Prognostic factors in stroke rehabilitation: the possible role of pharmacological treatment

Pathophysiology, Diagnosis, Prognosis, and Prevention of Poststroke Epilepsy: Clinical and Research Implications

Poststroke epilepsy (PSE) is associated with higher mortality and poor functional and cognitive outcomes in patients with stroke. With the remarkable development of acute stroke treatment, there is a growing number of survivors with PSE. Although approximately 10% of patients with stroke develop PSE, given the significant burden of stroke worldwide, PSE is a significant problem in stroke survivors. Therefore, the attention of health policymakers and significant funding are required to promote PSE prevention research. The current PSE definition includes unprovoked seizures occurring more than 7 days after stroke onset, given the high recurrence risks of seizures. However, the pathologic cascade of stroke is not uniform, indicating the need for a tissue-based approach rather than a time-based one to distinguish early seizures from late seizures. EEG is a commonly used tool in the diagnostic work-up of PSE. EEG findings during the acute phase of stroke can potentially stratify the risk of subsequent seizures and predict the development of poststroke epileptogenesis. Recent reports suggest that cortical superficial siderosis, which may be involved in epileptogenesis, is a promising marker for PSE. By incorporating such markers, future risk-scoring models could guide treatment strategies, particularly for the primary prophylaxis of PSE. To date, drugs that prevent poststroke epileptogenesis are lacking. The primary challenge involves the substantial cost burden due to the difficulty of reliably enrolling patients who develop PSE. There is, therefore, a critical need to determine reliable biomarkers for PSE. The goal is to be able to use them for trial enrichment and as a surrogate outcome measure for epileptogenesis. Moreover, seizure prophylaxis is essential to prevent functional and cognitive decline in stroke survivors. Further elucidation of factors that contribute to poststroke epileptogenesis is eagerly awaited. Meanwhile, the regimen of antiseizure medications should be based on individual cardiovascular risk, psychosomatic comorbidities, and concomitant medications. This review summarizes the current understanding of poststroke epileptogenesis, its risks, prognostic models, prophylaxis, and strategies for secondary prevention of seizures and suggests strategies to advance research on PSE.

Stroke Rehabilitation and Motor Recovery

OBJECTIVE

Up to 50% of the nearly 800,000 patients who experience a new or recurrent stroke each year in the United States fail to achieve full independence afterward. More effective approaches to enhance motor recovery following stroke are needed. This article reviews the rehabilitative principles and strategies that can be used to maximize post-stroke recovery.

LATEST DEVELOPMENTS

Evidence dictates that mobilization should not begin prior to 24 hours following stroke, but detailed guidelines beyond this are lacking. Specific classes of potentially detrimental medications should be avoided in the early days poststroke. Patients with stroke who are unable to return home should be referred for evaluation to an inpatient rehabilitation facility. Research suggests that a substantial increase in both the dose and intensity of upper and lower extremity exercise is beneficial. A clinical trial supports vagus nerve stimulation as an adjunct to occupational therapy for motor recovery in the upper extremity. The data remain somewhat mixed as to whether robotics, transcranial magnetic stimulation, functional electrical stimulation, and transcranial direct current stimulation are better than dose-matched traditional exercise. No current drug therapy has been proven to augment exercise poststroke to enhance motor recovery.

ESSENTIAL POINTS

Neurologists will collaborate with rehabilitation professionals for several months following a patient's stroke. Many questions still remain about the ideal exercise regimen to maximize motor recovery in patients poststroke. The next several years will likely bring a host of new research studies exploring the latest strategies to enhance motor recovery using poststroke exercise.

