NIHSS is not enough for cognitive screening in acute stroke: A cross-sectional, retrospective study

Risk factors for stroke outcomes in adults: Stroke in China

This study aimed to determine the possible risk factors for stroke outcomes based on prospective cohort study in China. A total of 146 stroke patients were recruited and divided into 2 groups, which assessed using the modified Rankin Scale (mRS), good outcomes (mRS <= 2) and poor outcomes group (mRS > 2). Demographic, clinical, and laboratory characteristics of participants were obtained from the medical record. The multivariable logistic regression analysis was employed to assess the risk factors for stroke outcomes. Of 146 participants, 28 (19.18%) were presented with poor outcomes at day 90. As a result of multivariable logistic regression analysis, a significantly increased risk of stroke outcomes was found in patients with Barthel Index (BI) score (stroke (OR 1.50, 95% CI 1.21 ~ 1.85, P < .001) and IS (OR 1.48, 95% CI 1.20 ~ 1.83, P < .001)).

Death and ADL Dependency After Scoring Zero on the NIHSS: A Swedish Retrospective Registry-Based Study

Background and Objectives

Of all strokes, mild strokes (defined as 5 points or less on the National Institutes of Health Stroke Scale [NIHSS]) are in the majority. However, up to one-third of patients with mild strokes still exhibit significant deficits 3 months after the stroke. Studies on the presumably mildest strokes, defined by zero points on the NIHSS (0-NIHSS) at admission, are scarce. Hence, we aimed to study patient characteristics and outcomes among patients with 0-NIHSS strokes.

Methods

Our retrospective registry-based study included a total of 6,491 adult patients with stroke admitted to 3 different stroke units in Gothenburg, Sweden, from November 2014 to June 2019. Our main outcome was a composite measure including death and activities of daily living (ADL) dependency 3 months after the stroke. Analyses of patient characteristics were followed by adjusted analyses including multiple confounders.

Results

In total, 5,945 patients had data on NIHSS at admission, of whom 1,412 (24%) presented with a 0-NIHSS stroke. Among these, the median age was 72 years, 600 (42%) were female, and 86 (6%) had a hemorrhagic stroke. Among previously ADL-independent patients, 65 (6%) were either dead or ADL-dependent 3 months after the stroke. Prestroke physical inactivity (OR 2.48, 95% CI 1.40-4.38) and age (OR 1.05 per gained year, 95% CI 1.02-1.08) significantly increased the risk of death and ADL dependency.

Discussion

One of 17 patients has either died or become ADL-dependent 3 months after a 0-NIHSS stroke, stressing that these strokes are not always benign. Older and physically inactive patients are at greater risk of an adverse outcome.

Task Cortical Connectivity Reveals Different Network Reorganizations between Mild Stroke Patients with Cortical and Subcortical Lesions

Accumulating efforts have been made to investigate cognitive impairment in stroke patients, but little has been focused on mild stroke. Research on the impact of mild stroke and different lesion locations on cognitive impairment is still limited. To investigate the underlying mechanisms of cognitive dysfunction in mild stroke at different lesion locations, electroencephalograms (EEGs) were recorded in three groups (40 patients with cortical stroke (CS), 40 patients with subcortical stroke (SS), and 40 healthy controls (HC)) during a visual oddball task. Power envelope connectivity (PEC) was constructed based on EEG source signals, followed by graph theory analysis to quantitatively assess functional brain network properties. A classification framework was further applied to explore the feasibility of PEC in the identification of mild stroke. The results showed worse behavioral performance in the patient groups, and PECs with significant differences among three groups showed complex distribution patterns in frequency bands and the cortex. In the delta band, the global efficiency was significantly higher in HC than in CS (p = 0.011), while local efficiency was significantly increased in SS than in CS (p = 0.038). In the beta band, the small-worldness was significantly increased in HC compared to CS (p = 0.004). Moreover, the satisfactory classification results (76.25% in HC vs. CS, and 80.00% in HC vs. SS) validate the potential of PECs as a biomarker in the detection of mild stroke. Our findings offer some new quantitative insights into the complex mechanisms of cognitive impairment in mild stroke at different lesion locations, which may facilitate post-stroke cognitive rehabilitation.

