Stroke Research and Treatment The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . 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. Conductive Education as a Method of Stroke Rehabilitation: A Single Blinded Randomised Controlled Feasibility Study Thu, 23 Jun 2016 11:29:53 +0000 Background. Conductive Education for stroke survivors has shown promise but randomised evidence is unavailable. This study assessed the feasibility of a definitive randomised controlled trial to evaluate efficacy. Methods. Adult stroke survivors were recruited through local community notices. Those completing the baseline assessment were randomised using an online program and group allocation was independent. Intervention group participants received 10 weekly 1.5-hour sessions of Conductive Education at the National Institute of Conductive Education in Birmingham, UK. The control group participants attended two group meetings. The study evaluated the feasibility of recruitment procedures, delivery of the intervention, retention of participants, and appropriateness of outcome measures and data collection methods. Independent assessments included the Barthel Index, the Stroke Impact Scale, the Timed Up and Go test, and the Hospital Anxiety and Depression Scale. Results. Eighty-two patients were enrolled; 77 completed the baseline assessment (46 men, mean age 62.1 yrs.) and were randomised. 70 commenced the intervention () or an equivalent waiting period (). 32/37 completed the 10-week training and 32/33 the waiting period. There were no missing items from completed questionnaires and no adverse events. Discussion. Recruitment, intervention, and assessment methods worked well. Transport issues for intervention and assessment appointments require review. Conclusion. A definitive trial is feasible. This trial is registered with ISRCTN84064492. Judith Bek, Melanie R. Brown, Jagjeet Jutley-Neilson, Nicholas C. C. Russell, Pia A. J. Huber, and Catherine M. Sackley Copyright © 2016 Judith Bek et al. All rights reserved. Influence of Medication on Fatigue Six Months after Stroke Sun, 19 Jun 2016 12:18:08 +0000 Poststroke fatigue (PSF) is frequent and affects patients’ quality of life. Medication use was hypothesized as being responsible for PSF. Our objective was to evaluate potential relationships between 6-month PSF and medication use at discharge and 6 months after an ischemic stroke. This study is part of STROKDEM, an ongoing longitudinal cohort study, whose main aim is to determine predictors of poststroke dementia. Patients were included within 72 hours after an ischemic stroke and followed up with standardized evaluations. Medication use 7 days and 6 months after stroke was rated, and polypharmacy was defined as the number of categories of treatments received by a patient. PSF was evaluated using the Chalder Fatigue Scale. Medical history, vascular risk factors, depression, anxiety, and sleep disturbances were evaluated. One hundred and fifty-three patients were included: 52.9% presented PSF. PSF at 6 months was not predicted by medication use at discharge nor associated with medication use at month 6. We found severity of PSF to be increased in patients with polypharmacy. Our results suggest that PSF is not a side effect of drugs use, which more reflects presence of disturbances frequently observed after stroke such as depression, anxiety, or sleep disturbances. Clinical study is registered on (NCT01330160). Amélie Ponchel, Julien Labreuche, Stéphanie Bombois, Christine Delmaire, Régis Bordet, and Hilde Hénon Copyright © 2016 Amélie Ponchel et al. All rights reserved. Promoting Optimal Physical Exercise for Life: An Exercise and Self-Management Program to Encourage Participation in Physical Activity after Discharge from Stroke Rehabilitation—A Feasibility Study Mon, 30 May 2016 12:51:45 +0000 People with stroke do not achieve adequate levels of physical exercise following discharge from rehabilitation. We developed a group exercise and self-management program (PROPEL), delivered during stroke rehabilitation, to promote uptake of physical activity after discharge. This study aimed to establish the feasibility of a larger study to evaluate the effect of this program on participation in self-directed physical activity. Participants with subacute stroke were recruited at discharge from one of three rehabilitation hospitals; one hospital offered