Seizures and epilepsy after intracerebral hemorrhage: an update

Seizures are common after intracerebral hemorrhage, occurring in 6-15% of the patients, mostly in the first 72 h. Their incidence reaches 30% when subclinical or non-convulsive seizures are diagnosed by continuous electroencephalogram. Several risk factors for seizures have been described including cortical location of intracerebral hemorrhage, presence of intraventricular hemorrhage, total hemorrhage volume, and history of alcohol abuse. Seizures after intracerebral hemorrhage may theoretically be harmful as they can lead to sudden blood pressure fluctuations, increased intracranial pressure, and neuronal injury due to increased metabolic demand. Some recent studies suggest that acute symptomatic seizures (occurring within 7 days of stroke) are associated with worse functional outcome and increased risk of death despite accounting for other known prognostic factors such as age and baseline hemorrhage volume. However, the impact of seizures on prognosis is still debated and it remains unclear if treating or preventing seizures might lead to improved clinical outcome. Thus, the currently available scientific evidence does not support the routine use of antiseizure medication as primary prevention among patients with intracerebral hemorrhage. Only prospective adequately powered randomized-controlled trials will be able to answer whether seizure prophylaxis in the acute or longer term settings is beneficial or not in patients with intracerebral hemorrhage.

Incidence, Implications, and Management of Seizures Following Ischemic and Hemorrhagic Stroke

PURPOSE OF REVIEW

In this review, we summarize the recent literature regarding the incidence and treatment of seizures arising after ischemic and hemorrhagic strokes. Additionally, we identify open questions in guidelines and standard clinical care to aid future studies aiming to improve management of seizures in post-stroke patients.

RECENT FINDINGS

Studies demonstrate an increasing prevalence of seizures following strokes, probably a consequence of advances in post-stroke management and expanding use of continuous EEG monitoring. Post-stroke seizures are associated with longer hospitalization and increased mortality; therefore, prevention and timely treatment of seizures are important. The standard of care is to treat recurrent seizures with anti-epileptic drugs (AEDs) regardless of the etiology. However, there are no established guidelines currently for prophylactic use of AEDs following a stroke. The prevalence of post-stroke seizures is increasing. Further studies are needed to determine the risk factors for recurrent seizures and epilepsy after strokes and optimal treatment strategies.

Sex differences in post-stroke aphasia rates are caused by age. A meta-analysis and database query

BACKGROUND

Studies have suggested that aphasia rates are different in men and women following stroke. One hypothesis says that men have more lateralized language function than women. Given unilateral stroke, this would lead to a prediction of men having higher aphasia rates than women. Another line of observations suggest that women are more severely affected by stroke, which could lead to a higher aphasia rate among women. An additional potential confounding variable could be age, given that women are typically older at the time of stroke.

METHODS & PROCEDURES

This study consists of two parts. First, a meta-analysis of the available reports of aphasia rates in the two sexes was conducted. A comprehensive literature search yielded 25 studies with sufficient information about both aphasia and gender. These studies included a total of 48,362 stroke patients for which aphasia rates were calculated. Second, data were extracted from an American health database (with 1,967,038 stroke patients), in order to include age and stroke severity into a regression analysis of sex differences in aphasia rates.

OUTCOMES & RESULTS

Both analyses revealed significantly larger aphasia rates in women than in men (1.1-1.14 ratio). This speaks against the idea that men should be more lateralized in their language function. When age and stroke severity were included as covariates, sex failed to explain any aphasia rate sex difference above and beyond that which is explained by age differences at time of stroke.

Stroke-related epilepsy

Stroke is the cause of about 10% of all epilepsy and 55% of newly diagnosed seizures among the elderly. Although recent advances in acute stroke therapy have improved longevity, there has been a consequent rise in the prevalence of stroke-related epilepsy (STRE). Many clinical studies make a distinction between early (within 7 days of onset of stroke) and late (beyond 7 days of onset of stroke) seizures based on presumed pathophysiological differences. Although early seizures are thought to be the consequence of local metabolic disturbances without altered neuronal networks, late seizures are thought to occur when the brain has acquired a predisposition for seizures. Overall, STRE has a good prognosis, being well controlled by antiepileptic drugs. However, up to 25% of cases become drug resistant. STRE can also result in increased morbidity, longer hospitalization, greater disability at discharge and greater resource utilization. Additional controlled trials are needed to explore the primary and secondary prevention of STRE as well as to provide high-quality evidence on efficacy and tolerability of antiepileptic drugs to guide treatment of STRE. Robust pre-clinical and clinical prediction models of STRE are also needed to develop treatments to prevent the transformation of infarcted tissue into an epileptic focus.

