Stroke Research and Treatment The latest articles from Hindawi © 2018 , Hindawi Limited . All rights reserved. The Importance of Assessing Nutritional Status to Ensure Optimal Recovery during the Chronic Phase of Stroke Thu, 11 Jan 2018 08:46:38 +0000 Background. Despite evidence that many of the consequences of stroke that hinder recovery (i.e., obesity, muscle atrophy, and functional declines) have nutritionally modifiable behavior components, little attention has been focused on the significance of nutrition beyond the acute phase of stroke. Objective. This literature review summarizes the evidence for and against the influence of nutrition on optimal recovery and rehabilitation in chronic (>6 months) stroke. Results. The literature, which is mainly limited to cross-sectional studies, suggests that a suboptimal nutritional status, including an excess caloric intake, reduced protein intake, and micronutrient deficiencies, particularly the B-vitamins, vitamin D, and omega 3 fatty acids, may have deleterious effects on metabolic, physical, and psychological functioning in chronic stroke survivors. Conclusions. Careful evaluation of dietary intake, especially among those with eating disabilities and preexisting malnutrition, may aid in the identification of individuals at increased nutritional risk through which early intervention may benefit recovery and rehabilitation and prevent further complications after stroke. Monica C. Serra Copyright © 2018 Monica C. Serra. All rights reserved. Resistance Training and Stroke: A Critical Analysis of Different Training Programs Wed, 20 Dec 2017 10:03:40 +0000 The aim of this study was to carry out a literature review on the overall benefits of resistance training (RT) after stroke and undertake a critical analysis of the resistance exercise programs surveyed (rest interval between sets and exercises, number of sets, number of repetitions, intensity, duration of training, and weekly frequency). To obtain articles for the review, we searched PubMed, Google Scholar, and Physiotherapy Evidence Database (PEDro). Inclusion criteria were considered using the PICO (population, intervention, control/comparison, and outcome variables) model. The following characteristics were recorded for all articles: type of study, author, year of publication, participants (time after stroke, sample size, and age), benefits of RT, and structured resistance exercise programs. Positive effects of training were found on anxiety status, quality of life, muscle hypertrophy, cognitive function, strength, and muscle power. Only 5 studies described the main variables of RT in detail. Lack of control of some variables of RT may negatively affect the results of this practice. The findings of the present study may further inform health and physical conditioning professionals on the importance and necessity of using the main variables in the search for benefits for individuals with stroke. Bruno Bavaresco Gambassi, Hélio José Coelho-Junior, Paulo Adriano Schwingel, Fabiano de Jesus Furtado Almeida, Tânia Maria Gaspar Novais, Paula de Lourdes Lauande Oliveira, Bismarck Ascar Sauaia, Cristiane Dominice Melo, Marco Carlos Uchida, and Bruno Rodrigues Copyright © 2017 Bruno Bavaresco Gambassi et al. All rights reserved. Audiovisual Biofeedback-Based Trunk Stabilization Training Using a Pressure Biofeedback System in Stroke Patients: A Randomized, Single-Blinded Study Wed, 20 Dec 2017 07:32:40 +0000 The purpose of this study was to assess the effects of audiovisual biofeedback-based trunk stabilization training using a pressure biofeedback system (PBS) in stroke patients. Forty-three chronic stroke patients, who had experienced a stroke more than 6 months ago and were able to sit and walk independently, participated in this study. The subjects were randomly allocated to an experimental group () or a control group (). The experimental group participated in audiovisual biofeedback-based trunk stabilization training for 50 minutes/day, 5 days/week, for 6 weeks. The control group underwent trunk stabilization training without any biofeedback. The primary outcome of this study was the thickness of the trunk muscles. The secondary outcomes included static sitting balance ability and dynamic sitting balance ability. The thickness of the trunk muscles, static sitting balance ability, and dynamic sitting balance ability were significantly improved in the experimental group compared to the control group (). The present study showed that trunk stabilization training using a PBS had a positive effect on the contracted ratio of trunk muscles and balance ability. By providing audiovisual feedback, the PBS enables accurate and effective training of the trunk muscles, and it is an effective method for trunk stabilization. Sangwoo Jung, Kyeongjin Lee, Myungjoon Kim, and Changho Song Copyright © 2017 Sangwoo Jung et al. All rights reserved. Improving Upper Extremity Function and Quality of Life with a Tongue Driven Exoskeleton: A Pilot Study Quantifying Stroke Rehabilitation Mon, 18 Dec 2017 09:34:17 +0000 Stroke is a leading cause of long-term disability around the world. Many survivors experience upper extremity (UE) impairment with few rehabilitation opportunities, secondary to a lack of voluntary muscle control. We developed a novel rehabilitation paradigm (TDS-HM) that uses a Tongue Drive System (TDS) to control a UE robotic device (Hand Mentor: HM) while engaging with an interactive user interface. In this study, six stroke survivors with moderate to severe UE impairment completed 15 two-hour sessions of TDS-HM training over five weeks. Participants were instructed to move their paretic arm, with synchronized tongue commands to track a target waveform while using visual feedback to make accurate movements. Following TDS-HM training, significant improvements in tracking performance translated into improvements in the UE portion of the Fugl-Meyer Motor Assessment, range of motion, and all subscores for the Stroke Impact Scale. Regression modeling found daily training time to be a significant predictor of decreases in tracking error, indicating the presence of a potential dose-response relationship. The results of this pilot study indicate that the TDS-HM system can elicit significant improvements in moderate to severely impaired stroke survivors. This pilot study gives preliminary insight into the volume of treatment time required to improve outcomes. Stephen N. Housley, David Wu, Kimberly Richards, Samir Belagaje, Maysam Ghovanloo, and Andrew J. Butler Copyright © 2017 Stephen N. Housley et al. All rights reserved. A Systematic Review of the Causes and Management of Ischaemic Stroke Caused by Nontissue Emboli Mon, 16 Oct 2017 00:00:00 +0000 Introduction. The inadvertent or purposeful introduction of foreign bodies or substances can lead to cerebral infarction if they embolize to the brain. Individual reports of these events are uncommon but may increase with the increased occurrences of their risk factors, for example, intra-arterial procedures. Method. We searched EMBASE and MEDLINE for articles on embolic stroke of nontissue origin. 