The worldwide burden of stroke: current status and future projections

Exploring Stroke Patients’ Needs after Discharge from Rehabilitation Centres: Meta-Ethnography

Healthcare providers must consider stroke survivors needs in order to enable a good quality of life after stroke. This review aimed to investigate the perceived needs of the stroke survivors across various domains of care following their discharge from hospital. A meta-ethnographic review of qualitative studies that reported needs of stroke patients after discharge from rehabilitation services was conducted. Main searches were conducted on the following electronic databases: Ovid Medline (1946 to 2021), CINAHL plus (EBSCO), AMED (EBSCO), PsycINFO (1967 to 2021), the Cochrane Library, and PubMed in June 2022. Main outcomes were related to stroke survivors’ views, experiences, and preferences on physical, psychological, social, rehabilitation needs, and other identified needs. Twenty-seven studies were included in the final analysis. The findings show that existing rehabilitation provision for stroke survivors does not address the long-term needs of stroke survivors. Two main issues were revealed concerning the unmet needs of stroke survivors: (1) a lack of information availability and suitability and (2) inadequacy of care and services. It is crucial to further investigate the needs of patients in Asian countries and the Middle East as there is very limited understanding of patients’ needs in the community in these regions.

"Design of a Suspension Lever Mechanism in Biomedical Robotic System"

The article discusses the design of a suspended lever mechanism with elastic elements, which is used as a safety device in a robotic system for the rehabilitation of the lower limbs. The article analyzes the existing mechanical structures of devices for rehabilitation, identifies the problems of operation, design, and safety systems and suggests a new design of the device. The process of reverse development of a lever mechanism scheme to ensure safety during rehabilitation of the lower limbs is presented. The design of the lever mechanism consists of movable levers connected by elastic elements. The device allows you to dampen the force during active rehabilitation. The power calculation of the lever mechanism in the rehabilitation system was carried out. The article addresses the issues present in the current mechanical designs with a brief discussion on the system architecture.

Association between in-hospital frailty and health-related quality of life after stroke: the Nor-COAST study

Background

Stroke survivors are known to have poorer health-related quality of life (HRQoL) than the general population, but less is known about characteristics associated with HRQoL decreasing through time following a stroke. This study aims to examine how in-hospital frailty is related to HRQoL from 3 to 18 months post stroke.

Method

Six hundred twenty-five participants hospitalised with stroke were included and followed up at 3 and/or 18 months post stroke. Stroke severity was assessed the day after admission with the National Institutes of Health Stroke Scale (NIHSS). A modified Fried phenotype was used to assess in-hospital frailty; measures of exhaustion, physical activity, and weight loss were based on pre-stroke status, while gait speed and grip strength were measured during hospital stay. HRQoL at 3- and 18-months follow-up were assessed using the five-level version of the EuroQol five-dimensional descriptive system (EQ-5D-5L) and the EuroQol visual analogue scale (EQ-5D VAS). We conducted linear mixed effect regression analyses unadjusted and adjusted for sex, age, and stroke severity to investigate the association between in-hospital frailty and post-stroke HRQoL.

Results

Mean (SD) age was 71.7 years (11.6); mean NIHSS score was 2.8 (4.0), and 263 (42.1%) were female. Frailty prevalence was 10.4%, while 58.6% were pre-frail. The robust group had EQ-5D-5L index and EQ-5D VAS scores at 3 and 18 months comparable to the general population. Also at 3 and 18 months, the pre-frail and frail groups had significantly lower EQ-5D-5L indices than the robust group (p <  0.001), and the frail group showed a larger decrease from 3 to 18 months in the EQ-5D-5L index score compared to the robust group (− 0.056; 95% CI − 0.104 to − 0.009; p = 0.021). There were no significant differences in change in EQ-5D VAS scores between the groups.

Conclusion

This study on participants mainly diagnosed with mild strokes suggests that robust stroke patients have fairly good and stable post-stroke HRQoL, while post-stroke HRQoL is impaired and continues to deteriorate among patients with in-hospital frailty. This emphasises the importance of a greater focus on frailty in stroke units.

Trial registration

ClinicalTrials.gov (NCT02650531).

