 200 patients who met the criteria, baseline characteristics, electrocardiograms, and major adverse cardiovascular events (MACE) were reviewed. Patients were characterized into two groups with normal and elevated troponins. Primary end point was nonfatal myocardial infarction during follow-up period after discharge. The secondary end points were MACE and death from any cause. Results. For 200 patients, 17 patients had positive troponins. Baseline characteristics were as follows: age , 64% African Americans, 78% with hypertension, and 22% with previous CVA. During mean follow-up of 20.1 months, 7 patients (41.2%) in elevated troponin and 6 (3.3%) patients in normal troponin group had nonfatal myocardial infarction (). MACE (41.2% versus 14.2%, ) and death from any cause (41.2% versus 14.5%, ) were significant in the positive troponin group. Conclusions. Elevated cardiac troponin in patients with acute stroke and no evidence of ACS is strong predictor of long-term cardiac outcomes. Farhan Raza, Mohamad Alkhouli, Paul Sandhu, Reema Bhatt, and Alfred A. Bove Copyright © 2014 Farhan Raza et al. All rights reserved. Impact of Serum Nutritional Status on Physical Function in African American and Caucasian Stroke Survivors Wed, 29 Oct 2014 12:39:04 +0000 Background. The purpose of this study is to compare serum nutritional profiles in chronic stroke survivors to a representative sample of US Adults (NHANESIII) and determine whether these serum markers differed by race and impact physical function in stroke. Methods. Fasting serum samples were collected for analysis of lipids, uric acid, and albumin in 145 African American (AA) and 111 Caucasian (C) stroke survivors (age: 60 ± 1 years [mean ± SEM]). A six-minute walk was performed in a subset of stroke survivors (N = 134). Results. Triglycerides were higher and HDL-cholesterol and albumin lower in C than AA women stroke survivors (Ps < 0.05). Uric acid was lower in C than AA stroke survivors (P < 0.05). Compared to NHANESIII, HDL-cholesterol, albumin, and hemoglobin generally were lower (Ps < 0.05) and lipids were more favorable in stroke (Ps < 0.01). Uric acid was related to six-minute walk performance among a subset of stroke survivors (P < 0.05). Conclusion. In stroke, racial differences exist with regard to serum nutritional risk, but these differences are similar to that observed in the general population. Regardless of race, nutritional risk appears elevated above that of the general population with regard to many of the serum markers. As a modifiable biomarker, uric acid should be monitored closely as it may provide insight into the functional risk of stroke survivors. Monica C. Serra, Charlene E. Hafer-Macko, Frederick M. Ivey, Richard F. Macko, and Alice S. Ryan Copyright © 2014 Monica C. Serra et al. All rights reserved. Poststroke Outcomes Tue, 14 Oct 2014 08:01:43 +0000 Bruce Ovbiagele, Steve Kautz, Wayne Feng, and DeAnna L. Adkins Copyright © 2014 Bruce Ovbiagele et al. All rights reserved. Sex, Diastolic Blood Pressure, and Outcome after Thrombolysis for Ischemic Stroke Mon, 15 Sep 2014 11:38:12 +0000 Background. The goal of this study was to identify differences in risk factors and functional outcome between the two sexes in patients treated with thrombolysis for ischemic stroke. Methods. This cohort study audited data from patients treated with thrombolysis for ischemic stroke during a 3-year period at Södersjukhuset, Stockholm. Results. Of the 355 patients included in the study, 162 (45%) were women and 193 (54%) were men. Women were older with a median age of 76 years; median age for men was 69 years (). Diastolic blood pressure was lower for women compared to men (). At admission fewer women had a favorable modified Rankin Scale score compared to men (93.8% versus 99%, ). Three months after discharge functional status did not differ significantly between the two sexes. Diastolic blood pressure was associated to functional outcome only in men when sex specific odds ratios were calculated (OR, 5.7; 95% CI, 1.7–20). Conclusion. The study indicates that females appear to gain a relatively greater benefit from thrombolytic therapy than men due to a better functional recovery. A higher diastolic blood pressure increases the risk for a worse prospective functional status in men. David Nathanson, Cesare Patrone, Thomas Nyström, and Mia von Euler Copyright © 2014 David Nathanson et al. All rights reserved. The Role of Prestroke Glycemic Control on Severity and Outcome of Acute Ischemic Stroke Mon, 08 Sep 2014 07:26:41 +0000 Background/Aim. Relatively few studies have investigated the association of prestroke glycemic control and clinical outcome in acute ischemic stroke (IS) patients, regardless of presence of diabetes mellitus (DM). The aim of this study was to investigate the importance of prestroke glycemic control on survival, stroke severity, and functional outcome of patients with acute IS. Methods. We performed a retrospective survival analysis of 501 patients with IS admitted to