1889 articles were identified and screened and 216 articles were ultimately reviewed in full text and included in qualitative analysis. Articles deemed relevant were assessed by a second reviewer to confirm compatibility with the inclusion criteria. References of included articles were reviewed for relevant publications. We categorized the pathology of the emboli into the following groups: air embolism (141 reports), other arterial gas embolisms (49 reports), missiles and foreign bodies (16 reports), and others, including drug embolism, cotton wool, and vascular sclerosant agents. Conclusion. Air and gaseous embolism are becoming more common with increased use of interventional medical procedures and increased popularity of sports such as diving. There is increasing evidence for the use of hyperbaric oxygen for such events. Causes of solid emboli are diverse. More commonly reported causes include bullets, missiles, and substances used in medical procedures. Ciaran Judge, Sarah Mello, David Bradley, and Joseph Harbison Copyright © 2017 Ciaran Judge et al. All rights reserved. Impact of Spasticity on Balance Control during Quiet Standing in Persons after Stroke Thu, 14 Sep 2017 00:00:00 +0000 Background. Balance impairments, falls, and spasticity are common after stroke, but the effect of spasticity on balance control after stroke is not well understood. Methods. In this cross-sectional study, twenty-seven participants with stroke were divided into two groups, based on ankle plantar flexor spasticity level. Fifteen individuals with high spasticity (Modified Ashworth Scale (MAS) score of ≥2) and 12 individuals with low spasticity (MAS score <2) completed quiet standing trials with eyes open and closed conditions. Balance control measures included centre of pressure (COP) root mean square (RMS), COP velocity, and COP mean power frequency (MPF) in anterior-posterior and mediolateral (ML) directions. Trunk sway was estimated using a wearable inertial measurement unit to measure trunk angle, trunk velocity, and trunk velocity frequency amplitude in pitch and roll directions. Results. The high spasticity group demonstrated greater ML COP velocity, trunk roll velocity, trunk roll velocity frequency amplitude at 3.7 Hz, and trunk roll velocity frequency amplitude at 4.9 Hz, particularly in the eyes closed condition (spasticity by vision interaction). ML COP MPF was greater in the high spasticity group. Conclusion. Individuals with high spasticity after stroke demonstrated greater impairment of balance control in the frontal plane, which was exacerbated when vision was removed. Reza Rahimzadeh Khiabani, George Mochizuki, Farooq Ismail, Chris Boulias, Chetan P. Phadke, and William H. Gage Copyright © 2017 Reza Rahimzadeh Khiabani et al. All rights reserved. Serum Uric Acid Is Associated with Poor Outcome in Black Africans in the Acute Phase of Stroke Sun, 10 Sep 2017 09:45:00 +0000 Background. Prognostic significance of serum uric acid (SUA) in acute stroke still remains controversial. Objectives. To determine the prevalence of hyperuricemia and its association with outcome of stroke patients in the Douala General Hospital (DGH). Methods. This was a hospital based prospective cohort study which included acute stroke patients with baseline SUA levels and 3-month poststroke follow-up data. Associations between high SUA levels and stroke outcomes were analyzed using multiple logistic regression and survival analysis (Cox regression and Kaplan-Meier). Results. A total of 701 acute stroke patients were included and the prevalence of hyperuricemia was 46.6% with a mean SUA level of 68.625 ± 24 mg/l. Elevated SUA after stroke was associated with death (OR = 2.067; 95% CI: 1.449–2.950; p < 0.001) but did not predict this issue. However, an independent association between increasing SUA concentration and mortality was noted in a Cox proportional hazards regression model (adjusted HR = 1.740; 95% CI: 1.305–2.320; p < 0.001). Furthermore, hyperuricemia was an independent predictor of poor functional outcome within 3 months after stroke (OR = 2.482; 95% CI: 1.399–4.404; p = 0.002). Conclusion. The prevalence of hyperuricemia in black African stroke patients is quite high and still remains a predictor of poor outcome. Yacouba N. Mapoure, Chia Mark Ayeah, M. S. Doualla, H. Ba, Hugo B. Mbatchou Ngahane, Salomon Mbahe, and Henry N. Luma Copyright © 2017 Yacouba N. Mapoure et al. All rights reserved. The Severity of Intracranial Hemorrhages Measured by Free Hemoglobin in the Brain Depends on the Anticoagulant Class: Experimental Data Thu, 20 Jul 2017 09:11:49 +0000 Background and Purpose. Anticoagulant therapy is broadly used to prevent thromboembolic events. Intracranial hemorrhages are serious complications of anticoagulation, especially with warfarin. Direct oral anticoagulants reduce but do not eliminate the risk of intracranial hemorrhages. The aim of this study is to determine the degree of intracranial hemorrhage after application of anticoagulants without additional triggers. Methods. Rats were treated with different anticoagulant classes (vitamin K antagonists, heparin, direct thrombin inhibitor, and factor Xa inhibitor). Brain hemorrhages were assessed by the free hemoglobin concentration in the brain parenchyma. Results. Vitamin K antagonists (warfarin and brodifacoum) significantly increased free hemoglobin in the brain. Among direct oral anticoagulants, thrombin inhibitor dabigatran also significantly increased free hemoglobin in the brain, whereas treatment with