Cardiac autonomic dysfunction and functional outcome after ischaemic stroke

The effect of motor imagery and action observation on autonomic functions in patients with chronic stroke

OBJECTIVES

This study aimed to investigate the effects of motor imagery (MI), action observation (AO), and action execution (AE) interventions on the autonomic nervous system (ANS) in individuals with chronic stroke.

METHODS

This was a single-center, randomized, case-control study. Thirty-six patients were randomly assigned to MI (n = 10), AO (n = 15), and the AE group (n = 11). Heart rate (HR)-based measurements (HR, heart rate variability (HRV)) and blood pressure were evaluated before the practice of each group. In the MI group, participants were instructed to imagine themselves walking at their own comfortable pace for 5 minutes. Meanwhile, in the AO group, participants were shown a video of a person walking for 5 minutes. Finally, in the AE group, participants were instructed to actually walk for 5 minutes. Then, all measurements were taken again.

RESULTS

A statistically significant difference was found in HR and mean RR interval within the AE group (p < 0.05). There was a statistically significant difference in the Root Mean Square of Successive Differences Between Normal Heartbeats (RMSSD) (ms) within the AO group (p < 0.05). There was a significant difference in HR and mean RR intervals (ms) between groups (p < 0.05). According to post-hoc analyses, HR was statistically significantly higher in the AE group compared to the other groups, and the mean RR interval was statistically significantly lower (p < 0.05).

CONCLUSIONS

In conclusion, in patients with chronic stroke, AE and AO may affect ANS by increasing sympathetic activation. It is recommended for future studies to evaluate whether patients actually engage in imagery during the MI task.

Heart rate turbulence in acute ischemic stroke

BACKGROUND

Heart rate turbulence (HRT), an ECG-based marker of autonomic cardiac regulation, has shown high prognostic value in patients with established cardiovascular diseases, while data in patients with acute ischemic stroke are scarce.

PATIENTS AND METHODS

The HRT parameters turbulence onset and turbulence slope were analyzed using Holter-ECG recordings from patients with acute ischemic stroke, consecutively enrolled in the prospective observational HEBRAS study. HRT was categorized as normal (category 0; both parameters normal), abnormal (category 1; one parameter abnormal), or severely abnormal (category 2; both parameters abnormal). Outcomes of interest were functional outcome according to modified Rankin Scale (mRS) score at 3 months, mortality at 1 year, newly detected atrial fibrillation (AF), and evidence of focal myocardial fibrosis on cardiovascular MRI.

RESULTS

HRT was assessed in 335 patients in sinus rhythm (median age 69 years, 37% female, median NIHSS score 2 on admission), including 262 (78%) with normal HRT, 47 (14%) with abnormal and 26 (8%) with severely abnormal HRT. Compared with normal HRT, severely abnormal HRT was associated with increased disability [higher mRS] at 3 months (adjusted odds ratio [aOR]: 2.9, 95% confidence interval [CI]: 1.3-6.6), new AF (aOR: 3.5, 95% CI: 1.1-10.6), MRI-detected myocardial fibrosis (aOR: 5.8, 95% CI: 1.3-25.9), but not with mortality at 1 year after stroke (aOR: 3.0, 95% CI: 0.7-13.9). Abnormal HRT was not associated with the analyzed outcomes.

CONCLUSIONS

Severely abnormal HRT was associated with increased disability and previously unknown cardiac comorbidities. The potential role of HRT in selecting patients for extended AF monitoring and cardiac imaging should be further investigated.

Novel metrics of sleep-disordered breathing are associated with outcome after ischemic stroke

OBJECTIVE/BACKGROUND

Standard measures of sleep-disordered breathing (SDB) that rely on count data may not sufficiently capture SDB severity or reflect downstream consequences of SDB. We hypothesized that novel metrics derived from pulse rate, oxygen saturation, and nasal pressure would be associated with stroke outcomes.

PATIENTS/METHODS

Shortly after ischemic stroke, participants in a population-based study were offered ApneaLink Plus testing. Signal analysis was used to generate 166 metrics from the nasal pressure cannula and finger probe, categorized as: autonomic (based on pulse rate variability), oximetry-derived, nasal pressure-derived, and mixed oxygen and nasal pressure-derived measures. Three-month outcome assessments included functional and cognitive outcomes and stroke recurrence. Tobit regression and Cox proportional hazards models were used to examine associations between each sleep apnea metric and the three outcomes, unadjusted and adjusted for multiple potential confounders. Models were adjusted for multiple comparisons.