Sahlgrenska University Hospital from February 15, 2005, through May 31, 2009. The outcomes of interest were acute and long-term survival; the stroke severity (NIHSS) and the functional outcome, mRS, at 12 months. Results. HbA1c was a good predictor of acute (HR 1.45; CI, 1.09 to 1.93, ) and long-term mortality (HR 1.29; CI 1.03 to 1.62; ). Furthermore, HbA1c >6% was significantly correlated with acute stroke severity (OR 1.29; CI 1.01 to 1.67; ) and predicted worse functional outcome at 12 months (OR 2.68; CI 1.14 to 6.03; ). Conclusions. Our study suggests that poor glycemic control (baseline HbA1c) prior to IS is an independent risk factor for poor survival and a marker for increased stroke severity and unfavorable long-term functional outcome. Clara Hjalmarsson, Karin Manhem, Lena Bokemark, and Björn Andersson Copyright © 2014 Clara Hjalmarsson et al. All rights reserved. Walking Adaptability after a Stroke and Its Assessment in Clinical Settings Thu, 28 Aug 2014 09:58:48 +0000 Control of walking has been described by a tripartite model consisting of stepping, equilibrium, and adaptability. This review focuses on walking adaptability, which is defined as the ability to modify walking to meet task goals and environmental demands. Walking adaptability is crucial to safe ambulation in the home and community environments and is often severely compromised after a stroke. Yet quantification of walking adaptability after stroke has received relatively little attention in the clinical setting. The objectives of this review were to examine the conceptual challenges for clinical measurement of walking adaptability and summarize the current state of clinical assessment for walking adaptability. We created nine domains of walking adaptability from dimensions of community mobility to address the conceptual challenges in measurement and reviewed performance-based clinical assessments of walking to determine if the assessments measure walking adaptability in these domains. Our literature review suggests the lack of a comprehensive well-tested clinical assessment tool for measuring walking adaptability. Accordingly, recommendations for the development of a comprehensive clinical assessment of walking adaptability after stroke have been presented. Such a clinical assessment will be essential for gauging recovery of walking adaptability with rehabilitation and for motivating novel strategies to enhance recovery of walking adaptability after stroke. Chitralakshmi K. Balasubramanian, David J. Clark, and Emily J. Fox Copyright © 2014 Chitralakshmi K. Balasubramanian et al. All rights reserved. Does Inhibitory Repetitive Transcranial Magnetic Stimulation Augment Functional Task Practice to Improve Arm Recovery in Chronic Stroke? Wed, 13 Aug 2014 12:46:46 +0000 Introduction. Restoration of upper extremity (UE) functional use remains a challenge for individuals following stroke. Repetitive transcranial magnetic stimulation (rTMS) is a noninvasive modality that modulates cortical excitability and is being explored as a means to potentially ameliorate these deficits. The purpose of this study was to evaluate, in the presence of chronic stroke, the effects of low-frequency rTMS to the contralesional hemisphere as an adjuvant to functional task practice (FTP), to improve UE functional ability. Methods. Twenty-two individuals with chronic stroke and subsequent moderate UE deficits were randomized to receive 16 sessions (4 times/week for 4 weeks) of either real-rTMS or sham-rTMS followed by 1-hour of paretic UE FTP. Results. No differences in UE outcomes were revealed between the real-rTMS and sham-rTMS intervention groups. After adjusting for baseline differences, no differences were revealed in contralesional cortical excitability postintervention. In a secondary analysis, data pooled across both groups revealed small, but statistically significant, improvements in UE behavioral measures. Conclusions. rTMS did not augment changes in UE motor ability in this population of individuals with chronic stroke. The chronicity of our participant cohort and their degree of UE motor impairment may have contributed to inability to produce marked effects using rTMS. Dorian K. Rose, Carolynn Patten, Theresa E. McGuirk, Xiaomin Lu, and William J. Triggs Copyright © 2014 Dorian K. Rose et al. All rights reserved. Erratum to “Stroke Survivors Scoring Zero on the NIH Stroke Scale Score Still Exhibit Significant Motor Impairment and Functional Limitation” Tue, 12 Aug 2014 07:20:20 +0000 Brittany Hand, Stephen J. Page, and Susan White Copyright © 2014 Brittany Hand et al. All rights reserved. Rasch Analysis of a New Hierarchical Scoring System for Evaluating Hand Function on the Motor Assessment Scale for Stroke Thu, 07 Aug 2014 06:19:25 +0000 Objectives. (1) To develop two independent measurement scales for use as items assessing hand movements and hand activities within the Motor Assessment Scale (MAS), an existing instrument used for clinical assessment of motor performance in stroke