the PROPEL program whereas the other two did not (comparison group; COMP). A high proportion (11/16) of eligible PROPEL program participants consented to the study. Fifteen COMP participants were also recruited. Compliance with wearing an accelerometer for 6 weeks continuously and completing physical activity questionnaires was high (>80%), whereas only 34% of daily heart rate data were available. Individuals who completed the PROPEL program seemed to have higher outcome expectations for exercise, fewer barriers to physical activity, and higher participation in physical activity than COMP participants (Hedge’s ). The PROPEL program delivered during stroke rehabilitation shows promise for reducing barriers to exercise and increasing participation in physical activity after discharge. This study supports feasibility of a larger randomized trial to evaluate this program. Avril Mansfield, Svetlana Knorr, Vivien Poon, Elizabeth L. Inness, Laura Middleton, Louis Biasin, Karen Brunton, Jo-Anne Howe, and Dina Brooks Copyright © 2016 Avril Mansfield et al. All rights reserved. The R18 Polyarginine Peptide Is More Effective Than the TAT-NR2B9c (NA-1) Peptide When Administered 60 Minutes after Permanent Middle Cerebral Artery Occlusion in the Rat Tue, 10 May 2016 16:18:13 +0000 We examined the dose responsiveness of polyarginine R18 (100, 300, and 1000 nmol/kg) when administered 60 minutes after permanent middle cerebral artery occlusion (MCAO). The TAT-NR2B9c peptide, which is known to be neuroprotective in rodent and nonhuman primate stroke models, served as a positive control. At 24 hours after MCAO, there was reduced total infarct volume in R18 treated animals at all doses, but this reduction only reached statistical significance at doses of 100 and 1000 nmol/kg. The TAT-NR2B9c peptide reduced infarct volume at doses of 300 and 1000 nmol/kg, but not to a statistically significant extent, while the 100 nmol/kg dose was ineffective. The reduction in infarct volume with R18 and TAT-NR2B9c peptide treatments was mirrored by improvements in one or more functional outcomes (namely, neurological score, adhesive tape removal, and rota-rod), but not to a statistically significant extent. These findings further confirm the neuroprotective properties of polyarginine peptides and for R18 extend its therapeutic time window and dose range, as well as demonstrating its greater efficacy compared to TAT-NR2B9c in a severe stroke model. The superior neuroprotective efficacy of R18 over TAT-NR2B9c highlights the potential of this polyarginine peptide as a lead candidate for studies in human stroke. D. Milani, N. W. Knuckey, R. S. Anderton, J. L. Cross, and B. P. Meloni Copyright © 2016 D. Milani et al. All rights reserved. Effect of Treatment Delay, Stroke Type, and Thrombolysis on the Effect of Glyceryl Trinitrate, a Nitric Oxide Donor, on Outcome after Acute Stroke: A Systematic Review and Meta-Analysis of Individual Patient from Randomised Trials Sun, 17 Apr 2016 06:41:23 +0000 Background. Nitric oxide (NO) donors are a candidate treatment for acute stroke and two trials have suggested that they might improve outcome if administered within 4–6 hours of stroke onset. We assessed the safety and efficacy of NO donors using individual patient data (IPD) from completed trials. Methods. Randomised controlled trials of NO donors in patients with acute or subacute stroke were identified and IPD sought from the trialists. The effect of NO donor versus control on functional outcome was assessed using the modified Rankin scale (mRS) and death, by time to randomisation. Secondary outcomes included measures of disability, mood, and quality of life. Results. Five trials (4,197 participants) were identified, all involving glyceryl trinitrate (GTN). Compared with control, GTN lowered blood pressure by 7.4/3.3 mmHg. At day 90, GTN did not alter any clinical measures. However, in 312 patients randomised within 6 hours of stroke onset, GTN was associated with beneficial shifts in the mRS (odds ratio (OR) 0.52, 95% confidence interval (CI) 0.34–0.78) and reduced death (OR 0.32, 95% CI 0.14–0.78). Conclusions. NO donors do not alter outcome in patients with recent stroke. However, when administered within 6 hours, NO donors might improve outcomes in both ischaemic and haemorrhagic stroke. Philip M. Bath, Lisa Woodhouse, Kailash Krishnan, Craig Anderson, Eivind