Post-stroke pain on long-term follow-up: the Bergen stroke study

MCC950 as a promising candidate for blocking NLRP3 inflammasome activation: A review of preclinical research and future directions

The NOD-like receptor thermal protein domain associated protein 3 (NLRP3) inflammasome is a key component of the innate immune system that triggers inflammation and pyroptosis and contributes to the development of several diseases. Therefore, blocking the activation of the NLRP3 inflammasome has therapeutic potential for the treatment of these diseases. MCC950, a selective small molecule inhibitor, has emerged as a promising candidate for blocking NLRP3 inflammasome activation. Ongoing research is focused on elucidating the specific targets of MCC950 as well as assessfing its metabolism and safety profile. This review discusses the diseases that have been studied in relation to MCC950, with a focus on stroke, Alzheimer's disease, liver injury, atherosclerosis, diabetes mellitus, and sepsis, using bibliometric analysis. It then summarizes the potential pharmacological targets of MCC950 and discusses its toxicity. Furthermore, it traces the progression from preclinical to clinical research for the treatment of these diseases. Overall, this review provides a solid foundation for the clinical therapeutic potential of MCC950 and offers insights for future research and therapeutic approaches.

"I will try anything" the experience of working age stroke survivors living with chronic post-stroke pain: an interpretative phenomenological analysis

PURPOSE

To investigate the experience of working age adults living with chronic post-stroke pain in the United Kingdom (UK).

METHODS

Semi-structured interviews were conducted with eight working age (46-64 years) UK-based stroke survivors who experience chronic post-stroke pain (≥3 months). The interviews were analysed using interpretative phenomenological analysis.

RESULTS

The analysis led to three Group Experiential Themes: "The Solitude of the Pain Experience," "Unsatisfactory Healthcare and the Need for Self-Care" and "The Development of Pain Acceptance." Findings suggest that individuals see their post-stroke pain as an invisible disability, which is overlooked and misunderstood by others. Furthermore, in the absence of a differential post-stroke pain diagnosis, clear, accurate information and alternatives to pharmacological treatments, individuals with post-stroke pain invest their own resources in finding answers and a way to live with the pain.

CONCLUSIONS

The findings suggest the need for further education on post-stroke pain for healthcare professionals, the consideration of pain in post-stroke assessments, the need for clear differential pain diagnoses and the provision of accurate information to patients. Research is needed to establish non-pharmacological evidence-based treatment approaches, such as pain management programmes, peer support and psychological interventions.

Is there a relationship between somatosensory impairment and the perception of pain in stroke survivors? An exploratory study

Pain and somatosensory impairments are commonly reported following stroke. This study investigated the relationship between somatosensory impairments (touch detection, touch discrimination and proprioceptive discrimination) and the reported presence and perception of any bodily pain in stroke survivors. Stroke survivors with somatosensory impairment ( N  = 45) completed the Weinstein Enhanced Sensory Test (WEST), Tactile Discrimination Test, and Wrist Position Sense Test for quantification of somatosensation in both hands and the McGill Pain Questionnaire, visual analog scale and the Neuropathic Pain Symptom Inventory (NPSI) for reporting presence and perception of pain. No relationship was observed between somatosensory impairment (affected contralesional hand) of touch detection, discriminative touch or proprioceptive discrimination with the presence or perception of pain. However, a weak to moderate negative relationship between touch detection in the affected hand (WEST) and perception of pain intensity (NPSI) was found, suggesting that stroke survivors with milder somatosensory impairment of touch detection, rather than severe loss, are likely to experience higher pain intensity [rho = -0.35; 95% confidence interval (CI), -0.60 to -0.03; P  = 0.03]. Further, a moderate, negative relationship was found specifically with evoked pain (NPSI) and touch detection in the affected hand (rho = -0.43; 95% CI, -0.72 to -0.02; P  = 0.03). In summary, our findings indicate a weak to moderate, albeit still uncertain, association, which prevents making a definitive conclusion. Nevertheless, our findings contribute to our understanding of the complexities surrounding the experience of pain in survivors of stroke and provide direction for future studies.

Cortical-striatal network functional connectivity markers in poststroke fatigue: a single-centre fMRI case-control study protocol

INTRODUCTION

Structural and functional abnormalities in the cortical-striatal network (CSN) are hypothesised to play a key role in the pathogenesis of neurological disease-associated fatigue. Some small-scale functional MRI (fMRI) studies have suggested that poststroke fatigue (PSF) is related to focal functional connectivity (FC) changes. To date, there has been no published large-scale fMRI study on PSF. This planned study will examine the role of the CSN FC on PSF.

METHODS AND ANALYSIS

The planned study will be a prospective cohort study conducted at the Neurology Unit of the Prince of Wales Hospital. We will recruit 738 participants. The project duration will be 36 months. A psychiatrist will administer the Fatigue Severity Scale (FSS) at 3 months (P1) following the index stroke. PSF is defined as an FSS Score≥4.0. PSF severity will be defined by the FSS total score at P1. Participants with PSF at P1 will undergo two follow-up assessments at 9 (P2) and 15 (P3) months post stroke. PSF remission at P2 or P3 will be defined as a 50% reduction in FSS. Participants will undergo MRI examinations within 2 weeks of the 3-month poststroke assessment. Structural MRI, resting-state fMRI and diffusion tensor imaging will be performed. FC, structural connectivity, infarcts, cerebral microbleeds and white matter hyperintensities will be analysed. For the primary analysis, the effect of PSF on the FC, structural connectivity and diffusion metrics of CSN of stroke survivors, voxel-wise two-sample t-tests will be performed with FDR correction for multiple comparison and significance level set at p<0.05.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Joint Chinese University of Hong Kong-New Territories East Cluster clinical research ethics committee. The study findings will be shared through peer-reviewed journal publications, national and international conferences and social media platforms.

Long-term headache after spontaneous intracerebral haemorrhage

BACKGROUND

Though headache is commonly observed after stroke and may affect survivors' quality of life, it has rarely been studied after spontaneous intracerebral haemorrhage (ICH). In a cohort of ICH survivors, we assessed the long-term prevalence and determinants of headache.

METHODS

We screened consecutive ICH survivors enrolled in the prospective, single-centre Prognosis of Intracerebral Haemorrhage study for headache 1, 3, and 6 years after ICH, according to the International Headache Society's criteria. Depressive and anxiety symptoms severity was measured at 1-year follow-up. Variables associated with the presence of headache 1 year after ICH were analyzed using univariate and multivariable models.

RESULTS

Among the 146 patients included in this study, 31 (21%), 25 (19%), and 14 (20%) patients reported headache at 1-, 3-, and 6-year follow-up, respectively. In an age-adjusted model, patients with headache at ICH onset (adjusted odds ratio [aOR] 2.75; 95% CI 1.02-7.42) and previous history of headache (aOR 4.60; 95% CI 1.74-12.1) were associated with headache at 1-year follow-up. Patients with headache were more likely to report depressive and anxiety symptoms at 1-year follow-up (both p < 0.02).

CONCLUSIONS

One in five ICH survivors suffered from headache and patients who reported headache at ICH onset were especially at risk.

