Stroke Research and Treatment The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . 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. Medicolegal Considerations with Intravenous Tissue Plasminogen Activator in Stroke: A Systematic Review Wed, 04 Sep 2013 15:31:13 +0000 Background. Intravenous tPA (tissue plasminogen activator) therapy remains underutilized in patients with Acute Ischemic Stroke (AIS). Anecdotal data indicates that physicians are increasingly liable for administering and for failure to administer tPA. Methods. An extensive search of Medline, Embase, Westlaw, LexisNexis Legal, and Google Scholar databases was performed. Case studies that involved malpractice litigation in ischemic stroke and thrombolytic therapy were analyzed systematically. Results. We identified 789 ischemic stroke litigation cases, of which 46 cases were related to intravenous tPA and stroke litigation. Case descriptions of 40 cases were available. Data for verdicts were available for 38 patients. The most frequent plaintiff claim was related to failure to administer intravenous tPA (38, 95%). Only 2 (5.0%) claim involved complications of treatment with tPA. Hospitals were defendants in majority of the 36 cases. Physicians were involved in 33 cases. While ED physicians were involved in 25 (60.52%) cases, neurologists were involved in 8 (20.0%) cases. There were 26 (65%) defendant-favored and 12 (30%) plaintiff-favored verdicts. Conclusion. Physicians and hospitals are at an increased risk of litigation in patients with AIS when in IV-tPA is being considered for treatment. While majority of the cases litigated were cases where tPA was not administered, only about 1 in 20 cases was litigated when complications occurred. Archit Bhatt, Adnan Safdar, Dhara Chaudhari, Diane Clark, Amber Pollak, Arshad Majid, and Mounzer Kassab Copyright © 2013 Archit Bhatt et al. All rights reserved. Acute Stroke Imaging: Recent Updates Thu, 18 Jul 2013 08:31:16 +0000 Acute ischemic stroke imaging is one of the leading causes of death and disability worldwide. Neuroimaging plays a crucial role in early diagnosis and yields essential information regarding tissue integrity, a factor that remains a key therapeutic determinant. Given the widespread public health implications of stroke and central role of neuroimaging in overall management, acute stroke imaging remains a heavily debated, extensively researched, and rapidly evolving subject. There has been recent debate in the scientific community due to divided opinions on the use of CT perfusion and access-related limitations of MRI. In this paper we review and summarize recent updates relevant to acute stroke imaging and propose an imaging paradigm based on the recently available evidence. Prachi Dubey, Sachin Pandey, and Gul Moonis Copyright © 2013 Prachi Dubey et al. All rights reserved. Advances in Our Understanding of “Resistance” to Antiplatelet Agents for Prevention of Ischemic Stroke Sun, 14 Jul 2013 10:28:41 +0000 We review the role of aspirin and clopidogrel for prevention of ischemic stroke and explore the concept of antiplatelet therapy resistance both from a laboratory and clinical perspective and genetic polymorphisms that might influence platelet reactivity with clopidogrel administration. Debates have raged over the years about the application of platelet function tests in clinical practice. We conclude that platelet function testing is not indicated in routine clinical practice. This recommendation is supported by clinical guideline statements, a lack of a global platelet function measure, and limitations of current platelet function test methods as applied in practice. We discuss a recently hypothesized hierarchy of patient characteristics in relation to which patients are most likely to benefit from platelet function studies based on acuity (i.e., risk) of cardiovascular disease. A focus of antiplatelet therapy administration should include emphasis on compliance/adherence and in the example of aspirin, use of well-absorbed forms of aspirin and avoidance of drugs that may interact with aspirin to inhibit its mechanism of action (e.g., certain nonsteroidal anti-inflammatory drugs). Philip B. Gorelick and Muhammad U. Farooq Copyright © 2013 Philip B. Gorelick and Muhammad U. Farooq. All rights reserved. Aneurysmal Subarachnoid Hemorrhage Models: Do They Need a Fix? Wed, 26 Jun 2013 08:44:20 +0000 The discovery of tissue plasminogen activator to treat acute stroke is a success story of research on preventing brain injury following transient cerebral ischemia (TGI). That this discovery depended upon development of embolic animal model reiterates that proper stroke modeling is the key to develop new treatments. In contrast to TGI, despite extensive research, prevention or treatment of brain injury following aneurysmal subarachnoid hemorrhage (aSAH) has not been achieved. A lack of adequate aSAH disease model may have contributed