Acute neurological stroke care in Europe: results of the European Stroke Care Inventory

Combining modified Graeb score and intracerebral hemorrhage score to predict poor outcome in patients with spontaneous intracerebral hemorrhage undergoing surgical treatment

Objective

Spontaneous intracerebral hemorrhage (sICH) is a frequently encountered neurosurgical disease. The purpose of this study was to evaluate the relationship between modified Graeb Score (mGS) at admission and clinical outcomes of sICH and to investigate whether the combination of ICH score could improve the accuracy of outcome prediction.

Methods

We retrospectively reviewed the medical records of 511 patients who underwent surgery for sICH between January 2017 and June 2021. Patient outcome was evaluated by the Glasgow Outcome Scale (GOS) score at 3 months following sICH, where a GOS score of 1–3 was defined as a poor prognosis. Univariate and multivariate logistic regression analyses were conducted to determine risk factors for unfavorable clinical outcomes. Receiver operating characteristic (ROC) curve analysis was performed to detect the optimal cutoff value of mGS for predicting clinical outcomes. An ICH score combining mGS was created, and the performance of the ICH score combining mGS was assessed for discriminative ability.

Results

Multivariate analysis demonstrated that a higher mGS score was an independent predictor for poor prognosis (odds ratio [OR] 1.207, 95% confidence interval [CI], 1.130–1.290, p < 0.001). In ROC analysis, an optimal cutoff value of mGS to predict the clinical outcome at 3 months after sICH was 11 (p < 0.001). An increasing ICH-mGS score was associated with increased poor functional outcome. Combining ICH score with mGS resulted in an area under the curve (AUC) of 0.790, p < 0.001.

Conclusion

mGS was an independent risk factor for poor outcome and it had an additive predictive value for outcome in patients with sICH. Compared with the ICH score and mGS alone, the ICH score combined with mGS revealed a significantly higher discriminative ability for predicting postoperative outcome.

The Use of Deep Learning to Predict Stroke Patient Mortality

The increase in stroke incidence with the aging of the Korean population will rapidly impose an economic burden on society. Timely treatment can improve stroke prognosis. Awareness of stroke warning signs and appropriate actions in the event of a stroke improve outcomes. Medical service use and health behavior data are easier to collect than medical imaging data. Here, we used a deep neural network to detect stroke using medical service use and health behavior data; we identified 15,099 patients with stroke. Principal component analysis (PCA) featuring quantile scaling was used to extract relevant background features from medical records; we used these to predict stroke. We compared our method (a scaled PCA/deep neural network [DNN] approach) to five other machine-learning methods. The area under the curve (AUC) value of our method was 83.48%; hence; it can be used by both patients and doctors to prescreen for possible stroke.

Care and Discharge Outcome of Acute Stroke in Lebanon: A Hospital-Based Study

The present study was conducted to assess stroke care and outcomes in two Lebanese hospitals. Patients admitted in 2012 and 2013 were retrospectively selected. Data were extracted from medical records for time to hospital arrival, stroke severity, management, and discharge outcomes. A Cox regression analysis was then conducted to predict time to in-hospital death. A total of 201 patients were included (mean age = 69.2 years), among whom 50% arrived within a delay of 3.75 hours. Half underwent brain imaging in the first hour, and nine patients received an acute intervention. Forty-four patients died at the hospital; 142 were discharged home, among whom 98 patients were dependent in their daily activities. Stroke severity on admission and time from onset to arrival were found to be significantly associated to the time to in-hospital death (adjusted hazard ratio [HRa] = 1.13 and HRa = 0.98 respectively; p < 0.05). The study sheds light on high case fatality and dependency rates at discharge among stroke patients in Lebanese hospitals.

Is the prescription right? A review of non-vitamin K antagonist anticoagulant (NOAC) prescriptions in patients with non-valvular atrial fibrillation. Safe prescribing in atrial fibrillation and evaluation of non-vitamin K oral anticoagulants in stroke prevention (SAFE-NOACS) group

BACKGROUND

Non-vitamin K antagonist oral anticoagulants (NOACs) are a major advance for stroke prevention in atrial fibrillation (AF). Use of the vitamin K antagonist (VKA), warfarin, has dropped 40% since 2010 in our institution. There is limited Irish hospital data on NOAC prescribing for stroke prevention.

METHOD

Single centre, retrospective observational cohort study of consecutive AF patients at increased risk of stroke and/or awaiting electrical cardioversion. Data on prescribed NOACs from February 2010 till July 2015 was collected from the electronic inpatient record. Appropriateness of prescriptions was based on CHA2DS2-VASC score and accuracy on individual NOAC SPCs. Potential drug interactions and bleeding risk were also quantified.

RESULTS

A total of 348 patients AF and increased risk of stroke (CHA2DS2-VASC score > 1 for men and > 2 for women) were studied. Forty-eight percent were female with a mean age 71 ± 18.6 years, 52% of whom were > 75. Mean CHA2DS2-Vasc and HAS-BLED scores were 4.1 ± 1.8 and 1.4 ± 0.8, respectively. Rivaroxaban, dabigatran and apixaban were prescribed to 154 (54.2%), 106 (34.3%) and 41 (13.2%) patients, respectively. 20.4% had inaccurate prescriptions; 92.9% (n = 65) underdosed and 7.1% (n = 5) on inappropriately higher doses. Neither choice of NOAC, age, history of anaemia, previous bleeding or co-prescribed antiplatelets influenced the accuracy of prescription (p = NS), but decreased renal function appeared to do so (p = 0.05).

CONCLUSION

Our study highlights significant inaccuracies in NOAC prescribing. Patients commenced on NOACs should be assessed and followed up in a multidisciplinary AF clinic to ensure safe and effective prescribing and stroke prevention.