Validation of general pain scores from multidomain assessment tools in stroke

Purpose

We describe how well general pain reported in multidomain assessment tools correlated with pain-specific assessment tools; associations between general pain, activities of daily living and independence after stroke.

Materials and methods

Analyses of individual participant data (IPD) from the Virtual International Stroke Trials Archive (VISTA) described correlation coefficients examining (i) direct comparisons of assessments from pain-specific and multidomain assessment tools that included pain, (ii) indirect comparisons of pain assessments with the Barthel Index (BI) and modified Rankin Scale (mRS), and (iii) whether pain identification could be enhanced by accounting for reported usual activities, self-care, mobility and anxiety/depression; factors associated with pain.

Results

European Quality of Life 3- and 5-Level (EQ-5D-3L and EQ-5D-5L), RAND 36 Item Health Survey 1.0 (SF-36) or the 0-10 Numeric Pain Rating Scale (NPRS) were available from 10/94 studies (IPD = 10,002). The 0-10 NPRS was the only available pain-specific assessment tool and was a reference for comparison with other tools. Pearson correlation coefficients between the 0-10 NPRS and (A) the EQ-5D-3L and (B) EQ5D-5 L were r = 0.572 (n = 436) and r = 0.305 (n = 1,134), respectively. mRS was better aligned with pain by EQ-5D-3L (n = 8,966; r = 0.340) than by SF-36 (n = 623; r = 0.318). BI aligned better with pain by SF-36 (n = 623; r = -0.320). Creating a composite score using the EQ-5D 3 L and 5 L comprising pain, mobility, usual-activities, self-care and anxiety/depression did not improve correlation with the 0-10 NPRS.

Discussion

The EQ-5D-3L pain domain aligned better than the EQ-5D-5L with the 0-10 NPRS and may inform general pain description where resources and assessment burden hinder use of additional, pain-specific assessments.

Persistent headache attributed to past ischemic stroke: A prospective cohort study

OBJECTIVE

To assess the incidence, characteristics, and risk factors for developing persistent headache attributed to past ischemic stroke.

BACKGROUND

Although the most recent International Classification of Headache Disorders has recognized the existence of persistent headache attributed to past ischemic stroke, there has been limited research in this area.

METHODS

This was a prospective cohort study. We initially assessed patients hospitalized with ischemic stroke admitted within 72 h of symptom onset. All patients underwent diffusion-weighted magnetic resonance imaging. These patients were re-interviewed by telephone 1 year after the stroke. Semi-structured questionnaires, the National Institutes of Health Stroke Scale (NIHSS), and six-item Headache Impact Test were used.

RESULTS

A total of 119 participants answered the interview conducted 1 year after the stroke. The mean (standard deviation) age was 64 (13.1) years, 82/119 (68.9%) were female, and the median (interquartile range) NIHSS score was 2 (1.0-4.0). The incidence rate of persistent headache attributed to past ischemic stroke was 12/119 (10.1%; 95% confidence interval [CI] 5.3-17.0%). The most frequent pattern presented was a migraine-like pattern in seven of the 12 (58.3%) patients, which had a substantial/severe impact on five of the 12 (41.7%). For most patients this headache continued, although it began to improve. Previous migraine (odds ratio 7.1, 95% CI 1.06-50.0; p = 0.043) and headache intensity in the acute phase of stroke (odds ratio 1.75, 95% CI 1.13-2.7; p = 0.012) were associated with the occurrence of persistent headache attributed to past ischemic stroke.

CONCLUSION

Persistent headache attributed to past ischemic stroke is a frequent complication after stroke. It often has a significant impact on patients' lives and presents a migraine-like pattern as its most frequent phenotype.

Post-stroke fatigue: a review of development, prevalence, predisposing factors, measurements, and treatments

Background

Post-stroke fatigue (PSF) is a ubiquitous and overwhelming symptom for most stroke survivors. However, there are no effective management strategies for PSF, which is partly due to our limited understanding.

Objective

In this paper, we review the development, prevalence, predisposing factors, measurements, and treatments of PSF.

Results

PSF is an independent symptom after stroke, with a prevalence ranging from 42 to 53%, which depends on the selection of measurement tools and stroke characteristics. It is affected by biological, physical, and psychological factors, among which inflammation may play a key role.

Conclusion

Numerous but non-specific evaluation measurement tools limit the management of PSF. In clinical practice, it may be beneficial to identify PSF by combining scales and objective indexes, such as walking tests and electromyographic examinations. There are no evidence-based interventions to improve PSF. However, increasing evidence suggests that transcranial direct-current stimulation and mindfulness-based interventions may become promising treatments. Further studies are urgently needed to better understand the etiology of PSF, thereby providing the basis for developing new measurement tools and targeted treatments.

Stellate ganglion block ameliorated central post-stroke pain with comorbid anxiety and depression through inhibiting HIF-1α/NLRP3 signaling following thalamic hemorrhagic stroke

BACKGROUND

Central post-stroke pain (CPSP) is an intractable and disabling central neuropathic pain that severely affects patients' lives, well-being, and socialization abilities. However, CPSP has been poorly studied mechanistically and its treatment remains challenging. Here, we used a rat model of CPSP induced by thalamic hemorrhage to investigate its underlying mechanisms and the effect of stellate ganglion block (SGB) on CPSP and emotional comorbidities.

METHODS

Thalamic hemorrhage was produced by injecting collagenase IV into the ventral-posterolateral nucleus (VPL) of the right thalamus. The up-and-down method with von Frey hairs was used to measure the mechanical allodynia. Behavioral tests were carried out to examine depressive and anxiety-like behaviors including the open field test (OFT), elevated plus maze test (EPMT), novelty-suppressed feeding test (NSFT), and forced swim test (FST). The peri-thalamic lesion tissues were collected for immunofluorescence, western blotting, and enzyme-linked immunosorbent assay (ELISA). Genetic knockdown of thalamic hypoxia-inducible factor-1α (HIF-1α) and NOD-like receptor thermal protein domain associated protein 3 (NLRP3) with microinjection of HIF-1α siRNA and NLRP3 siRNA into the VPL of thalamus were performed 3 days before collagenase injection into the same regions. Microinjection of lificiguat (YC-1) and MCC950 into the VPL of thalamus were administrated 30 min before the collagenase injection in order to inhibited HIF-1α and NLRP3 pharmacologically. Repetitive right SGB was performed daily for 5 days and laser speckle contrast imaging (LSCI) was conducted to examine cerebral blood flow.