survivors; (2) To examine the psychometric properties of these new measurement scales. Design. Scale development, followed by a multicenter observational study. Setting. Inpatient and outpatient occupational therapy programs in eight hospital and rehabilitation facilities in the United States and Canada. Participants. Patients receiving stroke rehabilitation following left (52%) or right (48%) cerebrovascular accident; mean age 64.2 years (sd 15); median 1 month since stroke onset. Intervention. Not applicable. Main Outcome Measures. Data were tested for unidimensionality and reliability, and behavioral criteria were ordered according to difficulty level with Rasch analysis. Results. The new scales assessing hand movements and hand activities met Rasch expectations of unidimensionality and reliability. Conclusion. Following a multistep process of test development, analysis, and refinement, we have redesigned the two scales that comprise the hand function items on the MAS. The hand movement scale contains an empirically validated 10-behavior hierarchy and the hand activities item contains an empirically validated 8-behavior hierarchy. Joyce S. Sabari, Michelle Woodbury, and Craig A. Velozo Copyright © 2014 Joyce S. Sabari et al. All rights reserved. The Adverse Effect of Spasticity on 3-Month Poststroke Outcome Using a Population-Based Model Thu, 24 Jul 2014 00:00:00 +0000 Several devices and medications have been used to address poststroke spasticity. Yet, spasticity’s impact on outcomes remains controversial. Using data from a cohort of 460 ischemic stroke patients, we previously published a validated multivariable regression model for predicting 3-month modified Rankin Score (mRS) as an indicator of functional outcome. Here, we tested whether including spasticity improved model fit and estimated the effect spasticity had on the outcome. Spasticity was defined by a positive response to the question “Did you have spasticity following your stroke?” on direct interview at 3 months from stroke onset. Patients who had expired by 90 days or did not have spasticity data available were excluded. Spasticity affected the 3-month functional status (, to 0.645) after accounting for age, diabetes, leukoaraiosis, and retrospective NIHSS. Using spasticity as a covariable, the model’s changed from 0.599 to 0.622. In our model, the presence of spasticity in the cohort was associated with a worsened 3-month mRS by an average of 0.4 after adjusting for known covariables. This significant adverse effect on functional outcomes adds predictive value beyond previously established factors. S. R. Belagaje, C. Lindsell, C. J. Moomaw, K. Alwell, M. L. Flaherty, D. Woo, K. Dunning, P. Khatri, O. Adeoye, D. Kleindorfer, J. Broderick, and B. Kissela Copyright © 2014 S. R. Belagaje et al. All rights reserved. Role of Matrix Metalloproteinase Activity in the Neurovascular Protective Effects of Angiotensin Antagonism Thu, 24 Jul 2014 00:00:00 +0000 Background and Purpose. Oxidative stress and matrix metalloproteinase (MMP) activity have been identified as key mediators of early vascular damage after ischemic stroke. Somewhat surprisingly, the angiotensin II type 1 receptor (AT1) blocker, candesartan, has been shown to acutely increase MMP activity while providing neurovascular protection. We aimed to determine the contribution of MMP and nitrative stress to the effects of angiotensin blockade in experimental stroke. Methods. Wistar rats (n = 9–14/group; a total of 99) were treated in a factorial design with candesartan 1 mg/kg IV, alone or in combination with either a peroxynitrite decomposition catalyst, FeTPPs, 30 mg/kg IP or GM6001 50 mg/kg IP (MMP inhibitor). Neurological deficit, infarct, size and hemorrhagic transformation (HT) were measured after 3 h of middle cerebral artery occlusion (MCAO) and 21 h of reperfusion. MMP activity and nitrotyrosine expression were also measured. Results. Candesartan reduced infarct size and HT when administered alone () and in combination with FeTPPs (). GM6001 did not significantly affect HT when administered alone, but the combination with candesartan caused increased HT () and worsened neurologic score (). Conclusions. Acute administration of candesartan reduces injury after stroke despite increasing MMP activity, likely by an antioxidant mechanism. Tauheed Ishrat, Anna Kozak, Ahmed Alhusban, Bindu Pillai, Maribeth H. Johnson, Azza B. El-Remessy, Adviye Ergul, and Susan C. Fagan Copyright © 2014 Tauheed Ishrat et al. All rights reserved. Differences in Plantar Flexor Fascicle Length and Pennation Angle between Healthy and Poststroke Individuals and Implications for Poststroke Plantar Flexor Force Contributions Wed, 23 Jul 2014 08:16:52 +0000 Poststroke plantar flexor muscle weakness has been attributed to muscle atrophy and impaired activation, which cannot collectively explain the limitations in force-generating capability of the entire muscle group. It is of interest whether changes in poststroke plantar flexor muscle fascicle length