European Stroke Organisation certification of stroke units and stroke centres

To improve quality and to overcome the wide discrepancies in stroke care both within- and between European countries, the European Stroke Organisation Executive Committee initiated in 2007 activities to establish certification processes for stroke units and stroke centres. The rapidly expanding evidence base in stroke care provided the mandate for the European Stroke Organisation Stroke Unit-Committee to develop certification procedures for stroke units and stroke centres with the goals of setting standards for stroke treatment in Europe, improving quality and minimising variation. The purpose of this article is to present the certification criteria and the auditing process for stroke units and stroke centres that aim to standardise and harmonise care for stroke patients, and hence become members of the European Stroke Organisation Stroke Unit and Stroke Centre network. Standardised application forms and guidelines for national and international auditors have been developed and updated by members of the European Stroke Organisation Stroke Unit-Committee. Key features are availability of trained personnel, diagnostic equipment, acute treatment and collaboration with other stroke-caregivers. After submission, the application is reviewed by one national and two international auditors. Based on their reports, the Stroke Unit-Committee will make a final decision. Validating on-site visits for a subset of stroke units and stroke centres are planned. We herein describe a novel, European Stroke Organisation-based online certification process of stroke units and stroke centres. This is a major step forward towards high-quality stroke care across Europe. The additional value by connecting high-quality European Stroke Organisation Stroke Unit and Stroke Centre is facilitation of future collaboration and research activities, enabling building and maintenance of a high-quality stroke care network in Europe.

Stroke networks and telemedicine: An Italian national survey

Stroke is the leading cause of disability and death. Nowadays, clinical benefits of stroke units and thrombolysis in ischemic stroke are evidence-based. Also the benefit of endovascular treatment for acute ischemic stroke has been established. Telemedicine has been used to improve access to care by allowing a neurologist at a remote location to interact with the patient and their family members. Prior studies have shown that the use of telemedicine for acute ischemic stroke is not only safe and effective, but it also increases the utilization of tPA, improving patient outcomes. This study aimed to investigate the diffusion of telemedicine in Italian stroke networks with an online questionnaire to assess: type of stroke care setting, Volume of thrombolysis- thrombectomy/year, access to stroke care between different hospitals, the presence of imaging sharing protocols within the network or patients dispatchment screening; type of network solutions. We have interviewed 24 Italian neurologists, working in large urban areas, from north southward, including Italian islands. In particular, these neurologists represented 14 different regions and 20 countries. A majority of neurologists replying to the survey (47.83%) worked in large general hospitals or smaller general hospitals (26%) and a smaller number of physicians (17.3%) were committed in University Hospital or (8.7%) independent foundation hospitals. The 60.87% of stroke networks involved in the survey had a low thrombolysis/year volume while the 30.43% had a thrombolysis/year volume above 100. According to the survey a local stroke network was established in 87.50% of cases. In the 45.83% of cases, the hospitals care is not homogeneous within the network. A network for the consultation of neuroimaging between hospitals is available in 33.33% of cases. Whitin those describing an active network for Teleconsult the 57.14% used personal devices, while only the 25 % use professional teleconference system, and in 25% of cases used medical devices. Our findings demonstrated a relevant diffusion of Teleconsult in Italian stroke networks. The systems adopted are mostly individual solutions not integrated in protocolled pathways. These findings may encourage a systematization of Telemedicine medical curricula to increase larger access to neurological consults.

Cortical modulation of cardiac autonomic activity in ischemic stroke patients

The cardiovascular system is regulated by the autonomic nervous system, under cortical modulation. Stroke can induce cardiac autonomic imbalance, therefore, causing secondary cardiovascular complications. Heart rate variability (HRV) analysis is a simple method to appraise the autonomic nervous function. The purpose of this study was to investigate the cardiac autonomic activity in patients that suffered an ischemic stroke in middle cerebral artery (MCA) territory. Using Biopac Acquisition System, we monitored ECG in rest condition and during Ewing's tests. From these measurements, HRV parameters (using time and frequency domain analysis) were determined in 20 right MCA and 20 left MCA ischemic stroke patients, in the first 6 months after the acute event. Data were compared with 20 age- and sex-matched healthy controls. All the patients were right handed. In ischemic stroke patients, HRV parameters were significantly modified compared to controls (p < 0.05) and we found asymmetric responses to different stimulation autonomic tests between right and left hemisphere. Parameters illustrating the parasympathetic predominance in time domain (RMSSD) and frequency domain (HF) analysis were higher in left hemisphere stroke compared to right hemisphere stroke patients (p < 0.01) in resting state. From Ewing's battery test, patients with left hemisphere ischemic stroke showed predominance of parasympathetic activity to deep breathing (p < 0.01), while HRV parameters in right hemisphere ischemic stroke patients described a reduced cardiac parasympathetic innervation (p < 0.01). Cardiac autonomic imbalance occurs more often after right hemisphere ischemic stroke. HRV study may highlight cardiac dysfunctions that increase the risk of cardiovascular complications and portends a poor long-term outcome.

Stroke and Thrombolysis in Developing Countries

Summary of review

The epidemiology of stroke is well investigated in the developed world; however, in the developing world stroke is less well documented. Most of the available stroke data from these countries are hospital-based. Stroke thrombolysis is currently used in few developing countries like Brazil, Argentina, Senegal, Iran, Pakistan, China, Thailand, and India. The two main barriers for implementation of thrombolysis therapy in developing countries are the high cost of tissue plasminogen activator and lack of proper infrastructure. Most of the centers with the infrastructure to deliver thrombolysis for stroke are predominantly private sector, and only available in urban areas.

Conclusion

Until a more cost-effective thrombolytic agent and the proper infrastructure for widespread use of thrombolysis therapy are available, developing nations should focus on primary and secondary stroke prevention strategies and the establishment of stroke units wherever possible. Such multi-faceted approaches will be more cost-effective for developing countries than the use of thrombolysis.

Prevalence of the Factor XIII Val34Leu Polymorphism in Korean Patients with Deep Vein Thrombosis

OBJECTIVE

According to recent reports, a common polymorphism resulting in Val to Leu substitution, located 3 amino acids (Val34Leu) upstream of the thrombin cleavage site of FXIII A, has been related to a lower incidence of deep vein thrombosis (DVT). And, a different expression pattern has been shown across nations and races. However, the frequency of FXIII polymorphism expression in Koreans has not been reported in normal individuals or DVT-patient groups.

DESIGN

Case-control study in Korean population.

METHODS

We investigated the distribution of factor XIII Val34Leu polymorphisms in Korean patients of DVT (50 cases) and Korean healthy controls (100 cases), using real-time polymerase chain reaction for single nucleotide polymorphism genotyping.