Identifying stroke-related quantified evidence from electronic health records in real-world studies

BACKGROUND

Stroke is one of the leading causes of death and disability worldwide. The National Institutes of Health Stroke Scale (NIHSS) scores in electronic health records (EHRs), which quantitatively describe patients' neurological deficits in evidence-based treatment, are crucial in stroke-related clinical investigations. However, the free-text format and lack of standardization inhibit their effective use. Automatically extracting the scale scores from the clinical free text so that its potential value in real-world studies is realized has become an important goal.

OBJECTIVE

This study aims to develop an automated method to extract scale scores from the free text of EHRs.

METHODS

We propose a two-step pipeline method to identify NIHSS items and numerical scores and validate its feasibility using a freely accessible critical care database: MIMIC-III (Medical Information Mart for Intensive Care III). First, we utilize MIMIC-III to create an annotated corpus. Then, we investigate possible machine learning methods for two subtasks, NIHSS item and score recognition and item-score relation extraction. In the evaluation, we conduct both task-specific and end-to-end evaluations and compare our method with the rule-based method using precision, recall and F1 scores as evaluation metrics.

RESULTS

We use all available discharge summaries of stroke cases in MIMIC-III. The annotated NIHSS corpus contains 312 cases, 2929 scale items, 2774 scores and 2733 relations. The results show that the best F1-score of our method was 0.9006, which was attained by combining BERT-BiLSTM-CRF and Random Forest, and it outperformed the rule-based method (F1-score = 0.8098). In the end-to-end task, our method could successfully recognize the item "1b level of consciousness questions", the score "1" and their relation "('1b level of consciousness questions', '1', 'has value')" from the sentence "1b level of consciousness questions: said name = 1", while the rule-based method could not.

CONCLUSIONS

The two-step pipeline method we propose is an effective approach to identify NIHSS items, scores and their relations. With its help, clinical investigators can easily retrieve and access structured scale data, thereby supporting stroke-related real-world studies.

A register-based study on associations between pre-stroke physical activity and cognition early after stroke (part of PAPSIGOT)

The objective was to investigate if pre-stroke physical activity is associated with intact cognition early after stroke. The study design was a cross-sectional, register-based study. The study sample included 1111 adults with first stroke (mild or moderate severity) admitted to three Swedish stroke units. The main outcome was cognition. The associations of pre-stroke physical activity, age, sex, smoking, diabetes, atrial fibrillation, previous TIA, statin treatment, hypertension treatment, reperfusion therapies, stroke severity, and education on the outcome cognition were analyzed using binary logistic regression. Physical activity was assessed within 48 h of admittance, and cognition was screened during stroke unit care. The results were: mean age 70 years, 40% women, 61% pre-stroke physically active, and 53% with post-stroke cognitive impairment. Patients with pre-stroke light or moderate physical activity have higher odds for intact cognition compared to inactive: odds ratio (95% confidence interval) 1.32 (0.97-1.80) and 2.04 (1.18-3.53), respectively. In addition to pre-stroke physical activity, people with younger age, a higher level of education, less severe stroke (more mild than moderate), being non-diabetic, and non-smoking have higher odds for intact cognition. In conclusion physical activity before stroke is associated with intact cognition in patients with mild and moderate stroke.

Quantitative EEG Correlates with NIHSS and MoCA for Assessing the Initial Stroke Severity in Acute Ischemic Stroke Patients

BACKGROUND: National Institutes of Health Stroke Scale (NIHSS) and Montreal Cognitive Assessment (MoCA) measure stroke severity by assessing the functional and cognitive outcome, respectively. However, they cannot be used to measure subtle evolution in clinical symptoms during the early phase. Quantitative EEG (qEEG) can detect any subtle changes in CBF and brain metabolism thus may also benefit for assessing the severity. AIM: This study aims to identify the correlation between qEEG with NIHSS and MoCA for assessing the initial stroke severity in acute ischemic stroke patients. METHODS: This was a cross-sectional study. We recruited 30 patients with first-ever acute ischemic stroke hospitalized in Dr. Sardjito General Hospital, Yogyakarta, Indonesia. We measured the NIHSS, MoCA score, and qEEG parameter during the acute phase of stroke. Correlation and regression analysis was completed to investigate the relationship between qEEG parameter with NIHSS and MoCA. RESULTS: Four acute qEEG parameter demonstrated moderate-to-high correlations with NIHSS and MoCA. DTABR had positive correlation with NIHSS (r = 0.379, p = 0.04). Meanwhile, delta-absolute power, DTABR, and DAR were negatively correlated with MoCA score (r = −0.654, p = 0.01; r = −0.397, p = 0.03; and r = −0.371, p = 0.04, respectively). After adjusted with the confounding variables, delta-absolute power was independently associated with MoCA score, but not with NIHSS (B = −2.887, 95% CI (−4.304–−1.470), p < 0.001). CONCLUSIONS: Several qEEG parameters had significant correlations with NIHSS and MoCA in acute ischemic stroke patients. The use of qEEG in acute clinical setting may provide a reliable and efficient prediction of initial stroke severity. Further cohort study with larger sample size and wide range of stroke severity is still needed.