RESULTS

Thalamic hemorrhage caused persistent mechanical allodynia and anxiety- and depression-like behaviors. Accompanying the persistent mechanical allodynia, the expression of HIF-1α and NLRP3, as well as the activities of microglia and astrocytes in the peri-thalamic lesion sites, were significantly increased. Genetic knockdown of thalamic HIF-1α and NLRP3 significantly attenuated mechanical allodynia and anxiety- and depression-like behaviors following thalamic hemorrhage. Further studies revealed that intra-thalamic injection of YC-1, or MCC950 significantly suppressed the activation of microglia and astrocytes, the release of pro-inflammatory cytokines, the upregulation of malondialdehyde (MDA), and the downregulation of superoxide dismutase (SOD), as well as mechanical allodynia and anxiety- and depression-like behaviors following thalamic hemorrhage. In addition, repetitive ipsilateral SGB significantly restored the upregulated HIF-1α/NLRP3 signaling and the hyperactivated microglia and astrocytes following thalamic hemorrhage. The enhanced expression of pro-inflammatory cytokines and the oxidative stress in the peri-thalamic lesion sites were also reversed by SGB. Moreover, LSCI showed that repetitive SGB significantly increased cerebral blood flow following thalamic hemorrhage. Most strikingly, SGB not only prevented, but also reversed the development of mechanical allodynia and anxiety- and depression-like behaviors induced by thalamic hemorrhage. However, pharmacological activation of thalamic HIF-1α and NLRP3 with specific agonists significantly eliminated the therapeutic effects of SGB on mechanical allodynia and anxiety- and depression-like behaviors following thalamic hemorrhage.

CONCLUSION

This study demonstrated for the first time that SGB could improve CPSP with comorbid anxiety and depression by increasing cerebral blood flow and inhibiting HIF-1α/NLRP3 inflammatory signaling.

Characterization of persistent headache attributed to past stroke

BACKGROUND

Persistent headache attributed to past stroke (PHAPS) is a controversial entity, recently included in the third edition of the International Classification of Headache Disorders (ICHD-3) despite being described only in retrospective studies.

OBJECTIVE

To determine the frequency and characteristics of PHAPS in patients admitted with acute stroke.

METHODS

We selected all patients with headache associated with acute stroke (HAAS) from a prospective, single-center registry of patients with acute stroke admitted to a Neurology ward between November 2018 and December 2019. We analyzed demographic, clinical, and neuroimaging data. We assessed the follow-up with a phone call questionnaire at 6 to 12 months.

RESULTS

Among 121 patients with acute stroke, only 29 (24.0%) had HAAS. From these, 6 (5.0%) were lost to follow-up. In total, 23 (20.0%) patients answered the 6- to 12-month follow-up questionnaire and were included in this study. The median age of the sample was 53 years (interquartile range [IQR]: 38-78 years), and there was no sex predominance. Of the 10 patients (8,3%) that had persistent headache, 8 (6.6%) suffered from previous chronic headaches; however, they all mentioned a different kind of headache, and 1 (0,8%) probably had headache secondary to medication.

CONCLUSIONS

In the present study, only 10 out of 121 stroke patients (8.3%) referred persistent headache at the 6- to 12-month follow-up, but the majority already suffered from previous chronic headache, which raises the question that the actual prevalence of PHAPS may be lower than previously reported.

Fatigue 7 years post-stroke: Predictors and correlated features

Background

Post‐stroke fatigue (PSF) is common with great impact on quality of life. We explored predictive and cross‐sectionally correlated features in the long term after ischemic stroke.

Methods

This study comprises 430 participants of the prospective Sahlgrenska Academy Study on Ischemic Stroke (SAHLSIS), aged 18–69 years at index stroke. Information on acute stroke severity and cardiovascular risk factors was collected at index stroke. After 7 years, PSF was assessed by the Daily Fatigue Impact Scale (D‐FIS). Cognitive, neurological, and functional outcomes, and symptoms of depression and anxiety, pain, insomnia, and physical activity were also assessed. Associations between baseline variables and PSF were analyzed by ordinal regression. Correlations between PSF and cross‐sectionally assessed variables, and between PSF and baseline variables, were analyzed with Spearman's or point‐biserial correlation for the whole sample and in sex‐stratified analyses.

Results

At 7 years post‐stroke, 80% of the participants reported some impact of fatigue. Female sex and stroke severity were independently associated with PSF, whereas no associations were detected with baseline cardiovascular risk factors. In cross‐sectional analyses at 7 years, we found correlations between PSF and poor functional, neurological, and cognitive outcomes, as well as depressive symptoms, anxiety, insomnia, pain, and low physical activity (p < .001 throughout). The correlation with insomnia was stronger in women than in men (two‐way ANOVA interaction test, p = .03).

Conclusions

Our findings confirm that PSF is common in the long term after ischemic stroke and show a complex interplay with sex and several other outcomes. Future studies should address causal relationships and interventions towards fatigue and coexisting features.

Persistent headache after first-ever ischemic stroke: clinical characteristics and factors associated with its development

BACKGROUND

It is poorly described how often headache attributed to stroke continues for more than 3 months, i.e. fulfils the criteria for persistent headache attributed to ischemic stroke. Our aims were: 1) to determine the incidence of persistent headache attributed to past first-ever ischemic stroke (International headache society categories 6.1.1.2); 2) to describe their characteristics and acute treatment; 3) to analyse the prevalence of medication overuse headache in patients with persistent headache after stroke; 4) to evaluate factors associated with the development of persistent headache after stroke.

METHODS

The study population consisted of 550 patients (mean age 63.1, 54% males) with first-ever ischemic stroke, among them 529 patients were followed up at least three months after stroke. Standardized semi-structured interview forms were used to evaluate these headaches during professional face-to-face interviews at stroke onset and telephone interviews at 3 months.

RESULTS

At three months, 61 patients (30 women and 31 men, the mean age 60.0) of 529 (11.5%) follow-up patients had a headache after stroke: 34 had a new type of headache, 21 had a headache with altered characteristics and 6 patients had a headache without any changes. Therefore 55 (10.4%) patients had a persistent headache attributed to ischemic stroke. Their clinical features included: less severity of accompanying symptoms, slowly decreasing frequency and development of medication overuse headache in one-third of the patients. The following factors were associated with these headaches: lack of sleep (29.1%, p = 0.009; OR 2.3; 95% CI 1.2-4.3), infarct in cerebellum (18.2%, p = 0.003; OR 3.0; 95% CI 1.4-6.6), stroke of undetermined etiology (50.9%, p = 0.003; OR 2.3; 95% CI 1.3-4.1), less than 8 points by NIHSS score (90.9%, p = 0.007; OR 3.4; 95% CI 1.4-8.6) and low prevalence of large-artery atherosclerosis (12.7%, p = 0.006; OR 0.3; 95% CI 0.2-0.80).

CONCLUSION

Persistent headache attributed to ischemic stroke is not rare and frequently leads to medication overuse. The problem is often neglected because of other serious consequences of stroke but actually, it has a considerable impact on quality of life. It should be a focus of interest in the follow-up of stroke patients.

Exploring the relationship between fatigue and circulating levels of the pro-inflammatory biomarkers interleukin-6 and C-reactive protein in the chronic stage of stroke recovery: A cross-sectional study

Background

The precise mechanisms underlying the aetiology of post-stroke fatigue remain poorly understood. Inflammation has been associated with clinically significant fatigue across a number of neurological disorders; however, at present there is a lack of evidence regarding the association of fatigue and inflammation in the chronic phase of stroke recovery.