to this failure. TGI is an important component of aSAH and shares mechanism of injury with it. We hypothesized that modifying aSAH model using experience acquired from TGI modeling may facilitate development of treatment for aSAH and its complications. This review focuses on similarities and dissimilarities between TGI and aSAH, discusses the existing TGI and aSAH animal models, and presents a modified aSAH model which effectively mimics the disease and has a potential of becoming a better resource for studying the brain injury mechanisms and developing a treatment. Fatima A. Sehba and Ryszard M. Pluta Copyright © 2013 Fatima A. Sehba and Ryszard M. Pluta. All rights reserved. Pathophysiological Role of Global Cerebral Ischemia following Subarachnoid Hemorrhage: The Current Experimental Evidence Wed, 12 Jun 2013 09:23:19 +0000 Subarachnoid hemorrhage (SAH) is the subtype of stroke with one of the highest mortality rates and the least well-understood pathophysiologies. One of the very early events which may occur after SAH is a significant decrease of cerebral perfusion pressure (CPP) caused by the excessive increase of intracranial pressure during the initial bleeding. A severely decreased CPP results in global cerebral ischemia, an event also occurring after cardiac arrest. The aim of the current paper is to review the pathophysiological events occurring in experimental models of SAH and global cerebral ischemia and to evaluate the contribution and the importance of global cerebral ischemia for the pathophysiology of SAH. Nikolaus Plesnila Copyright © 2013 Nikolaus Plesnila. All rights reserved. Advances in the Critical Care Management of Ischemic Stroke Thu, 16 May 2013 14:35:09 +0000 Given recent advances in diagnostic modalities and revascularization capabilities, clinicians are not only able to rapidly and accurately identify acute ischemic stroke, but may also be able to aggressively intervene to minimize the extent of infarction. In those cases where revascularization cannot occur and/or the extent of infarction is large, there are multiple strategies to prevent secondary decompensation as the stroke evolves, for instance, if malignant cerebral edema should develop. In this paper, we will review the indications for specialized ICU care for an ischemic stroke patient, the treatment principles, and strategies employed by neurointensivists to minimize secondary neuronal injury, the literature in support of such strategies (and the questions to be addressed by future studies), all with the ultimate goal of increasing the likelihood of favorable neurologic outcomes in our ischemic stroke population. Vineeta Singh and Nancy J. Edwards Copyright © 2013 Vineeta Singh and Nancy J. Edwards. All rights reserved. Rehabilitation with Poststroke Motor Recovery: A Review with a Focus on Neural Plasticity Tue, 30 Apr 2013 13:20:29 +0000 Motor recovery after stroke is related to neural plasticity, which involves developing new neuronal interconnections, acquiring new functions, and compensating for impairment. However, neural plasticity is impaired in the stroke-affected hemisphere. Therefore, it is important that motor recovery therapies facilitate neural plasticity to compensate for functional loss. Stroke rehabilitation programs should include meaningful, repetitive, intensive, and task-specific movement training in an enriched environment to promote neural plasticity and motor recovery. Various novel stroke rehabilitation techniques for motor recovery have been developed based on basic science and clinical studies of neural plasticity. However, the effectiveness of rehabilitative interventions among patients with stroke varies widely because the mechanisms underlying motor recovery are heterogeneous. Neurophysiological and neuroimaging studies have been developed to evaluate the heterogeneity of mechanisms underlying motor recovery for effective rehabilitation interventions after stroke. Here, we review novel stroke rehabilitation techniques associated with neural plasticity and discuss individualized strategies to identify appropriate therapeutic goals, prevent maladaptive plasticity, and maximize functional gain in patients with stroke. Naoyuki Takeuchi and Shin-Ichi Izumi Copyright © 2013 Naoyuki Takeuchi and Shin-Ichi Izumi. All rights reserved. Is Weight-Bearing Asymmetry Associated with Postural Instability after Stroke? A Systematic Review Sun, 28 Apr 2013 14:19:03 +0000 Introduction. Improvement of postural stability is an important goal during poststroke rehabilitation. Since weight-bearing asymmetry (WBA) towards the nonparetic leg is common, training of weight-bearing symmetry has been a major focus in post-stroke balance rehabilitation. It is assumed that restoration of a more symmetrical weight distribution is associated with improved postural stability. Objective. To determine to what extent WBA is associated with postural instability in people after