Deciphering the stroke-built environment nexus in transitional cities: Conceptual framework, empirical evidence, and implications for proactive planning intervention

Adverse lifestyle-associated health outcomes, and stroke in particular, have been aggravated in transitional countries under high-speed urbanisation. Against this backdrop, deciphering the nexus between built environments (BEs) and lifestyle-associated health outcomes is of importance for crafting proactive interventions. The existing literature on this topic, however, fails to sufficiently capture the multiplicity of health-related BEs and, in turn, the complexity of such a nexus, largely challenging the applicability of established frameworks and the reliability of relevant findings. Looking at the case of stroke in Wuhan, China, this research aims to flesh out the understanding of the nexus between multidimensional BEs and lifestyle-associated health outcomes in transitional cities, with regards to conceptual framework and empirical evidence. To this end, we clarified stroke-related BE elements and integrated them into one conceptual framework. We then visualised stroke risk and examined its BE determinants using the Bayesian conditional autoregressive model. The visualisation results showed that stroke risks exhibited significant clustering in the high-density urban core. The statistical analysis found that, after the data were controlled for sociodemographic characteristics, net population density and building density were positively associated with stroke risk. In contrast, an abundance of public parks and institutional land use and access to medical care facilities have presented negative correlations with stroke risk, regardless of urban density. Our research reveals that compact urban developments might not be a silver bullet for health promotion in transitional cities, calling for an urgent need to scrutinise their applicability. To offset the adverse effects of increasingly dense urban environments, more efforts should also be made to provide better access to the identified salubrious resources. Furthermore, we argue that the establishment of comprehensive conceptual frameworks that connect BEs and lifestyle-associated health outcomes deserves to be highlighted in further research, planning intervention schemes, and health impact assessment projects.

Current status of stroke in Qatar: Including data from the BRAINS study

Background

Qatar is located on the north-eastern coast of the Arabian Peninsula. Qatari natives account for less than 15% of the population while the largest migrant group comprising 60% derives from South Asia. Despite projections that stroke burden in Qatar will increase with population ageing, epidemiological studies focusing on stroke in Qatar are relatively scarce.

Method

We reviewed the available epidemiological publications relating to Qatar. In addition, we have added to this knowledge by incorporating Qatari data from the on-going Bio-Repository of DNA in Stroke, an independent multinational database of stroke patients.

Results

Qatar has low reported incidence and mortality rates of 58 and 9.17 per 100,000 per year, respectively, which may be explained by its middle-aged migrant worker majority population. Correspondingly, South Asian migrants in Qatar suffered younger strokes than Qatari natives (48.7 vs 63.4 years, P < 0.001). Among the most common risk factors identified in stroke patients were hypertension (77.9%), diabetes (43.8%) and hypercholesterolemia (28.5%). Ischaemic stroke was the most frequent subtype amongst migrant South Asians (71.1%). The majority of stroke cases had computed tomography and/or magnetic resonance imaging scans, but only 11.1% of ischaemic strokes were thrombolysed. Qataris on one-year follow up were more often found to have died (6.5% vs 0.3%) and had further stroke/transient ischaemic attack events (17.4% vs 6.4%, P = 0.009) compared to South Asians.

Conclusion

The burden of stroke is increasing in Qatar, and considerable disparities are observed between the native and migrant populations which likely will require different approaches to management by its healthcare system.

Combining the benefits of tele-rehabilitation and virtual reality-based balance training: a systematic review on feasibility and effectiveness

PURPOSE

A motivational surrounding is desirable in stroke rehabilitation considering the need to train repetitively to improve balance, even after discharge from rehabilitation facilities. This review aims to investigate whether it is feasible to combine virtual reality (VR) which allows exercising in game-like environments with tele-rehabilitation in a community-dwelling stroke population.

METHODS

Literature searches were conducted in five databases, for example, PubMed and the Cochrane Library. Randomized controlled trial (RCT) and non-RCT investigating feasibility and effectiveness of VR-based tele-rehabilitation were included. Based on the risk of bias and study design, methodological quality is ranked according to the GRADE guidelines.

RESULTS

Seven studies (n = 120) were included, of which four are RCTs. Evidence regarding therapy adherence and perceived enjoyment of VR, as well as a cost-benefit of tele-rehabilitation emphasizes feasibility. Equal effects are reported comparing this approach to a therapist-supervised intervention in the clinical setting on balance and functional mobility.