factor Xa inhibitor rivaroxaban did not have significant effect on the free hemoglobin concentration. Conclusions. Our data indicates that the severity of brain hemorrhages depends on the anticoagulant class and it is more pronounced with vitamin K antagonists. Kyle M. Ware, Douglas L. Feinstein, Israel Rubinstein, Prudhvi Battula, Jose Otero, Lee Hebert, Tzu-Fei Wang, Alexandra Ivanova, Shweta Chaudhary, Jessica Hemminger, and Sergey V. Brodsky Copyright © 2017 Kyle M. Ware et al. All rights reserved. Daily Variation in the Occurrence of Different Subtypes of Stroke Thu, 22 Jun 2017 00:00:00 +0000 Three thousand two hundred and ninety-eight patients admitted to our Stroke Unit with hemorrhagic, large artery atherosclerosis, cardioembolic, small-vessel occlusion, and undetermined etiology-cryptogenic strokes were included in the study. The circadian variability in onset in each stroke subgroup and the associations with various risk factors were analyzed. In each subgroup, a significant minority of patients suffered from stroke during sleep. In the ischemic group, hypercholesterolemia, paroxysmal atrial fibrillation, and previous myocardial infarction facilitated the onset during waking. During waking, stroke onset was significantly higher in the morning compared to the afternoon both in the hemorrhagic and in the ischemic type. In hemorrhagic stroke, a previous stroke was associated with a lower early morning occurrence. In large artery atherosclerosis stroke, males were at higher risk of early morning occurrence . In small-vessel occlusion stroke, hypertension is significantly more present in the morning compared to the afternoon onset . Circadian patterns of stroke onset were observed both in hemorrhagic and in ischemic stroke, irrespective of the ischemic subgroup. In all groups, stroke was more likely to occur during waking than during sleep and, in the diurnal period, during morning than during afternoon. Moreover, sex and some clinical factors influence the diurnal pattern. Luciana Ripamonti, Roberto Riva, Fabiola Maioli, Corrado Zenesini, and Gaetano Procaccianti Copyright © 2017 Luciana Ripamonti et al. All rights reserved. Risk Factors and Etiology of Young Ischemic Stroke Patients in Estonia Sun, 18 Jun 2017 07:06:28 +0000 Objectives. Reports on young patients with ischemic stroke from Eastern Europe have been scarce. This study aimed to assess risk factors and etiology of first-ever and recurrent stroke among young Estonian patients. Methods. We performed a retrospective study of consecutive ischemic stroke patients aged 18–54 years who were treated in our two hospitals from 2003 to 2012. Results. We identified 741 patients with first-ever stroke and 96 patients with recurrent stroke. Among first-time patients, men predominated in all age groups. The prevalence of well-documented risk factors in first-time stroke patients was 83% and in the recurrent group 91%. The most frequent risk factors were hypertension (53%), dyslipidemia (46%), and smoking (35%). Recurrent stroke patients had fewer less well-documented risk factors compared to first-time stroke patients (19.8 versus 30.0%, ). Atrial fibrillation was the most common cause of cardioembolic strokes (48%) and large-artery atherosclerosis (LAA) was the cause in 8% among those aged <35 years. Compared to first-time strokes, recurrent ones were more frequently caused by LAA (14.3 versus 24.0%, ) and less often by other definite etiology (8.5 versus 1.0%, ). Conclusions. The prevalence of vascular risk factors among Estonian young stroke patients is high. Premature atherosclerosis is a cause in a substantial part of very young stroke patients. Siim Schneider, Alina Kornejeva, Riina Vibo, and Janika Kõrv Copyright © 2017 Siim Schneider et al. All rights reserved. To Use or Not to Use Metformin in Cerebral Ischemia: A Review of the Application of Metformin in Stroke Rodents Sun, 28 May 2017 00:00:00 +0000 Ischemic strokes are major causes of death and disability. Searching for potential therapeutic strategies to prevent and treat stroke is necessary, given the increase in overall life expectancy. Epidemiological reports indicate that metformin is an oral antidiabetic medication that can reduce the incidence of ischemic events in patients with diabetes mellitus. Its mechanism of action has not been elucidated, but metformin pleiotropic effects involve actions in addition to glycemic control. AMPK activation has been described as one of the pharmacological mechanisms that explain the action of metformin and that lead to neuroprotective effects. Most experiments done in the cerebral ischemia model, via middle cerebral artery occlusion in rodents (MCAO), had positive results favoring metformin’s neuroprotective role and involve several cellular pathways like oxidative stress, endothelial nitric oxide synthase activation, activation of angiogenesis and neurogenesis, autophagia, and apoptosis. We will review the pharmacological properties of metformin and its possible mechanisms that lead to neuroprotection in cerebral ischemia. Isaac Arbeláez-Quintero and Mauricio Palacios Copyright © 2017 Isaac Arbeláez-Quintero and Mauricio Palacios. All rights reserved. Epidemiology and Management of Atrial Fibrillation and Stroke: Review of Data from Four European Countries Sun, 28 May 2017 00:00:00 +0000 In Europe, 1–3% of the population suffers from atrial fibrillation (AF) and has increased stroke risk. By 2060 a doubling in number of cases and great burden in managing this medical condition are expected. This paper offers an overview of data on epidemiology and management of AF and stroke in four European countries as well as the interconnection between these dimensions. A search index was developed to access multiple scientific and “grey” literatures. Information was prioritised based on strength of evidence and date. Information on country reports was double-checked with national experts. The overall prevalence of AF is consistent across countries. France has the lowest stroke incidence and mortality, followed by Netherland and UK, while Romania has higher rates. GPs or medical specialists are responsible for AF treatment; exception are the special thrombosis services in the Netherlands. Prevention measurements are only present in UK through screening programs. Although international and