Berge, Gary A. Ford, Thompson G. Robinson, Jeffrey L. Saver, Nikola Sprigg, Joanna M. Wardlaw, and Blood pressure in Acute Stroke Collaboration (BASC) Copyright © 2016 Philip M. Bath et al. All rights reserved. Analysis of the Modified Rankin Scale in Randomised Controlled Trials of Acute Ischaemic Stroke: A Systematic Review Sun, 20 Mar 2016 11:38:23 +0000 Background. Historically, most acute stroke clinical trials were neutral statistically, with trials typically dichotomising ordinal scales, such as the modified Rankin Scale. Studies published before 2007 have shown that preserving the ordinal nature of these scales increased statistical power. A systematic review of trials published since 2007 was conducted to reevaluate statistical methods used and to assess whether practice has changed. Methods. A search of electronic databases identified RCTs published between January 2007 and July 2014 in acute ischaemic stroke using an ordinal dependency scale as the primary outcome. Findings. Forty-two RCTs were identified. The majority used a dichotomous analysis (25, 59.5%), eight (21.4%) retained the ordinal scale, and nine (19.0%) used another type of analysis. Conclusions. Trials published since 2007 still favoured dichotomous analyses over ordinal. Stroke trials, where appropriate, should consider retaining the ordinal nature of dependency scales. Aimie Nunn, Philip M. Bath, and Laura J. Gray Copyright © 2016 Aimie Nunn et al. All rights reserved. Retracted: Results of Surgical and Nonsurgical Treatment of Aneurysms in a Developing Country Mon, 01 Feb 2016 14:23:30 +0000 Stroke Research and Treatment Copyright © 2016 Stroke Research and Treatment. All rights reserved. The Effect of Electromagnetic Field Treatment on Recovery from Ischemic Stroke in a Rat Stroke Model: Clinical, Imaging, and Pathological Findings Mon, 01 Feb 2016 14:02:48 +0000 Stroke is a leading cause of death and disability. Effects of stroke include significant deficits in sensory-motor skills and cognitive abilities. At present, there are limited effective interventions for postacute stroke patients. In this preliminary research we studied a new noninvasive, very low intensity, low frequency, electromagnetic field treatment (VLIFE), targeting a neural network, on an in vivo stroke rat model. Eighteen rats were divided into three groups: sham (M1) and two treatment groups which were exposed to VLIFE treatment for 4 weeks, one using theta waves (M2) and another using beta waves (M3); all groups were followed up for an additional month. Results indicate that the M2 and M3 treated groups showed recovery of sensorimotor functional deficits, as demonstrated by Modified Neurological Severity Score and forelimb placement tests. Brain MRI imaging results show a decrease in perilesional edema and lateral ventricle widening in the treated groups. Fiber tracts’ imaging, following VLIFE treatment, showed a higher white matter integrity compared to control. Histological findings support neural regeneration processes. Our data suggest that VLIFE treatment, targeting a specific functional neural network by frequency rather than location, promotes neuronal plasticity after stroke and, as a result, improves clinical recovery. Further studies will investigate the full potential of the treatment. Y. Segal, L. Segal, T. Blumenfeld-Katzir, E. Sasson, V. Poliansky, E. Loeb, A. Levy, A. Alter, and N. Bregman Copyright © 2016 Y. Segal et al. All rights reserved. Pharyngeal Electrical Stimulation for Treatment of Poststroke Dysphagia: Individual Patient Data Meta-Analysis of Randomised Controlled Trials Tue, 24 Nov 2015 14:18:34 +0000 Background. Dysphagia after stroke is common, associated independently with poor outcome, and has limited treatment options. Pharyngeal electrical stimulation (PES) is a novel treatment being evaluated for treatment of poststroke dysphagia. Methods. We searched electronically for randomised controlled trials of PES in dysphagic patients within 3 months of stroke. Individual patient data were analysed using regression, adjusted for trial, age, severity, and baseline score. The coprimary outcomes were radiological aspiration (penetration aspiration score, PAS) and clinical dysphagia (dysphagia severity rating scale, DSRS) at 2 weeks; secondary outcomes included functional outcome, death, and length of stay in hospital. Results. Three completed trials were