RESULTS

With regard to the frequency of the FXIII polymorphism in DVT patients and in the general control group, all 50 cases in the patient group and 100 cases in the control group were found to be Val34 homozygotes.

CONCLUSIONS

The Val34Leu polymorphism of FXIII was not found in Korean people, and compared with Caucasians, a noticeably low incidence of DVT was shown. Thus, the preventive effect of the Val34 allele of FXIII on the formation of thrombi was shown.

Improving Outcomes Achieved by a New Stroke Program in Hungary

Background

Stroke is a devastating disease with increasing incidence and prevalence due to population aging. Even with the best care, a proportion of patients dies or is left with significant neurological and cognitive disability. Organization of stroke centers markedly improved outcomes worldwide. We initiated a ‘lysis alarm’ program in September 2013 at our medical center.

Methods

This is a retrospective review of electronic data from patients with acute ischemic stroke before (October 2012-June 2013) and after (October 2013-June 2014) the ‘lysis alarm’ program was introduced at our medical center.

Results

Prior to the introduction of the stroke program, there were only 19 thrombolysis procedures in 777 acute stroke patients in 9 months, while this figure rose to 32 thrombolysis procedures in 737 acute stroke patients after the initiation of the program. The ‘door-to-needle’ time decreased from 88 to 71 min when the two study periods were compared. These changes were associated with decreased stroke mortality in patients receiving thrombolytic treatment (16% prior to the program and 9% during the program). In 2013, there were 1,439 thrombolysis procedures, representing 3.2% of all stroke cases throughout Hungary. After the introduction of the ‘lysis alarm’ program, we have reached a 4% thrombolysis rate at our medical center.

Conclusions

Our thrombolysis rate is higher than the national average, but still low compared to the rates of Western European countries. We are continuously working to enhance our stroke program. Here, we discuss those components that need to be further refined in order to improve stroke intervention and outcome.

Management of ischemic stroke in Central and Eastern Europe

Stroke is one of the leading causes of disability in Europe. Central and Eastern European countries have the highest incidence and mortality rates through Europe. The improvements in stroke prevention and treatment in Central and Eastern European countries did not completely reach the quality parameters present in Western European countries. We present features of current management of stroke in Central and Eastern European countries.

A review of technological and clinical aspects of robot-aided rehabilitation of upper-extremity after stroke

Cerebrovascular accident (CVA) or stroke is one of the leading causes of disability and loss of motor function. Millions of people around the world are effected by it each year. Stroke results in disabled arm function. Restoration of arm function is essential to regaining activities of daily living (ADL). Along with traditional rehabilitation methods, robot-aided therapy has emerged in recent years. Robot-aided rehabilitation is more intensive, of longer duration and more repetitive. Using robots, repetitive dull exercises can turn into a more challenging and motivating tasks such as games. Besides, robots can provide a quantitative measure of the rehabilitation progress. This article overviews the terms used in robot-aided upper-limb rehabilitation. It continues by investigating the requirements for rehabilitation robots. Then the most outstanding works in robot-aided upper-limb rehabilitation and their control schemes have been investigated. The clinical outcomes of the built robots are also given that demonstrates the usability of these robots in real-life applications and their acceptance. This article summarizes a review done along with a research on the design, simulation and control of a robot for use in upper-limb rehabilitation after stroke. Implications for Rehabilitation Reviewing common terms in rehabilitation of upper limb using robots Reviewing rehabilitation robots built up to date Reviewing clinical outcomes of the mentioned rehabilitation robots.

The influence of dynamic orthosis training on upper extremity function after stroke: a pilot study

The goal of this study was to assess the use of a dynamic orthosis on upper extremity function in chronic stroke patients. A case series approach was utilized, with provision of a training program (3x/week, 50 minutes/session for 8 weeks) and employment of a dynamic orthosis. Six volunteers with persistent hemiparesis due to a single, unilateral stroke performed task-oriented movements with the aid of a dynamic orthosis. Tests were administered before and after training. Functional capacity was assessed using the TEMPA (Test d'Évaluation des Membres Supérieurs de Personnes Âgées) test. The Wilcoxon test was used for pre-training and post-training comparisons of TEMPA scores. The volunteers showed significant improvement of upper extremity function in the performance of a bilateral task (p = 0.01) and three unilateral tasks (p = 0.04). This pilot study suggests that the dynamic orthosis associated with the performance of functional tasks can have positive outcomes regarding the improvement of functional capacity of upper extremity.

Management of acute ischemic stroke

Stroke is one of the most common causes of morbidity and mortality in hospitalized patients in the United States. A proper understanding of stroke mechanisms helps to guide specific case management. The only therapy approved by the US Food and Drug Administration for the management of acute ischemic stroke is initiation of intravenous recombinant tissue plasminogen activator within 3 hours of symptom onset. Other treatment options include intra-arterial recombinant tissue plasminogen activator, mechanical thrombectomy, clot retrieval, or a combination of these approaches. In this article, we provide an evidence-based review of the diagnostic approach for acute ischemic stroke, including recognizing common stroke mimics. We detail the initial medical management of acute stroke and the medical and surgical therapeutic interventions for patients who have sustained acute ischemic stroke.

Stroke care in Central Eastern Europe: current problems and call for action

Stroke is a major medical problem and one of the leading causes of mortality and disability all over in Europe. However, there are significant East-West differences in stroke care as well as in stroke mortality and morbidity rates. Central and Eastern European countries that formerly had centralized and socialist health care systems have serious and similar problems in organizing health and stroke care 20 years after the political transition. In Central and Eastern Europe, stroke is more frequent, the mortality rate is higher, and the victims are younger than in Western Europe. High-risk patients live in worse environmental conditions, and the socioeconomic consequences of stroke further weaken the economic development of these countries. To address these issues, a round table conference was organized. The main aim of this conference was to discuss problems to be solved related to acute and chronic stroke care in Central and Eastern European countries, and also, to exchange ideas on possible solutions. In this article, the discussed problems and possible solutions will be summarized, and introduce 'The Budapest Statement of Stroke Experts of Central and Eastern European countries'.

[Ebrictus study. Functional results, survival, and potential years of life lost after the first stroke]

AIM

To determine the mortality, degree of dependence, survival, and years of life lost (YLL) after first episode of stroke.

DESIGN

Cohort study.

LOCATION

Community based register.