stroke. Methods. Electronic databases were searched (Cochrane, MEDLINE, EMBASE, and CINAHL) until March 2012. Main Eligibility Criteria. (1) Participants were people after stroke. (2) The association between WBA and postural stability was reported. Quality of reporting was assessed with the STROBE checklist and a related tool for reporting of confounding. Results. Nine observational studies met all criteria. Greater spontaneous WBA was associated with higher center of pressure (COP) velocity and with poorer synchronization of COP trajectories between the legs (two and one studies, resp.). Evidence for associations between WBA and performance on clinical balance tests or falls was weak. Conclusion. Greater WBA after stroke was associated with increased postural sway, but the current literature does not provide evidence for a causal relationship. Further studies should investigate whether reducing WBA would improve postural stability. Jip F. Kamphuis, Digna de Kam, Alexander C. H. Geurts, and Vivian Weerdesteyn Copyright © 2013 Jip F. Kamphuis et al. All rights reserved. Early Poststroke Rehabilitation Using a Robotic Tilt-Table Stepper and Functional Electrical Stimulation Sun, 14 Apr 2013 09:28:08 +0000 Background. Stroke frequently leaves survivors with hemiparesis. To prevent persistent deficits, rehabilitation may be more effective if started early. Early training is often limited because of orthostatic reactions. Tilt-table stepping robots and functional electrical stimulation (FES) may prevent these reactions. Objective. This controlled convenience sample study compares safety and feasibility of robotic tilt-table training plus FES (ROBO-FES) and robotic tilt-table training (ROBO) against tilt-table training alone (control). A preliminary assessment of efficacy is performed. Methods. Hemiparetic ischemic stroke survivors (age years, days after stroke) were assigned to 30 days of ROBO-FES (), ROBO (), or control () in addition to conventional physical therapy. Impedance cardiography and transcranial doppler sonography were performed before, during, and after training. Hemiparesis was assessed using the British Medical Research Council (MRC) strength scale. Results. No serious adverse events occurred; 8 patients in the tilt-table group prematurely quit the study because of orthostatic reactions. Blood pressure and CBFV dipped % during robot training. In 52% of controls mean arterial pressure decreased by %. ROBO-FES increased leg strength by points, ROBO by more than control (, ). CBFV increased in both robotic groups more than in controls (). Conclusions. Robotic tilt-table exercise with or without FES is safe and may be more effective in improving leg strength and cerebral blood flow than tilt table alone. Alexey N. Kuznetsov, Natalia V. Rybalko, Vadim D. Daminov, and Andreas R. Luft Copyright © 2013 Alexey N. Kuznetsov et al. All rights reserved. Hip Fractures in Persons with Stroke Thu, 04 Apr 2013 09:46:03 +0000 Background. Our aim was to determine the incidence of hip fractures within two years after stroke, to identify associated factors, to evaluate which test instruments that best could identify people at risk, and to describe the circumstances that prevailed when they sustained their hip fractures. Method. A total of 377 persons with first-ever stroke were followed up for a 24-month period. Stroke severity, cognition, and associated medical conditions were registered. The following test instruments were used: National Institutes of Health Stroke Scale, Mini-Mental State Examination, Berg Balance Scale, Timed Up & Go, and Stops Walking When Talking. Result. Sixteen of the persons fractured their hip within the study period, which corresponds to an incidence of 32 hip fractures per 1000 person-years. Persons with fractures more often had impaired vision and cognitive impairment and more had had previous fractures. Of the investigated test instruments, Timed Up & Go was the best test to predict fractures. Conclusion. The incidence of hip fractures in persons with stroke was high in this study. Persons with previous fractures, and visual and cognitive defects are at the greatest risk. Certain test instruments could be used in order to find people at risk, which should be targeted for fall preventive measures. Åsa G. Andersson, Åke Seiger, and Peter Appelros Copyright © 2013 Åsa G. Andersson et al. All rights reserved. Reducing Haemorrhagic Transformation after Thrombolysis for Stroke: A Strategy Utilising Minocycline Thu, 04 Apr 2013 09:43:55 +0000 Haemorrhagic transformation (HT) of recently ischaemic brain is a feared complication of thrombolytic therapy that may be caused or compounded by ischaemia-induced activation of matrix metalloproteinases (MMPs). The tetracycline antibiotic minocycline inhibits matrix MMPs and reduces macroscopic HT in rodents with stroke treated with tissue plasminogen activator (tPA). The West Australian Intravenous