Aims

The aim of this study was to examine fatigue in a cohort of stroke survivors in the chronic phase of stroke, compared with matched controls, and to explore associations between the pro-inflammatory cytokine interleukin-6, high-sensitivity C-reactive Protein and fatigue.

Methods

We performed an exploratory cross-sectional study of 70 people in the chronic phase of stroke recovery, and 70 age matched controls. Fatigue was assessed using the Fatigue Assessment Scale. Interleukin-6 was measured in serum using a commercially available enzyme immunoassay kit. Both outcome measures were assessed contemporaneously.

Results

Clinically significant fatigue, defined as a score ≥24 on the Fatigue Assessment Scale, was reported by 60% of stroke survivors, and 15.7% of controls. The odds of experiencing clinically significant fatigue was 8.04 times higher among stroke survivors compared to control participants (odds ratio 8.045; 95% CI: 3.608, 17.939; P ​< ​0.001). The fatigue score was significantly correlated with the level of both interleukin-6 and high-sensitivity c-reactive protein, however once entered into a linear regression model with cardiovascular covariables, this relationship was no longer statistically significant.

Conclusions

This study shows that fatigue may be associated with systemic inflammation in the chronic phase of stroke. The pathological mechanisms underlying post-stroke fatigue and its clinical implications require further study.

[Headache and cerebrovascular diseases]

Headache is a common symptom of acute and chronic cerebrovascular diseases. Headache can be symptomatic in patients with various forms of vascular pathology of the brain but primary headaches are much more common. Secondary headaches in acute cerebrovascular accidents may be the first symptom, and in some cases, a risk factor or complication of stroke. In chronic cerebrovascular diseases, headache may be the predominant symptom in the early stages and resolve in the later stages of the disease. At the same time, the severity, nature and course of headache cannot be considered as reliable signs of cerebrovascular disease. Meanwhile, the verification of the headache form is important from the point of view of determining the priorities of diagnosis and therapy.

Serum cystatin C was a marker of poststroke fatigue in hypertensive intracerebral hemorrhage

INTRODUCTION

The relationship between poststroke fatigue (PSF) and serum Cystatin C (Cys-C) levels in hypertensive intracerebral hemorrhage (HICH) patients has not been determined. In this study, we investigated the association between serum Cys-C levels and PSF in HICH patients.

METHODS

A total of 125 patients with HICH were enrolled. Fatigue assessment was performed 6 months after HICH onset. The presence of PSF was defined as Fatigue Severity Scale (FSS) of 4 or more. Serum Cys-C levels were measured within 24 hr after admission. The correlation between FSS score and Cys-C level was analyzed by Spearman's correlation. Receiver operating characteristic (ROC) curves for PSF were calculated using Cys-C values.

RESULTS

Of enrolled 125 patients in the study, 36.0% who developed PSF were divided to the PSF group, which had higher Cys-C levels compared with the no-PSF group. There was significant positive correlation between FSS score and serum Cys-C level. Receiver operating characteristic curves for PSF revealed an area under the curve of 0.86 for Cys-C. High admission Cys-C (>0.75mg/L) yielded specificity of 93.7%, positive predictive value of 87.5%, and negative predictive value of 88.2%. In multivariate analysis, Cys-C increased by 1 mg/dl (0.1 mg/L), and the risk of PSF in patients increased by 2.55 times (odds ratio = 2.55, 95% CI: 1.65-3.95, p < .001).

CONCLUSIONS

High Cys-C levels have predictive value for PSF and can be used as one screening indicator for PSF occurrence.

Development and Internal Validation of a Nomogram to Predict Post-Stroke Fatigue After Discharge

OBJECTIVES

We aimed to develop and validate a nomogram for the individualized prediction of the risk of post-stroke fatigue (PSF) after discharge.

MATERIALS AND METHODS

Fatigue was measured using the Fatigue Assessment Scale. Multivariable logistic regression analysis was applied to build a prediction model incorporating the feature selected in the least absolute shrinkage and selection operator regression model. Discrimination, calibration, and clinical usefulness of the predictive model were assessed using the C-index, calibration plot, and decision curve analysis. Internal validation was conducted using bootstrapping validation. Finally, a web application was developed to facilitate the use of the nomogram.

RESULTS

We developed a nomogram based on 95 stroke patients. The predictors included in the nomogram were sex, pre-stroke sarcopenia, acute phase fatigue, dysphagia, and depression. The model displayed good discrimination, with a C-index of 0.801 (95% confidence interval: 0.700-0.902) and good calibration. A high C-index value of 0.762 could still be reached in the interval validation. Decision curve analysis showed that the risk of PSF after discharge was clinically useful when the intervention was decided at the PSF risk possibility threshold of 10% to 90%.

CONCLUSION

This nomogram could be conveniently used to provide an individual, visual, and precise prediction of the risk probability of PSF after being discharged home. Thus, as an aid in decision-making, physicians and other healthcare professionals can use this predictive method to provide early intervention or a discharge plan for stroke patients during the hospitalization period.

Presença de dor após o acidente vascular cerebral e sua relação com a função e a qualidade de vida

Objetivo: Avaliar a presença da dor em indivíduos com acidente vascular cerebral (AVC) e sua relação com o desempenho funcional e a qualidade de vida (QV). Métodos: Estudo transversal onde 50 indivíduos com AVC atendidos em um centro de reabilitação foram avaliados por meio da Escala Visual Numérica (EVN), Questionário de Dor McGill, SF-36 e Índice de Barthel (IB). A estatística inferencial foi realizada por meio do Teste T e do coeficiente de correlação de Pearson. Resultados: A presença de dor foi verificada em 64% da população, com média sete na EVN e expressivo número e intensidade de descritores do McGill. Os pacientes com dor apresentaram piores escores para QV nos domínios saúde mental (p = 0,046), estado geral da saúde (p = 0,021), aspectos emocionais (p = 0,034) e dor (p < 0,0001). A dor no hemicorpo hígido estava presente em 37% dos pacientes. A EVN correlacionou-se com o estado geral da saúde da SF-36 (r = -0,359; p = 0,043); já o McGill com a saúde mental (r = -0,364; p = 0,041), capacidade funcional (r = -0,365; p = 0,039) e aspectos emocionais (r = -0,374; p = 0,035). Não houve relação entre a dor e o IB. Conclusões: Este estudo mostrou alta incidência e intensidade de dor em indivíduos com AVC, mesmo em reabilitação. A presença da dor interferiu mais na QV do que na função e o McGill relacionou-se com mais domínios da SF-36 do que a EVN.

Migraine and Ischemic Stroke: Deciphering the Bidirectional Pathway

Migraine and stroke are common, disabling neurological conditions with several theories being proposed to explain this bidirectional relationship. Migraine is considered as a benign neurological disorder, but research has revealed a connection between migraine and stroke, predominantly those having migraine with aura (MA). Among migraineurs, females with MA are more susceptible to ischemic stroke and may have a migrainous infarction. Migrainous infarction mostly occurs in the posterior circulation of young women. Although there are several theories about the potential relationship between MA and stroke, the precise pathological process of migrainous infarction is not clear. It is assumed that cortical spreading depression (CSD) might be one of the essential factors for migrainous infarction. Other factors that may contribute to migrainous infarction may be genetic, hormonal fluctuation, hypercoagulation, and right to left cardiac shunts. Antimigraine drugs, such as ergot alkaloids and triptans, are widely used in migraine care. Still, they have been found to cause severe vasoconstriction, which may result in the development of ischemia. It is reported that patients with stroke develop migraines during the recovery phase. Both experimental and clinical data suggest that cerebral microembolism can act as a potential trigger for MA. Further studies are warranted for the treatment of migraine, which may lead to a decline in migraine-related stroke. In this present article, we have outlined various potential pathways that link migraine and stroke.

