Accuracy of NIH Stroke Scale for diagnosing aphasia

Prediction of Upper Limb Motor Recovery by the PREP2 Algorithm in a Nonselected Population: External Validation and Influence of Cognitive Syndromes

BACKGROUND

Early prediction of poststroke motor recovery is challenging in clinical settings. The Prediction recovery potential (PREP2) algorithm is the most accurate approach for prediction of Upper Limb function available to date but lacks external validation.

OBJECTIVES

(i) To externally validate the PREP2 algorithm in a prospective cohort, (ii) to study the characteristics of patients misclassified by the algorithm, and (iii) to compare the performance according to the presence of cognitive syndromes (aphasia, neglect, cognitive disorders).

METHODS

We enrolled 143 patients with stroke and upper extremity weakness persistent at Day 3. Evaluation to predict the recovery status according to the PREP2 algorithm included age, SAFE and NIHSS scores at Day 3 and transcranial magnetic stimulation to determine the presence of the motor-evoked potential before day seven. Actual recovery (excellent, good, limited, or poor) was defined based on the Action Research Arm test score at 3 months. Accuracy was computed by comparing the predictions of the PREP2 and the actual category of the patient. Additionally, to investigate misclassifications and the impact of cognitive syndromes, we recorded SAFE and NIHSS scores at Day 7, the Montreal Cognitive Assessment (MoCA) score, the presence of aphasia and neglect and Magnetic Resonance Imaging was used to evaluate the corticospinal tract lesion load.

RESULTS

The PREP2 algorithm showed a very good predictive value with 78% accuracy [95% CI: 71.2%-86.1%], especially for the extreme categories of recovery (EXCELLENT 87.5% [95% CI: 78.9%-96.2%] and POOR 94.9% [95% CI: 87.9%-100%]), and only 46.5% [95% CI: 19.05%-73.25%] for the GOOD category and even worse than chance for the LIMITED category 0%. Pessimistic predictions (false-negative cases) had a drastic improvement in the SAFE score acutely compared to that of well-predicted patients with unfavorable recovery (P < 001). The predictive value of PREP2 decreased significantly when patients had cognitive disorders (MoCA score <24) versus not (69.4% [95% CI: 52.8%-86.1%] vs 93.1% [95% CI: 83.9%-100%], P = .01).

CONCLUSION

Our study provides an external validation of the PREP2 algorithm in a prospective population and underlines the importance of taking into account cognitive syndromes in motor recovery prediction.

Return to work for stroke survivors with aphasia: A quantitative scoping review

The international incidence of stroke in people of working age is rising. As such, meaningful work return is a major rehabilitation goal for many individuals, including those with aphasia. This scoping review aimed to outline the post-stroke aphasia evidence related to work outcomes, factors influencing employment along with contemporary vocational-language and communication rehabilitation practice. The review employed terms related to aphasia, stroke, rehabilitation, and return to work in publications preceding 25.6.2023. Data were descriptively analysed, and vocational outcomes were summarized at defined timepoints. Of the 908 articles reviewed, 31 papers were included. Individuals with post-stroke aphasia consistently have lower rates of return to work than those post-stroke without aphasia. Employment at one year was 34.29% for those with aphasia compared to 58.46% for people without aphasia. No literature reported vocational-language assessment practices and there were minimal work-focused aphasia interventions identified. There was insufficient evidence to clearly identify person-related, rehabilitation, workplace or other factors influencing work return. This scoping review has identified that there are gaps in knowledge about the factors that influence work return and targeted vocational rehabilitation for this group. Future research to optimize return to work for individuals with aphasia is recommended.

An exploratory study of longitudinal trajectory of language, swallowing and cognition post endovascular clot retrieval

BACKGROUND

Endovascular clot retrieval (ECR) is known to reduce global disability at 3 months post stroke however limited research exists regarding the trajectory of specific clinical impairments including language, swallowing and cognitive deficits between onset and 3 months.