PARTICIPANTS

A total of 553 subjects between 15-90 years with a first episode of definitive or transitory stroke were recruited between 01/04/2006 and 31/03/2008.

MEASUREMENTS

The analyses were performed with the use of time-to-event methods, according to the intention-to-treat principle. The level of dependency was assessed according to the Barthel Scale one year after stroke; YLL (1-70 years) from the mean life expectancies at birth; survival analysis by Kaplan-Meier's curves, bivariate analysis comparing the variables between patients who had survived and those who died, and Cox's multivariate.

RESULTS

The mean age was 73.3 (±11.6 years. The mean time of follow-up was 29.7 ± 13,4 months, during which 26.6% of the patients died. The mean Barthel score fell by >20%, particularly among women. There was moderate or greater dependence in 41.5% (95%CI 30.6-52.8%) of the subjects. The overall accumulative probability of survival was 0.96 (95% CI 0.94-0.97) in the first month and 0.69 (95% CI 0.65-0.72) in the fourth year. The thrombolytic treatment showed a protective effect on mortality, particularly among the women. The main predictive variables were, history of recurrent cardiovascular event (RR 6.7, 95% CI 2.2-21.7) and aging (RR 1.08, 95% CI 1.01-1.2). The average YLL was 11.5/10000/year SD7.2, and higher among men.

CONCLUSION

There are differences in functional outcome, mortality, and potential years of life lost by gender. A new cardiovascular event is an independent prognostic factor of survival.

A review on bio-cooperative control in gait rehabilitation

While gait rehabilitation robots have become increasingly common to automate treadmill training, their efficacy is still controversial. Current robots lack the ability to react compliantly to the user's voluntary effort and cognitive intention. Bio-cooperative control concepts allow integrating the patient into the control loop as part of the plant rather than seeing him as a source of disturbance. Closed loop control is thereby performed on a physiological and psychological level. In this paper, we review the concept of bio-cooperative control implemented with neurological patients during robot-assisted gait rehabilitation. We highlight its clinical importance and review our work on control strategies that allow bio-cooperative control. We finish by discussing the future potential of bio-cooperative control in rehabilitation robotics.

Effects of intensive arm training with an electromechanical orthosis in chronic stroke patients: a preliminary study

OBJECTIVES

To evaluate the use of an electromechanical device, comprising an exoskeleton, a static orthosis, and a glove, for functional rehabilitation of the elbow and hand in patients with hemiparesis, and to compare it with physical therapy rehabilitation.

DESIGN

Pretest-posttest design.

SETTING

Rehabilitation laboratory.

PARTICIPANTS

Volunteer sample of persons (N=12) with persistent hemiparesis from a single, unilateral stroke within the past 3 to 36 months.

INTERVENTIONS

The volunteers were randomly divided into 2 groups. One group was treated with a conventional program of physiotherapy, and another group participated in a training program in which an electromechanical orthosis was used. All volunteers received 24 sessions, held 3 times a week for 8 weeks.

MAIN OUTCOME MEASURES

Modified Ashworth Scale (MAS), Fugl-Meyer Assessment (FMA), and electromyogram (EMG) amplitude.

RESULTS

No statistical difference was found in the initial and final values of the MAS. Both groups showed a significant increase for the total scores of the FMA. However, only the group treated with the orthosis showed an increase in FMA scores related to the wrist and hand joint. The EMG analysis showed increased EMG amplitudes for all muscles in the group treated with the orthosis, whereas the group treated with physiotherapy showed gains in electromyographic activity only in the extensor digitorum communis. Intergroup comparison showed that the initial FMA scores of the wrist/hand were higher in the group treated with physiotherapy. However, after training, the scores in the group that used the orthosis were equivalent to those of the physiotherapy group.

CONCLUSIONS

The results suggest that this device can be an auxiliary tool to help the conventional rehabilitation program of motor function of the affected upper extremity.

[Cerebrovascular disease morbidity on the territory of the municipality of Doljevac]

INTRODUCTION

Cerebrovascular diseases have drawn great public attention recently due to a high death rate and an even higher disability rate. The aim of the research was to determine the basic descriptive-epidemic characteristics of patients with cerebrovascular diseases, to assess the incidence rate according to the gender and age, as well as mortality and the disease prognosis after one-year follow up period.

MATERIAL AND METHODS

A prospective survey was conducted, and the study included all registered patients with cerebrovascular diseases from the municipality of Doljevac in the period from 2005-2007, who were monitored for 1 year since the onset of the disease.

RESULTS

During the period monitored, there were a total of 230 patients suffering from this disease. The average standardised incidence rate in both genders was 274.67. Ischemic brain stroke occurred in 146 (63.4%) subjects, the intracerebral haemorrhage in 39 (17%) and the subarachnoid haemorrhage occurred in 9 (3.9%). The 90-day lethality was 14.8%; 1-year lethality was 21.7%. Out of 123 patients (53.4%), who were recorded to have various degree of disability, 44 (35.8%) were independent in everyday activities, 41 (33.3%) needed assistance while walking and maintaining personal hygiene, whereas 38 (30.9) were bedridden. After a year of monitoring, 30 (13.1%) patients suffered a recurrent brain stroke.

CONCLUSION

Cerebrovascular disease morbidity rate was found to be increasing. However, there were no statistically significant differences in morbidity by diagnosis and the disease outcome between genders.

Controlling patient participation during robot-assisted gait training

Background

The overall goal of this paper was to investigate approaches to controlling active participation in stroke patients during robot-assisted gait therapy. Although active physical participation during gait rehabilitation after stroke was shown to improve therapy outcome, some patients can behave passively during rehabilitation, not maximally benefiting from the gait training. Up to now, there has not been an effective method for forcing patient activity to the desired level that would most benefit stroke patients with a broad variety of cognitive and biomechanical impairments.

Methods

Patient activity was quantified in two ways: by heart rate (HR), a physiological parameter that reflected physical effort during body weight supported treadmill training, and by a weighted sum of the interaction torques (WIT) between robot and patient, recorded from hip and knee joints of both legs. We recorded data in three experiments, each with five stroke patients, and controlled HR and WIT to a desired temporal profile. Depending on the patient's cognitive capabilities, two different approaches were taken: either by allowing voluntary patient effort via visual instructions or by forcing the patient to vary physical effort by adapting the treadmill speed.

