On the prognosis of outcome after stroke

Unilateral spatial neglect

Unilateral spatial neglect is a complex, but fascinating, deficit in attention that may occur following stroke. The phrase "unilateral spatial neglect" belies the complex mixture of disorders in representational memory, hypokinesia in the opposite hemispace, and inattention to sensory stimuli in the opposite hemispace. Unilateral spatial neglect occurs as a result of damage to the posterior parietal cortex, frontal lobe, cingulate gyrus, striatum, thalamus, or specific brain-stem nuclei. This neural network for attention is an excellent example of how different anatomic areas work together to produce a specific behavior. Traditional treatment strategies for USN have focused on training attention in the left hemispace using a variety of techniques, including sensory awareness, visual scanning, and spatial organization. Recently, additional treatment strategies have emerged that focus on representational aspects of brain functioning. These strategies have included visual and movement imagery,30 manipulation of sensory input that conveys perception of the head in space, and manipulation of visual input using prisms and eye patches. The complex nature of USN provides numerous directions for future research. Continued research will play a pivotal role in devising effective treatment strategies for patients with USN.

Predicting outcomes of patients in Japan after first acute stroke using a simple model

OBJECTIVE

Prediction of patient outcome can be useful as an aid to clinical decision making. Many studies, including my own, have constructed predictive multivariate models for outcome following stroke rehabilitation therapy, but these have often required several minutes work with a pocket calculator. The aim is to develop a simple, easy-to-use model that has strong predictive power.

METHODS

Four hundred sixty-four consecutive patients with first stroke who were admitted to a rehabilitation hospital during a period of 19 mo were enrolled in the study. Sex, age, the stroke type, Functional Independence Measure total score on admission (X), onset to admission interval (number of days from stroke onset to rehabilitation admission), and length of rehabilitation hospital stay (number of days from hospital admission to discharge) were the independent variables. Functional Independence Measure total score at discharge (Y) was the dependent variable.

RESULTS

Stepwise multiple regression analysis resulted in the model containing age (P < 0.0001), X (P < 0.0001), and onset to admission interval (P < 0.0001). The equation was: Y = 68.6 - 0.32 (age) + 0.80X - 0.13 (onset to admission interval), a multiple correlation coefficient (R) = 0.82, and a multiple correlation coefficient squared (R2) = 0.68. Simple regression analysis revealed the relation between Xand Y: Y = 0.85X + 37.36, and R = 0.80 R2 = 0.64. In fact, plots of X vs. Ywere nonlinear, but seemed to be able to be linearized by some form of equation. It was found that there is a linear relation between logX and Y. The equation is Y = 106.88x - 95.35, where x = logX, R = 0.84, and R2 = 0.70. The correlation is improved by a regression analysis of a natural logarithmic transformation of X (R = 0.84 vs. R = 0.82).

CONCLUSION

The results in this study confirm that the simple regression model using a logarithmic transformation of X (R = 0.84) has predictive power over the simple regression model (R = 0.80). This model is well validated and clinically useful.

Predicting models of outcome stratified by age after first stroke rehabilitation in Japan

OBJECTIVE

A multivariate model predicting the function at discharge following inpatient rehabilitation has been previously produced. The aim of this study is to determine predictors of function at discharge for stroke outcome and examine their accuracy of prediction.

DESIGN

Four hundred sixty-four stroke patients were enrolled. Sex, the nature of the stroke, age, onset to rehabilitation admission interval and length of rehabilitation hospital stay were obtained from their medical records. Patients were divided into the following five groups according to age: < or = 49, 50-59, 60-69, 70-79, and > or = 80 yr. Disability was assessed on admission and at discharge by the FIM. Stepwise multiple regression analysis was performed in each group.

RESULTS

The model for patients aged 60-69 yr was best for accuracy of prediction and explained 76% of variation for discharge FIM total score. The equation: (expected discharge FIM total score) = 111.88 + 0.08 x (the type of stroke) - 0.11 x (age) + 0.81 x (admission FIM total score) - 0.12 x (onset to rehabilitation admission interval), R = 0.87, R2 = 0.76, P < 0.0001. The type of stroke = 1 for cerebral infarction and 0 otherwise. Length of rehabilitation stay is not selected as a predictor.