AIMS

To assess language, swallowing, and cognitive performance following ECR and explore whether impairment severity is correlated with modified Thrombolysis in Cerebral Infarction score (mTICI), stroke severity or quality of life (QoL).

METHODS

Assessment was completed within 7 days (T1), 1 month (T2) and 3 months (T3) post-stroke. Performance was measured with the Functional Oral Intake Scale (FOIS), Repeatable Battery for Assessment of Neuropsychological Status (RBANS), Trail Making Test (TMT A and B) and Brixton Spatial Awareness Test. The Western Aphasia Battery (WAB) was used for left hemisphere stroke. QoL was measured with the Stroke and Aphasia Quality of Life Scale.

RESULTS

Twenty-five participants (median 72 years; 64% male) were prospectively recruited following ECR. High reperfusion success (68% mTICI 3) and low stroke severity post ECR (median 24 h NIHSS = 3, IQR 7-18) were noted. At T1, 10 participants presented with aphasia, eight required a modified diet and 20 had impaired cognition. At T3 all had recovered to a normal oral diet, 39% had persistent cognitive impairment and 45% of patients with left hemisphere stroke remained aphasic. Performance on the WAB, FOIS, RBANS and TMT changed significantly over time (all p < 0.05). The severity score at T1 for all measures, excluding TMT B and Brixton, was significantly correlated with 24 h NIHSS. WAB scores at T3 were correlated with QoL (r = 0.618; p = 0.043).

CONCLUSION

This exploratory study found the longitudinal performance of language, swallowing and cognition significantly improved over time and severity in the first-week post-ECR was correlated with 24 h NIHSS rather than the degree of reperfusion.

WHAT THIS PAPER ADDS

What is already known on the subject Randomised control trials have demonstrated the benefit of ECR in patients with ischemic stroke using global measures of disability and function. Limited research exists regarding the trajectory of specific clinical impairments including language, swallowing and cognitive deficits. There is also a reliance on screening assessments and a lack of consideration of the influence of co-occurring impairments. What this paper adds to existing knowledge This prospective study is amongst the first to explore the longitudinal trajectory of language, swallowing and cognitive impairment using a standardised assessment battery. Twenty-four-hour NIHSS was significantly correlated with language, swallowing, global cognition and some measures of executive function. Language performance post ECR was correlated with domain-specific cognitive assessment of attention, immediate memory and delayed memory, which differed from swallowing performance post ECR that correlated with measures of executive function. What are the potential or actual clinical implications of this work? It is important for speech-language pathologists and the wider medical team to monitor language, swallowing and cognitive performance post ECR regardless of treatment success. Stroke severity at 24 h post-ECR influences the severity of language, swallowing and cognitive impairments.

Meta-analysis and systematic review of the relationship between sex and the risk or incidence of poststroke aphasia and its types

OBJECTIVE

To analyse and discuss the association of gender differences with the risk and incidence of poststroke aphasia (PSA) and its types, and to provide evidence-based guidance for the prevention and treatment of poststroke aphasia in clinical practice.

DATA SOURCES

Embase, PubMed, Cochrane Library and Web of Science were searched from January 1, 2002, to December 1, 2023.

STUDY SELECTION

Including the total number of strokes, aphasia, the number of different sexes or the number of PSA corresponding to different sex.

DATA EXTRACTION

Studies with missing data, aphasia caused by nonstroke and noncompliance with the requirements of literature types were excluded.

DATA SYNTHESIS

36 papers were included, from 19 countries. The analysis of 168,259 patients with stroke and 31,058 patients with PSA showed that the risk of PSA was 1.23 times higher in female than in male (OR = 1.23, 95% CI = 1.19-1.29, P < 0.001), with a prevalence of PSA of 31% in men and 36% in women, and an overall prevalence of 34% (P < 0.001). Analysis of the risk of the different types of aphasia in 1,048 patients with PSA showed a high risk in females for global, broca and Wenicke aphasia, and a high risk in males for anomic, conductive and transcortical aphasia, which was not statistically significant by meta-analysis. The incidence of global aphasia (males vs. females, 29% vs. 32%) and broca aphasia (17% vs 19%) were higher in females, and anomic aphasia (19% vs 14%) was higher in males, which was statistically significant (P < 0.05).