Minocycline and TPA Stroke Study (WAIMATSS) aims to determine the safety and efficacy of adding minocycline to tPA in acute ischaemic stroke. The WAIMATSS is a multicentre, prospective, and randomised pilot study of intravenous minocycline, 200 mg 12 hourly for 5 doses, compared with standard care, in patients with ischaemic stroke treated with intravenous tPA. The primary endpoint is HT diagnosed by brain CT and MRI. Secondary endpoints include clinical outcome measures. Some illustrative cases from the early recruitment phase of this study will be presented, and future perspectives will be discussed. David J. Blacker, David Prentice, Anthony Alvaro, Timothy R. Bates, Michael Bynevelt, Andrew Kelly, Lay Kun Kho, Edith Kohler, Graeme J. Hankey, Andrew Thompson, and Taryn Major Copyright © 2013 David J. Blacker et al. All rights reserved. Increased Cell Fusion in Cerebral Cortex May Contribute to Poststroke Regeneration Wed, 03 Apr 2013 10:47:03 +0000 In this study, we used a model of a hemorrhagic stroke in a motor zone of the cortex in rats at the age of 3 months The report shows that cortical neurons can fuse with oligodendrocytes. In formed binuclear cells, the nucleus of an oligodendrocyte undergoes neuron specific reprogramming. It can be confirmed by changes in chromatin structure and in size of the second nucleus, by expression of specific neuronal markers and increasing total transcription rate. The nucleus of an oligodendrocyte likely transforms into a second neuronal nucleus. The number of binuclear neurons was validated with quantitative analysis. Fusion of neurons with oligodendrocytes might be a regenerative process in general and specifically following a stroke. The appearance of additional neuronal nuclei increases the functional outcome of the population of neurons. Participation of a certain number of binuclear cells in neuronal function might compensate for a functional deficit that arises from the death of a subset of neurons. After a stroke, the number of binuclear neurons increased in cortex around the lesion zone. In this case, the rate of recovery of stroke-damaged locomotor behavior also increased, which indicates the regenerative role of fusion. Alexander Paltsyn, Svetlana Komissarova, Ivan Dubrovin, and Aslan Kubatiev Copyright © 2013 Alexander Paltsyn et al. All rights reserved. Detection of Paroxysmal Atrial Fibrillation in Stroke/Tia Patients Tue, 26 Mar 2013 16:49:26 +0000 One-third of stroke and transient ischemic attack (TIA) are cryptogenic, and paroxysmal atrial fibrillation (PAF) has been suggested as a possible cause for these cryptogenic strokes. Multiple studies have recently evaluated long-term cardiac rhythm monitoring with good yield for PAF. The duration of monitoring varies between studies as well as the qualifying event definition. Moreover, the clinical significance of very brief atrial fibrillation events is unclear in the literature. This paper provides an overview of current advances in the detection of paroxysmal atrial fibrillation, the clinical and genetic factors predictive of arrhythmia detection, and the therapeutic dilemma concerning this approach. Muhib Khan and Daniel J. Miller Copyright © 2013 Muhib Khan and Daniel J. Miller. All rights reserved. The Cog-4 Subset of the National Institutes of Health Stroke Scale as a Measure of Cognition: Relationship with Baseline Factors and Functional Outcome after Stroke Using Data from the Virtual International Stroke Trials Archive Tue, 26 Mar 2013 14:29:55 +0000 Background. Assessing poststroke cognitive impairment is complex. A subscale of the NIHSS, the Cog-4, has been proposed as a quick test of “cognitive impairment.” but a study of its properties in a larger dataset is lacking. Methods. Data from 9,147 patients with acute stroke from the VISTA archive was used to generate Cog-4 scores. The statistical properties of Cog-4, its relationship with baseline clinical characteristics, and other functional outcome measures at day 90 were assessed. Results. Mean age of patients was 69.2 years and 45.8%, were females. Day-90 Cog-4 was highly positively skewed (skewness 0.926). Patients with left hemispheric stroke had higher day-90 Cog-4 score (). Age, stroke severity, and previous stroke were significant predictors of Cog-4. Cog-4 was significantly correlated with dependency (modified Rankin Scale, ), and disability (Barthel Index, ). Conclusions. The Cog-4 scale at day 90 cannot be considered a useful test of cognition since it only superficially measures cognition. It is heavily dependent on the side of stroke, is inevitably associated with functional outcome (being a subset of the NIHSS), and suffers from a profound “floor” effect. Specific and validated measures are more appropriate for the assessment of poststroke cognition than Cog-4. Sandeep Ankolekar, Cheryl Renton, Nikola Sprigg, and Philip M. W. Bath Copyright © 2013 Sandeep Ankolekar et al. All rights reserved.