Results

We successfully controlled patient activity quantified by WIT and by HR to a desired level. The setup was thereby individually adaptable to the specific cognitive and biomechanical needs of each patient.

Conclusion

Based on the three successful approaches to controlling patient participation, we propose a metric which enables clinicians to select the best strategy for each patient, according to the patient's physical and cognitive capabilities. Our framework will enable therapists to challenge the patient to more activity by automatically controlling the patient effort to a desired level. We expect that the increase in activity will lead to improved rehabilitation outcome.

Oral antiplatelet therapy in stroke prevention. Minireview

BACKGROUND

Antiplatelet therapy plays a crucial role in the primary and secondary prevention of noncardioembolic ischemic stroke / transient ischemic attacks (IS/TIA). Several antiplatelet agents are available. This review deals with the characteristics of particular antiplatelet agents as well as choice of antiplatelet treatment in various situations, based on the evidence and international recommendations.

METHODS

PubMed and Stroke Trials Registry on-line databases and the European Stroke Organisation Guidelines for Management of IS/TIA 2008 and update of the recommendations of the American Heart Association / American Stroke Association Council 2008 on Stroke were used.

RESULTS

Acetylsalicylic acid (ASA) is the only antiplatelet drug used in primary prevention, mainly to reduce the risk of myocardial infarction (MI), but also in women aged 45 years or more and in some patients with non-valvular atrial fibrillation to reduce risk of IS/TIA. In the secondary prevention of noncardioembolic IS/TIA, ASA in combination with long release dipyridamole (DIP) and clopidogrel (CLOP) alone are considered first choice therapies. The choice of the particular antiplatelet agent should be individualized according to the patient risk factor profiles and treatment tolerance. ASA alone or triflusal can be used alternatively in patients who cannot be treated with either ASA+DIP or CLOP. The use of indobufen should be considered only in patients in need of temporary interruption of the antiplatelet therapy. Ticlopidine (TIC) should not be newly introduced into the treatment. Currently, insufficient data are available on the use of cilostazol in IS/TIA prevention.

Effects of intensive arm training with the rehabilitation robot ARMin II in chronic stroke patients: four single-cases

Background

Robot-assisted therapy offers a promising approach to neurorehabilitation, particularly for severely to moderately impaired stroke patients. The objective of this study was to investigate the effects of intensive arm training on motor performance in four chronic stroke patients using the robot ARMin II.

Methods

ARMin II is an exoskeleton robot with six degrees of freedom (DOF) moving shoulder, elbow and wrist joints. Four volunteers with chronic (≥ 12 months post-stroke) left side hemi-paresis and different levels of motor severity were enrolled in the study. They received robot-assisted therapy over a period of eight weeks, three to four therapy sessions per week, each session of one hour.

Patients 1 and 4 had four one-hour training sessions per week and patients 2 and 3 had three one-hour training sessions per week. Primary outcome variable was the Fugl-Meyer Score of the upper extremity Assessment (FMA), secondary outcomes were the Wolf Motor Function Test (WMFT), the Catherine Bergego Scale (CBS), the Maximal Voluntary Torques (MVTs) and a questionnaire about ADL-tasks, progress, changes, motivation etc.

Results

Three out of four patients showed significant improvements (p < 0.05) in the main outcome. The improvements in the FMA scores were aligned with the objective results of MVTs. Most improvements were maintained or even increased from discharge to the six-month follow-up.

Conclusion

Data clearly indicate that intensive arm therapy with the robot ARMin II can significantly improve motor function of the paretic arm in some stroke patients, even those in a chronic state. The findings of the study provide a basis for a subsequent controlled randomized clinical trial.

Use of time by physiotherapists and occupational therapists in a stroke rehabilitation unit: A comparison between four European rehabilitation centres

PURPOSE

The aim of this study was to compare the time allocated to therapeutic activities (TA) and non-therapeutic activities (NTA) of physiotherapists (PT) and occupational therapists (OT) in stroke rehabilitation units in four European countries.

METHOD

Therapists documented their activities in 15-min periods for two weeks. They recorded: activity, number of patients, number of stroke patients, involvement of other people, location and frequency of each activity. Kruskal-Wallis tests and negative binomial regression models were used to compare activities between professional groups and between units.

RESULTS

The average proportion of TA per day ranged between 32.9% and 66.1% and was higher for PT than for OT in each unit. For OT, significant differences emerged between the units in the proportion of time allocated to TA compared to NTA with British OTs spending significantly less time in TA. In the Belgian unit, three times less time was spent on patient-related co-ordination activities (e.g., administration, ward rounds) compared to the British and Swiss units.

CONCLUSIONS

Time allocation differed between PT and OT and between units, affecting the time available for TA. Further investigation is necessary to study the effect of work organization in stroke rehabilitation units on the efficiency of rehabilitation regimes.

Stroke Units: Many Questions, Some Answers

Background The development of specialized stroke units has been a landmark innovation in acute stroke care. However, the high scientific evidence level for the recommendation for stroke units to provide clinical attention for acute stroke patients does not correspond to the level of stroke unit implementation. A narrative, nonsystematic review on published studies on stroke units was conducted, with special emphasis on those demonstrating their efficacy and effectiveness. We also attempt to provide some answers to several open questions regarding practical issues of stroke units.

A review of the early discharge experiences of stroke survivors and their carers

AIMS AND OBJECTIVES

Understanding the experiences of stroke patients and their carers during the early days following discharge from hospital is an important aspect of providing appropriate care during this crucial time.

BACKGROUND

Due to the diverse changes that can result from a stroke, adjustment to returning home may raise many issues for those involved. A review of research was undertaken with the aim of identifying what is already known about experiences at this time.

DESIGN

Systematic review.

METHOD

Search of electronic databases.

RESULTS

The review revealed that recognition of the impact of stroke on patients and carers is improving, with many studies focussing on the longer-term aspects of stroke recovery. Research into the early discharge experiences of stroke patients and/or their carers is often limited to retrospective, longitudinal studies. With the continuing shift towards care in the community, patients and carers can increasingly expect more recovery to be taking place at home at an even earlier stage. Earlier discharge may have important implications for those involved. The review also highlighted that patients with aphasia have frequently been excluded from stroke research and that social roles are important aspects in stroke recovery.