national guidelines are available, undertreatment is present in all countries. Despite differences in healthcare systems and management of AF, epidemiology is comparable between three of the countries. Romania is an outlier, by being limited in data accessibility. This knowledge can contribute to improved AF care in Europe. Andreea D. Ceornodolea, Roland Bal, and Johan L. Severens Copyright © 2017 Andreea D. Ceornodolea et al. All rights reserved. Remote Assessment of Platelet Function in Patients with Acute Stroke or Transient Ischaemic Attack Wed, 24 May 2017 00:00:00 +0000 Background. The TARDIS trial assessed the safety and efficacy of intensive versus guideline antiplatelet agents given for one month in patients with acute stroke or TIA. The aim of this substudy was to assess the effect of antiplatelet agents taken at baseline on platelet function reactivity and activation. Methods. Platelet function, assessed by remotely measured surface expression of P-selectin, was assessed in patients at their time of randomisation. Data are median fluorescence values. Results. The aspirin P-selectin test demonstrated that platelet expression was lower in 494 patients taking aspirin than in 162 patients not: mean 210 (SD 188) versus 570 (435), difference 360.3 (95% CI 312.2–408.4) (). Aspirin did not suppress P-selectin levels below 500 units in 23 (4.7%) patients. The clopidogrel test showed that platelet reactivity was lower in 97 patients taking clopidogrel than in 585 patients not: 655 (296) versus 969 (315), difference 314.5 (95% CI 247.3–381.7) (). Clopidogrel did not suppress P-selectin level below 860 units in 24 (24.7%) patients. Conclusions. Aspirin and clopidogrel suppress stimulated platelet P-selectin, although one-quarter of patients on clopidogrel have high on-treatment platelet reactivity. Platelet function testing may be performed remotely in the context of a large multicentre trial. Trial registration ISRCTN47823388. Philip M. Bath, Jane May, Katie Flaherty, Lisa J. Woodhouse, Natalia Dovlatova, Sue C. Fox, Timothy J. England, Kailash Krishnan, Thompson G. Robinson, Nikola Sprigg, Stan Heptinstall, and TARDIS Investigators Copyright © 2017 Philip M. Bath et al. All rights reserved. Sequence Analysis of Long-Term Readmissions among High-Impact Users of Cerebrovascular Patients Tue, 16 May 2017 00:00:00 +0000 Objective. Understanding the chronological order of the causes of readmissions may help us assess any repeated chain of events among high-impact users, those with high readmission rate. We aim to perform sequence analysis of administrative data to identify distinct sequences of emergency readmissions among the high-impact users. Methods. A retrospective cohort of all cerebrovascular patients identified through national administrative data and followed for 4 years. Results. Common discriminating subsequences in chronic high-impact users () of ischaemic stroke () were “urological conditions-chest infection,” “chest infection-urological conditions,” “injury-urological conditions,” “chest infection-ambulatory condition,” and “ambulatory condition-chest infection” (). Among TIA patients (), common discriminating () subsequences among chronic high-impact users were “injury-urological conditions,” “urological conditions-chest infection,” “urological conditions-injury,” “ambulatory condition-urological conditions,” and “ambulatory condition-chest infection.” Among the chronic high-impact group of intracranial haemorrhage () common discriminating subsequences () were “dementia-injury,” “chest infection-dementia,” “dementia-dementia-injury,” “dementia-urine infection,” and “injury-urine infection.” Conclusion. Although common causes of readmission are the same in different subgroups, the high-impact users had a higher proportion of patients with distinct common sequences of multiple readmissions as identified by the sequence analysis. Most of these causes are potentially preventable and can be avoided in the community. Ahsan Rao, Alex Bottle, Ara Darzi, and Paul Aylin Copyright © 2017 Ahsan Rao et al. All rights reserved. Association between Embolic Stroke Patterns, ESUS Etiology, and New Diagnosis of Atrial Fibrillation: A Secondary Data Analysis of the Find-AF Trial Thu, 27 Apr 2017 08:45:07 +0000 Background. Atrial fibrillation (AF) is an important cause of embolic stroke of undetermined source (ESUS). Imaging-patterns like multiple infarcts, simultaneous involvement of different circulations, infarcts of different ages, and isolated cortical infarcts are likely to indicate cardioembolic stroke. The aim of our study was to evaluate the association between embolic stroke patterns, ESUS, and the new diagnosis of AF. Methods. Stroke etiology and imaging characteristics from patients included in the Find-AF study were obtained. Embolic stroke patterns in CT- or MR-imaging were correlated with the diagnosis of ESUS as well as the short- (on baseline ECG and during 7-day Holter) and long-term (12-month follow-up) diagnosis of AF. Results. From 281 patients included in the Find-AF study, 127 (45.2%) patients with ischemic lesions detected in CT or MRI were included. 26 (20.5%) of these patients had ESUS. At least one embolic stroke pattern was detected in 67 (52.7%) patients. Embolic stroke patterns were not associated with ESUS (OR 1.57, 0.65–3.79, ), the short-term (OR 0.64, 0.26–1.58, ) or long-term diagnosis of AF (OR 0.72, 0.31–1.68, ). Conclusions. This secondary data analysis of the Find-AF study could not provide evidence for an association between embolic stroke patterns, ESUS, and the new diagnosis of AF. Ilko L. Maier, Katharina Schregel, André Karch, Mark Weber-Krueger, Rafael T. Mikolajczyk, Raoul Stahrenberg, Klaus Gröschel, Mathias Bähr, Michael Knauth, Marios-Nikos Psychogios, Rolf Wachter, and Jan Liman Copyright © 2017 Ilko L. Maier et al. All rights reserved. Revisiting Hemicraniectomy: Late Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Stroke and the Role of Infarct Growth Rate Thu, 16 Mar 2017 00:00:00 +0000 Objective and Methods. The outcome in late decompressive hemicraniectomy in malignant middle cerebral artery stroke and the optimal timings of surgery has not been addressed by the randomized trials and pooled analysis. Retrospective, multicenter, cross-sectional study to measure outcome following DHC under 