RESULTS

Of the 530 participants, the median age was 65 (IQR: 57, 73), 49 % were female, and 64 % were Mexican American. Without covariate adjustment, 23 of 166 variables were associated with functional outcome, 43 were associated with cognitive outcome, and 1 was associated with stroke recurrence. After adjustment, 7 mixed, oximetry, or nasal pressure-based metrics and 1 autonomic metric were associated with functional outcome, but none was associated with cognitive outcome or stroke recurrence.

CONCLUSIONS

Many novel metrics of SDB were associated with important stroke outcomes, and 8 novel metrics were associated with functional outcome in adjusted models. This raises hypotheses about pathways by which SDB may negatively impact stroke outcomes.

The Effects of Autonomic Dysfunction on Functional Outcomes in Patients with Acute Stroke

Autonomic dysfunction is a common complication of acute stroke, which impairs functional outcomes and increases mortality. There is a lack of well-established knowledge regarding the influence of autonomic dysfunction in patients with acute stroke. This study aims to investigate the impact of the severity of autonomic dysfunction on functional outcomes in patients with acute stroke. A retrospective analysis was conducted at a single center, involving 22 patients diagnosed with acute stroke. The severity of autonomic dysfunction was evaluated based on the Composite Autonomic Scoring Scale (CASS). The modified Barthel Index, Berg Balance Scale, Functional Ambulatory Category, and modified Rankin Scale were designated as functional outcome measures. The impact of the severity of autonomic dysfunction on functional outcomes was analyzed using one-way analysis of covariance (ANCOVA). A statistically significant difference was observed between the initial and follow-up functional outcomes based on the severity of autonomic dysfunction. This study presents evidence that the severity of autonomic dysfunction influences functional prognosis in patients with acute stroke. The findings will serve as additional considerations for the rehabilitation of patients with acute stroke.

Data lake-driven analytics identify nocturnal non-dipping of heart rate as predictor of unfavorable stroke outcome at discharge

BACKGROUND

Post-stroke heart rate (HR) and heart rate variability (HRV) changes have been proposed as outcome predictors after stroke. We used data lake-enabled continuous electrocardiograms to assess post-stroke HR and HRV, and to determine the utility of HR and HRV to improve machine learning-based predictions of stroke outcome.

METHODS

In this observational cohort study, we included stroke patients admitted to two stroke units in Berlin, Germany, between October 2020 and December 2021 with final diagnosis of acute ischemic stroke or acute intracranial hemorrhage and collected continuous ECG data through data warehousing. We created circadian profiles of several continuously recorded ECG parameters including HR and HRV parameters. The pre-defined primary outcome was short-term unfavorable functional outcome after stroke indicated through modified Rankin Scale (mRS) score of > 2.

RESULTS

We included 625 stroke patients, 287 stroke patients remained after matching for age and National Institute of Health Stroke Scale (NIHSS; mean age 74.5 years, 45.6% female, 88.9% ischemic, median NIHSS 5). Both higher HR and nocturnal non-dipping of HR were associated with unfavorable functional outcome (p < 0.01). The examined HRV parameters were not associated with the outcome of interest. Nocturnal non-dipping of HR ranked highly in feature importance of various machine learning models.

CONCLUSIONS

Our data suggest that a lack of circadian HR modulation, specifically nocturnal non-dipping, is associated with short-term unfavorable functional outcome after stroke, and that including HR into machine learning-based prediction models may lead to improved stroke outcome prediction.