CONCLUSIONS

To prepare patients and carers better for the impact of returning home, further research is needed into their experiences at this significant time, particularly in the UK. There is also a need to facilitate the inclusion of those with aphasia in stroke research.

RELEVANCE TO CLINICAL PRACTICE

An improved understanding of the issues facing stroke patients and carers during their early days at home should facilitate the preparation for discharge in the hospital setting and allow more focussed follow-up services in the community.

Guidelines for management of ischaemic stroke and transient ischaemic attack 2008

This article represents the update of the European Stroke Initiative Recommendations for Stroke Management. These guidelines cover both ischaemic stroke and transient ischaemic attacks, which are now considered to be a single entity. The article covers referral and emergency management, Stroke Unit service, diagnostics, primary and secondary prevention, general stroke treatment, specific treatment including acute management, management of complications, and rehabilitation.

Patients' and bystanders' awareness of stroke and pre-hospital delay after stroke onset: perspectives for thrombolysis in West Pomerania Province, Poland

OBJECTIVE

Thrombolysis is a time-dependent therapy. It is therefore very important how fast stroke patients can reach hospital. The present study was designed to assess which proportion of patients with stroke (from the population of Szczecin, the capital of West Pomerania Province, Poland) reaches hospital within the recommended time from the thrombolytic therapy point of view. The purpose of our study was also to elucidate which factors can influence the time before the ambulance service is called.

PATIENTS AND METHODS

The study involved 1,015 patients with stroke admitted to the Emergency Department of the University Hospital, Szczecin.

RESULTS

235 patients (23.1%) were admitted to the hospital within the appropriate period for thrombolytic therapy. Hospital arrival time was significantly earlier in older patients and in patients with severer neurological deficits. We also observed a tendency for faster hospitalization of women, the highly educated, and patients regularly using antiplatelet drugs for cardiovascular disease prevention.

CONCLUSIONS

The percentage of stroke patients hospitalized within 2 h after stroke onset should be increased. The most susceptible subpopulations in our country seem to be older patients, the highly educated and patients regularly using antiplatelet drugs for cardiovascular disease prevention.

Stroke-unit care for acute stroke patients: an observational follow-up study

BACKGROUND

Large numbers of stroke patients arrive at hospital at a very early stage, and effective treatments for the acute phase of the disease are available. However, evidence that patients with acute stroke benefit from stroke-unit care is scarce. Our aim was to determine whether admission to a stroke unit, rather than a conventional ward, affected the outcome of patients with acute stroke.

METHODS

We did an observational follow-up study of 11 572 acute stroke patients hospitalised within 48 h of the onset of symptoms either in a stroke unit (n=4936) or in a conventional ward (6636). Patients were identified retrospectively from discharge records from 260 Italian hospitals. The primary outcome was mortality or disability (Rankin score greater than two), assessed prospectively by independent, masked assessors 2 years after admission. Analyses were adjusted for patient characteristics and clustered at the hospital level.

FINDINGS

Overall, 1576 patients died in hospital; 2169 died during the follow-up period. 347 patients were lost to follow-up. Compared with conventional-ward care, stroke-unit care was associated with a reduced probability of death or being disabled at the end of follow-up (odds ratio 0.81, 95% CI 0.72-0.91; p=0.0001). The potential benefit was significant across all age ranges and clinical characteristics, except for unconsciousness. No specific elements of setting, organisation, or process of care were associated with outcome.

INTERPRETATION

Admission to a stroke-unit ward with dedicated beds and staff within 48 h of onset should be recommended for all patients with acute stroke.

First experience with intravenous thrombolysis in ischemic stroke in Serbia

Introduction Systemic thrombolytic therapy in the first three hours of acute ischemic stroke (IS) significantly improves its outcome. This therapy was approved for treatment in USA in 1997, and in most European countries in 2002. First intravenous thrombolysis of IS in Serbia was carried out in February 2006. Objective We present our preliminary experience with intravenous thrombolysis in treating patients with acute IS and compare it with the results of other clinical studies. Method All patients with IS treated with intravenous thrombolysis in our department were included in the study. The time of stroke onset, first neurological exam, time of CT exam and beginning of therapy were recorded. The early CT signs of ischemia were graded by the ASPECTS score. Neurological deficit was assessed with NIHSS score and functional outcome with modified Rankin Scale (mRS). Results During the eight-month period intravenous thrombolysis was given to 12 patients with acute IS, aged 18 to 66 years, of whom 75% were younger than 55 years. Median time from symptom onset to hospital door was 57.5 minutes, median time door-to-CT was 32.5 minutes, and the time from symptom onset to treatment was 155 minutes. Early CT signs of ischemia were present in 10 patients with median ASPECTS score 9. Median initial NIHSS score was 16.5 with its decline during the first 24 hours for at least 5 points in 58% of patients. Symptomatic intracerebral haemorrhage was present in one patient. After 30 days of follow-up 42% of patients had favourable outcome (mRS?1). In only 2 patients the outcome was poor (mRS 4-5). One patient died with signs of cardiac failure. Conclusion Despite a small number of patients with short time of follow up, these results with thrombolysis in acute IS were found to be consistent with other authors? reports. Uniqueness of our series of patients who received thrombolysis as compared to other studies was their very young age.

Early surgical treatment vs conservative management for spontaneous supratentorial intracerebral hematomas: A prospective randomized study

BACKGROUND

Treatment of primary SICH is still controversial. The aim of this study was to investigate the effectiveness of craniotomy and early hematoma evacuation vs nonoperative management in patients with SICH.

METHODS

A prospective randomized study of craniotomy and early hematoma removal vs best medical management was performed in 108 patients with primary SICH. Surgical or medical treatment was initiated within 8 hours post ictus. Principal eligibility criterium was the presence of neurologic impairment associated with a spontaneous subcortical or putaminal hemorrhage bigger than 30 mL. Outcomes were assessed at 1 year post ictus.

RESULTS

Analysis of outcome revealed a significantly higher percentage of GOS scores higher than 3 for the surgical patients, compared with those of the conservative group (33% and 9%, respectively; P < .05). By contrast, the mortality rates between operated and conservatively managed patients did not differ significantly. The main prognostic variables were the initial neurologic status, hematoma volume, and location. Stratifications of these parameters and analysis showed that the positive effect of surgery on the quality of survival was statistically not valid for patients with GCS scores lower than 8 or ICH volumes 80 mL or higher at the time of enrollment.