48 or over 48 hours using the modified Rankin scale [mRS] and dichotomized as favorable ≤4 or unfavorable >4 at three months. Results. In total, 137 patients underwent DHC. Functional outcome analyzed as mRS 0–4 versus mRS 5-6 showed no difference in this split between early and late operated on patients [] and mortality []. Multivariate analysis showed that age ≥ 55 years, MCA with additional infarction, septum pellucidum deviation ≥1 cm, and uncal herniation were independent predictors of poor functional outcome at three months. In the “best” multivariate model, second infarct growth rate [IGR2] >7.5 ml/hr, MCA with additional infarction, and patients with temporal lobe involvement were independently associated with surgery under 48 hours. Both first infarct growth rate [IGR1] and second infarct growth rate [IGR2] were nearly double [] in patients with early surgery [under 48 hours]. Conclusions. The outcome and mortality in malignant middle cerebral artery stroke patients operated on over 48 hours of stroke onset were comparable to those of patients operated on less than 48 hours after stroke onset. Our data identifies IGR, temporal lobe involvement, and middle cerebral artery with additional infarct as independent predictors for early surgery. Saadat Kamran, Naveed Akhtar, Abdul Salam, Ayman Alboudi, Kainat Kamran, Arsalan Ahmed, Rabia A. Khan, Mohsin K. Mirza, Jihad Inshasi, and Ashfaq Shuaib Copyright © 2017 Saadat Kamran et al. All rights reserved. Factors Associated with Poststroke Anxiety: A Systematic Review and Meta-Analysis Wed, 22 Feb 2017 11:13:42 +0000 Background and Purpose. Anxiety affects 25% of stroke survivors. There are no effective treatments. Poststroke depression, prestroke anxiety and depression, locus of control, coping, confidence, fatigue, and sleep are factors that may be associated with poststroke anxiety and can potentially be targeted by therapy. We systematically reviewed the literature and performed a meta-analysis to identify associations with these factors. Methods. We searched electronic databases from January 2014 to July 2015 to complement a literature search performed from inception to May 2014. Study quality was assessed using an internationally endorsed checklist. We used odds ratios (ORs) to estimate the strength of associations and random-effects modelling to calculate summary effect sizes. Results. There were 24 studies recruiting 15448 patients. Quality of reporting was satisfactory. 13 studies with 2408 patients reported associations between poststroke anxiety and poststroke depression (, 95% confidence interval: 2.23, 9.74). One study reported association with prestroke anxiety, three with prestroke depression, one with fatigue, and two with sleep. No studies reported on locus of control, coping, or confidence. Conclusion. Poststroke anxiety was associated with depression but there are limited data on other modifiable associations. Further research is needed to identify potential targets for treatment. Francesca Wright, Simiao Wu, Ho-Yan Yvonne Chun, and Gillian Mead Copyright © 2017 Francesca Wright et al. All rights reserved. Brain Symmetry Index in Healthy and Stroke Patients for Assessment and Prognosis Mon, 30 Jan 2017 00:00:00 +0000 Objective. Quantitative neurophysiological signal parameters are of value in predicting motor recovery after stroke. The novel role of EEG-derived brain symmetry index for motor function prognostication in the subacute phase after stroke is explored. Methods. Ten male stroke patients and ten matched healthy controls were recruited. Motor function was first assessed clinically using the MRC score, its derivative Motricity Index, and the Fugl–Meyer assessment score. EEG was subsequently recorded first with subjects at rest and then during hand grasping motions, triggered by visual cues. Brain symmetry index (BSI) was used to identify the differences in EEG-quantified interhemispheric cortical power asymmetry observable in healthy versus cortical and subcortical stroke patients. Subsequently, any correlation between BSI and motor function was explored. Results. BSI was found to be significantly higher in stroke subjects compared to healthy controls (). The difference in BSI was more pronounced in the cortical stroke subgroup (). BSI showed only a mild general decrease on repeated monthly recording. Notably, a statistically significant correlation was observed between early BSI and Fugl–Meyer score later in recovery (). Conclusions. Brain symmetry index is increased in the subacute poststroke phase and correlates with motor function 1-2 months after stroke. Andrei Agius Anastasi, Owen Falzon, Kenneth Camilleri, Malcolm Vella, and Richard Muscat Copyright © 2017 Andrei Agius Anastasi et al. All rights reserved. Feasibility of a Nurse-Led Weekend Group Exercise Program for People after Stroke Tue, 24 Jan 2017 17:16:51 +0000 Background. Additional physical activity including repetitive task practice can improve outcomes after stroke. The additional practice can be facilitated by therapists and family members or could also be delivered by nursing staff. Objective. To investigate the feasibility of a nurse-led weekend exercise program after stroke. Participants. Individuals after stroke, who participated in a weekend exercise program during their hospital admission. Methods. A retrospective audit of the number of referrals to and amount of exercise repetitions achieved in a nurse-led weekend exercise program was undertaken. The weekend exercise program occurs on each Saturday and Sunday for one hour. The repetitions of exercise completed during each class were documented by staff. An audit was conducted to ascertain the amount and type of exercise completed within the class. Results. During the study period 284 people were referred to the exercise program. The mean number of exercise repetitions completed per participant in each class was 180.7 (SD 205.4). The number of exercise repetitions completed by participants was highly variable ranging from 0 to 1190 per class. Conclusion. The amount of average exercise repetitions completed in the Weekend Warrior program was large but with significant variability. A nurse-led exercise class is a feasible method of delivering exercise opportunities to individuals in hospital after stroke. Katharine Scrivener, Raymond