identified: 73 patients, age 72 (12) years, severity (NIHSS) 11 (6), DSRS 6.7 (4.3), mean PAS 4.3 (1.8). Compared with no/sham stimulation, PES was associated with lower PAS, 3.4 (1.7) versus 4.1 (1.7), mean difference −0.9 (), and lower DSRS, 3.5 (3.8) versus 4.9 (4.4), mean difference −1.7 (). Length of stay in hospital tended to be shorter: 50.2 (25.3) versus 71.2 (60.4) days (). Functional outcome and death did not differ between treatment groups. Conclusions. PES was associated with less radiological aspiration and clinical dysphagia and possibly reduced length of stay in hospital across three small trials. Polly Scutt, Han S. Lee, Shaheen Hamdy, and Philip M. Bath Copyright © 2015 Polly Scutt et al. All rights reserved. Improvement in Paretic Arm Reach-to-Grasp following Low Frequency Repetitive Transcranial Magnetic Stimulation Depends on Object Size: A Pilot Study Tue, 17 Nov 2015 14:35:19 +0000 Introduction. Low frequency repetitive transcranial magnetic stimulation (LF-rTMS) delivered to the nonlesioned hemisphere has been shown to improve limited function of the paretic upper extremity (UE) following stroke. The outcome measures have largely included clinical assessments with little investigation on changes in kinematics and coordination. To date, there is no study investigating how the effects of LF-rTMS are modulated by the sizes of an object to be grasped. Objective. To investigate the effect of LF-rTMS on kinematics and coordination of the paretic hand reach-to-grasp (RTG) for two object sizes in chronic stroke. Methods. Nine participants received two TMS conditions: real rTMS and sham rTMS conditions. Before and after the rTMS conditions, cortico-motor excitability (CE) of the nonlesioned hemisphere, RTG kinematics, and coordination was evaluated. Object sizes were 1.2 and 7.2 cm in diameter. Results. Compared to sham rTMS, real rTMS significantly reduced CE of the non-lesioned M1. While rTMS had no effect on RTG action for the larger object, real rTMS significantly improved movement time, aperture opening, and RTG coordination for the smaller object. Conclusions. LF-rTMS improves RTG action for only the smaller object in chronic stroke. The findings suggest a dissociation between effects of rTMS on M1 and task difficulty for this complex skill. Jarugool Tretriluxana, Shailesh Kantak, Suradej Tretriluxana, Allan D. Wu, and Beth E. Fisher Copyright © 2015 Jarugool Tretriluxana et al. All rights reserved. The Effect of Telemedicine on Access to Acute Stroke Care in Texas: The Story of Age Inequalities Mon, 12 Oct 2015 06:24:48 +0000 Background. Ischemic stroke is a time sensitive disease with the effectiveness of treatment decreasing over time. Treatment is more likely to occur at Primary Stroke Centers (PSC); thus rapid access to acute stroke care through stand-alone PSCs or telemedicine (TM) is vital for all Americans. The objective of this study is to determine if disparities exist in access to PSCs or the extended access to acute stroke care provided by TM. Methods. Data from the US Census Bureau and the 2010 Neilson Claritas Demographic Estimation Program, American Hospital Association annual survey, and The Joint Commission list of PSCs and survey response data for all hospitals in the state of Texas were used. Results. Over 64% of block groups had 60-minute ground access to acute stroke care. The odds of a block group having 60-minute access to acute stroke care decreased with age, despite adjustment for sex, race, ethnicity, socioeconomic status, urbanization, and total population. Conclusion. Our survey of Texas hospitals found that as the median age of a block group increased, the odds of having access to acute stroke care decreased. Karen C. Albright, Amelia K. Boehme, Michael T. Mullen, Tzu-Ching Wu, Charles C. Branas, James C. Grotta, Sean I. Savitz, Catherine Wolff, Bisakha Sen, and Brendan G. Carr Copyright © 2015 Karen C. Albright et al. All rights reserved. Copeptin: Limited Usefulness in Early Stroke Differentiation? Mon, 08 Jun 2015 13:36:20 +0000 Background. Stroke can be a challenging diagnosis in an emergency-setting. We sought to determine whether copeptin may be a useful biomarker to differentiate between ischemic stroke (IS), transient ischemic attack (TIA), and stroke-mimics. Methods. In patients with suspected stroke arriving within 4.5 hours of symptom-onset, copeptin-levels were