Critical issue on the extinction and inattention subtest of NIHSS scale: an analysis on post-acute stroke patients attending inpatient rehabilitation

Objectives

This study aims to evaluate the diagnostic performance of NIHSS extinction and inattention item, compared to the results of the Oxford Cognitive Screen (OCS) heart subtest. Additionally, the possible role of the NIHSS visual field subtest on the NIHSS extinction and inattention subtest performance is explored and discussed.

Methods

We analysed scores on NIHSS extinction and inattention subtest, NIHSS visual field subtest, and OCS heart subtest on a sample of 118 post-stroke patients.

Results

Compared to OCS heart subtest, the results on NIHSS extinction and inattention subtest showed an accuracy of 72.9% and a moderate agreement level (Cohen’s kappa = 0.404). Furthermore, a decrease in NIHSS accuracy detecting neglect (61.1%) was observed in patients with pathological scores in NIHSS visual field item.

Conclusions

Extreme caution is recommended for the diagnostic performance of extinction and inattention item of NIHSS. Signs of neglect may not be detected by NIHSS, and may be confused with visual field impairment.

Trial registration

This study refers to an observational study protocol submitted to ClinicalTrials.gov with identifier: NCT03968627. The name of the registry is “Development of a National Protocol for Stroke Rehabilitation in a Multicenter Italian Institution” and the date of the registration is the 30th May 2019.

Barriers to cognitive screening in acute stroke units

Cognitive impairment is common after stroke. However, not all patients with stroke undergo cognitive screening, despite recommendations. The aim of this retrospective, explorative study was to examine the barriers to cognitive screening in acute stroke units. Data were retrieved from two Swedish Stroke registries. The outcome variable was cognitive screening during the stay at acute stroke units. Forty-three candidate explanatory variables were considered for analysis, encompassing sociodemographic factors and stroke-related outcomes during the stay at acute stroke units. The Least Absolute Shrinkage and Selection Operator and decision-tree methods were used. Of the 1120 patients (56% male, mean age: 72 years, 50% with mild stroke), 44% did not undergo cognitive screening. Walking 10 m post-stroke was the most important attribute for decisions regarding cognitive screening. The classification accuracy, sensitivity, and specificity of the model were 70% (95% CI 63–75%), 71% (63–78%), and 67% (55–77%), respectively. Patient-related parameters that influenced cognitive screening with a valid and reliable screening instrument in acute stroke units included new stroke during the hospitalisation, aphasia at admission, mobility problems, impaired verbal output skills, and planned discharge to another care facility. The barriers to cognitive screening were both patient- and organisation-related, suggesting the need for patient-tailored cognitive screening tools as well as the implementation and systematic adherence to guidelines.

Development of a short-form Swedish version of the Montreal Cognitive Assessment (s-MoCA-SWE): protocol for a cross-sectional study

INTRODUCTION

Short forms of the Montreal Cognitive Assessment (MoCA) have allowed quick cognitive screening. However, none of the available short forms has been created or validated in a Swedish sample of patients with stroke.The aim is to develop a short-form Swedish version of the MoCA (s-MoCA-SWE) in a sample of patients with acute and subacute stroke. The specific objectives are: (1) to identify a subgroup of MoCA items that have the potential to form the s-MoCA-SWE; (2) to determine the optimal cut-off value of s-MoCA-SWE for predicting cognitive impairment and (3) and to compare the psychometric properties of s-MoCA-SWE with those of previously developed MoCA short forms.

METHODS AND ANALYSIS

This is a statistical analysis protocol for a cross-sectional study. The study sample will comprise patients from Väststroke, a local stroke registry from Gothenburg, Sweden and Efficacy oF Fluoxetine-a randomisEd Controlled Trial in Stroke (EFFECTS), a randomised controlled trial in Sweden. The s-MoCA-SWE will be developed by using exploratory factor analysis and the boosted regression tree algorithm. The cut-off value of s-MoCA-SWE for impaired cognition will be determined based on binary logistic regression analysis. The psychometric properties of s-MoCA-SWE will be compared with those of other MoCA short forms by using cross-tabulation and area under the receiving operating characteristic curve analyses.