CONCLUSIONS

Tele-rehabilitation could be a promising tool to overcome burdens that restrict accessibility to rehabilitation in the future. VR can increase motivation allowing longer and more training sessions in community-dwelling stroke survivors. Therefore, combining the benefits of both approaches seems convenient. Although evidence is still sparse, functional improvements seem to be equal compared to a similar intervention with therapist-supervision in the clinic, suggesting that for cost-efficient rehabilitation parts of therapy can be transferred to the homes. Implications for rehabilitation The use of tele-rehabilitation could be a promising tool to overcome burdens that restrict the access of stroke survivors to long-term rehabilitative care. VR-based interventions are game-like and therefore seem to provide a motivational environment which allows longer exercise sessions and greater adherence to therapy.

Beta adrenoceptor blockade ameliorates impaired glucose tolerance and alterations of the cerebral ceramide metabolism in an experimental model of ischemic stroke

Background:

Sphingolipids are versatile signaling molecules derived from membrane lipids of eukaryotic cells. Ceramides regulate cellular processes such as proliferation, differentiation and apoptosis and are involved in cellular stress responses. Experimental evidence suggests a pivotal role of sphingolipids in the pathogenesis of cardiovascular diseases, including ischemic stroke. A neuroprotective effect has been shown for beta-adrenergic antagonists in rodent stroke models and supported by observational clinical data. However, the exact underlying pathophysiological mechanisms are still under investigation. We aimed to examine the influence of propranolol on the ceramide metabolism in the stroke-affected brain.

Methods:

Mice were subjected to 60 or 180 min transient middle cerebral artery occlusion (tMCAO) and infarct size, functional neurological deficits, glucose tolerance, and brain ceramide levels were assessed after 12, 24, and 72 h to evaluate whether the latter two processes occur in a similar time frame. Next, we assessed the effects of propranolol (10 mg/kg bw) at 0, 4 and 8 h after tMCAO and FTY720 (fingolimod; 1 mg/kg) on infarct size, functional outcome, immune cell counts and brain ceramide levels at 24 h after 60 min tMCAO.

Results:

We found a temporal coincidence between stroke-associated impaired glucose tolerance and brain ceramide accumulation. Whereas propranolol reduced ischemic lesion size, improved functional outcome and reduced brain ceramide accumulation without an effect on circulating immune cells, FTY720 showed the known neuroprotective effect and strong reduction of circulating immune cells without affecting brain ceramide accumulation.

Conclusions:

Propranolol ameliorates both stroke-associated impairment of glucose tolerance and brain ceramide accumulation which are temporally linked, strengthening the evidence for a role of the sympathetic nervous system in regulating post-stroke glucose metabolism and its metabolic consequences in the brain.

The burden of mood-disorder/cerebrovascular disease comorbidity: essential neurobiology, psychopharmacology, and physical activity interventions

Cardio-vascular diseases (CVDs) and CVD-related disorders (including cerebrovascular diseases; CBVDs) are a major public health concern as they represent the leading cause of mortality and morbidity in developed countries. Patients with CVDs and CBVDs co-morbid with mood disorders, especially bipolar disorder (BD) and major depressive disorder (MDD), suffer reduced quality-of-life and significant disability adjusted for years of life and mortality. The relationship between CVDs/CBVDs and mood disorders is likely to be bidirectional. Evidence for shared genetic risk of pathways involved in stress reaction, serotonin or dopamine signalling, circadian rhythms, and energy balance was reported in genome-wide association studies. There is some evidence of a neuroprotective effect of various antidepressants, which may be boosted by physical exercise, especially by aerobic ones. Patients with CVDs/CBVDs should be routinely attentively evaluated for the presence of mood disorders, with tools aimed at detecting both symptoms of depression and of hypomania/mania. Behavioural lifestyle interventions targeting nutrition and exercise, coping strategies, and attitudes towards health should be routinely provided to patients with mood disorders, to prevent the risk of CVDs/CBVDs. A narrative review of the evidence is herein provided, focusing on pharmacological and physical therapy interventions.

