Stroke Research and Treatment The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . All rights reserved. Retracted: Results of Surgical and Nonsurgical Treatment of Aneurysms in a Developing Country Mon, 01 Feb 2016 14:23:30 +0000 Stroke Research and Treatment Copyright © 2016 Stroke Research and Treatment. All rights reserved. The Effect of Electromagnetic Field Treatment on Recovery from Ischemic Stroke in a Rat Stroke Model: Clinical, Imaging, and Pathological Findings Mon, 01 Feb 2016 14:02:48 +0000 Stroke is a leading cause of death and disability. Effects of stroke include significant deficits in sensory-motor skills and cognitive abilities. At present, there are limited effective interventions for postacute stroke patients. In this preliminary research we studied a new noninvasive, very low intensity, low frequency, electromagnetic field treatment (VLIFE), targeting a neural network, on an in vivo stroke rat model. Eighteen rats were divided into three groups: sham (M1) and two treatment groups which were exposed to VLIFE treatment for 4 weeks, one using theta waves (M2) and another using beta waves (M3); all groups were followed up for an additional month. Results indicate that the M2 and M3 treated groups showed recovery of sensorimotor functional deficits, as demonstrated by Modified Neurological Severity Score and forelimb placement tests. Brain MRI imaging results show a decrease in perilesional edema and lateral ventricle widening in the treated groups. Fiber tracts’ imaging, following VLIFE treatment, showed a higher white matter integrity compared to control. Histological findings support neural regeneration processes. Our data suggest that VLIFE treatment, targeting a specific functional neural network by frequency rather than location, promotes neuronal plasticity after stroke and, as a result, improves clinical recovery. Further studies will investigate the full potential of the treatment. Y. Segal, L. Segal, T. Blumenfeld-Katzir, E. Sasson, V. Poliansky, E. Loeb, A. Levy, A. Alter, and N. Bregman Copyright © 2016 Y. Segal et al. All rights reserved. Pharyngeal Electrical Stimulation for Treatment of Poststroke Dysphagia: Individual Patient Data Meta-Analysis of Randomised Controlled Trials Tue, 24 Nov 2015 14:18:34 +0000 Background. Dysphagia after stroke is common, associated independently with poor outcome, and has limited treatment options. Pharyngeal electrical stimulation (PES) is a novel treatment being evaluated for treatment of poststroke dysphagia. Methods. We searched electronically for randomised controlled trials of PES in dysphagic patients within 3 months of stroke. Individual patient data were analysed using regression, adjusted for trial, age, severity, and baseline score. The coprimary outcomes were radiological aspiration (penetration aspiration score, PAS) and clinical dysphagia (dysphagia severity rating scale, DSRS) at 2 weeks; secondary outcomes included functional outcome, death, and length of stay in hospital. Results. Three completed trials were identified: 73 patients, age 72 (12) years, severity (NIHSS) 11 (6), DSRS 6.7 (4.3), mean PAS 4.3 (1.8). Compared with no/sham stimulation, PES was associated with lower PAS, 3.4 (1.7) versus 4.1 (1.7), mean difference −0.9 (), and lower DSRS, 3.5 (3.8) versus 4.9 (4.4), mean difference −1.7 (). Length of stay in hospital tended to be shorter: 50.2 (25.3) versus 71.2 (60.4) days (). Functional outcome and death did not differ between treatment groups. Conclusions. PES was associated with less radiological aspiration and clinical dysphagia and possibly reduced length of stay in hospital across three small trials. Polly Scutt, Han S. Lee, Shaheen Hamdy, and Philip M. Bath Copyright © 2015 Polly Scutt et al. All rights reserved. Improvement in Paretic Arm Reach-to-Grasp following Low Frequency Repetitive Transcranial Magnetic Stimulation Depends on Object Size: A Pilot Study Tue, 17 Nov 2015 14:35:19 +0000 Introduction. Low frequency repetitive transcranial magnetic stimulation (LF-rTMS) delivered to the nonlesioned hemisphere has been shown to improve limited function of the paretic upper extremity (UE) following stroke. The outcome measures have largely included clinical assessments with little investigation on changes in kinematics and coordination. To date, there is no study investigating how the effects of LF-rTMS are modulated by the sizes of an object to be grasped. Objective. To investigate the effect of LF-rTMS on kinematics and coordination of the paretic hand reach-to-grasp (RTG) for two object sizes in chronic stroke. Methods. Nine participants received two TMS conditions: real rTMS and sham rTMS conditions. Before and after the rTMS conditions, cortico-motor excitability (CE) of the nonlesioned hemisphere, RTG kinematics, and coordination was evaluated. Object sizes were 1.2 and 7.2 cm in diameter. Results. Compared to sham rTMS, real rTMS significantly reduced CE of the non-lesioned M1. While rTMS had no effect on RTG action for the larger object, real rTMS significantly improved movement time, aperture opening, and RTG coordination for the smaller object. Conclusions. LF-rTMS improves RTG action for only the smaller object in chronic stroke. The findings suggest a dissociation between effects of rTMS on M1 and task difficulty for this complex skill. Jarugool Tretriluxana, Shailesh Kantak, Suradej Tretriluxana, Allan D. Wu, and Beth E. Fisher Copyright © 2015 Jarugool Tretriluxana et al. All rights reserved. The Effect of Telemedicine on Access to Acute Stroke Care in Texas: The Story of Age Inequalities Mon, 12 Oct 2015 06:24:48 +0000 Background. Ischemic stroke is a time sensitive disease with the effectiveness of treatment decreasing over time. Treatment is more likely to occur at Primary Stroke Centers (PSC); thus rapid access to acute stroke care through stand-alone PSCs or telemedicine (TM) is vital for all