Headache at the Chronic Stage of Ischemic Stroke

BACKGROUND

Headache in ischemic stroke survivors after the acute stage is incompletely described.

OBJECTIVE

We aimed to prospectively describe the characteristics of headache and the predictors of headache at the chronic stage after ischemic stroke.

METHODS

We conducted a prospective observational cohort study including 102 acute ischemic stroke patients admitted to a Stroke Unit. Patients were interviewed at the acute and the chronic stage (12 months after stroke). Characteristics of those headaches were collected using a previously validated headache questionnaire enabling headache classification following the International Headache Society criteria. Pre-stroke headache history was registered using the same instrument.

RESULTS

Forty-five patients out of 89 with completed follow-up (51%) reported headache at the chronic stage. In most of the patients, headache was sporadic, mild, pressure-like, with a duration of minutes to hours, with characteristics of tension-type headache in 51% (n = 23/45). Headache was a reactivation of pre-stroke headache in 33% (n = 15/45), different from pre-stroke headache in 44% (n = 20/45), and of new-onset in 22% (n = 10/45). Only 1 patient had a new-onset headache at the acute stage that persisted with the same characteristics at the chronic stage. Pre-stroke headache (OR = 5.3; 95% CI [2.01-13.98] P = .001) and female sex (OR = 3.5; 95% CI [1.3-9.4] P = .013) predicted headache at the chronic stage after stroke, controlling for age, severity, and location of stroke.

CONCLUSIONS

Headache in ischemic stroke survivors at the chronic stage is more frequent in women and in patients with pre-stroke headache. It is most frequently a headache with different characteristics of the pre-stroke headache and only rarely a new-onset headache starting at the acute stage and persisting at the chronic stage.

Use of analgesics in acute stroke patients with inability to self-report pain: a retrospective cohort study

BACKGROUND

Pain is a common and burdensome complication in patients with acute stroke. We assessed the impact of impaired communication in stroke patients on pain assessment and treatment.

METHODS

We included 909 (507 male, mean age 71.8 years) patients admitted to our stroke unit from 01/2015 to 12/2015 in the analysis. Patients were assigned to four groups: able to communicate (AC), not able to communicate prior to index stroke (P-NAC), due to focal symptoms of index stroke (S-NAC), due to a reduced level of consciousness (C-NAC). Pain prevalence, documentation of pain and use of analgesics were evaluated. C-NAC patients were excluded from analyses regarding analgesic treatment due to relevant differences in patient characteristics.

RESULTS

746 patients (82.1%) were classified as AC, 25 (2.8%) as P-NAC, 90 (9.9%) as S-NAC and 48 (5.3%) as C-NAC. Pain was documented on the Numeric Rating Scale and in form of free text by nurses and physicians. Nurses documented pain more frequently than physicians (p < 0.001). Pain prevalence was 47.0% (n.s. between groups). The use of analgesic medication increased from 48.7% in the AC group, to 76.0% in the P-NAC group, and 77.8% in the S-NAC group (p < 0.001). Opioid use was significantly more frequent in NAC patients (p < 0.001). The response to the treatment was poorly documented with significantly lowest rates in S-NAC patients (p < 0.001).

CONCLUSIONS

Our study suggests that post-stroke pain in patients with inability to communicate is not attended enough, not systematically assessed and therefore not sufficiently treated.

A cohort study of the association between psychosocial factors and pain in patients with Spinal Cord Injury and Stroke

PURPOSE

To explore associations between psychosocial factors and pain intensity and pain interference in a population with a new neurological injury on admission to rehabilitation, and after six months.

MATERIALS AND METHODS

A longitudinal, prospective cohort study with participants with stroke or Spinal Cord Injury (SCI) completing questionnaires for pain intensity and interference, mental health, pain coping strategies and pain attitudes and beliefs within two weeks of admission to inpatient rehabilitation. After six months, participants completed measures of pain intensity and pain interference only.

RESULTS

In all 32 participants completed the questionnaires at baseline and 19 after six months. Several associations between a person's mental health and certain beliefs were associated with pain outcomes. Additionally, poorer baseline mental health was associated with greater pain intensity and pain interference after six months, and a stronger belief in a medical cure for pain at baseline was associated with less pain intensity and pain interference after six months.

CONCLUSIONS

Psychosocial factors are associated with pain early after stroke and SCI. Psychosocial factors are also associated with pain outcomes several months after stroke and SCI. This highlights the importance of psychosocial factors in both of these populations and their relationship with pain outcomes.

Remote poststroke headache in children: Characteristics and association with stroke recurrence

Background

New-onset headache after stroke is common among adult stroke survivors. However, pediatric data are limited. The primary aim of this study was to investigate the prevalence of new-headache after pediatric ischemic stroke. Secondary outcomes were to describe the characteristics of patients experiencing poststroke headache and the association between poststroke headache and stroke recurrence.

Methods

We conducted a single-center retrospective study on children aged 30 days to 18 years with a confirmed radiographic diagnosis of arterial ischemic stroke (AIS) from January 1, 2008, to December 31, 2016. Patients were identified from an internal database, with additional data abstracted from the electronic medical record. Poststroke headache (occurring >30 days after stroke) was identified through electronic searches of the medical record and confirmed by chart review.

Results

Of 115 patients with confirmed AIS, 41 (36%) experienced poststroke headache, with headache developing a median of 6 months after stroke. Fifty-one percent of patients with poststroke headache presented to the emergency department for headache evaluation; 81% of the patients had an inpatient admission for headache. Older age at stroke (odds ratio [OR] 21.5; p = 0.0001) and arteriopathy (OR 8.65; p = 0.0029) were associated with development of poststroke headache in a multivariable analysis. Seventeen patients (15%) had a recurrent stroke during the study period. Poststroke headache was associated with greater risk for stroke recurrence (p = 0.049).

Conclusions

Remote poststroke headache is a common morbidity among pediatric stroke survivors, particularly in older children. Headaches may increase health care utilization, including neuroimaging and hospital admissions. We identified a possible association between poststroke headache and stroke recurrence.

Central post-stroke pain: predictors and relationship with magnetic resonance imaging and somatosensory evoked potentials

BACKGROUND

Central post-stroke pain (CPSP) is an under-recognized complication of stroke although it can lead to deterioration in quality of life and impairment in activities of daily living. Its estimated prevalence varies between 18.6 and 49%.

OBJECTIVE

To investigate the prevalence and predictors of CPSP in ischemic stroke patients and to find its relationship with somatosensory evoked potentials (SSEPs) and magnetic resonance imaging.