and pennation angle influence the individual force-generating capability and whether plantar flexor weakness is due to uniform changes in individual muscle force contributions. Fascicle lengths and pennation angles for the soleus, medial, and lateral gastrocnemius were measured using ultrasound and compared between ten hemiparetic poststroke subjects and ten healthy controls. Physiological cross-sectional areas and force contributions to poststroke plantar flexor torque were estimated for each muscle. No statistical differences were observed for any muscle fascicle lengths or for the lateral gastrocnemius and soleus pennation angles between paretic, nonparetic, and healthy limbs. There was a significant decrease () in the paretic medial gastrocnemius pennation angle compared to both nonparetic and healthy limbs. Physiological cross-sectional areas and force contributions were smaller on the paretic side. Additionally, bilateral muscle contributions to plantar flexor torque remained the same. While the architecture of each individual plantar flexor muscle is affected differently after stroke, the relative contribution of each muscle remains the same. John W. Ramsay, Thomas S. Buchanan, and Jill S. Higginson Copyright © 2014 John W. Ramsay et al. All rights reserved. Poststroke Muscle Architectural Parameters of the Tibialis Anterior and the Potential Implications for Rehabilitation of Foot Drop Wed, 16 Jul 2014 13:01:56 +0000 Poststroke dorsiflexor weakness and paretic limb foot drop increase the risk of stumbling and falling and decrease overall functional mobility. It is of interest whether dorsiflexor muscle weakness is primarily neurological in origin or whether morphological differences also contribute to the impairment. Ten poststroke hemiparetic individuals were imaged bilaterally using noninvasive medical imaging techniques. Magnetic resonance imaging was used to identify changes in tibialis anterior muscle volume and muscle belly length. Ultrasonography was used to measure fascicle length and pennation angle in a neutral position. We found no clinically meaningful bilateral differences in any architectural parameter across all subjects, which indicates that these subjects have the muscular capacity to dorsiflex their foot. Therefore, poststroke dorsiflexor weakness is primarily neural in origin and likely due to muscle activation failure or increased spasticity of the plantar flexors. The current finding suggests that electrical stimulation methods or additional neuromuscular retraining may be more beneficial than targeting muscle strength (i.e., increasing muscle mass). John W. Ramsay, Molly A. Wessel, Thomas S. Buchanan, and Jill S. Higginson Copyright © 2014 John W. Ramsay et al. All rights reserved. Y-Stenting for Bifurcation Aneurysm Coil Embolization: What is the Risk? Thu, 10 Jul 2014 11:45:01 +0000 The use of two stents in a “Y” configuration (Y-stenting) to assist with coil embolization of complex bifurcation aneurysms has been accepted as an alternative to clip reconstruction of a select subset of challenging aneurysms. We review the risks associated with Y-stenting, including its procedural complication rates, angiographic occlusion rates, rerupture, and retreatment rates. Alejandro M. Spiotta, Jonathan Lena, M. Imran Chaudry, Raymond D. Turner, and Aquilla S. Turk Copyright © 2014 Alejandro M. Spiotta et al. All rights reserved. Do Improvements in Balance Relate to Improvements in Long-Distance Walking Function after Stroke? Thu, 10 Jul 2014 08:16:18 +0000 Stroke survivors identify a reduced capacity to walk farther distances as a factor limiting their engagement at home and in community. Previous observational studies have shown that measures of balance ability and balance self-efficacy are strong predictors of long-distance walking function after stroke. Consequently, recommendations to target balance during rehabilitation have been put forth. The purpose of this study was to determine if the changes in balance and long-distance walking function observed following a 12-week poststroke walking rehabilitation program were related. For thirty-one subjects with hemiparesis after stroke, this investigation explored the cross-sectional (i.e., before training) and longitudinal (i.e., changes due to intervention) relationships between measures of standing balance, walking balance, and balance self-efficacy versus long-distance walking function as measured via the 6-minute walk test (6MWT). A regression model containing all three balance variables accounted for 60.8% of the variance in 6MWT performance (; ; ); however, only dynamic balance (FGA) was an independent predictor () of 6MWT distance. Interestingly, changes in balance were unrelated to changes in the distance walked (each correlation coefficient , ). For persons after stroke similar to those studied, improving balance may not be sufficient to improve long-distance walking function. Louis N. Awad, Darcy S. Reisman, and Stuart A. Binder-Macleod Copyright © 2014 Louis N. Awad et al. All rights reserved. Autologous Bone Marrow Mononuclear Cells Intrathecal Transplantation in Chronic Stroke Tue, 08 Jul 2014 10:59:30 +0000 Cell therapy is being widely explored in the management of stroke and has demonstrated great potential. It has been shown to assist in the remodeling of the central nervous system by inducing neurorestorative effect through the process of angiogenesis, neurogenesis, and reduction of glial scar formation. In this study, the effect of intrathecal administration of autologous bone marrow mononuclear cells (BMMNCs) is analyzed on the recovery process of patients with chronic stroke. 