CONCLUSIONS

There are gender differences in the incidence and types of PSA. The risk of PSA in female is higher than that in male.

The non-paretic-hand-to-opposite-ear test: A simple test to detect aphasia and neglect and an indicator of large anterior vessel occlusion in patients with suspected acute stroke

INTRODUCTION

Aphasia and neglect in combination with hemiparesis are reliable indicators of large anterior vessel occlusion (LAVO). Prehospital identification of these symptoms is generally considered difficult by emergency medical service (EMS) personnel. Therefore, we evaluated the simple non-paretic-hand-to-opposite-ear (NPE) test to identify aphasia and neglect with a single test. As the NPE test includes a test for arm paresis, we also evaluated the diagnostic ability of the NPE test to detect LAVO in patients with suspected stroke.

METHODS

In this prospective observational study, we performed the NPE test in 1042 patients with suspected acute stroke between May 2021 and May 2022. We analyzed the correlation between the NPE test and the aphasia/neglect items of the National Institutes of Health Stroke Scale. Additionally, the predictive values of the NPE test for LAVO detection were calculated.

RESULTS

The NPE test showed a strong, significant correlation with both aphasia and neglect. A positive NPE test result predicted LAVO with a sensitivity of 0.70, a specificity of 0.88, and an accuracy of 0.85. Logistic regression analysis showed an odds ratio of 16.14 (95% confidence interval 10.82-24.44) for predicting LAVO.

CONCLUSION

The NPE test is a simple test for the detection of both aphasia and neglect. With its predictive values for LAVO detection being comparable to the results of LAVO scores in the prehospital setting, this simple test might be a promising test for prehospital LAVO detection by EMS personnel. Further prospective prehospital validation is needed.

Incidence of post-stroke depression symptoms and potential risk factors in adults with aphasia in a comprehensive stroke center

INTRODUCTION

Depression may be a frequent sequela after stroke, however, its incidence has rarely been reported. The likelihood of post-stroke depression (PSD) may relate to individual factors including the presence of aphasia, which also complicates PSD diagnosis. The current study's purpose was to investigate the incidence of PSD symptoms in adults with aphasia, compare it to the incidence of PSD symptoms in adults without aphasia, and to identify potential risk factors for developing PSD in adults with aphasia.

METHOD

Incidence proportions and relative risk were calculated using data compiled from 970 patient records at an urban tertiary care academic institution and comprehensive stroke center throughout the year of 2019. Focusing exclusively on adults with aphasia, the selected variables of age, gender, race, and aphasia severity were used to conduct logistic regression analyses to explore potential risk factors contributing to the development of PSD.

RESULTS

Adults with aphasia were 7.408 times more likely to exhibit PSD symptoms than adults without aphasia. Logistic regression controlling for the presence of aphasia showed a significant relationship between aphasia severity and post-stroke depression symptoms. Adults with aphasia were 2.06 times more likely to experience post-stroke depression symptoms with every 1-point increase in aphasia severity.

CONCLUSIONS

These findings align with earlier evidence identifying aphasia as a risk factor for experiencing PSD symptoms and also suggest aphasia severity is proportionate to the risk. This highlights the need for early identification of PSD symptoms in persons with aphasia in order to provide timely interventions.