Bringing High-Dose Neurorestorative Behavioral Training Into the Acute Stroke Unit

ABSTRACT

Stroke remains common and is a leading cause of adult disability. While there have been enormous system changes for the diagnosis and delivery of hyperacute stroke treatments at comprehensive stroke centers, few advances have been made in those same centers for treatments focused on behavioral recovery and brain repair. Specifically, during the early hospital period, there is a paucity of approaches available for reduction of impairment beyond what is expected from spontaneous biological recovery. Thus, patients in the early stroke recovery period are not receiving the kind of training needed, at the requisite intensity and dose, to exploit a potential critical period of heightened brain plasticity that could maximize true recovery instead of just compensation. Here, we describe an ongoing pilot program to reconfigure the acute stroke unit experience to allow for a new emphasis on brain repair. More specifically, we have introduced a novel room-based video-gaming intervention; restorative neuroanimation, into the acute stroke hospital setting. This new intervention provides the opportunity for an extra hour(s) of high-intensity neurorestorative behavioral treatment that is complementary to conventional rehabilitation. To accomplish this, system redesign was required to insert this new treatment into the patient day, to properly stratify patients behaviorally and physiologically for the treatment, to optimize the digital therapeutic approach itself, and to maintain the impairment reduction after discharge.

Interactions between the Autonomic Nervous System and the Immune System after Stroke

Acute stroke is one of the leading causes of morbidity and mortality worldwide. Stroke-induced immune-inflammatory response occurs in the perilesion areas and the periphery. Although stroke-induced immunosuppression may alleviate brain injury, it hinders brain repair as the immune-inflammatory response plays a bidirectional role after acute stroke. Furthermore, suppression of the systemic immune-inflammatory response increases the risk of life-threatening systemic bacterial infections after acute stroke. Therefore, it is essential to explore the mechanisms that underlie the stroke-induced immune-inflammatory response. Autonomic nervous system (ANS) activation is critical for regulating the local and systemic immune-inflammatory responses and may influence the prognosis of acute stroke. We review the changes in the sympathetic and parasympathetic nervous systems and their influence on the immune-inflammatory response after stroke. Importantly, this article summarizes the mechanisms on how ANS regulates the immune-inflammatory response through neurotransmitters and their receptors in immunocytes and immune organs after stroke. To facilitate translational research, we also discuss the promising therapeutic approaches modulating the activation of the ANS or the immune-inflammatory response to promote neurologic recovery after stroke. © 2022 American Physiological Society. Compr Physiol 12:3665-3704, 2022.

Heart Rate Variability and Recurrent Stroke and Myocardial Infarction in Patients With Acute Mild to Moderate Stroke

Objectives: In patients with acute ischemic stroke, reduced heart rate variability (HRV) may indicate poor outcome. We tested whether HRV in the acute phase of stroke is associated with higher rates of mortality, recurrent stroke, myocardial infarction (MI) or functional outcome.

Materials and Methods: Patients with acute mild to moderate ischemic stroke without known atrial fibrillation were prospectively enrolled to the investigator-initiated Heart and Brain interfaces in Acute Ischemic Stroke (HEBRAS) study (NCT 02142413). HRV parameters were assessed during the in-hospital stay using a 10-min section of each patient's ECG recording at day- and nighttime, calculating time and frequency domain HRV parameters. Frequency of a combined endpoint of recurrent stroke, MI or death of any cause and the respective individual events were assessed 12 months after the index stroke. Patients' functional outcome was measured by the modified Rankin Scale (mRS) at 12 months.

Results: We included 308 patients (37% female, median NIHSS = 2 on admission, median age 69 years). Complete follow-up was achieved in 286/308 (93%) patients. At 12 months, 32 (9.5%), 5 (1.7%) and 13 (3.7%) patients had suffered a recurrent stroke, MI or death, respectively. After adjustment for age, sex, stroke severity and vascular risk factors, there was no significant association between HRV and recurrent stroke, MI, death or the combined endpoint. We did not find a significant impact of HRV on a mRS ≥ 2 12 months after the index stroke.

Conclusion: HRV did not predict recurrent vascular events in patients with acute mild to moderate ischemic stroke.