Tourany, Mary McNamara-Holmes, Karl Schurr, Simone Dorsch, and Catherine Dean Copyright © 2017 Katharine Scrivener et al. All rights reserved. Renal Dysfunction Is an Independent Risk Factor for Poor Outcome in Acute Ischemic Stroke Patients Treated with Intravenous Thrombolysis: A New Cutoff Value Tue, 03 Jan 2017 00:00:00 +0000 Objective. This study was set to assess the effect of renal dysfunction on outcome of stroke patients treated with intravenous thrombolysis (IVT). Methods. This multicenter research involved 403 patients from January 2009 to March 2015. Patients were divided into two groups: (1) control group with GFR ≥ 45 mL/min/1.73 m2 and (2) low GFR group with GFR < 45 mL/min/1.73 m2. Outcome measurements were poor outcome (mRS 3–6) and mortality at 3 months and symptomatic intracerebral hemorrhage (SICH) within the first 24–36 hours. Univariate and multivariate regression analyses were performed, and odds ratios (ORs) were determined at 95% confidence intervals (CIs). Results. Univariate analyses determined that every decrease of GFR by 10 mL/min/1.73 m2 significantly increased the risk of poor outcome (OR 1.19, 95% CI 1.09–1.30, ) and mortality (OR 1.18, 95% CI 1.06–1.32, ). In multivariate regression, adjusted for all variables with value < 0.1, low GFR (GFR < 45 versus GFR equal to or more than 45) was associated with poor outcome (OR adjusted 2.15, 95% CI 1.01–4.56, ). Conclusion. In IVT for acute stroke, renal dysfunction with GFR < 45 mL/min/1.73 m2 before treatment determined increased odds for poor outcome compared to GFR of more than 45 mL/min/1.73 m2. Elyar Sadeghi-Hokmabadi, Demet Funda Baş, Mehdi Farhoudi, Aliakbar Taheraghdam, Daryoush Savadi Oskouei, Mohammad Yazdchi, Maziyar Hashemilar, Nevzat Uzuner, Reshad Mirnour, Ertugrul Colak, and Atilla Özcan Özdemir Copyright © 2017 Elyar Sadeghi-Hokmabadi et al. All rights reserved. Thrombin Generation in Acute Ischaemic Stroke Sun, 25 Dec 2016 13:13:20 +0000 Introduction. Stroke remains a global leading cause of death and disability. Traditional description of plasma biology in the aftermath of acute ischaemic stroke favours development of hypercoagulability, resulting from complex interplay between plasma and endothelial factors. However, no single assay measures the overall global coagulation process. We postulate that thrombin generation would assist in identifying coagulation abnormalities after acute stroke. Aim. To investigate the coagulation abnormalities after acute ischaemic stroke using thrombin generation. Methods. We evaluated thrombin generation, measured with calibrated automated thrombography in stroke of different aetiological types () within 48 hours of symptoms onset (baseline) and in the second week (time 2) and in normal healthy volunteers (). Results. Two-point thrombin generation assays showed prolonged lag time and time to peak at baseline (3.3 (2.9, 4.0) versus 3.6 (3.2, 4.7); ) and (3.3 (2.9, 4.0) versus 3.6 (3.2, 4.7); ), respectively, and at time 2 (3.5 (2.9, 4.2) versus 4.0 (3.1, 4.9); ) and (5.9 (5.3, 6.6) versus 6.8 (5.8, 7.7) ), respectively, in cardioembolic stroke (), when compared to noncardioembolic stroke (). The result was reproduced in multiple comparisons between acute ischaemic stroke subgroups and normal healthy volunteers. Endogenous thrombin potential and peak thrombin did not indicate hypercoagulability after acute ischaemic stroke, and thrombolytic therapy did not affect thrombin generation assays. Conclusion. Our findings suggest that thrombin generation in platelet poor plasma is not useful in defining hypercoagulability in acute ischaemic stroke. This is similar to observed trend in coronary artery disease and contrary to other hypercoagulable states. Ibrahim O. Balogun, Lara N. Roberts, Raj Patel, Rohan Pathansali, Lalit Kalra, and Roopen Arya Copyright © 2016 Ibrahim O. Balogun et al. All rights reserved. Therapists’ Perspective on Virtual Reality Training in Patients after Stroke: A Qualitative Study Reporting Focus Group Results from Three Hospitals Mon, 12 Dec 2016 07:06:36 +0000 Background. During the past decade, virtual reality (VR) has become a new component in the treatment of patients after stroke. Therefore aims of the study were (a) to get an insight into experiences and expectations of physiotherapists and occupational therapists in using a VR training system and (b) to investigate relevant facilitators, barriers, and risks for implementing VR training in clinical practice. Methods. Three focus groups were conducted with occupational therapists and physiotherapists, specialised in rehabilitation of patients after stroke. All data were audio-recorded and transcribed verbatim. The study was analysed based on a phenomenological approach using qualitative content analysis. Results. After code refinements, a total number of 1289 codes emerged out of 1626 statements. Intercoder reliability increased from 53% to 91% until the last focus group. The final coding scheme included categories on a four-level hierarchy: first-level categories are (a) therapists and VR, (b) VR device, (c) patients and VR, and (d) future prospects and potential of VR developments. Conclusions. Results indicate that interprofessional collaboration is needed to develop future VR technology and to devise VR implementation strategies in clinical practice. In principal, VR technology devices were seen as supportive for a general health service model. Ludwig Schmid, Andrea Glässel, and Corina Schuster-Amft Copyright © 2016 Ludwig Schmid et al. All rights reserved. Variables That Best Differentiate In-Patient Acute Stroke from Stroke-Mimics with Acute Neurological Deficits Tue, 06 Dec 2016 11:30:50 +0000 Introduction. Strokes and stroke-mimics have been extensively studied in the emergency department setting. Although in-hospital strokes are less studied in comparison to strokes in the emergency department, they are a source of significant direct and indirect costs. Differentiating in-hospital strokes from stroke-mimics is important. Thus, our study aimed to identify variables that can differentiate in-hospital strokes from stroke-mimics. Methods. We present here a retrospective analysis of 93 patients over a one-year period (2009 to 2010), who were evaluated for a concern of in-hospital strokes. Results. About two-thirds (57) of these patients