Stroke Research and Treatment The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . 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. 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. 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. Sedentary Behaviour and Physical Activity of People with Stroke in Rehabilitation Hospitals Wed, 19 Mar 2014 12:05:43 +0000 Background. Sedentary behaviour is associated with health risks, independent of physical activity. This study aimed to investigate patterns of sedentary behaviour and physical activity among stroke survivors in rehabilitation hospitals. Methods. Stroke survivors admitted to four Swedish hospital-based rehabilitation units were recruited ≥7 days since stroke onset and their activity was measured using behavioural mapping. Sedentary behaviour was defined as lying down or sitting supported. Results. 104 patients were observed (53% men). Participants spent an average of 74% (standard deviation, SD 21%) of the observed day in sedentary activities. Continuous sedentary bouts of ≥1 hour represented 44% (SD 32%) of the observed day. A higher proportion (30%, SD 7%) of participants were physically active between 9:00 AM and 12:30 PM, compared to the rest of the observed day (23%, SD 6%, ). Patients had higher odds of being physically active in the hall (odds ratio, OR 1.7, ) than in the therapy area. Conclusions. The time stroke survivors spend in stroke rehabilitation units may not be used in the most efficient way to promote maximal recovery. Interventions to promote reduced sedentary time could help improve outcome and these should be tested in clinical trials. Anna Sjöholm, Monica Skarin, Leonid Churilov, Michael Nilsson, Julie Bernhardt, and Thomas Lindén Copyright © 2014 Anna Sjöholm et al. All rights reserved. Stroke Survivors Scoring Zero on the NIH Stroke Scale Score Still Exhibit Significant Motor Impairment and Functional Limitation Mon, 17 Mar 2014 07:18:01 +0000 Objective. To determine the National Institutes of Health Stroke Scale’s (NIHSS’s) association with upper extremity (UE) impairment and functional outcomes. Design. Secondary, retrospective analysis of randomized controlled trial data. Setting. Not applicable. Participants. 146 subjects with stable, chronic stroke-induced hemiparesis. Intervention. The NIHSS, the UE Fugl-Meyer (FM), and the Arm Motor Ability Test (AMAT) were administered prior to their participation in a multicenter randomized controlled trial. Main Outcome Measures. The NIHSS, FM, and AMAT. Results. The association between the NIHSS and UE impairment was statistically significant but explained less than 4% of the variance among UE FM scores. The association between NIHSS total score and function as measured by the AMAT was not statistically significant . Subjects scoring a “zero” on the NIHSS exhibited discernible UE motor deficits and varied scores on the UE FM and AMAT. Conclusion. While being used in stroke trials, the NIHSS may have limited ability to discriminate between treatment responses, even when only a relatively narrow array of impairment levels exists among patients. Given these findings, NIHSS use should be restricted to acute stroke studies and clinical settings with the goal of reporting stroke severity. Brittany Hand, Stephen J. Page, and Susan White Copyright © 2014 Brittany Hand et al. All rights reserved. Sit-to-Stand in People with Stroke: Effect of Lower Limb Constraint-Induced Movement Strategies Sun, 16 Mar 2014 11:47:57 +0000 Background. Weight-bearing asymmetry and impaired balance may contribute to the increased fall risk in people with stroke when rising to stand from sitting. Objective. This study investigated the effect of constraint-induced movement (CIM) strategies on weight-bearing symmetry and balance during sit-to-stand in people with stroke. Methods. A nonrandom convenience sample of fifteen people with stroke performed the sit-to-stand task using three CIM strategies including a solid or compliant (foam) block strategy, with the unaffected limb placed on the block, and an asymmetrical foot position strategy, with the unaffected limb placed ahead of the affected limb. Duration of the task, affected limb weight-bearing, and centre of pressure and centre of mass displacement were measured in the frontal and sagittal plane. Results. Affected limb weight-bearing was increased and frontal plane centre of pressure and centre of mass moved toward the affected limb compared to baseline with all CIM strategies. Centre of mass displacement in the sagittal plane was greater with the compliant block and asymmetrical foot strategies. Conclusions. The CIM strategies demonstrated greater loading of the affected limb and movement of the centre of pressure and centre of mass toward the affected limb. The compliant block and asymmetrical foot conditions may challenge sagittal plane balance during sit-to-stand in people with stroke. Charla Krystine Gray and Elsie Culham Copyright © 2014 Charla Krystine Gray and Elsie Culham. All rights reserved. Functional Balance and Motor