The role of β2 adrenergic receptor on infection development after ischaemic stroke

Mechanisms underlying post-stroke immune impairments and subsequent development of fatal lung infection have been suggested to involve multiple pathways, including hyperactivation of the sympathetic nervous system (SNS), which results in the excessive release of catecholamines and activation of β-adrenergic receptors (βARs). Indeed, previous reports from experimental studies demonstrated that post-stroke infection can be inhibited with treatment of β-blockers. However, the effectiveness of β-blockers in reducing post-stroke infection has yielded mixed results in retrospective clinical trials and its use remain controversial. In this study, we performed mid-cerebral artery occlusion in mice either genetically deficient in β₂-adrenergic receptor (β₂AR) or treated with non-selective and selective βAR antagonists to explore the contributions of the SNS in the development of post-stroke lung infection. Stroke induced a systemic activation of the SNS as indicated by elevated levels of plasma catecholamines and UCP-1 activity. However, β₂AR deficient mice showed similar degrees of post-stroke immune impairment and infection rate compared to wildtype counterparts, potentially due to compensatory mechanisms common in transgenic animals. To overcome this, we treated post-stroke wildtype mice with pharmacological inhibitors of the βARs, including the non-selective antagonist propranolol (PPL) and selective β₂AR antagonist ICI-118551. Both pharmacological strategies to block the action of SNS signalling were unable to reduce infection in mice that underwent ischaemic stroke. Overall, our data suggests that other mechanisms independent or in combination with β₂AR activation contribute to the development of post-stroke infection.

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Ischaemic stroke induced a systemic activation of the sympathetic nervous system.

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Mice deficient of β₂ adrenergic receptor showed similar post-stroke infection and signs of immune impairment compared to wildtype counterparts.

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Pharmacological blockade of sympathetic signalling was unable to reduce infection in mice after stroke.

Heart rate variability as a biomarker of functional outcomes in persons with acquired brain injury: Systematic review and meta-analysis

This review aimed to quantify correlations between heart rate variability (HRV) and functional outcomes after acquired brain injury (ABI). We conducted a literature search from inception to January 2020 via electronic databases, using search terms with HRV, ABI, and functional outcomes. Meta-analyses included 16 studies with 906 persons with ABI. Results demonstrated significant associations: Low frequency (LF) (r = -0.28) and SDNN (r = -0.33) with neurological function; LF (r = -0.33), High frequency (HF) (r = -0.22), SDNN (r = -0.22), and RMSSD (r = -0.23) with emotional function; and LF (r = 0.34), HF (r = 0.41 to 0.43), SDNN (r = 0.43 to 0.51), and RMSSD (r = 0.46) with behavioral function. Results indicate that higher HRV is related to better neurological, emotional, and behavioral functions after ABI. In addition, persons with stroke showed lower HF (SMD = -0.50) and SDNN (SMD = -0.75) than healthy controls. The findings support the use of HRV as a biomarker to facilitate precise monitoring of post-ABI functions.

Effects of rehabilitation programs on heart rate variability after stroke: a systematic review

BACKGROUND

It has been shown that the autonomic nervous system can be modulated by physical exercise after stroke, but there is a lack of evidence showing rehabilitation can be effective in increasing heart rate variability (HRV).

OBJECTIVE

To investigate the effectiveness and safety of rehabilitation programs in modulating HRV after stroke.

METHODS

The search strategy was based in the PICOT (patients: stroke; interventions: rehabilitation; comparisons: any control group; outcomes: HRV; time: acute, subacute and chronic phases of stroke). We searched MEDLINE, CENTRAL, CINAHL, LILACS, and SCIELO databases without language restrictions, and included randomized controlled trials (RCTs), quasi-randomized controlled trials (quasi-RCTs), and non-randomized controlled trials (non-RCTs). Two authors independently assessed the risk of bias and we used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to rate the certainty of the evidence for each included study.

RESULTS

Four studies (two RCTs with low certainty of the evidence and two non-RCTs with very low certainty of the evidence) were included. Three of them showed significant cardiac autonomic modulation during and after stroke rehabilitation: LF/HF ratio (low frequency/high frequency) is higher during early mobilization; better cardiac autonomic balance was observed after body-mind interaction in stroke patients; and resting SDNN (standard deviation of normal R-R intervals) was significantly lower among stroke patients indicating less adaptive cardiac autonomic control during different activities.

CONCLUSIONS

There are no definitive conclusions about the main cardiac autonomic repercussions observed in post-stroke patients undergoing rehabilitation, although all interventions are safe for patients after stroke.

Development of a prediction model for ascent and descent staircase independence during the sub-acute rehabilitation phase in individuals post-stroke

BACKGROUND

Nearly half of individuals post-stroke are dependent in their daily activities. The ability to ascend and descend stairs is an important component of independence in the community.