PATIENTS AND METHODS

Sixty five consecutive patients with recent first attack of ischemic stroke who were admitted to the Neurology Department, Suez Canal University Hospitals were recruited. Patients were subjected to clinical assessment, Hamilton depression rating scale, brain MRI, short-form McGill Pain Questionnaire (SF-MPQ), daily pain rating scale (DPRS), stimulus evoked pain, and SSEPs.

RESULTS

The total prevalence rate of CPSP was 35.4% (n = 23). The mean age of the patients developed CPSP was significantly lower than those without CPSP (p = 0.004). Deep sensory dysfunction was statistically significantly higher among CPSP group than non-CPSP group (p = 0.001). CPSP group showed statistically significant higher prevalence of thalamic stroke (p = 0.007), as well as significant abnormalities in inter-peak interval (IPL) of median and tibial nerves SSEPs (p < 0.05). Thalamic group showed higher abnormalities in IPL of median and tibial nerves compared to extra-thalamic group, but without statistically differences.

CONCLUSION

The prevalence of CPSP was found to be 35.4%. Predictors of CPSP include; deep sensory dysfunction, prolongation of tibial N21-P40 IPL, smoking history, age < 50 years, presence of thalamic stroke and prolongation of median N9-N20 IPL.

New-onset pain in the early phase and three months following stroke - data from a multicenter study

BACKGROUND

The reported prevalence of pain after stroke varies considerably, depending on how pain is measured, time after stroke, and characteristics of the selected population. The aims of this study were to investigate the prevalence and distribution of new-onset pain initially and three months after stroke in a general Norwegian cohort, and to examine whether symptoms of anxiety or depression were associated with new-onset pain after stroke.

MATERIAL AND METHODS

Stroke patients were included from eleven different hospitals within 14 days after stroke onset. Pain was assessed at inclusion and three months after stroke, and the distribution of pain was marked on a body map. New-onset pain was defined as pain reported by the patients to have occurred after the stroke. Symptoms of anxiety and depression were evaluated using the Hospital Anxiety and Depression Scale.

RESULTS

A total of 390 patients were included. Pain data were available in 142 patients at both inclusion and follow-up, while 245 patients had available data for the regression analysis. In patients with follow-up data, new-onset pain occurred in 14 (9.9%) patients at inclusion and in 31 (21.8%) patients three months later, P=0.005. New-onset pain in the affected upper limb and bilaterally in the lower limbs was more common at three months than initially after stroke. Symptoms of anxiety were associated with new-onset pain (OR=1.13, 95% CI 1.01-1.27, P=0.030).

CONCLUSION

This study shows that new-onset pain occurs in one out of ten patients initially after stroke and in one out of five patients three months after stroke, and it was associated with symptoms of anxiety. This raises the question of whether easing symptoms of anxiety might help to prevent or treat new pain after stroke.

A Narrative Review of Persistent Post-Stroke Headache - A New Entry in the International Classification of Headache Disorders, 3rd Edition

BACKGROUND

Persistent post-stroke headache is a clinical entity that has recently entered the International Classification of Headache Disorders, 3rd edition. In contrast to acute headache attributed to stroke, the epidemiology, clinical features, potential pathophysiology, and management of persistent post-stroke headache have not been reviewed.

METHODS

We summarize the literature describing persistent headache attributed to stroke.

RESULTS

Persistent headache after ischemic or hemorrhagic stroke affects up to 23% of patients. These persistent headaches tend to have tension-type features and are more frequent and severe than acute stroke-related headaches. Risk factors include younger age, female sex, pre-existing headache disorder, and comorbid post-stroke fatigue or depression. Other factors including obstructive sleep apnea or musculoskeletal imbalances may contribute to headache persistence. Although more evidence is needed, it may be reasonable to treat persistent post-stroke headache according to headache semiology.

CONCLUSION

Recognition of persistent post-stroke headache as a separate clinical entity from acute stroke-attributed headache is the first step toward better defining its natural history and most effective treatment strategies.

Poststroke Fatigue: Emerging Evidence and Approaches to Management: A Scientific Statement for Healthcare Professionals From the American Heart Association

At least half of all stroke survivors experience fatigue; thus, it is a common cause of concern for patients, caregivers, and clinicians after stroke. This scientific statement provides an international perspective on the emerging evidence surrounding the incidence, prevalence, quality of life, and complex pathogenesis of poststroke fatigue. Evidence for pharmacological and nonpharmacological interventions for management are reviewed, as well as the effects of poststroke fatigue on both stroke survivors and caregivers.

Factors associated with multidimensional aspect of post-stroke fatigue in acute stroke period

BACKGROUND

Post-stroke fatigue (PSF) is a frequent and distressing consequence of stroke, and can be both acute and long lasting. We aimed to investigate multidimensional aspects of acute PSF and to determine the clinical factors relevant to acute PSF.

METHODS

We collected data of 101 patients admitted to the hospital for acute stroke. PSF was assessed using the Multidimensional Fatigue Inventory within 2 weeks of stroke. Measures included Mini-Mental State Examination, Hospital Anxiety and Depression Scale, and Functional Independence Measure. Stroke character, lesion location, and clinical variables that potentially influence PSF were also collected.

RESULTS

The prevalence of pathological fatigue is 56.4% within 2 weeks of stroke. Binary logistic regression analysis revealed that anxiety was the only predictor for presence of PSF (OR=1.32, 95% CI: 1.13-1.53, P<0.001). Multivariate stepwise regression analysis showed anxiety, right lesion side, thalamus, and/or brainstem were independently associated with general fatigue, right lesion side, depression, diabetes mellitus, and anxiety with physical fatigue, depression with reduced activity, depression, and BMI with reduced motivation, depression, and diabetes mellitus with mental fatigue.

CONCLUSIONS

PSF was highly prevalent in the acute phase, and specific factors including lesion location (right side lesion, thalamic and brainstem lesion), anxiety, and depression were independently associated with multidimensional aspects of PSF. Further study is needed to elucidate how specific structural lesions and anxiety symptoms relate to the development of early fatigue following stroke.

Musculoskeletal and central pain at 1 year post-stroke: associated factors and impact on quality of life

BACKGROUND AND PURPOSE

Pain is common in post-stroke patients and has been shown to be associated with depression, fatigue, and decreased quality of life (QOL). However, studies examining different types of post-stroke pain are scarce. We investigated differences in the related factors and their QOL impacts between musculoskeletal pain (MSP) and central post-stroke pain (CPSP).

METHODS

We assessed 364 consecutive stroke patients who were admitted to Asan Medical Center and contacted 12 months after stroke onset. We categorized pain and paresthesia as MSP, CPSP, combined pain, or other pain. Post-stroke depression (Beck Depression Inventory), fatigue (Fatigue Severity Scale), sleep disturbance (Verran Snyder-Halpern scale), social support (ENRICHED Social Support Instrument), and QOL (Medical Outcome Study 36-Item Short Form) were assessed.