measured in initial blood-samples. The final diagnosis was adjudicated by vascular neurologists blinded to copeptin-values. Results. Of all 36 patients with available copeptin-values (median age 71 years, IQR: 54–76; 44% female), 20 patients (56%) were diagnosed with IS, no patient was diagnosed with hemorrhagic stroke, nine patients (25%) were diagnosed with TIA, and seven patients (19%) were stroke-mimics. Copeptin-levels (in pmol/L) tended to be higher in patients with IS [19.1 (11.2–48.5)] compared to TIA [9.4 (5.4–13.8)]. In stroke-mimics the range of values was extremely broad [33.3 (7.57–255.7)]. The diagnostic accuracy of copeptin for IS was 63% with a sensitivity of 80% and a positive predictive value of 64%. Conclusion. In this cohort of patients copeptin-levels within 4.5 hours of symptom onset were higher in patients with IS compared to TIA but the broad range of values in stroke-mimics limits diagnostic accuracy. This trial is registered with UTN: U1111-1119-7602. Johannes von Recum, Julia Searle, Anna Slagman, Jörn Ole Vollert, Matthias Endres, Martin Möckel, and Martin Ebinger Copyright © 2015 Johannes von Recum et al. All rights reserved. Factors Associated with Poststroke Fatigue: A Systematic Review Mon, 25 May 2015 09:38:41 +0000 Background. Poststroke fatigue (PSF) is a frequent, disabling symptom that lacks a consensual definition and a standardized evaluation method. The (multiple) causes of PSF have not been formally characterized. Objective. To identify factors associated with PSF. Method. A systematic review of articles referenced in MEDLINE. Only original studies having measured PSF and potentially associated factors were included. Data was extracted from articles using predefined data fields. Results. Although PSF tends to be more frequent in female patients and older patients, sociodemographic factors do not appear to have a major impact. There are strong associations between PSF and emotional disturbances (such as depression and anxiety). PSF may also be linked to attentional disturbances (mainly slowing in processing speed). The literature data have failed to demonstrate a clear impact of the type and severity of stroke. It has been suggested that PSF results from alterations in the frontothalamostriatal system and/or inflammatory processes. Pain, sleep disorders, and prestroke fatigue also appeared to be associated with PSF. Implications. A better understanding of PSF may improve stroke patient care and facilitate the development of effective treatments. Amélie Ponchel, Stéphanie Bombois, Régis Bordet, and Hilde Hénon Copyright © 2015 Amélie Ponchel et al. All rights reserved. Medical Acute Complications of Intracerebral Hemorrhage in Young Adults Mon, 02 Feb 2015 06:34:31 +0000 Background. Frequency and impact of medical complications on short-term mortality in young patients with intracerebral hemorrhage (ICH) have gone unstudied. Methods. We reviewed data of all first-ever nontraumatic ICH patients between 16 and 49 years of age treated in our hospital between January 2000 and March 2010 to identify medical complications suffered. Logistic regression adjusted for known ICH prognosticators was used to identify medical complications associated with mortality. Results. Among the 325 eligible patients (59% males, median age 42 [interquartile range 34–47] years), infections were discovered in 90 (28%), venous thrombotic events in 13 (4%), cardiac complications in 4 (1%), renal failure in 59 (18%), hypoglycemia in 15 (5%), hyperglycemia in 165 (51%), hyponatremia in 146 (45%), hypernatremia in 91 (28%), hypopotassemia in 104 (32%), and hyperpotassemia in 27 (8%). Adjusted for known ICH prognosticators and diabetes, the only independent complication associated with 3-month mortality was hyperglycemia (plasma glucose >8.0 mmol/L) (odds ratio: 5.90, 95% confidence interval: 2.25–15.48, ). Three or more separate complications suffered also associated with increased mortality (7.76, 1.42–42.49, ). Conclusions. Hyperglycemia is a frequent complication of ICH in young adults and is independently associated with increased mortality. However, multiple separate complications increase mortality even further. Riku-Jaakko Koivunen, Elena Haapaniemi, Jarno Satopää, Mika Niemelä, Turgut Tatlisumak, and Jukka Putaala Copyright © 2015 Riku-Jaakko Koivunen et al. All rights reserved. Protocol Variations and Six-Minute Walk Test Performance in Stroke Survivors: A Systematic Review with Meta-Analysis Tue, 20 Jan 2015 13:44:16 +0000 Objective. To investigate the use of the six-minute walk test (6MWT) for stroke survivors, including adherence to 6MWT protocol guidelines and distances achieved. Methods. A systematic search was conducted from inception to March 2014. Included studies reported a baseline (intervention studies) or first instance (observational studies) measure for the 6MWT performed by stroke survivors regardless of time after stroke.  