ETHICS AND DISSEMINATION

The Väststroke study has received ethical approval from the Regional Ethical Review Board in Gothenburg (346-16) and the Swedish Ethical Review Authority (amendment 2019-04299). The handling of data generated within the framework of quality registers does not require written informed consent from patients. The EFFECTS study has received ethical approval from the Stockholm Ethics Committee (2013/1265-31/2 on 30 September 2013). All participants provided written consent. Results will be published in an international, peer-reviewed journal, presented at conferences and communicated to clinical practitioners in local meetings and seminars.

Silver Jubilee of Stroke Thrombolysis With Alteplase: Evolution of the Therapeutic Window

In 1995, the results of a landmark clinical trial by National Institute of Neurological Disorders and Stroke (NINDS) made a paradigm shift in managing acute cerebral ischemic stroke (AIS) patients at critical care centers. The study demonstrated the efficacy of tissue-type plasminogen activator (tPA), alteplase in improving neurological and functional outcome in AIS patients when administered within 3 h of stroke onset. After about 12 years of efforts and the results of the ECASS-III trial, it was possible to expand the therapeutic window to 4.5 h, which still represents a major logistic issue, depriving many AIS patients from the benefits of tPA therapy. Constant efforts in this regards are directed toward either speeding up the patient recruitment for tPA therapy or expanding the current tPA window. Efficient protocols to reduce the door-to-needle time and advanced technologies like telestroke services and mobile stroke units are being deployed for early management of AIS patients. Studies have demonstrated benefit of thrombolysis guided by perfusion imaging in AIS patients at up to 9 h of stroke onset, signifying “tissue window.” Several promising pharmacological and non-pharmacological approaches are being explored to mitigate the adverse effects of delayed tPA therapy, thus hoping to further expand the current tPA therapeutic window without compromising safety. With accumulation of scientific data, stroke organizations across the world are amending/updating the clinical recommendations of tPA, the only US-FDA approved drug for managing AIS patients. Alteplase has been a part of our neurocritical care and we intend to celebrate its silver jubilee by dedicating this review article discussing its journey so far and possible future evolution.

The diagnostic and prognostic performance of Lp-PLA2 in acute ischemic stroke

OBJECTIVE

We aimed to investigate the correlation between serum lipoprotein-associated phospholipase A2 (Lp-PLA2) level and acute ischemic stroke (AIS) severity and recurrence, which could indicate the diagnostic and prognostic values of Lp-PLA2.

METHODS

Two hundred and fifty-one AIS patients who were diagnosed in the department of neurology, China-Japan Union Hospital, from April 2018 to June 2019 and 100 non-cerebrovascular disease patients were included in this study. Demographic data and clinical materials including age, sex, BMI, medical history, bad habits, imaging data, blood tests, etc., were collected. Stroke severity and risk were evaluated, respectively. AIS patients were followed up for 6 months for stroke recurrence monitoring.

RESULTS

The AIS group had significantly higher Lp-PLA2 level than the control group. High Lp-PLA2 level was the independent risk factor of AIS (OR 1.010; 95% CI 1.007-1.013, P<0.001). Admission NIHSS was compared between Lp-PLA2 categories dichotomized by median. Serum Lp-PLA2 level was positively correlated with NIHSS (r=0.268, P<0.001). Mild stroke group and severe stroke group were defined based on NIHSS. Compared with the mild stroke group, the severe stroke group had higher smoking ratio, posterior circulation stenosis incidence, LDL level, Lp-PLA2 level and admission Essen score. Logistic regression showed Lp-PLA2 levels per 50ng/mL (OR 1.381, 95% CI 1.212-1.573, P<0.001) and Lp-PLA2 category (OR 2.420, 95% CI 1.363-4.297, P=0.003) were both independently associated with severe stroke. During the 6-month follow-up of all 251 AIS patients, 31 stroke recurrence cases were observed. Both Lp-PLA2 levels per 50ng/mL (OR 1.420, 95% CI 1.212-1.664, P<0.001) and Lp-PLA2 category (OR 2.726, 95% CI 1.201-6.178, P=0.016) were significantly associated with the stroke recurrence. Under the receiver Operating Characteristic curve, Lp-PLA2 showed significant predicting ability for stroke recurrence (AUC 0.723; 95% CI 0.620-0.826, P<0.001).