Impairment Correlations with Gait Parameters during Timed Up and Go Test across Three Attentional Loading Conditions in Stroke Survivors Thu, 13 Mar 2014 13:36:50 +0000 The aim of this study was to determine whether stroke survivor’s gait performance during dual-task Timed Up and Go (TUG) test is correlated with the level of functional balance and motor impairment. Thirty stroke survivors (22 men, 8 women) were recruited for this study. The level of functional balance (Berg Balance Scale) and motor impairment (Fugl-Meyer assessment lower extremity) were assessed prior to the TUG test. TUG test was conducted under three attentional loading conditions (single, dual motor, and dual-cognitive). The time and number of steps were used to quantify gait parameters. The Spearmen’s rank correlation coefficient was used to evaluate the relationship between these variables. There was moderate to strong negative correlation between functional balance and gait parameters (range −0.53 to −0.73, ). There was a weak negative correlation observed between the time taken to complete the single task and motor impairment (; ) dual motor task and motor impairment (; ). However, there were no significant correlations between lower limb motor impairment and the number of steps in all conditions. These findings suggest that functional balance may be an influential domain of successful dual-task TUG in stroke. Haidzir Manaf, Maria Justine, and Mazlifah Omar Copyright © 2014 Haidzir Manaf et al. All rights reserved. Five Years of Acute Stroke Unit Care: Comparing ASU and Non-ASU Admissions and Allied Health Involvement Mon, 03 Mar 2014 10:04:15 +0000 Background. Evidence indicates that Stroke Units decrease mortality and morbidity. An Acute Stroke Unit (ASU) provides specialised, hyperacute care and thrombolysis. John Hunter Hospital, Australia, admits 500 stroke patients each year and has a 4-bed ASU. Aims. This study investigated hospital admissions over a 5-year period of all strokes patients and of all patients admitted to the 4-bed ASU and the involvement of allied health professionals. Methods. The study retrospectively audited 5-year data from all stroke patients admitted to John Hunter Hospital and from nonstroke patients admitted to the ASU . The study’s primary outcomes were admission rates, length of stay (days), and allied health involvement. Results. Over 5 years, 47% of stroke patients were admitted to the ASU. More male stroke patients were admitted to the ASU (ch; ). There was a trend over time towards parity between the number of stroke and nonstroke patients admitted to the ASU. When compared to those admitted elsewhere, ASU stroke patients had a longer length of stay (; ) and were more likely to receive allied healthcare. Conclusion. This is the first study to report 5 years of ASU admissions. Acute Stroke Units may benefit from a review of the healthcare provided to all stroke patients. The trends over time with respect to the utilisation of the John Hunter Hospitall’s ASU have resulted in a review of the hospitall’s Stroke Unit and allied healthcare. Isobel J. Hubbard, Malcolm Evans, Sarah McMullen-Roach, Jodie Marquez, and Mark W. Parsons Copyright © 2014 Isobel J. Hubbard et al. All rights reserved. Predictors of In-Hospital Mortality for Stroke in Douala, Cameroon Tue, 25 Feb 2014 08:30:39 +0000 Background. The objective of this study was to describe complications in hospitalized patients for stroke and to determine the predictive factors of intrahospital mortality from stroke at the Douala General Hospital (DGH) in Cameroon. Patients and Methods. A prospective cross-sectional study was carried out from January 1, 2010 to December 31, 2012, at the DGH. All the patients who were aged more than 15 years with established diagnosis of stroke were included. A univariate analysis was done to look for factors associated with the risk of death, whilst the predictive factors of death were determined in a multivariate analysis following Cox regression model. Results. Of the 325 patients included patients, 68.1% were males and the mean age was 58.66 ± 13.6 years. Ischaemic stroke accounted for 52% of the cases. Sepsis was the leading complications present in 99 (30.12%) cases. Independent predicting factors of in-hospital mortality were Glasgow Coma Scale lower than 8 (HR = 2.17 95% CI 4.86–36.8; ), hyperglycaemia at admission (HR = 3.61 95% CI 1.38–9.44; ), and hemorrhagic stroke (HR = 5.65 95% CI 1.77–18; ). Conclusion. The clinician should systematically diagnose and treat infectious states and hyperglycaemia in stroke. N. Y. Mapoure, C. B. Tchaleu Nguenkam, H. B. Mbatchou Ngahane, A. Dzudie, A. Coulibaly, N. G. Mounjouopou, E. Vaissaba, N. H. Luma, S. A. Mouelle, and A. K. Njamnshi Copyright © 2014 N. Y. Mapoure et al. All rights reserved. Advances and Potential New Treatments in Stroke Management Mon, 17 Feb 2014 11:45:20 +0000 Majaz Moonis, Padma Srivastava, Magdy Selim, and Marc Fisher Copyright © 2014 Majaz Moonis et al. All rights reserved. Combining rTMS and Task-Oriented Training in the