Results. Of 127 studies (participants n = 6,012) that met the inclusion criteria, 64 were also suitable for meta-analysis. Only 25 studies made reference to the American Thoracic Society (ATS) standards for the 6MWT, and 28 reported using the protocol standard 30 m walkway. Thirty-nine studies modified the protocol walkway, while 60 studies did not specify the walkway used. On average, stroke survivors walked 284 ± 107 m during the 6MWT, which is substantially less than healthy age-matched individuals. The meta-analysis identified that changes to the ATS protocol walkway are associated with reductions in walking distances achieved. Conclusion. The 6MWT is now widely used in stroke studies. The distances achieved by stroke patients indicate substantially compromised walking ability. Variations to the standard 30 m walkway for the 6MWT are common and caution should be used when comparing the values achieved from studies using different walkway lengths. A. Dunn, D. L. Marsden, E. Nugent, P. Van Vliet, N. J. Spratt, J. Attia, and R. Callister Copyright © 2015 A. Dunn et al. All rights reserved. Outcome Determinants of Stroke in a Brazilian Primary Stroke Center Thu, 11 Dec 2014 10:45:41 +0000 Background. Stroke mortality in Brazil is one of the highest among Western countries. Nonetheless, stroke outcome determinants are still poorly known in this country. In this study we evaluate outcome determinants of stroke in a primary stroke center in São Paulo, Brazil. Methods. We evaluated demographic, clinical, and outcome data of patients with ischemic stroke (IS), transient ischemic attack (TIA), and intracerebral hemorrhage (ICH) admitted at “Hospital Paulistano,” São Paulo, Brazil. In-hospital mortality and functional outcome determinants were assessed. Univariate and binary logistic regression analysis were performed. Results. Three hundred forty-one patients were included in the study, 52.2% being male with years. The stroke type distribution was IS: 59.2%, TIA: 29.6%, and ICH: 11.1%. ICH was associated with greater severity and poorer functional outcome. The determinants of poorer functional outcome were higher NIHSS, lower Glasgow score, and lower oxygen saturation level. The most important mortality determinant was the presence of visual symptoms. Conclusions. The stroke mortality and stroke outcome determinants found in the present study do not remarkably differ from studies carried out in developed countries. Stroke prognosis studies are crucial to better understand the high burden of stroke in Brazil. Gustavo W. Kuster, Lívia A. Dutra, Israel P. Brasil, Evelyn P. Pacheco, Márcio A. C. Arruda, Cristiane Volcov, and Renan B. Domingues Copyright © 2014 Gustavo W. Kuster et al. All rights reserved. Elevated Cardiac Troponin in Acute Stroke without Acute Coronary Syndrome Predicts Long-Term Adverse Cardiovascular Outcomes Tue, 04 Nov 2014 08:31:02 +0000 Background. Elevated cardiac troponin in acute stroke in absence of acute coronary syndrome (ACS) has unclear long-term outcomes. Methods. Retrospective analysis of 566 patients admitted to Temple University Hospital from 2008 to 2010 for acute stroke was performed. Patients were included if cardiac troponin I was measured and had no evidence of ACS and an echocardiogram was performed. Of 200 patients who met the criteria, baseline characteristics, electrocardiograms, and major adverse cardiovascular events (MACE) were reviewed. Patients were characterized into two groups with normal and elevated troponins. Primary end point was nonfatal myocardial infarction during follow-up period after discharge. The secondary end points were MACE and death from any cause. Results. For 200 patients, 17 patients had positive troponins. Baseline characteristics were as follows: age , 64% African Americans, 78% with hypertension, and 22% with previous CVA. During mean