Glial Fibrillary Acidic Protein Serum Levels Distinguish between Intracerebral Hemorrhage and Cerebral Ischemia in the Early Phase of Stroke

BACKGROUND

Recent studies have suggested that glial fibrillary acidic protein (GFAP) serum concentrations distinguish between intracerebral hemorrhage (ICH) and ischemic stroke (IS) shortly after symptom onset. In this prospective multicenter trial we validated GFAP in an independent patient cohort and assessed the quantitative relationship between GFAP release, bleeding size, and localization.

METHODS

We included patients with a persistent neurological deficit (NIH Stroke Scale ≥4) suggestive of stroke within 6 h of symptom onset. Blood samples were drawn at hospital admission. GFAP serum concentrations were measured using an electrochemiluminometric immunoassay. Primary endpoint was the final diagnosis established at hospital discharge (ICH, IS, or stroke mimic).

RESULTS

202 patients were included (45 with ICH, 146 with IS, 11 stroke mimics). GFAP concentrations were significantly higher in ICH than in IS patients [median (interquartile range) 0.16 μg/L (0.04-3.27) vs 0.01 μg/L (0.01-0.01), P <0.001]. A GFAP cutoff of 0.03 μg/L provided a sensitivity of 77.8% and a specificity of 94.2% in distinguishing ICH from IS and stroke mimics [ROC analysis area under the curve 0.872 (95% CI, 0.802-0.942), P <0.001]. GFAP serum concentrations were positively correlated with ICH volume. Lobar ICH volumes were larger and thus associated with higher GFAP concentrations as compared to deep ICH.

CONCLUSIONS

Serum GFAP was confirmed to be a biomarker indicating ICH in patients presenting with acute stroke symptoms. Very small ICH may be missed owing to less tissue destruction.

Regulation of ABC efflux transporters at blood-brain barrier in health and neurological disorders

The strength of the blood-brain barrier (BBB) in providing protection to the central nervous system from exposure to circulating chemicals is maintained by tight junctions between endothelial cells and by a broad range of transporter proteins that regulate exchange between CNS and blood. The most important transporters that restrict the permeability of large number of toxins as well as therapeutic agents are the ABC transporters. Among them, P-gp, BCRP, MRP1 and MRP2 are the utmost studied. These efflux transporters are neuroprotective, limiting the brain entry of neurotoxins; however, they could also restrict the entry of many therapeutics and contribute to CNS pharmacoresistance. Characterization of several regulatory pathways that govern expression and activity of ABC efflux transporters in the endothelium of brain capillaries have led to an emerging consensus that these processes are complex and contain several cellular and molecular elements. Alterations in ABC efflux transporters expression and/or activity occur in several neurological diseases. Here, we review the signaling pathways that regulate expression and transport activity of P-gp, BCRP, MRP1 and MRP2 as well as how their expression/activity changes in neurological diseases. This article is part of a Special Issue entitled SI: Neuroprotection.

Sexual function after strokes

Strokes are the second leading cause of death and the third leading cause of disability worldwide. Thanks in part to better and more available diagnosis, treatment, and rehabilitation, the vast majority of stroke patients tend to survive strokes, particularly in the industrialized world. Motor disability and cognitive changes such as aphasia and visuospatial disorders are most often considered among the major contributors to stroke burden. This chapter discusses disorders of sexual functions as another frequent sequel of strokes. Strokes generally induce hyposexuality, but in some instances they may be followed by hypersexuality. There is some evidence suggesting that lesions of either hemisphere affect sexual activities, but for different reasons: aphasia and depression after left-hemisphere lesions, a deficit in arousal and perhaps visuospatial disorders after right-hemisphere lesions. Psychologic, psychosocial, and physical factors, as well as medications, play an important role. A better understanding of the psychosocial and physiologic mechanisms underlying sexual functioning can provide insight into improving sexual activity and therefore quality of life in patients affected by strokes and other brain lesions.

Development and preliminary testing of a novel wheelchair integrated exercise/ rehabilitation system

The people with spinal cord injuries (SCI) or post stroke hemiplegia are easily exposed to secondary problems due to limited mobility. A new wheelchair integrated lower limb exercise/rehabilitation system is proposed to help their daily living and rehabilitation. The system consists of three main modules: 1) an electric wheelchair, 2) a lifter which raises and supports the subject's body weight, and 3) a lower limb exoskeleton. This paper describes the concept of the entire system and configurations of the prototype. In the design of the lower limb exoskeleton, the ergonomic joint mechanisms are introduced to assist the natural daily motions based on the biomechanics of each hip, knee and ankle joint.