were determined to have a stroke, and the remaining (36) were stroke-mimics. Patients with in-hospital strokes were more likely to be obese (), have been admitted to the cardiology service (), have atrial fibrillation (), have a weak hand or hemiparesis (), and have a prior history of stroke (), whereas, when the consults were called for “altered mental status” but no other deficits (), it is likely a stroke-mimic. Conclusion. This study demonstrates that in-hospital strokes are a common occurrence, and knowing the variables can aid in their timely diagnosis and treatment. P. Natteru, M. R. Mohebbi, P. George, D. Wisco, J. Gebel, and C. R. Newey Copyright © 2016 P. Natteru et al. All rights reserved. Increased Blood Pressure Variability Is Associated with Worse Neurologic Outcome in Acute Anterior Circulation Ischemic Stroke Tue, 15 Nov 2016 06:50:23 +0000 Background. Although research suggests that blood pressure variability (BPV) is detrimental in the weeks to months after acute ischemic stroke, it has not been adequately studied in the acute setting. Methods. We reviewed acute ischemic stroke patients from 2007 to 2014 with anterior circulation stroke. Mean blood pressure and three BPV indices (standard deviation, coefficient of variation, and successive variation) for the intervals 0–24, 0–72, and 0–120 hours after admission were correlated with follow-up modified Rankin Scale (mRS) in ordinal logistic regression models. The correlation between BPV and mRS was further analyzed by terciles of clinically informative stratifications. Results. Two hundred and fifteen patients met inclusion criteria. At all time intervals, increased systolic BPV was associated with higher mRS, but the relationship was not significant for diastolic BPV or mean blood pressure. This association was strongest in patients with proximal stroke parent artery vessel occlusion and lower mean blood pressure. Conclusion. Increased early systolic BPV is associated with worse neurologic outcome after ischemic stroke. This association is strongest in patients with lower mean blood pressure and proximal vessel occlusion, often despite endovascular or thrombolytic therapy. This hypothesis-generating dataset suggests potential benefit for interventions aimed at reducing BPV in this patient population. Adam de Havenon, Alicia Bennett, Gregory J. Stoddard, Gordon Smith, Haimei Wang, Jana Wold, Lee Chung, David L. Tirschwell, and Jennifer J. Majersik Copyright © 2016 Adam de Havenon et al. All rights reserved. Knowledge of Stroke Risk Factors among Stroke Survivors in Nigeria Tue, 01 Nov 2016 13:20:12 +0000 Background. Knowledge of stroke risk factors is expected to reduce the incidence of stroke—whether first-ever or recurrent. This study examined knowledge of stroke risk factors and its determinants among stroke survivors. Methods. A cross-sectional survey of consenting stroke survivors at two physiotherapy facilities in Nigeria was carried out. Sociodemographic and clinical data were obtained and knowledge of stroke risk factors (defined as the ability to mention at least one correct risk factor) was assessed using open-ended questionnaire. Data were treated with descriptive statistics and logistic regression analysis. Results. Sixty-nine stroke survivors (male = 72.5%; mean ± SD age = years) participated in the study. Thirty-four (49.4%) participants had knowledge of stroke risk factors. Only educational level was significantly associated with knowledge and participants with tertiary educational qualification were about 48 times (odds ratio = 48.5; CI = 7.6–309.8; ) more likely to be knowledgeable than those with no education. Conclusion. Less than half of the participants had knowledge of stroke risk factors. Participants with tertiary education were significantly more knowledgeable than those with lower educational qualifications. Effective means of educating stroke survivors on stroke risk factors should be identified and adopted. Grace Vincent-Onabajo and Taritei Moses Copyright © 2016 Grace Vincent-Onabajo and Taritei Moses. All rights reserved. Safety and Efficacy of Acute Clopidogrel Load in Patients with Moderate and Severe Ischemic Strokes Thu, 13 Oct 2016 12:06:23 +0000 Objective. To study the safety and efficacy of a clopidogrel loading dose in patients with moderate and severe acute ischemic strokes. Background. The safety of clopidogrel loading has been extensively investigated in patients with minor strokes and transient ischemic attacks. Methods. Acute ischemic stroke patients presenting consecutively to our center from 07/01/08 to 07/31/13 were screened. Clopidogrel loading was defined as at least 300 mg dose (with or without aspirin) given within 6 hours of admission. We compared outcomes in patients with baseline NIHSS > 3 with and without clopidogrel loading. Results. Inclusion criteria were met for 1011 patients (43.6% females, 69.1% black, median age 63). Patients with clopidogrel loading had lower baseline NIHSS than patients who were not loaded (8 versus 9, ). The two groups had similar risk for hemorrhagic transformation () and symptomatic hemorrhage (). Patients who were loaded had a lower rate of neurological worsening (38.9% versus 48.3%, ) and less in-hospital mortality (4.3% versus 13.4%, ) compared to those who were not loaded. The likelihood of having a poor functional outcome did not differ between the two groups after adjusting for NIHSS on admission (OR = 0.71, 95% CI 0.4633–1.0906, ). Conclusion. Clopidogrel loading dose was not associated with increased risk for hemorrhagic transformation or symptomatic intracranial hemorrhage in our retrospective study and was associated with reduced rates of neuroworsening following moderate and severe stroke. Amir Shaban, Dominique J. Monlezun, Natalia Rincon, Jonathan Tiu, Melisa Valmoria, and Sheryl Martin-Schild Copyright © 2016 Amir Shaban et al. All rights reserved. Occupational Therapy and Physiotherapy in Acute Stroke: Do Rural Patients Receive Less Therapy? Mon, 26 Sep 2016 13:51:28 +0000 Objective. To assess whether acute stroke patients in rural hospitals receive less occupational therapy and physiotherapy than those in metropolitan hospitals. Design. Retrospective case-control study of health data in patients ≤10 days after stroke. Setting. Occupational therapy and physiotherapy services