follow-up of 20.1 months, 7 patients (41.2%) in elevated troponin and 6 (3.3%) patients in normal troponin group had nonfatal myocardial infarction (). MACE (41.2% versus 14.2%, ) and death from any cause (41.2% versus 14.5%, ) were significant in the positive troponin group. Conclusions. Elevated cardiac troponin in patients with acute stroke and no evidence of ACS is strong predictor of long-term cardiac outcomes. Farhan Raza, Mohamad Alkhouli, Paul Sandhu, Reema Bhatt, and Alfred A. Bove Copyright © 2014 Farhan Raza et al. All rights reserved. Impact of Serum Nutritional Status on Physical Function in African American and Caucasian Stroke Survivors Wed, 29 Oct 2014 12:39:04 +0000 Background. The purpose of this study is to compare serum nutritional profiles in chronic stroke survivors to a representative sample of US Adults (NHANESIII) and determine whether these serum markers differed by race and impact physical function in stroke. Methods. Fasting serum samples were collected for analysis of lipids, uric acid, and albumin in 145 African American (AA) and 111 Caucasian (C) stroke survivors (age: 60 ± 1 years [mean ± SEM]). A six-minute walk was performed in a subset of stroke survivors (N = 134). Results. Triglycerides were higher and HDL-cholesterol and albumin lower in C than AA women stroke survivors (Ps < 0.05). Uric acid was lower in C than AA stroke survivors (P < 0.05). Compared to NHANESIII, HDL-cholesterol, albumin, and hemoglobin generally were lower (Ps < 0.05) and lipids were more favorable in stroke (Ps < 0.01). Uric acid was related to six-minute walk performance among a subset of stroke survivors (P < 0.05). Conclusion. In stroke, racial differences exist with regard to serum nutritional risk, but these differences are similar to that observed in the general population. Regardless of race, nutritional risk appears elevated above that of the general population with regard to many of the serum markers. As a modifiable biomarker, uric acid should be monitored closely as it may provide insight into the functional risk of stroke survivors. Monica C. Serra, Charlene E. Hafer-Macko, Frederick M. Ivey, Richard F. Macko, and Alice S. Ryan Copyright © 2014 Monica C. Serra et al. All rights reserved. Poststroke Outcomes Tue, 14 Oct 2014 08:01:43 +0000 Bruce Ovbiagele, Steve Kautz, Wayne Feng, and DeAnna L. Adkins Copyright © 2014 Bruce Ovbiagele et al. All rights reserved. Sex, Diastolic Blood Pressure, and Outcome after Thrombolysis for Ischemic Stroke Mon, 15 Sep 2014 11:38:12 +0000 Background. The goal of this study was to identify differences in risk factors and functional outcome between the two sexes in patients treated with thrombolysis for ischemic stroke. Methods. This cohort study audited data from patients treated with thrombolysis for ischemic stroke during a 3-year period at Södersjukhuset, Stockholm. Results. Of the 355 patients included in the study, 162 (45%) were women and 193 (54%) were men. Women were older with a median age of 76 years; median age for men was 69 years (). Diastolic blood pressure was lower for women compared to men (). At admission fewer women had a favorable modified Rankin Scale score compared to men (93.8% versus 99%, ). Three months after discharge functional status did not differ significantly between the two sexes. Diastolic blood pressure was associated to functional outcome only in men when sex specific odds ratios were calculated (OR, 5.7; 95% CI, 1.7–20). Conclusion. The study indicates that females appear to gain a relatively greater benefit from thrombolytic therapy than men due to a better functional recovery. A higher diastolic blood pressure increases the risk for a worse prospective functional status in men. David Nathanson, Cesare Patrone, Thomas Nyström, and Mia von Euler Copyright © 2014 David Nathanson et al. All rights reserved. The Role of Prestroke Glycemic Control on Severity and Outcome of Acute Ischemic Stroke Mon, 08 Sep 2014 07:26:41 +0000 Background/Aim. Relatively few studies have investigated the association of prestroke glycemic control and clinical outcome in acute ischemic stroke (IS) patients, regardless of presence of diabetes mellitus (DM). The aim of this study was to investigate the importance of prestroke glycemic control on survival, stroke severity, and functional outcome of patients with acute IS. Methods. We performed a retrospective