CONCLUSION

The stratification of patients by age is useful to determine predictors of function at discharge for stroke outcome and to improve their accuracy of prediction.

The role of unilateral spatial neglect in rehabilitation of right brain-damaged ischemic stroke patients: a matched comparison

OBJECTIVE

To assess the specific influence of unilateral spatial neglect (USN) on rehabilitation outcome.

DESIGN

A case-control study in consecutive stroke inpatients.

SETTING

Rehabilitation hospital.

PATIENTS

One hundred seventy-eight patients with sequelae of first stroke, enrolled in homogeneous subgroups, matched for age (within 1yr) and onset admission interval (within 3d), and difference because of the presence of USN, evaluated by a specific neuropsychologic battery.

INTERVENTIONS

All patients received physical rehabilitation: physiotherapy for 60 minutes twice a day (once on Saturday), 6 days a week, within 24 hours of admission. USN-positive (USN(+)) patients received specific treatment of 5, 1-hour sessions per week, for 8 consecutive weeks: (1) visual scanning, (2) reading and copying, (3) copying of line drawings on a dot matrix, and (4) describing a scene. Patients were assessed with neurologic (Canadian Neurological Scale), neuropsychiatric (Hamilton Depression Rating Scale), neuroradiologic, and functional (Barthel Index, Rivermead Mobility Index [RMI]) examinations.

MAIN OUTCOME MEASURES

Length of stay, efficiency (average daily increase in Barthel Index), effectiveness (amount of potential improvement achieved during rehabilitation) of treatment and percentage of low- and high-response patients calculated on the Barthel Index and the RMI, and percentage of urinary incontinence and return home were evaluated. Odds ratios (ORs) of dropouts and of low and high therapeutic response were also quantified.

RESULTS

Compared with USN-negative patients, USN(+) patients had significantly more severe baseline neurologic and functional status at admission, less effectiveness and efficiency on activities of daily living (ADLs) and mobility, a higher percentage of low responders, longer hospitalization, a higher percentage of persistent incontinence at discharge (20.5% vs 4.9%), and a lower percentage of high responders and patients returning home. The presence of USN was incompatible with a high therapeutic response, for both ADLs (OR= 2.94, 95% confidence interval [CI]= 1.05-8.20; b +/- standard error = 1.08 +/- .52, p< .05), and mobility (OR = 7.16, 95% CI = 2.78-18.44; b = 1.97 +/- .52, p < .001) and was a relevant prognostic factor for institutional discharge (OR = 5.62, 95% CI = 1.63-19.38; b = 1.73 +/-.63, p < .01, accuracy 88.41%).

CONCLUSIONS

The results of this study provide further strong evidence of the relationship between USN and disability in right brain-damaged patients and of its unfavorable impact on rehabilitation, despite the cognitive training performed by all USN(+) patients.

Comorbidity and rehabilitation

Screening patients admitted to a rehabilitation center has become important. Actually, co-existing diseases are not very often evaluated and their importance is underestimated. At our department 166 consecutive patients were enrolled. The Cumulative Illness Rating Scale (CIRS) appeared to be the most suitable for these cases. In this series, stroke patients presented with higher severity and higher comorbidity than the hip fracture patients. The hip fracture cases were older but the stroke cases had higher severity and comorbidity. Comorbidity, also, showed a significant negative correlation with FIM in the stroke patients. These data show that severe comorbid conditions influence the functional autonomy. Severity and comorbidity were correlated both in the hip fracture and stroke cases. A review of geriatric literature demonstrates lower values in patients in rehabilitation. The difference is due to our accurate selection of patients at admission, where general health conditions are considered. In conclusion, the CIRS should be used as a method for selecting patients at admission and as a prognostic index for improvement at discharge. The CIRS, however, has some inconveniences and amelioration is necessary, such as the inclusion of a double testing (admission-discharge), psychiatric disturbances and a new item for skin alone. The Severity Index was higher in women, who were older than men, whereas, comorbidity was the same. In the patients suffering from hip fracture, the age was higher in women, but dependence, severity and comorbidity did not statistically differ between the groups.