Point-of-Care Testing Using a Neuropsychology Pocketcard Set: A Preliminary Validation Study

Neurocognitive screening instruments usually require printed sheets and additional accessories, and can be unsuitable for low-threshold use during ward rounds or emergency workup, especially in patients with motor impairments. Here, we test the utility of a newly developed neuropsychology pocketcard set for point-of-care testing. For aphasia and neglect assessment, modified versions of the Language Screening Test and the Bells Test were validated on 63 and 60 acute stroke unit patients, respectively, against expert clinical evaluation and the original pen-and-paper Bells Test. The pocketcard aphasia test achieved an excellent area under the curve (AUC) of 0.94 (95% CI: 0.88−1, p < 0.001). Using an optimal cut-off of ≥2 mistakes, sensitivity was 91% and specificity was 81%. The pocketcard Bells Task, measured against the clinical neglect diagnosis, achieved higher sensitivity (89%) and specificity (88%) than the original paper-based instrument (78% and 75%, respectively). Separately, executive function tests (modified versions of the Trail Making Test [TMT] A and B, custom Stroop color naming task, vigilance ‘A’ Montreal Cognitive Assessment item) were validated on 44 inpatients with epilepsy against the EpiTrack® test battery. Pocketcard TMT performance was significantly correlated with the original EpiTrack® versions (A: r = 0.64, p < 0.001; B: r = 0.75, p < 0.001). AUCs for the custom Stroop task, TMT A and TMT B for discriminating between normal and pathological EpiTrack® scores were acceptable, excellent and outstanding, respectively. Quick point-of-care testing using a pocketcard set is feasible and yields diagnostically valid information.

Incidence of aphasia in ischemic stroke

INTRODUCTION

A decrease in ischemic stroke (IS) incidence has been observed in high income countries during the last decades. Whether this has influenced the occurrence of aphasia in IS is uncertain. We therefore examined the incidence rate and potentially related determinants of aphasia in IS.

METHODS

We prospectively examined consecutive patients admitted to hospital with first-ever acute IS between 1 March 2017 and 28 February 2018 as part of the Lund Stroke Register (LSR) Study, comprising patients from the uptake area of Skåne University Hospital, Lund, Sweden. Patients were assessed with National Institutes of Health Stroke Scale (NIHSS) at stroke onset. Presence of aphasia was evaluated with NIHSS item 9 (language). We registered IS subtypes and risk factors. To investigate possible temporal changes in aphasia incidence, we made comparisons with corresponding LSR data from 2005-2006. Incidence rates were calculated and adjusted to the European Standard Population and to the Swedish population.

RESULTS

Among 308 included IS patients, 30% presented with aphasia (n=91; 95%CI: 25-35) a proportion of aphasia in IS that was similar to 2005-2006. The incidence rate of aphasia was 31 per 100 000 person-years adjusted to the European Standard Population (95%CI: 25-38 per 100 000 person-years) corresponding to a significant decrease of 30% between 2005-2006 and 2017-2018. The decrease was significantly more pronounced in men. The initial severity of aphasia remained unchanged, with the majority of patients having severe to global aphasia. No significant differences between vascular stroke risk factors were noted among stroke patients with or without aphasia.

CONCLUSION

Even though the overall IS incidence rate has decreased during the first decades of the 21st century, the proportion of IS patients with aphasia at stroke onset remains stable at 30%. Aphasia continues to be an important symptom that needs to be considered in stroke care and rehabilitation.

Eloquent Lower Grade Gliomas, a Highly Vulnerable Cohort: Assessment of Patients' Functional Outcome After Surgery Based on the LoG-Glio Registry