Americans. The objective of this study is to determine if disparities exist in access to PSCs or the extended access to acute stroke care provided by TM. Methods. Data from the US Census Bureau and the 2010 Neilson Claritas Demographic Estimation Program, American Hospital Association annual survey, and The Joint Commission list of PSCs and survey response data for all hospitals in the state of Texas were used. Results. Over 64% of block groups had 60-minute ground access to acute stroke care. The odds of a block group having 60-minute access to acute stroke care decreased with age, despite adjustment for sex, race, ethnicity, socioeconomic status, urbanization, and total population. Conclusion. Our survey of Texas hospitals found that as the median age of a block group increased, the odds of having access to acute stroke care decreased. Karen C. Albright, Amelia K. Boehme, Michael T. Mullen, Tzu-Ching Wu, Charles C. Branas, James C. Grotta, Sean I. Savitz, Catherine Wolff, Bisakha Sen, and Brendan G. Carr Copyright © 2015 Karen C. Albright et al. All rights reserved. Copeptin: Limited Usefulness in Early Stroke Differentiation? Mon, 08 Jun 2015 13:36:20 +0000 Background. Stroke can be a challenging diagnosis in an emergency-setting. We sought to determine whether copeptin may be a useful biomarker to differentiate between ischemic stroke (IS), transient ischemic attack (TIA), and stroke-mimics. Methods. In patients with suspected stroke arriving within 4.5 hours of symptom-onset, copeptin-levels were measured in initial blood-samples. The final diagnosis was adjudicated by vascular neurologists blinded to copeptin-values. Results. Of all 36 patients with available copeptin-values (median age 71 years, IQR: 54–76; 44% female), 20 patients (56%) were diagnosed with IS, no patient was diagnosed with hemorrhagic stroke, nine patients (25%) were diagnosed with TIA, and seven patients (19%) were stroke-mimics. Copeptin-levels (in pmol/L) tended to be higher in patients with IS [19.1 (11.2–48.5)] compared to TIA [9.4 (5.4–13.8)]. In stroke-mimics the range of values was extremely broad [33.3 (7.57–255.7)]. The diagnostic accuracy of copeptin for IS was 63% with a sensitivity of 80% and a positive predictive value of 64%. Conclusion. In this cohort of patients copeptin-levels within 4.5 hours of symptom onset were higher in patients with IS compared to TIA but the broad range of values in stroke-mimics limits diagnostic accuracy. This trial is registered with UTN: U1111-1119-7602. Johannes von Recum, Julia Searle, Anna Slagman, Jörn Ole Vollert, Matthias Endres, Martin Möckel, and Martin Ebinger Copyright © 2015 Johannes von Recum et al. All rights reserved. Factors Associated with Poststroke Fatigue: A Systematic Review Mon, 25 May 2015 09:38:41 +0000 Background. Poststroke fatigue (PSF) is a frequent, disabling symptom that lacks a consensual definition and a standardized evaluation method. The (multiple) causes of PSF have not been formally characterized. Objective. To identify factors associated with PSF. Method. A systematic review of articles referenced in MEDLINE. Only original studies having measured PSF and potentially associated factors were included. Data was extracted from articles using predefined data fields. Results. Although PSF tends to be more frequent in female patients and older patients, sociodemographic factors do not appear to have a major impact. There are strong associations between PSF and emotional disturbances (such as depression and anxiety). PSF may also be linked to attentional disturbances (mainly slowing in processing speed). The literature data have failed to demonstrate a clear impact of the type and severity of stroke. It has been suggested that PSF results from alterations in the frontothalamostriatal system and/or inflammatory processes. Pain, sleep disorders, and prestroke fatigue also appeared to be associated with PSF. Implications. A better understanding of PSF may improve stroke patient care and facilitate the development of effective treatments. Amélie Ponchel, Stéphanie Bombois, Régis Bordet, and Hilde Hénon Copyright © 2015 Amélie Ponchel et al. All rights reserved. Medical Acute Complications of Intracerebral Hemorrhage in Young Adults Mon, 02 Feb 2015 06:34:31 +0000 Background. Frequency and impact of medical complications on short-term mortality in young patients with intracerebral hemorrhage (ICH) have gone unstudied. Methods. We reviewed data of all first-ever nontraumatic ICH patients between 16 and 49 years of age treated in our hospital between January 2000 and March 2010 to identify medical complications suffered. Logistic regression adjusted for known ICH prognosticators was used to identify medical complications associated with mortality. Results. Among the 325 eligible patients (59% males, median age 42 [interquartile range 34–47] years), infections were discovered in 90 (28%), venous thrombotic events in 13 (4%), cardiac complications in 4 (1%), renal failure in 59 (18%), hypoglycemia in 15 (5%), hyperglycemia in 165 (51%), hyponatremia in 146 (45%), hypernatremia in 91 (28%), hypopotassemia in 104 (32%), and hyperpotassemia in 27 (8%). Adjusted for known ICH prognosticators and diabetes, the only independent complication associated with 3-month mortality was hyperglycemia (plasma glucose >8.0 mmol/L) (odds ratio: 5.90, 95% confidence interval: 2.25–15.48, ). Three or more separate complications suffered also associated with increased mortality (7.76, 1.42–42.49, ). Conclusions. Hyperglycemia is a frequent complication of ICH in young adults and is independently associated with increased mortality. However, multiple separate complications increase mortality even further. Riku-Jaakko Koivunen, Elena Haapaniemi, Jarno Satopää, Mika Niemelä, Turgut Tatlisumak, and Jukka Putaala Copyright © 2015 Riku-Jaakko Koivunen et al. 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.