RESULTS

Of the 364 patients analyzed, 135 (37.1%) had pain, 78 (21.4%) had MSP, 22 (6.0%) had CPSP, 16 (4.4%) had combined pain, and 19 (5.2%) had other pain. In multivariate analyses, CPSP was related to modified Rankin scale (P=.004), sensory dysfunction (P<.001), thalamus lesion (P=.001), medulla lesion (P=.007), and fatigue (P=.026). MSP was related to motor dysfunction (P<.001) and fatigue (P=.003). QOL varied among groups with different types of pain (P<.001) and was the poorest in patients with combined pain.

CONCLUSIONS

Pain is common 12 months post-stroke. The factors associated with CPSP and MSP differ, but are both closely associated with fatigue rather than depression. QOL is the poorest in patients with combined pain. Management of pain and fatigue may be important for improving the QOL in stroke patients.

Post-stroke Mood and Emotional Disturbances: Pharmacological Therapy Based on Mechanisms

Post-stroke mood and emotional disturbances are frequent and diverse in their manifestations. Out of the many post-stroke disturbances, post-stroke depression, post-stroke anxiety, post-stroke emotional incontinence, post-stroke anger proneness, and post-stroke fatigue are frequent and important symptoms. These symptoms are distressing for both the patients and their caregivers, and negatively influence the patient's quality of life. Unfortunately, these emotional disturbances are not apparent and are therefore often unnoticed by busy clinicians. Their phenomenology, predicting factors, and pathophysiology have been under-studied, and are under-recognized. In addition, well-designed clinical trials regarding these symptoms are rare. Fortunately, these mood and emotional disturbances may be treated or prevented by various methods, including pharmacological therapy. To administer the appropriate therapy, we have to understand the phenomenology and the similarities and differences in the pathophysiological mechanisms associated with these emotional symptoms. This narrative review will describe some of the most common or relevant post-stroke mood and emotional disturbances. The phenomenology, factors or predictors, and relevant lesion locations will be described, and pharmacological treatment of these emotional disturbances will be discussed based on presumable pathophysiological mechanisms.

Pain among institutionalized stroke patients and its relation to emotional distress and social engagement

OBJECTIVE

Pain is a frequent long-term consequence of stroke, but its relation to emotional and social well-being is poorly studied in stroke populations. We aimed to identify the prevalence of substantial pain among institutionalized stroke patients and to explore its relation to emotional distress (ED) and low social engagement (SE).

METHODS

In a cross-sectional design, we collected data of 274 chronic stroke patients in Dutch nursing homes. Observation lists were filled out in structured interviews with qualified nurse assistants who knew the residents well. Pain and SE were measured with the Resident Assessment Instrument for Long-term Care Facilities, and ED was measured with the Neuropsychiatric Inventory Questionnaire (NPIQ).

RESULTS

Substantial pain was present in 28% of the residents, mostly located in the affected body side (68%). Multilevel regression analyses revealed that this pain was independently related to a 60% increase in NPIQ score (β 3.18 [1.84-4.53]) and to clinically relevant symptoms of delusions (odds ratio [OR] 8.45 [1.82-39.05]), agitation/aggression (OR 3.82 [1.76-8.29]), depression (OR 3.49 [1.75-6.98]), and anxiety (OR 2.32 [1.08-4.97]). Substantial pain was associated with low SE when adjusted for clinical covariates (OR 4.25 [1.72-10.53]), but only in residents with no/mild or severe cognitive impairment. This relation disappeared when additionally corrected for NPIQ score (OR 1.95 [0.71-5.39]).

CONCLUSIONS

Pain is a serious and multidimensional problem among institutionalized stroke patients. It is related to increased ED, which in turn can be a pathway to low SE as an indicator of social vulnerability. Future research should reveal how pain management in nursing homes can be tailored to the needs of this patient group.

Factors Associated with Poststroke Fatigue: A Systematic Review

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.

The impact of pain on health-related quality of life 3 months after stroke

BACKGROUND

Pain is common in stroke; however, its impacts on health-related quality of life (HRQoL) are unclear due to the limitations of previous studies.

OBJECTIVES

The current study aims to examine and compare the demographic and clinical characteristics of Chinese stroke patients with and without pain and explore the correlations between poststroke pain and HRQoL.

METHOD

Four hundreds and forty-one participants recruited in an acute stroke unit in a regional hospital. They were assessed 3 months after the index stroke with the following instruments. HRQoL was measured using the Short Form-12 (SF-12). The Chinese version of the Faces Pain Rating Scale-Revised (FPS-R) was used to determine the presence and intensity of pain. The demographic and clinical characteristics of patients were obtained using Barthel Index (BI), Fatigue Severity Scale (FSS), Geriatric Depression Scale (GDS), Anxiety subscale of the Hospital Anxiety and Depression Scale (HADSA), Instrumental Activities of Daily Living (IADL), Mini Mental State Examination (MMSE), Modified Rankin Scale (MRS), and National Institutes of Health Stroke Scale (NIHSS).

RESULTS

Of all participants screened, 167 reported pain and 69 had novel pain. The pain group had significantly lower physical component summary (PCS) scores after adjusting for sex, education, DSM-IV depression and BI, GDS, HADSA, and FSS scores. The FPS score was negatively correlated with a lower PCS score in patients with pain and with novel pain.

CONCLUSION

The presence and intensity of pain have significant negative effects on HRQoL in stroke survivors. Interventions for pain could make a valuable contribution to improving HRQoL in stroke survivors.

Long-term outcome after spinal cord infarctions

OBJECTIVES

To investigate long-term outcome in patients with spontaneous spinal cord infarctions and secondly to compare outcome with that of patients with cerebral infarction.

MATERIAL AND METHODS

The study includes 30 patients with spinal cord infarction discharged between 1995 and 2010. Surviving patients were contacted by telephone and sent a questionnaire. Data on employment, function, depression, fatigue, pain, and quality of life were obtained and compared to similar data obtained from a group of patients with cerebral infarction.

RESULTS

Seven patients with spinal cord infarction had died after a mean follow-up of 7.1 years. Mortality was associated with poor functioning in the acute phase. Thirteen of 20 responding patients were able to walk. Compared to patients with cerebral infarction, patients with spinal cord infarction had significantly lower mortality, poorer functioning, higher re-employment rate, and more pain.

CONCLUSION

Many patients with spinal cord infarction experience significant improvement. Even though functional outcome is worse, the mortality rate is lower and the frequency of re-employment higher among patients with spinal cord infarction compared to patients with cerebral infarction.

Development of persistent headache following stroke: A 3-year follow-up

Background

Headache following stroke has been described in previous studies with an incidence of 23%–54%, but a clear description of headache developing after stroke onset is still lacking. The aim of this study was to determine the incidence and characteristics of persistent novel headache after stroke and to describe the use of medication, including dipyridamole.

Methods

As a follow-up to a prospective study, a standardized questionnaire about characteristics of novel headache and medication use was sent out to surviving patients three years after their stroke.

Results

The questionnaire was sent to 256 patients and returned by 222, of whom 12% (26/222) of patients reported persistent novel headache. Dipyridamole had no significant influence on the incidence. Stroke-attributed headache according to predefined criteria was reported in 7.2% (16/222) of patients, with tension-type-like headache in 50.0%, migraine-like in 31.3% and medication overuse in 6.25% of patients. More than half of patients experienced moderate to severe pain and had a score of 55 or above on the Headache Impact Test-6 scale.