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential.

CONCLUSIONS

As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.).

Pharmacological interventions for unilateral spatial neglect after stroke

BACKGROUND

Unilateral spatial neglect (USN) is characterized by the inability to report or respond to people or objects presented on the side contralateral to the lesioned side of the brain and has been associated with poor functional outcomes and long stays in hospitals and rehabilitation centers. Pharmacological interventions (medical interventions only, use of drugs to improve the health condition), such as dopamine and noradrenergic agonists or pro-cholinergic treatment, have been used in people affected by USN after stroke, and effects of these treatments could provide new insights for health professionals and policy makers.

OBJECTIVES

To evaluate the effectiveness and safety of pharmacological interventions for USN after stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (April 2015), the Cochrane Central Register of Controlled Trials (April 2015), MEDLINE (1946 to April 2015), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to April 2015), EMBASE (1980 to April 2015), PsycINFO (1806 to April 2015) and Latin American Caribbean Health Sciences Literature (LILACS) (1982 to April 2015). We also searched trials and research registers, screened reference lists, and contacted study authors and pharmaceutical companies (April 2015).

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-randomized controlled trials (quasi-RCTs) of pharmacological interventions for USN after stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias in the included studies and extracted data.

MAIN RESULTS

We included in the review two studies with a total of 30 randomly assigned participants. We rated the quality of the evidence as very low as the result of study limitations, small numbers of events, and small sample sizes, with imprecision in the confidence interval (CI). We were not able to perform meta-analysis because of heterogeneity related to the different interventions evaluated between included studies. Very low-quality evidence from one trial (20 participants) comparing effects of rivastigmine plus rehabilitation versus rehabilitation on overall USN at discharge showed the following: Barrage (mean difference (MD) 0.30, 95% confidence interval (CI) -0.18 to 0.78); Letter Cancellation (MD 10.60, 95% CI 2.07 to 19.13); Sentence Reading (MD 0.20, 95% CI -0.69 to 1.09), and the Wundt-Jastrow Area Illusion Test (MD -4.40, 95% CI -8.28 to -0.52); no statistical significance was observed for the same outcomes at 30 days' follow-up. In another trial (10 participants), study authors showed statistically significant reduction in omissions in the three cancellation tasks under transdermal nicotine treatment (mean number of omissions 2.93 ± 0.5) compared with both baseline (4.95 ± 0.8) and placebo (5.14 ± 0.9) (main effect of treatment condition: F (2.23) = 11.06; P value < 0.0001). One major adverse event occurred in the transdermal nicotine treatment group, and treatment was discontinued in the affected participant. None of the included trials reported data on several of the prespecified outcomes (falls, balance, depression or anxiety, poststroke fatigue, and quality of life).

AUTHORS' CONCLUSIONS

The quality of the evidence from available RCTs was very low. The effectiveness and safety of pharmacological interventions for USN after stroke are therefore uncertain. Additional large RCTs are needed to evaluate these treatments.

New Developments on Drug Treatment Rehabilitation

Increasing interest has been directed to role of pharmaceuticals in the recovery of cerebrovascular events. However, only few scientific studies are available to date, and further research is needed. Amphetamine is the most extensively studied drug shown to promote recovery of function, although clinical data have lead to conflicting results. Other psychostimulants drugs have been proposed, as levodopa or methylphenidate, even if published data are still few. Recently, two studies have been published about the positive role of cholinesterase inhibitor donepezil on stroke recovery. However, such data must still be confirmed by randomized controlled trials. Antidepressant drugs have shown to be effective not only in improving depressive symptoms in stroke patients, but also in decreasing, although partially, the negative impact of poststroke depression on functional outcome. Serotoninergic agents may have a role in improving stroke recovery, in a fashion that is not dependent on their primary antidepressant activity. Last, it is important to be aware that certain drugs as clonidine, prazosin, dopamine receptor antagonists, benzodiazepines, phenytoin, and phenobarbital could have a detrimental effect on the poststroke recovery.