24 patients diagnosed with chronic stroke were administered cell therapy, followed by multidisciplinary neurorehabilitation. They were assessed on functional independence measure (FIM) objectively, along with assessment of standing and walking balance, ambulation, and hand functions. Out of 24 patients, 12 improved in ambulation, 10 in hand functions, 6 in standing balance, and 9 in walking balance. Further factor analysis was done. Patients of the younger groups showed higher percentage of improvement in all the areas. Patients who underwent cell therapy within 2 years after the stroke showed better changes. Ischemic type of stroke had better recovery than the hemorrhagic stroke. This study demonstrates the potential of autologous BMMNCs intrathecal transplantation in improving the prognosis of functional recovery in chronic stage of stroke. Further clinical trials are recommended. This trial is registered with NCT02065778. Alok Sharma, Hemangi Sane, Nandini Gokulchandran, Dipti Khopkar, Amruta Paranjape, Jyothi Sundaram, Sushant Gandhi, and Prerna Badhe Copyright © 2014 Alok Sharma et al. All rights reserved. Endovascular and Surgical Options for Ruptured Middle Cerebral Artery Aneurysms: Review of the Literature Sun, 06 Jul 2014 11:46:16 +0000 Middle cerebral artery (MCA) aneurysms are common entities, and those of the bifurcation are the most frequently encountered sublocation of MCA aneurysm. MCA bifurcation (MBIF) aneurysms commonly present with subarachnoid hemorrhage (SAH), are devastating, and are often lethal. At the present time, the treatment of ruptured MBIF aneurysms entails either endovascular or open microneurosurgical methods to permanently secure the aneurysm(s). The purpose of this report is to review the current available data regarding the relative superiority of endovascular versus open microneurosurgical clipping for the treatment of ruptured middle cerebral artery bifurcation aneurysms. David R. Santiago-Dieppa, Jeffrey S. Pannell, and Alexander A. Khalessi Copyright © 2014 David R. Santiago-Dieppa et al. All rights reserved. Functional Brain Correlates of Upper Limb Spasticity and Its Mitigation following Rehabilitation in Chronic Stroke Survivors Thu, 03 Jul 2014 00:00:00 +0000 Background. Arm spasticity is a challenge in the care of chronic stroke survivors with motor deficits. In order to advance spasticity treatments, a better understanding of the mechanism of spasticity-related neuroplasticity is needed. Objective. To investigate brain function correlates of spasticity in chronic stroke and to identify specific regional functional brain changes related to rehabilitation-induced mitigation of spasticity. Methods. 23 stroke survivors (>6 months) were treated with an arm motor learning and spasticity therapy (5 d/wk for 12 weeks). Outcome measures included Modified Ashworth scale, sensory tests, and functional magnetic resonance imaging (fMRI) for wrist and hand movement. Results. First, at baseline, greater spasticity correlated with poorer motor function () and greater sensory deficits (). Second, rehabilitation produced improvement in upper limb spasticity and motor function (). Third, at baseline, greater spasticity correlated with higher fMRI activation in the ipsilesional thalamus (, ). Fourth, following rehabilitation, greater mitigation of spasticity correlated with enhanced fMRI activation in the contralesional primary motor (, ), premotor (, ), primary sensory (, ), and associative sensory (, ) regions while controlling for changes in motor function. Conclusions. Contralesional motor regions may contribute to restoring control of muscle tone in chronic stroke. Svetlana Pundik, Adam D. Falchook, Jessica McCabe, Krisanne Litinas, and Janis J. Daly Copyright © 2014 Svetlana Pundik et al. All rights reserved. Changes in Predicted Muscle Coordination with Subject-Specific Muscle Parameters for Individuals after Stroke Wed, 25 Jun 2014 00:00:00 +0000 Muscle weakness is commonly seen in individuals after stroke, characterized by lower forces during a maximal volitional contraction. Accurate quantification of muscle weakness is paramount when evaluating individual performance and response to after stroke rehabilitation. The objective of this study was to examine the effect of subject-specific muscle force and activation deficits on predicted muscle coordination when using musculoskeletal