CONCLUSIONS

The study demonstrates that surgical patients with subcortical or putaminal hematomas showed better functional results than their conservatively treated counterparts. However, early ICH evacuation failed to improve the survival rates, as compared with best medical management.

Which model of stroke unit is better for stroke patient management?

The increasing prevalence of cerebrovascular diseases has made urgent the need to develop timely and effective treatment strategies to tackle this health problem. Stroke units (SUs) appear to be the ideal setting where the management of acute stroke patients, including specific treatments as thrombolysis, may be optimized. Which model of SU gives the best results is still an unsettled issue. The more intensive and timely multidisciplinary approach to the acute phase of stroke, the management of medical complications, and the earlier and more focused rehabilitation, are likely the most qualifying aspects of our Neurovascular treatment unit.

Model of Hospital-Supported Discharge After Stroke

Background and Purpose— Readmission rate within 6 months after a stroke is 40% to 50%. The purpose of the project was to evaluate whether an interdisciplinary stroke team could reduce length of hospital stay, readmission rate, increase patient satisfaction and reduce dependency of help.

Methods— One hundred and ninety-eight patients with acute stroke were randomized into 103 patients whose discharge was supported by an interdisciplinary stroke team and 95 control patients who received standard aftercare. Baseline characteristics were comparable in the 2 groups. The patients were evaluated after 6 and 12 months regarding functional status and need for help.

Results— Length of hospital admission was insignificantly shorter in the intervention compared with the control group (35.2 versus 39.8 days). There was no significant difference in readmission, GP-visits, and primary health care services. Furthermore, there was no significant difference in functional scores or patient satisfaction.

Conclusions— In this setting we could not show benefit of an interdisciplinary stroke team supporting patients at discharge perhaps because standard aftercare was very efficient already.

National variations in mortality and functional outcome: should we be worried?

International registries should be established to monitor process and outcome of care after stroke

Significant variation in mortality and functional outcome after acute ischaemic stroke between Western countries: data from the tinzaparin in acute ischaemic stroke trial (TAIST)

BACKGROUND

The medical care of patients with acute stroke varies considerably between countries. This could lead to measurable differences in mortality and functional outcome.

OBJECTIVE

To compare case mix, clinical management, and functional outcome in stroke between 11 countries.

METHODS

All 1484 patients from 11 countries who were enrolled into the tinzaparin in acute ischaemic stroke trial (TAIST) were included in this substudy. Information collected prospectively on demographics, risk factors, clinical features, measures of service quality (for example, admission to a stroke unit), and outcome were assessed. Outcomes were adjusted for treatment assignment, case mix, and service relative to the British Isles.

RESULTS

Differences in case mix (mostly minor) and clinical service (many of prognostic relevance) were present between the countries. Significant differences in outcome were present between the countries. When assessed by geographical region, death or dependency were lower in North America (odds ratio (OR) adjusted for treatment group only = 0.52 (95% confidence interval, 0.39 to 0.71) and north west Europe (OR = 0.54 (0.37 to 0.78)) relative to the British Isles; similar reductions were found when adjustments were made for 11 case mix variables and five service quality measures. Similarly, case fatality rates were lower in North America (OR = 0.44 (0.30 to 0.66)) and Scandinavia (OR = 0.50 (0.33 to 0.74)) relative to the British Isles, whether crude or adjusted for case mix and service quality.

CONCLUSIONS

Both functional outcome and case fatality vary considerably between countries, even when adjusted for prognostic case mix variables and measures of good stroke care. Differing health care systems and the management of patients with acute stroke may contribute to these findings.

Virtual reality in brain damage rehabilitation: review

Given the high incidence of brain injury in the population, brain damage rehabilitation is still a relatively undeveloped field. Virtual reality (VR) has the potential to assist current rehabilitation techniques in addressing the impairments, disabilities, and handicaps associated with brain damage. The main focus of much of the exploratory research performed to date has been to investigate the use of VR in the assessment of cognitive abilities, but there is now a trend for more studies to encompass rehabilitation training strategies. This review describes studies that have used VR in the assessment and rehabilitation of specific disabilities resulting from brain injury, including executive dysfunction, memory impairments, spatial ability impairments, attention deficits, and unilateral visual neglect. In addition, it describes studies that have used VR to try to offset some of the handicaps that people experience after brain injury. Finally, a table is included which, although not an exhaustive list of everything that has been published, includes many more studies that are relevant to the use of VR in the assessment and rehabilitation of brain damage. The review concludes that the use of VR in brain damage rehabilitation is expanding dramatically and will become an integral part of cognitive assessment and rehabilitation in the future.

Risk factors and in-hospital outcomes in stroke and myocardial infarction patients

BACKGROUND

Acute stroke (AS) and acute myocardial infarction (AMI) share major risk factors such as age, gender, and high blood pressure. The main objective of this study was to compare vascular risk factor profiles with in-hospital outcomes in AS and AMI patients.

METHODS

We evaluated 486 consecutive patients who were admitted to Bjelovar General Hospital with diagnoses of AS (ischaemic stroke or intracerebral haemorrhage; N = 380) or AMI (N = 106) during a one year period. The frequency of risk factors and in-patient mortality rates were assessed in both groups. For statistical analysis we used t-tests and chi2 tests.

RESULTS

AS patients were significantly older than AMI patients: the mean age for AS patients was 68.9 +/- 9.1 years, and for AMI patients was 62.8 +/- 11.7 years (p < 0.001). AMI was significantly more common than AS in patients younger than 65 years; 51% of this group had AMI and 26% had AS (p < 0.001). Hypertension was a more common risk factor in AS patients (69% AS patients vs. 58% AMI patients; p = 0.042). Patients who died did not differ significantly in age between the groups. In-patient mortality rates were significantly higher in AS than AMI cases (31% vs. 12%, p < 0.001 for all patients; 37% vs.5%, p < 0.001 for men). Women hospitalized for AMI were more likely to die in hospital than men (28% vs. 5%; p = 0.002).