CONCLUSION

High serum Lp-PLA2 level is correlated with AIS incidence, disease severity and recurrence, which could be utilized to guide clinical practice.

Post-stroke cognitive impairments and responsiveness to motor rehabilitation: A review

PURPOSE OF REVIEW

a)This review discusses the prevalence of cognitive deficits following stroke and their impact on responsiveness to therapeutic intervention within a motor learning context.

RECENT FINDINGS

b)Clinical and experimental studies have established that post-stroke cognitive and motor deficits may impede ambulation, augment fall risk, and influence the efficacy of interventions. Recent research suggests the presence of cognitive deficits may play a larger role in motor recovery than previously understood.

SUMMARY

c)Considering that cognitive impairments affect motor relearning, post-stroke motor rehabilitation therapies may benefit from formal neuropsychological testing. For example, early work suggests that in neurotypical adults, cognitive function may be predictive of responsiveness to motor rehabilitation and cognitive training may improve mobility. This sets the stage for investigations probing these topics in people post-stroke. Moreover, the neural basis for and extent to which these cognitive impairments influence functional outcome remains largely unexplored and require additional investigation.

TVA-based modeling of short-term memory capacity, speed of processing and perceptual threshold in chronic stroke patients undergoing cognitive training: case-control differences, reliability, and associations with cognitive performance

Attentional deficits following stroke are common and pervasive, and are important predictors for functional recovery. Attentional functions comprise a set of specific cognitive processes allowing to attend, filter and select among a continuous stream of stimuli. These mechanisms are fundamental for more complex cognitive functions such as learning, planning and cognitive control, all crucial for daily functioning. The distributed functional neuroanatomy of these processes is a likely explanation for the high prevalence of attentional impairments following stroke, and underscores the importance of a clinical implementation of computational approaches allowing for sensitive and specific modeling of attentional sub-processes. The Theory of Visual Attention (TVA) offers a theoretical, computational, neuronal and practical framework to assess the efficiency of visual selection performance and parallel processing of multiple objects. Here, in order to assess the sensitivity and reliability of TVA parameters reflecting short-term memory capacity (K), processing speed (C) and perceptual threshold (t 0), we used a whole-report paradigm in a cross-sectional case-control comparison and across six repeated assessments over the course of a three-week computerized cognitive training (CCT) intervention in chronic stroke patients (> 6 months since hospital admission, NIHSS ≤ 7 at hospital discharge). Cross-sectional group comparisons documented lower short-term memory capacity, lower processing speed and higher perceptual threshold in patients (n = 70) compared to age-matched healthy controls (n = 140). Further, longitudinal analyses in stroke patients during the course of CCT (n = 54) revealed high reliability of the TVA parameters, and higher processing speed at baseline was associated with larger cognitive improvement after the intervention. The results support the feasibility, reliability and sensitivity of TVA-based assessment of attentional functions in chronic stroke patients.

B-Type Natriuretic Peptide as a Significant Brain Biomarker for Stroke Triaging Using a Bedside Point-of-Care Monitoring Biosensor

Stroke is a widespread condition that causes 7 million deaths globally. Survivors suffer from a range of disabilities that affect their everyday life. It is a complex condition and there is a need to monitor the different signals that are associated with it. Stroke patients need to be rapidly diagnosed in the emergency department in order to allow the admission of the time-limited treatment of tissue plasminogen activator (tPA). Stroke diagnostics show the use of sophisticated technologies; however, they still contain limitations. The hidden information and technological advancements behind the utilization of biomarkers for stroke triaging are significant. Stroke biomarkers can revolutionize the way stroke patients are diagnosed, monitored, and how they recover. Different biomarkers indicate different cascades and exhibit unique expression patterns which are connected to certain pathologies in the human body. Over the past decades, B-type natriuretic peptide (BNP) and its derivative N-terminal fragment (NT-proBNP) have been increasingly investigated and highlighted as significant cardiovascular biomarkers. This work reviews the recent studies that have reported on the usefulness of BNP and NT-proBNP for stroke triaging. Their classification association is also presented, with increased mortality in stroke, correlation with cardioembolic stroke, and an indication of a second stroke recurrence. Moreover, recent scientific efforts conducted for the technological advancement of a bedside point-of-care (POC) device for BNP and NT-proBNP measurements are discussed. The conclusions presented in this review may hopefully assist in the major efforts that are currently being conducted in order to improve the care of stroke patients.