models for individuals after stroke. Maximum force generating ability and central activation ratio of the paretic plantar flexors, dorsiflexors, and quadriceps muscle groups were obtained using burst superimposition for four individuals after stroke with a range of walking speeds. Two models were created per subject: one with generic and one with subject-specific activation and maximum isometric force parameters. The inclusion of subject-specific muscle data resulted in changes in the model-predicted muscle forces and activations which agree with previously reported compensation patterns and match more closely the timing of electromyography for the plantar flexor and hamstring muscles. This was the first study to create musculoskeletal simulations of individuals after stroke with subject-specific muscle force and activation data. The results of this study suggest that subject-specific muscle force and activation data enhance the ability of musculoskeletal simulations to accurately predict muscle coordination in individuals after stroke. Brian A. Knarr, Darcy S. Reisman, Stuart A. Binder-Macleod, and Jill S. Higginson Copyright © 2014 Brian A. Knarr et al. All rights reserved. Racial/Ethnic Differences in Poststroke Rehabilitation Outcomes Sun, 15 Jun 2014 08:13:18 +0000 Background. Significant racial and ethnic disparities in stroke incidence, severity, and morbidity have been consistently reported; however, less is known about potential differences in poststroke rehabilitation outcomes. Objective. To examine racial and ethnic differences in poststroke rehabilitation outcomes. Methods. We completed an in-depth search of Medline and several major journals dedicated to publishing research articles on stroke, rehabilitation, and racial-ethnic patterns of disease over a 10-year period (2003–2012). We identified studies that reported rehabilitation outcomes and the race or ethnicity of at least two groups. Results. 17 studies involving 429,108 stroke survivors met inclusion criteria for the review. The majority (94%) of studies examined outcomes between Blacks and Whites. Of those studies examining outcomes between Blacks and Whites, 59% showed that Blacks were generally less likely to achieve equivalent functional improvement following rehabilitation. Blacks were more likely to experience lower FIM gain or change scores (range: 1–60%) and more likely to have lower efficiency scores (range: 5–16%) than Whites. Conclusions. Black stroke survivors appear to generally achieve poorer functional outcomes than White stroke survivors. Future studies are warranted to evaluate the precise magnitude of these differences, whether they go beyond chance, and the underlying contributory mechanisms. Charles Ellis, Hyacinth I. Hyacinth, Jamie Beckett, Wuwei Feng, Marc Chimowitz, Bruce Ovbiagele, Dan Lackland, and Robert Adams Copyright © 2014 Charles Ellis et al. All rights reserved. Flow Diverters for Intracranial Aneurysms Tue, 20 May 2014 05:30:35 +0000 Flow diverters (pipeline embolization device, Silk flow diverter, and Surpass flow diverter) have been developed to treat intracranial aneurysms. These endovascular devices are placed within the parent artery rather than the aneurysm sac. They take advantage of altering hemodynamics at the aneurysm/parent vessel interface, resulting in gradual thrombosis of the aneurysm occurring over time. Subsequent inflammatory response, healing, and endothelial growth shrink the aneurysm and reconstruct the parent artery lumen while preserving perforators and side branches in most cases. Flow diverters have already allowed treatment of previously untreatable wide neck and giant aneurysms. There are risks with flow diverters including in-stent thrombosis, perianeurysmal edema, distant and delayed hemorrhages, and perforator occlusions. Comparative efficacy and safety against other therapies are being studied in ongoing trials. Antiplatelet therapy is mandatory with flow diverters, which has highlighted the need for better evidence for monitoring and tailoring antiplatelet therapy. In this paper we review the devices, their uses, associated complications, evidence base, and ongoing studies. Yazan J. Alderazi, Darshan Shastri, Tareq Kass-Hout, Charles J. Prestigiacomo, and Chirag D. Gandhi Copyright © 2014 Yazan J. Alderazi et al. All rights reserved. Cognitive Dysfunction after On-Pump Operations: Neuropsychological Characteristics and Optimal Core Battery of Tests Wed, 30 Apr 2014 13:01:56 +0000 Postoperative cognitive dysfunction (POCD) is a mild form of perioperative ischemic brain injury, which emerges as memory decline, decreased attention, and decreased concentration during several months, or even years, after surgery. Here we present results of our three neuropsychological studies, which overall included 145 patients after on-pump operations. We found that the auditory memory span test (digit span) was more effective as a tool for registration of POCD, in comparison with the word-list learning and story-learning