Repairing the human brain after stroke: I. Mechanisms of spontaneous recovery

Stroke remains a leading cause of adult disability. Some degree of spontaneous behavioral recovery is usually seen in the weeks after stroke onset. Variability in recovery is substantial across human patients. Some principles have emerged; for example, recovery occurs slowest in those destined to have less successful outcomes. Animal studies have extended these observations, providing insight into a broad range of underlying molecular and physiological events. Brain mapping studies in human patients have provided observations at the systems level that often parallel findings in animals. In general, the best outcomes are associated with the greatest return toward the normal state of brain functional organization. Reorganization of surviving central nervous system elements supports behavioral recovery, for example, through changes in interhemispheric lateralization, activity of association cortices linked to injured zones, and organization of cortical representational maps. A number of factors influence events supporting stroke recovery, such as demographics, behavioral experience, and perhaps genetics. Such measures gain importance when viewed as covariates in therapeutic trials of restorative agents that target stroke recovery.

Rehabilitation of Left Brain-Damaged Ischemic Stroke Patients: The Role of Comprehension Language Deficits

BACKGROUND

Aphasia is considered a risk factor for disability after stroke. The aim of this study was to assess the specific influence of aphasia on rehabilitation results.

METHOD

A case-control study in consecutive left brain-damaged stroke inpatients, enrolled in three homogeneous subgroups [nonaphasic (NA) patients, aphasic with comprehension deficit (CD), and without comprehension deficit (NCD)] matched for age and onset-admission interval. Rehabilitation results (gain, efficiency, effectiveness of treatment, percentage and odds ratio of dropouts and of each degree of therapeutic response, assessed by Barthel Index and Rivermead Mobility Index) were compared among the subgroups.

RESULTS

Two hundred and forty patients with sequelae of a first stroke were enrolled. CD patients, as compared with NCD and NA ones, had a significantly more severe basal neurological and functional status at admission, minor effectiveness on ADL and mobility, a higher percentage of low responders on ADL and urinary incontinence at discharge, and a risk of low therapeutic response on ADL nearly 4 times higher than the other patients (OR = 4.22, 95% CI = 1.90-9.38). The rehabilitative behavior between NCD and NA was similar. However, all subgroups (NA, CD and NCD) showed a significant improvement (p < 0.001) between their basal and discharge score, both on BI and RMI.

CONCLUSIONS

Comprehension language deficit was confirmed to be a strong negative rehabilitation prognostic factor despite the speech therapy done by all CD patients.

Veterans Affairs/Department of Defense Clinical Practice Guideline for the Management of Adult Stroke Rehabilitation Care: executive summary

BACKGROUND

A panel of experts developed stroke rehabilitation guidelines for the Veterans Health Administration and Department of Defense Medical Systems.

METHODS

Starting from previously established guidelines, the panel evaluated published literature through 2002, using criteria developed by the US Preventive Services Task Force. Recommendations were based on evidence from randomized clinical trials, uncontrolled studies, or consensus expert opinion if definitive data were lacking.

RESULTS

Recommendations with Level I evidence include the delivery of poststroke care in a multidisciplinary rehabilitation setting or stroke unit, early patient assessment via the NIH Stroke Scale, early initiation of rehabilitation therapies, swallow screening testing for dysphagia, an active secondary stroke prevention program, and proactive prevention of venous thrombi. Standardized assessment tools should be used to develop a comprehensive treatment plan appropriate to each patient's deficits and needs. Medical therapy for depression or emotional lability is strongly recommended. A speech and language pathologist should evaluate communication and related cognitive disorders and provide treatment when indicated. The patient, caregiver, and family are essential members of the rehabilitation team and should be involved in all phases of the rehabilitation process. These recommendations are available in their entirety at http://stroke.ahajournals.org/cgi/content/full/36/9/e100. Evidence tables for each of the recommendations are also in the full document.

CONCLUSIONS

These recommendations should be equally applicable to stroke patients receiving rehabilitation in all medical system settings and are not based on clinical problems or resources unique to the Federal Medical System.