CONCLUSIONS

We found that age at the time of presentation was a significant differentiating factor between patients with AS and AMI. The only exceptions were women, whose ages at the onset of AS and AMI were similar. In contrast, patients who died did not differ significantly in age. We observed significantly higher inpatient mortality for men (when adjusted for age) than for women with AS. The five-fold higher in-patient mortality rate in women than in men with AMI is most likely to have resulted from other factors related to treatment.

The quality of acute stroke units on a nation-wide level: the Austrian Stroke Registry for acute stroke units

Concepts for stroke units that cover the acute phase vary. Therefore, the network of acute stroke units that is being set up in Austria in a uniform way is of general interest. This nationwide network has been established in accordance to evidence-based recommendations and prespecified criteria for available resources. The location for such a unit follows a maximum of 90-min isochrones (transport time) to the hospital. The quality of the network is currently documented and the results are reported. A nationwide stroke registry was prospectively performed on 15 stroke units that were already functional in this network. The aim was to document the quality performance of Austrian stroke units, focusing on rapid admissions, ready availability of investigations and therapies performed. Outcome measures were Barthel scale, Rankin score and percentages of complications. Between August 1998 and December 2000, 2,313 patients with ischemic stroke or with primary intracerebral hemorrhage admitted to an Austrian stroke unit within 24 h after onset of symptoms were prospectively included. Forty-three percent of the patients had a moderate or severe stroke. Fifty-seven percent of all patients were admitted to the stroke unit within 3 h after the onset of symptoms. Twenty-seven percent of these patients were brought in by ambulance accompanied by an emergency physician. Two percent of patients were admitted by helicopter. Fifty-four percent of patients had their first brain imaging within 30 min after admission, another 26% within 3 h. Intravenous thrombolysis was performed in 4.1% of patients. The overall stroke-unit mortality was about 6.8% and mortality at 3 months was 12.9%. The outcome at 3 months showed a modified Rankin Scale score of 0 or 1 in 47% of patients, denoting none or mild impairment. This network of acute stroke units is highly efficient in terms of rapid admissions, short intrahospital delays, as well as rapid use of readily available investigations. Stroke units seem to be well accepted by the general public and the medical community because our data show that all types of strokes are treated in Austrian stroke units, including severe strokes. The total number of concurrently treated acute strokes in other institutions across Austria is not known and no formal comparison with other systems of hospitalized care was undertaken, therefore further research is necessary.

Acute stroke treatment in Europe: a questionnaire-based survey on behalf of the EFNS Task Force on acute neurological stroke care

In 1997 the EFNS Task Force on Acute Neurological Stroke Care published its recommendations for acute stroke care (Brainin et al., 1997), which, in 1999, was followed by a stroke care inventory (Brainin et al., 2000) assessing the development of acute stroke care. In 2000 all 33 members of the EFNS Stroke Scientist Panel were asked to complete a questionnaire on the treatment of acute stroke in their country as of 2000. Data were based either on national surveys or a personal estimate of national practice, together with data from the personal practice of the panel member. Data from 22 countries were received. One of the principal findings is the lack of systematic evidence about practice in a significant number of European countries. Results illustrate that neurologists have a leading role in implementing acute stroke treatment guidelines and in adopting new therapeutic methods in most countries, but there is a wide variation in the application of different therapeutic procedures.

Aging has a complex effect on a rat model of ischemic stroke

Stroke in humans is usually associated with advanced age. Nevertheless, almost all animal models of ischemic stroke are based on young animals. The present study was designed to assess the effect of age on the development of ischemic injury in a model of focal brain ischemia in rats. Two age groups of Wistar rats were used: young adult (3 months) and old (24-26 months). Under halothane anesthesia, polyethylene microspheres (50 microm in diameter) were injected into the left common carotid artery following a temporary occlusion of the external carotid artery. Sham-operated rats underwent the same procedure but were injected with an identical volume (100 microl) of saline only. Rats of both experimental groups displayed neurological impairment after surgery. However, contrary to expectation, the young rats were more affected than the old rats. Young rats displayed an abrupt 30% decrement in neurological functions in the first week and then showed a partial functional recovery into a 12% decrement from the second week on. Old rats developed the neurological impairment gradually over a 2-week period (6.3% in the first week and 11% in the second week and thereafter). One month later, rats were tested in a water maze task. Again, performance was more impaired in the young ischemic rats than in the old rats. Histological evaluation revealed more extensive neurological damage in young ischemic as compared to old rats. Thus, although increased age has a critical effect on the evolution of the neurological impairment following focal brain ischemia and stroke, its effects in the rat model were more pronounced in the young animals.

A population study of stroke in West Ukraine: incidence, stroke services, and 30-day case fatality

BACKGROUND AND PURPOSE

According to World Health Organization statistics, Ukraine has extremely high stroke mortality. No population-based prospective studies of stroke incidence have been performed yet in this European country with approximately 50 million inhabitants. High reported rates of stroke mortality in official statistics conflict with some locally published incidence data in Ukraine. To obtain accurate data, we evaluated stroke incidence and 30-day case fatality in a prospective population study in the West Ukrainian city of Uzhgorod with a population of 126 000 inhabitants.

METHODS

Case certification by neurologists and follow-up at 30 days after stroke for all patients identified by any level of the health service system were performed for a 12-month period.

RESULTS

We identified 352 stroke cases. The age-standardized incidence was 341 and 238 of 100 000 and mortality was 83 and 69 of 100 000 with the use of the European or world standard population for standardization. Mean age of stroke patients was 63.4+/-12.5 years. Rate of hospitalization was 66%. Hospitalized patients were >10 years younger than those treated in their homes. The 30-day case fatality rates were 15.4% among hospitalized patients and 36.8% among those treated at home. Overall 30-day case fatality was 23.3%.

CONCLUSIONS

Stroke incidence and 30-day case fatality in this West Ukrainian city were similar to those of some West European countries and were much lower than what could be expected from World Health Organization statistics. The relatively low incidence rate seems accurate; because of the organization of local stroke services, it is not probable that a considerable proportion of patients with acute stroke could bypass all levels of the acute care health system. Local health statistics reported a much lower number of stroke cases and stroke deaths than found in our survey; thus, further study is needed to clarify the reason for the discrepancy between local data and the high reported stroke mortality in Ukraine.