tests. Nonverbal memory or visuoconstruction tests were sensitive to POCD in patients after intraoperative opening of cardiac chambers with increased cerebral air embolism. Psychomotor speed tests (digit symbol, or TMT A) registered POCD, which was characteristic for elderly atherosclerotic patients. Finally, we observed that there were significant effects of the order of position of a test on the performance on this test. For example, the postoperative performance on the core tests (digit span and digit symbol) showed minimal impairment when either of these tests was administered at the beginning of testing. Overall, our data shows that the selection of tests, and the order of which these tests are administered, may considerably influence the results of studies of POCD. Anna G. Polunina, Elena Z. Golukhova, Alla B. Guekht, Natalia P. Lefterova, and Leo A. Bokeria Copyright © 2014 Anna G. Polunina et al. All rights reserved. Bolus-Infusion Delays of Alteplase during Thrombolysis in Acute Ischaemic Stroke and Functional Outcome at 3 Months Wed, 30 Apr 2014 07:32:20 +0000 Background. The efficacy of alteplase in acute ischaemic stroke (AIS) is highly time dependent. Hence, alteplase is administered as soon as possible with a bolus followed by an infusion. Delays between bolus and infusion may occur, but the extent of these delays and the impact on outcome are unclear. Aims. We investigated the extent of bolus-infusion delays and the relationship between delays and stroke outcome. Method. We reviewed medical records of 276 patients who received alteplase for AIS at our centre between April, 2008, and June, 2013. Complete demographic and clinical data including 3-month modified Rankin Score (mRS) from 229 patients were analysed comparing delays of 0–8 and >8 minutes. Results. Overall mean (SD) bolus-infusion delay was 9 (7) minutes. Baseline characteristics were similar apart from more severe strokes in delays >8 minutes. Three-month outcomes were not significantly different although delays >8 minutes had lower functional independence rate (mRS 0-1: 23.1% versus 28.1%; adjusted OR 1.2 (95% CI 0.6 to 2.4, )) and higher mortality rate (18% versus 11%, OR 1.0, 95% CI 0.6 to 1.7, ). Conclusions. In this single centre series, bolus-infusion delays of alteplase in AIS were common and no effect of bolus-infusion delays on independence and mortality was found. Paul Acheampong, Margaret T. May, Gary A. Ford, and Anand K. Dixit Copyright © 2014 Paul Acheampong et al. All rights reserved. Co-Occurrence of Arthritis and Stroke amongst Middle-Aged and Older Adults in Canada Wed, 16 Apr 2014 07:07:32 +0000 Arthritis is a chronic inflammatory condition commonly associated with mobility restriction and reduced activity. To date, the extent to which arthritis is an independent risk factor for stroke is unclear, and important, in light of an aging population. The purpose of this study was to (i) quantify the cross-sectional association between stroke and arthritis and (ii) to determine whether the relationship differed in physically active and inactivemiddle-aged and older adults. Data was derived from the 2010 Canadian Community Health Survey ( ≥30 y). Multivariable logistic regression was used to estimate the association between arthritis and stroke in models adjusted for age, physical activity (PA), and demographic factors. Overall, individuals with arthritis were 4 times more likely to report a history of stroke (, 95% CI = 3.06–4.68), whereas those who were engaged in at least moderate PA (≥ 1.5 kcal/kg/day) were less than half as likely (0.45, 0.92−0.62). This effect was moderated by age, as younger (30–65 y: 3.27, 2.22–4.83) but not older adults (>65 y: 1.04, 0.8–1.35) with arthritis had elevated odds of stroke. Both physical inactivity and arthritis are associated with higher odds of stroke, effects of which are the strongest amongst 30–65 year olds. Roman Matveev and Chris I. Ardern Copyright © 2014 Roman Matveev and Chris I. Ardern. All rights reserved. Feasibility of Dual-Task Gait Training for Community-Dwelling Adults after Stroke: A Case Series Wed, 09 Apr 2014 07:44:14 +0000 This case series explored the feasibility and efficacy of cognitive-motor dual-task gait training in community-dwelling adults within 12 months of stroke. A secondary aim was to assess transfer of training to different dual-task combinations. Seven male participants within 12 months of stroke participated in 12 sessions of dual-task gait training. We examined single and dual-task performance in four different dual-task combinations at baseline, after 6 and 12 sessions, and if possible, at 1-month followup. Feasibility was assessed by asking participants to rate mental and physical fatigue, perceived difficulty, anxiety, and fear of falling at the end of each session. Five of the seven participants demonstrated reduced dual-task cost in gait speed in at least one of the dual-task combinations after the intervention. Analysis of the patterns of interference in the gait and cognitive tasks