Majority of lower grade glioma (LGG) are located eloquently rendering surgical resection challenging. Aim of our study was to assess rate of permanent deficits and its predisposing risk factors. We retrieved 83 patients harboring an eloquently located LGGs from the prospective LoG-Glio Database. Patients without surgery or incomplete postoperative data were excluded. Sign rank test, explorative correlations by Spearman ρ and multivariable regression for new postoperative deficits were calculated. Eloquent region involved predominantly motor (45%) and language (40%). At first follow up after 3 months permanent neuro-logical deficits (NDs) were noted in 39%. Mild deficits remained in 29% and severe deficits in 10%. Complete tumor removal (CTR) was successfully in 62% of intended cases. Postoperative and 3-month follow up National Institute of Health Stroke Score (NIHSS) showed significantly lower values than preoperatively (p<0.001). 38% cases showed a decreased NIHSS at 3-month, while occurrence was only 14% at 9-12-month follow up. 6/7 patients with mild aphasia recovered after 9-12 months, while motor deficits present at 3-month follow up were persistent in majority of patients. Eastern oncology group functional status (ECOG) significantly decreased by surgery (p < 0.001) in 31% of cases. Between 3-month and 9-12-months follow up no significant improvement was seen. In the multivariable model CTR (p=0.019, OR 31.9), and ECOG>0 (p=0.021, OR 8.5) were independent predictors for permanent postoperative deficit according to NIHSS at 3-month according to multivariable regression model. Patients harboring eloquently located LGG are highly vulnerable for permanent deficits. Almost one third of patients have a permanent reduction of their functional status based on ECOG. Risk of an extended resection has to be balanced with the respective oncological benefit. Especially, patients with impaired pre-operative status are at risk for new permanent deficits. There is a relevant improvement of neurological symptoms in the first year after surgery, especially for patients with slight aphasia.

A Review of Risk Factors and Predictors for Hemorrhagic Transformation in Patients with Acute Ischemic Stroke

Acute ischemic strokes (AIS) and hemorrhagic strokes lead to disabling neuropsychiatric and cognitive deficits. A serious and fatal complication of AIS is the occurrence of hemorrhagic transformation (HT). HT is cerebral bleeding that occurs after an ischemic event in the infarcted areas. This review summarises how specific risk factors such as demographic factors like age, gender, and race/ethnicity, comorbidities including essential hypertension, atrial fibrillation, diabetes mellitus, congestive heart failure, and ischemic heart disease along with predictors like higher NIHSS score, larger infarction size, cardioembolic strokes, systolic blood pressure/pulse pressure variability, higher plasma glucose levels, and higher body temperature during ischemic event, lower low-density lipoprotein and total cholesterol, early ischemic changes on imaging modalities, and some rare causes make an individual more susceptible to developing HT. We also discuss few other risk factors such as the role of blood-brain barrier, increased arterial stiffness, and globulin levels in patients postreperfusion using thrombolysis and mechanical thrombectomy. In addition, we discuss the implications of dual antiplatelet therapy and the length of treatment in reference to the incidence of developing HT. Current research into inflammatory mediators and biomarkers such as Cyclooxygenase-2, matrix metalloproteinases, and soluble ST2 and their potential role as treatment options for HT is also briefly discussed. Finally, this review calls for more research into use of dual antiplatelet and the timing of antiplatelet and anticoagulant use in reference to hemorrhagic transformation.

Clinical assessment and screening of stroke patients with aphasia: a best practices implementation project

INTRODUCTION AND AIMS

As a critical form of stroke damage, aphasia negatively impacts stroke patients' return to society. Speech and language intervention has been found to assist in optimizing poststroke aphasia patient outcomes; consequently, early identification and diagnosis are vital for poststroke aphasia to ensure that patients receive the rehabilitation they require. This project aimed to promote evidence-based practice (EBP) in the assessment and screening of stroke patients with aphasia and to improve the clinical outcomes of patients who suffer from poststroke aphasia in a large tertiary hospital.

METHODS

The current evidence implementation project was conducted in the neurology and rehabilitation departments of a tertiary hospital in China. Six audit criteria were developed for the baseline and follow-up audits. The project used the Joanna Briggs Institute's (JBI) PACES software, as well as JBI's Getting Research into Practice audit and feedback tool, to foster evidence-based healthcare in practice.

RESULTS

Although the performance of all evidence-based criteria during the baseline audit was poor, barriers were identified through baseline, and the project team carried out and implemented developed strategies following Getting Research into Practice resources. All the criteria improved from baseline after the follow-up cycle, with four out of six criteria achieving a compliance rate of 100%, and two evidence-based criteria recorded at 73 and 80% compliance, respectively.

CONCLUSION

The current project successfully increased EBP for the assessment and screening of stroke patients with aphasia. Further studies are needed to ensure the project's long-term sustainability.