Brain ischemic injury in rodents: the protective effect of EPO

Animal models constitute an indispensable tool to investigate human pathology. Here we describe the procedure to induce permanent and transient cerebral ischemia in the mouse and the rat. The model of transient occlusion of the middle cerebral artery (MCA) is performed by the insertion of an occlusive filament until the origin of the MCA while the permanent occlusion described in the mice is performed by a distal electrocoagulation of the MCA. Those models allow evaluating the efficiency of therapeutic strategy of ischemia from tissular aspect to behavioral and cognitive impairment assessment. They were widely used in the literature to evaluate the efficiency of different drugs including the cytokines and especially erythropoietin (EPO) or its derivatives.

Intra-arterial infusion of autologous bone marrow mononuclear cells in patients with moderate to severe middle cerebral artery acute ischemic stroke

Transplantation of autologous bone marrow mononuclear cells (BMMCs) has been proven safe in animal and human studies. However, there are very few studies in stroke patients. In this study, intra-arterial autologous BMMCs were infused in patients with moderate to severe acute middle cerebral artery infarcts. The subjects of this study included 20 patients with early or late spontaneous recanalization but with persistent deficits, in whom treatment could be initiated between 3 and 7 days after stroke onset. Mononuclear cells were isolated from bone marrow aspirates and infused at the proximal middle cerebral artery of the affected hemisphere. Safety analysis (primary endpoint) during the 6-month follow-up assessed death, any serious clinical events, neurological worsening with ≥ 4-point increase in National Institutes of Health Stroke Scale (NIHSS) scores, seizures, epileptogenic activity on electroencephalogram, and neuroimaging complications including new ischemic, hemorrhagic, or neoplastic lesions. Satisfactory clinical improvement (secondary endpoint) at 90 days was defined according to the pretreatment NIHSS scores as follows: modified Rankin Scale score of 0 in patients with NIHSS <8, modified Rankin Scale scores of 0-1 in patients with NIHSS 8-14, or modified Rankin Scale scores 0-2 in patients with NIHSS >14. Good clinical outcome was defined as mRS ≤2 at 90 days. Serial clinical, laboratory, electroencephalogram, and imaging evaluations showed no procedure-related adverse events. Satisfactory clinical improvement occurred in 6/20 (30%) patients at 90 days. Eight patients (40%) showed a good clinical outcome. Infusion of intra-arterial autologous BMMCs appears to be safe in patients with moderate to severe acute middle cerebral artery strokes. No cases of intrahospital mortality were seen in this pilot trial. Larger prospective randomized trials are warranted to assess the efficacy of this treatment approach.

Intravenous human umbilical cord blood transplantation for stroke: impact on infarct volume and caspase-3-dependent cell death in spontaneously hypertensive rats

Transplantation of human umbilical cord blood cells (HUCBC) produces reliable behavioral and morphological improvements in animal models of stroke. However, the mechanisms of action still have not been fully elucidated. The aim of the present study is the evaluation of potential neuroprotective effects produced by HUCBC in terms of reduced infarct volume and caspase-3-dependent cell death. Permanent middle cerebral artery occlusion was induced in 90 spontaneously hypertensive rats. The animals were randomly assigned to the control group (n=49) or the verum group (n=41). The cell suspension (8 × 10(6) HUCBC per kilogram bodyweight) or vehicle solution was intravenously administered 24h after stroke onset. Fifty subjects (n=25/25) were sacrificed after 25, 48, 72 and 96h, and brain specimens were removed for immunohistochemistry for MAP2, cleaved caspase-3 (casp3) and GFAP. Another 42 animals (n=26/16) were sacrificed after 0, 6, 24, 36 and 48h and their brains processed for quantitative PCR for casp3 and survivin. The infarct volume remained stable over the entire experimental period. However, cleaved casp3 activity increased significantly in the infarct border zone within the same time frame. Numerous cleaved casp3-positive cells were colocalized with the astrocytic marker GFAP, whereas cleavage of neuronal casp3 was observed rarely. Neither the infarct volume nor casp3 activity was significantly affected by cell transplantation. Delayed systemic transplantation of HUCBC failed to produce neuroprotective effects in a permanent stroke model using premorbid subjects.