suggested that the way in which the participants allocated their attention between the simultaneous tasks differed across tasks and, in many participants, changed over time. Dual-task gait training is safe and feasible within the first 12 months after stroke, and may improve dual-task walking speed. Individuals with a combination of physical and cognitive impairments may not be appropriate for dual-task gait training. Prudence Plummer, Raymond M. Villalobos, Moira S. Vayda, Myriam Moser, and Erin Johnson Copyright © 2014 Prudence Plummer et al. All rights reserved. Surface Electrical Stimulation for Treating Swallowing Disorders after Stroke: A Review of the Stimulation Intensity Levels and the Electrode Placements Wed, 02 Apr 2014 15:23:35 +0000 Neuromuscular electrical stimulation (NMES) for treating dysphagia is a relatively new therapeutic method. There is a paucity of evidence about the use of NMES in patients with dysphagia caused by stroke. The present review aimed to introduce and discuss studies that have evaluated the efficacy of this method amongst dysphagic patients following stroke with emphasis on the intensity of stimulation (sensory or motor level) and the method of electrode placement on the neck. The majority of the reviewed studies describe some positive effects of the NMES on the neck musculature in the swallowing performance of poststroke dysphagic patients, especially when the intensity of the stimulus is adjusted at the sensory level or when the motor electrical stimulation is applied on the infrahyoid muscles during swallowing. Marziyeh Poorjavad, Saeed Talebian Moghadam, Noureddin Nakhostin Ansari, and Mostafa Daemi Copyright © 2014 Marziyeh Poorjavad et al. All rights reserved. Endovascular and Surgical Treatment of Unruptured MCA Aneurysms: Meta-Analysis and Review of the Literature Tue, 01 Apr 2014 00:00:00 +0000 Introduction. The best treatment for unruptured middle cerebral artery (MCA) aneurysms is unclear. We perform a meta-analysis of recent publications to evaluate the results of unruptured MCA aneurysms treated with surgical clipping and endovascular coiling. Methods. A PubMed search for articles published between January 2004 and November 2013 was performed. The R statistical software package was used to create a random effects model for each desired incidence rate. Cochran’s Q test was used to evaluate possible heterogeneity among the rates observed in each study. Results. A total of 1891 unruptured MCA aneurysms, 1052 clipped and 839 coiled, were included for analysis. The complete occlusion rate at 6–9 months mean follow-up was 95.5% in the clipped group and 67.8% in the coiled group (). The periprocedural thromboembolism rate in the clipping group was 1.8% compared with 10.7% in the aneurysms treated by coiling (). The recanalization rate was 0% for clipping and 14.3% for coiling (). Modified Rankin scores of 0–2 were obtained in 98.9% of clipped patients compared to 95.5% of coiled (NS). Conclusions. This review weakly supports clipping as the preferred treatment of unruptured MCA aneurysms. Clinical outcomes did not differ significantly between the two groups. Spiros L. Blackburn, Abdelrahman M. Abdelazim, Andrew B. Cutler, Kevin T. Brookins, Kyle M. Fargen, Brian L. Hoh, and Yasha Kadkhodayan Copyright © 2014 Spiros L. Blackburn et al. All rights reserved. Factors Affecting the Ability of the Stroke Survivor to Drive Their Own Recovery outside of Therapy during Inpatient Stroke Rehabilitation Thu, 27 Mar 2014 14:21:13 +0000 Aim. To explore factors affecting the ability of the stroke survivor to drive their own recovery outside of therapy during inpatient rehabilitation. Method. One-on-one, in-depth interviews with stroke survivors () and their main carer (), along with two focus groups with clinical staff (). Data was thematically analysed according to group. Results. Stroke survivors perceived “dealing with loss,” whilst concurrently “building motivation and hope” for recovery affected their ability to drive their own recovery outside of therapy. In addition, they reported a “lack of opportunities” outside of therapy, with subsequent time described as “dead and wasted.” Main carers perceived stroke survivors felt “out of control … at everyone’s mercy” and lacked knowledge of “what to do and why” outside of therapy. Clinical staff perceived the stroke survivor’s ability to drive their own recovery was limited by the lack of “another place to go” and the “passive rehab culture and environment.” Discussion. To enable the stroke survivor to drive their own recovery outside of therapy, there is a need to increase opportunities for practice and promote active engagement. Suggested strategies include building the stroke survivor’s motivation and knowledge, creating an enriched environment, and developing daily routines to provide structure outside of therapy time. Xue Wen Eng, Sandra G. Brauer, Suzanne S. Kuys, Matthew Lord, and Kathryn S. Hayward Copyright © 2014 Xue Wen Eng et al. All rights reserved.