in four rural hospitals and one metropolitan hospital. Participants. Acute stroke patients admitted in one health district. Main Outcome Measures. Frequency and duration of face-to-face and indirect therapy sessions. Results. Rural hospitals admitted 363 patients and metropolitan hospital admitted 378 patients. Mean age was 73 years. Those in rural hospitals received more face-to-face () and indirect () occupational therapy when compared to those in the metropolitan hospital. Face-to-face sessions lasted longer (). Patients admitted to the metropolitan hospital received more face-to-face () and indirect () physiotherapy when compared to those admitted to rural hospitals. Face-to-face sessions were shorter (). Almost all were seen within 24 hours of referral. Conclusions. Acute stroke patients in Australian rural hospital may receive more occupational therapy and less physiotherapy than those in metropolitan hospitals. The dose of therapy was lower than recommended, and the referral process may unnecessarily delay the time from admission to a patient’s first therapy session. Josie Merchant, Gemma Kitsos, Samantha Ashby, Alex Kitsos, and Isobel J. Hubbard Copyright © 2016 Josie Merchant et al. All rights reserved. Systematic Review of Hospital Readmissions in Stroke Patients Wed, 07 Sep 2016 14:39:38 +0000 Background. Previous evidence on factors and causes of readmissions associated with high-impact users of stroke is scanty. The aim of the study was to investigate common causes and pattern of short- and long-term readmissions stroke patients by conducting a systematic review of studies using hospital administrative data. Common risk factors associated with the change of readmission rate were also examined. Methods. The literature search was conducted from 15 February to 15 March 2016 using various databases, such as Medline, Embase, and Web of Science. Results. There were a total of 24 studies (,126,617) included in the review. Only 4 studies assessed causes of readmissions in stroke patients with the follow-up duration from 30 days to 5 years. Common causes of readmissions in majority of the studies were recurrent stroke, infections, and cardiac conditions. Common patient-related risk factors associated with increased readmission rate were age and history of coronary heart disease, heart failure, renal disease, respiratory disease, peripheral arterial disease, and diabetes. Among stroke-related factors, length of stay of index stroke admission was associated with increased readmission rate, followed by bowel incontinence, feeding tube, and urinary catheter. Conclusion. Although risk factors and common causes of readmission were identified, none of the previous studies investigated causes and their sequence of readmissions among high-impact stroke users. Ahsan Rao, Emily Barrow, Sabine Vuik, Ara Darzi, and Paul Aylin Copyright © 2016 Ahsan Rao et al. All rights reserved. Ischemic Strokes: Observations from a Hospital Based Stroke Registry in Bangladesh Mon, 05 Sep 2016 16:22:36 +0000 Background. Stroke is an important morbidity for low and middle income countries like Bangladesh. We established the first stroke registry in Bangladesh. Methods. Data was collected from stroke patients who were admitted in Department of Neurology of BIRDEM with first ever stroke, aged between 30 and 90 years. Patients with intracerebral hemorrhage, subarachnoid and subdural hemorrhage, and posttrauma features were excluded. Results. Data was gathered from 679 stroke patients. Mean age was 60.6 years. Almost 68% of patients were male. Small vessel strokes were the most common accounting for 45.4% of all the patients followed by large vessel getting affected in 32.5% of the cases. Only 16 (2.4%) died during treatment, and 436 (64.2%) patients had their mRS score of 3 to 5. Age greater than 70 years was associated with poor outcome on discharge [OR 1.79 (95% CI: 1.05 to 3.06)] adjusting for gender, duration of hospital stay, HDL, and pneumonia. Age, mRS, systolic blood pressure, urinary tract infection, pneumonia, and stroke severity explained the Barthel score. Conclusion. Mortality was low but most of patient had moderate to severe disability at discharge. Age, mRS, systolic blood pressure, urinary tract infection, pneumonia, and stroke severity influenced the Barthel score. Nirmalendu Bikash Bhowmik, Aamir Abbas, Mohammad Saifuddin, Md. Rashedul Islam, Rumana Habib, Aminur Rahman, Md. Amirul Haque, Zahid Hassan, and Mohammad Wasay Copyright © 2016 Nirmalendu Bikash Bhowmik et al. All rights reserved. The Effects of POWER Training in Young and Older Adults after Stroke Sun, 17 Jul 2016 13:24:44 +0000 Background. Approximately 35,000 strokes occur annually in adults below the age of 40, and there is disappointingly little data describing their responses to rehabilitation. The purpose of this analysis was to determine the effects of Poststroke Optimization of Walking using Explosive Resistance (POWER) training in young (<40 years) and older (>60 years) adults and to describe relationships between training-induced improvements in muscular and locomotor function. Methods. Data was analyzed from 16 individuals with chronic stroke who participated in 24 sessions of POWER training. Outcomes included muscle power generation, self-selected walking speed (SSWS), 6-minute walk test, Fugl-Meyer motor assessment, Berg Balance Scale, and Dynamic Gait Index. Results. There were no significant differences between groups at baseline. Within-group comparisons revealed significant improvements in paretic and nonparetic knee extensor muscle power generation in both groups. Additionally, young participants significantly improved SSWS. Improvements in SSWS were more strongly associated with improvements in power generation on both sides in young versus older participants. Conclusions. Younger adults after stroke seem to preferentially benefit from POWER training, particularly when increasing gait speed is a rehabilitation goal. Future research should aim to further understand age-related differences in response to training to provide optimal treatments for all individuals following stroke. Jennifer L. Hunnicutt, Stacey E. Aaron, Aaron E. Embry, Brian Cence, Patrick Morgan, Mark G. Bowden, and Chris M. Gregory Copyright © 2016 Jennifer L. Hunnicutt et al. All rights reserved.