survival analysis of 501 patients with IS admitted to Sahlgrenska University Hospital from February 15, 2005, through May 31, 2009. The outcomes of interest were acute and long-term survival; the stroke severity (NIHSS) and the functional outcome, mRS, at 12 months. Results. HbA1c was a good predictor of acute (HR 1.45; CI, 1.09 to 1.93, ) and long-term mortality (HR 1.29; CI 1.03 to 1.62; ). Furthermore, HbA1c >6% was significantly correlated with acute stroke severity (OR 1.29; CI 1.01 to 1.67; ) and predicted worse functional outcome at 12 months (OR 2.68; CI 1.14 to 6.03; ). Conclusions. Our study suggests that poor glycemic control (baseline HbA1c) prior to IS is an independent risk factor for poor survival and a marker for increased stroke severity and unfavorable long-term functional outcome. Clara Hjalmarsson, Karin Manhem, Lena Bokemark, and Björn Andersson Copyright © 2014 Clara Hjalmarsson et al. All rights reserved. Walking Adaptability after a Stroke and Its Assessment in Clinical Settings Thu, 28 Aug 2014 09:58:48 +0000 Control of walking has been described by a tripartite model consisting of stepping, equilibrium, and adaptability. This review focuses on walking adaptability, which is defined as the ability to modify walking to meet task goals and environmental demands. Walking adaptability is crucial to safe ambulation in the home and community environments and is often severely compromised after a stroke. Yet quantification of walking adaptability after stroke has received relatively little attention in the clinical setting. The objectives of this review were to examine the conceptual challenges for clinical measurement of walking adaptability and summarize the current state of clinical assessment for walking adaptability. We created nine domains of walking adaptability from dimensions of community mobility to address the conceptual challenges in measurement and reviewed performance-based clinical assessments of walking to determine if the assessments measure walking adaptability in these domains. Our literature review suggests the lack of a comprehensive well-tested clinical assessment tool for measuring walking adaptability. Accordingly, recommendations for the development of a comprehensive clinical assessment of walking adaptability after stroke have been presented. Such a clinical assessment will be essential for gauging recovery of walking adaptability with rehabilitation and for motivating novel strategies to enhance recovery of walking adaptability after stroke. Chitralakshmi K. Balasubramanian, David J. Clark, and Emily J. Fox Copyright © 2014 Chitralakshmi K. Balasubramanian et al. All rights reserved. Does Inhibitory Repetitive Transcranial Magnetic Stimulation Augment Functional Task Practice to Improve Arm Recovery in Chronic Stroke? Wed, 13 Aug 2014 12:46:46 +0000 Introduction. Restoration of upper extremity (UE) functional use remains a challenge for individuals following stroke. Repetitive transcranial magnetic stimulation (rTMS) is a noninvasive modality that modulates cortical excitability and is being explored as a means to potentially ameliorate these deficits. The purpose of this study was to evaluate, in the presence of chronic stroke, the effects of low-frequency rTMS to the contralesional hemisphere as an adjuvant to functional task practice (FTP), to improve UE functional ability. Methods. Twenty-two individuals with chronic stroke and subsequent moderate UE deficits were randomized to receive 16 sessions (4 times/week for 4 weeks) of either real-rTMS or sham-rTMS followed by 1-hour of paretic UE FTP. Results. No differences in UE outcomes were revealed between the real-rTMS and sham-rTMS intervention groups. After adjusting for baseline differences, no differences were revealed in contralesional cortical excitability postintervention. In a secondary analysis, data pooled across both groups revealed small, but statistically significant, improvements in UE behavioral measures. Conclusions. rTMS did not augment changes in UE motor ability in this population of individuals with chronic stroke. The chronicity of our participant cohort and their degree of UE motor impairment may have contributed to inability to produce marked effects using rTMS. Dorian K. Rose, Carolynn Patten, Theresa E. McGuirk, Xiaomin Lu, and William J. Triggs Copyright © 2014 Dorian K. Rose et al. All rights reserved.