Rehabilitation of the Arm after Stroke: A Pilot Randomized Controlled Trial Tue, 03 Dec 2013 08:27:28 +0000 Introduction. Repetitive transcranial magnetic stimulation (rTMS) is a promising technique for promoting rehabilitation of arm function after stroke. The feasibility and impact of rTMS as an adjunct to traditional task-oriented training to improve arm function have not yet been demonstrated. Objective. Evaluate the feasibility of a randomized controlled trial aimed at determining the efficacy of rTMS as an adjunct to task-oriented therapy in facilitating restoration of arm function after stroke. Methods. Stratified block-randomized controlled trial set in the general community. Eleven stroke persons with mild to severe arm deficits were recruited and randomized to receive 8 sessions of real-rTMS or sham-rTMS followed by ninety minutes of arm tasks designed to improve function. Results. Medium to large, statistically significant effect sizes (0.49 to 1.63) were observed in both groups on several measures of arm function at the postintervention evaluation. Three out of four subjects in the real-TMS condition showed increased levels of corticomotor excitability after the first stimulation session. Conclusions. Preliminary evidence suggests that an rTMS protocol potent enough to induce transient increases in cortical excitability of the lesioned hemisphere is feasible but did not show promising results as an adjunct to task-specific training. This trial is registration with Clinical NCT00850408. Johanne Higgins, Lisa Koski, and Haiqun Xie Copyright © 2013 Johanne Higgins et al. All rights reserved. Does a History of Migraine Affect the Rate of Thrombolysis in Young Stroke Patients? Thu, 14 Nov 2013 10:25:16 +0000 Background. Migraine is prevalent in young patients and a frequent stroke mimic. To distinguish stroke mimics from true stroke can be difficult, and there is a possibility of misdiagnosing a stroke as a migrainous attack in patients with migraine. We aimed to investigate if a history of migraine affects the rate of thrombolytic therapy in young stroke patients. Methods. All patients below 50 years of age admitted in the period 2006–2013 to the Bergen Stroke Centre with acute ischaemic stroke were included. The rate of thrombolytic therapy in patients with migraine was compared to patients with no history of migraine. A multivariate analysis was performed to adjust confounding factors. Results. A total of 170 young stroke patients were enrolled, 49 with migraine and 121 with no migraine. In total, 10.2% of young patients with migraine received thrombolytic therapy, compared with 26.5% of young patients with nomigraine (). Migraine was associated with a low rate of thrombolytic therapy when adjusting for possible confounding factors (OR 0.19 CI: 0.05–0.72, ). Conclusion. Migraine is associated with a low rate of thrombolytic therapy in young patients admitted with acute ischaemic stroke. Migraine patients admitted with acute ischaemic stroke are at risk of maltreatment. Halvor Øygarden, Christopher Elnan Kvistad, Lars Thomassen, Ulrike Waje-Andreassen, and Halvor Naess Copyright © 2013 Halvor Øygarden et al. All rights reserved. Brain Injury after Transient Global Cerebral Ischemia and Subarachnoid Hemorrhage Tue, 12 Nov 2013 11:01:06 +0000 Fatima A. Sehba, Ryszard M. Pluta, and R. Loch Macdonald Copyright © 2013 Fatima A. Sehba et al. All rights reserved. Poststroke Hip Fracture: Prevalence, Clinical Characteristics, Mineral-Bone Metabolism, Outcomes, and Gaps in Prevention Wed, 25 Sep 2013 08:57:22 +0000 Objective. To assess the prevalence, clinical and laboratory characteristics, and short-term outcomes of poststroke hip fracture (HF). Methods. A cross-sectional study of 761 consecutive patients aged ≥60 years ( years; 75% females) with osteoporotic HF. Results. The prevalence of poststroke HF was 13.1% occurring on average 2.4 years after the stroke. The poststroke group compared to the rest of the cohort had a higher proportion of women, subjects with dementia, history of TIA, hypertension, coronary artery disease, secondary hyperparathyroidism, higher serum vitamin B12 levels (>350 pmol/L), walking aid users, and living in residential care facilities. The majority of poststroke HF patients had vitamin D insufficiency (68%) and excess bone resorption (90%). This group had a 3-fold higher incidence of postoperative myocardial injury and need for institutionalisation. In multivariate analysis, independent indicators of poststroke HF were female sex (OR 3.6), history of TIA (OR 5.2), dementia (OR 4.1), hypertension (OR 3.2), use of walking aid (OR 2.5), and higher vitamin B12 level (OR 2.3). Only 15% of poststroke patients received antiosteoporotic therapy prior to HF. Conclusions. Approximately one in seven HFs occurs in older stroke survivors and are associated with poorer outcomes. Early implementation of fracture prevention strategies is needed. Alexander Fisher, Wichat Srikusalanukul, Michael Davis, and Paul Smith Copyright © 2013 Alexander Fisher et al. All rights reserved.