Conclusion

Novel headache after stroke affects one in 10 patients and seems to be unrelated to dipyridamole use. Persistent headache attributed to stroke is similar to tension-type headache for half of patients.

Sleep duration and history of stroke among adults from the USA

Although short sleep duration is related to chronic conditions, such as hypertension, diabetes and obesity, the association with stroke is less well known. Using 2006-2011 National Health Interview Surveys, we assessed the association between self-reported duration of sleep and prevalence of stroke stratifying by age and sex. Of the 154 599 participants aged 18 years or older, 29.2%, 61.8% and 9.0% reported they sleep ≤6, 7-8 and ≥9 h per day, respectively. Corresponding age-standardized prevalence of stroke were 2.78%, 1.99% and 5.21% (P < 0.001). Logistic regression models showed a higher prevalence of stroke among those who slept ≤6 or ≥9 h a day compared with those who slept 7-8 h, after adjusting for sociodemographic, behavioural and health characteristics. Further stratifying by age and sex showed that the association of duration of sleep and stroke differed among different age or sex groups. Among young adults (18-44 years), a higher prevalence of stroke was found among women with short sleep. Higher prevalence of stroke was found among middle-aged men and women reporting short or long sleep duration. Among older adults (≥65 years), higher prevalence of stroke was found only among those who slept ≥9 h. In this national sample of adults, the association between duration of sleep and stroke varied by sex and age. Although there was an association of short sleep duration with stroke, we also observed the association of long sleep duration with stroke, especially among those aged 65 years or older.

Ischaemic stroke in young adults: risk factors and long-term consequences

Contrary to trends in most other diseases, the average age of ischaemic stroke onset is decreasing, owing to a rise in the incidence of stroke among 'young' individuals (under 50 years of age). This Review provides a critical overview of the risk factors and aetiology of young ischaemic stroke and addresses its long-term prognosis, including cardiovascular risk, functional outcome and psychosocial consequences. We highlight the diminishing role of 'rare' risk factors in the pathophysiology of young stroke in light of the rising prevalence of 'traditional' vascular risk factors in younger age groups. Long-term prognosis is of particular interest to young patients, because of their long life expectancy and major responsibilities during a demanding phase of life. The prognosis of young stroke is not as favourable as previously thought, with respect either to mortality or cardiovascular disease or to psychosocial consequences. Therefore, secondary stroke prevention is probably a life-long endeavour in most young stroke survivors. Due to under-representation of young patients in past trials, new randomized trials focusing on this age group are needed to confirm the benefits of long-term secondary preventive medication. The high prevalence of poor functional outcome and psychosocial problems warrants further study to optimize treatment and rehabilitation for these young patients.

Fatigue and pain: relationships with physical performance and patient beliefs after stroke

BACKGROUND

Fatigue and pain are common after stroke, potentially impacting stroke recovery.

OBJECTIVE

This study examines the frequency and impact of fatigue and pain in people with chronic stroke.

METHOD

Seventy-seven people with chronic stroke completed a one-time assessment consisting of a battery of self-report and performance tools to describe and quantify mobility issues post stroke. We assessed the proportion of individuals with fatigue and pain and the relationship between fatigue and pain and other variables including gait (10-meter walk and 6-minute walk test), balance (Berg Balance Scale), activity and participation (ICF Measure of Participation and Activities), chronic disease self-efficacy (Chronic Disease Self-Efficacy Scale), and balance self-efficacy (Activity-Specific Balance Confidence Scale). Additionally, subgroup comparisons were made between participants with and without coexisting fatigue and pain.

RESULTS

Fatigue and pain were reported by 66% and 45% of study participants, respectively. Thirty-four percent of the sample reported co-existing fatigue and pain. Participants with coexisting fatigue and pain demonstrated significantly lower chronic disease and balance self-efficacy and decreased activity than participants without coexisting fatigue and pain. Individually, fatigue correlated with balance, chronic disease self-efficacy, balance self-efficacy, activity, and participation, whereas pain correlated with chronic disease self-efficacy, balance self-efficacy, and activity.

CONCLUSION

Fatigue and pain are common after stroke and are negatively correlated with outcomes important to rehabilitation. Efforts focused on examining the impact of interventions on fatigue and pain are warranted. It is possible that changes to these body structure limitations could positively impact functional recovery and community re-entry after stroke.

Poor health-related quality of life is associated with long-term mortality in young adults with cerebral infarction

BACKGROUND

Our aim was to investigate the effect of health-related quality of life (HRQOL) on subsequent mortality in young ischemic stroke patients in a population-based study.

METHODS

Young ischemic stroke patients were invited to a follow-up on average 6 years after their index stroke. HRQOL was measured by Short-Form 36 (SF-36) and the Nottingham Health Profile (NPH). Data on socioeconomic and functional states were obtained. Subsequent survival was obtained by examining the official population registry. Multivariate analyses were performed.

RESULTS

One hundred eighty-eight patients were included. The mean age on follow-up was 48 years, and the subsequent follow-up period was 12 years. Cox regression analysis revealed that mortality was associated with NHP sum score (P < .001) after adjusting for age (P = .09), sex (P = .11), and alcoholism (P = .04). Cox regression analyses, including subscores of SF-36 or NHP separately, revealed that mortality was associated with pain (P = .05), sleep disturbances (P = .02), and physical function (P = .02) after adjusting for confounders.

CONCLUSIONS

Poor HRQOL is associated with subsequent long-term mortality in young adults with ischemic stroke and this may pertain particularly to pain, sleep disturbances and low physical fitness.

Pain following stroke, initially and at 3 and 18 months after stroke, and its association with other disabilities

BACKGROUND AND PURPOSE

A general hypothesis is that pain following stroke (PFS) causes disabilities. However, the clinical implication of PFS on other disabilities after stroke and vice versa has not been fully investigated. The aims of this observational study were to analyze the correlation between PFS and other disabilities at different time points after stroke, whether PFS can be a predictor of coming disabilities and whether other disabilities can be predictors of coming PFS.

METHODS

Patients with a first-ever stroke were assessed initially (n = 109), and at 3 (n = 95) and 18 months (n = 66) after stroke for PFS, mobility, self-care as well as touch, proprioceptive, muscle tone, and movement functions.

RESULTS

PFS was correlated to impaired upper extremity movement function on all occasions, while the correlations between PFS and other disabilities varied across the three occasions. Initial PFS and PFS at 3 months did not independently predict coming disabilities. Initial mobility limitation independently predicted PFS at 3 months and impaired touch function, initially and at 3 months, independently predicted PFS at 18 months. No other disabilities independently predicted coming PFS.

CONCLUSIONS

The present results do not support the hypothesis that PFS causes other disabilities. Our results indicate that PFS is correlated to other disabilities; however, no ultimate conclusions can be drawn on causality. PFS was not a predictor of coming disabilities, while some disabilities were predictors of coming PFS.