OBJECTIVE

To predict the future ability of post-stroke individuals at the beginning of the sub-acute rehabilitation phase to achieve ascending and descending staircase independence.

METHODS

36 participants were recruited for the study.

OUTCOME MEASURES

independence in ascending and descending stairs up to the end of the sub-acute rehabilitation phase. Predictive measures included the knee extensors Muscles Strength (MS), the seated Modified Functional Reach (MFR) test, and Heart Rate Variability (HRV) measures. Logistic and Cox regression were used.

RESULTS

Twenty-four participants (66.7%) completed the sub-acute rehabilitation phase being independent in ascending and descending stairs. MFR was the best predictor (R2 = 0.18), and with MS the best predictors for the time (days) to achieve this goal during the sub-acute rehabilitation. HRV measure was found to be the main predictor of the staircase ascent model (R2 = 0.32), and MFR the best predictor for the descent model (R2 = 0.24).

CONCLUSIONS

Balance performance is the main predictor of independence in ascending and descending stairs. Improving this component during the sub-acute rehabilitation phase might be reflected in achieving staircase independence.

The Association Between Heart Rate Variability and 90-Day Prognosis in Patients With Transient Ischemic Attack and Minor Stroke

Background: Low heart rate variability (HRV) is known to be associated with increased all-cause, cardiovascular, and cerebrovascular mortality but its association with clinical outcomes in patients with transient ischemic attack (TIA) or minor stroke is unclear.

Methods: We selected TIA and minor stroke patients from a prospective registration study. From each continuous electrocardiograph (ECG) record, each QRS complex was detected and normal-to-normal (N-N) intervals were determined. The standard deviation of all N-N intervals (SDNN) and the square root of the mean squared differences of successive N-N intervals (RMSSD) were calculated. Logistic regression analysis and Cox regression analysis were performed to assess the outcomes of patients at 90 days, and the odds and risk ratios (OR/HR) of each index quartile were compared.

Results: Compared with SDNN patients in the lowest quartile, neurological disability was significantly reduced in other quartile groups at 90 days, with significant differences [OR of group Q2 was 0.659; 95% confidence interval (CI), 0.482–0.900; p = 0.0088; OR of group Q3 was 0.662; 95% CI, 0.478–0.916; p = 0.0127; OR of group Q4 was 0.441; 95% CI, 0.305–0.639; p <0.0001]. Compared with the lowest quartile, the recurrence rate of TIA or minor stroke in patients of the two higher quartiles (Q3 and Q4) of SDNN was significantly reduced at 90 days (HR of Q3 group was 0.732; 95% CI, 0.539–0.995; p = 0.0461; HR of Q4 group was 0.528; 95% CI, 0.374–0.745; p = 0.0003).

Conclusions: Based on our findings, autonomic dysfunction is an adverse indicator for neurological function prognosis and stroke recurrence 90 days after TIA or minor stroke.

Targeting the Autonomic Nervous System for Risk Stratification, Outcome Prediction and Neuromodulation in Ischemic Stroke

Ischemic stroke is a worldwide major cause of mortality and disability and has high costs in terms of health-related quality of life and expectancy as well as of social healthcare resources. In recent years, starting from the bidirectional relationship between autonomic nervous system (ANS) dysfunction and acute ischemic stroke (AIS), researchers have identified prognostic factors for risk stratification, prognosis of mid-term outcomes and response to recanalization therapy. In particular, the evaluation of the ANS function through the analysis of heart rate variability (HRV) appears to be a promising non-invasive and reliable tool for the management of patients with AIS. Furthermore, preclinical molecular studies on the pathophysiological mechanisms underlying the onset and progression of stroke damage have shown an extensive overlap with the activity of the vagus nerve. Evidence from the application of vagus nerve stimulation (VNS) on animal models of AIS and on patients with chronic ischemic stroke has highlighted the surprising therapeutic possibilities of neuromodulation. Preclinical molecular studies highlighted that the neuroprotective action of VNS results from anti-inflammatory, antioxidant and antiapoptotic mechanisms mediated by α7 nicotinic acetylcholine receptor. Given the proven safety of non-invasive VNS in the subacute phase, the ease of its use and its possible beneficial effect in hemorrhagic stroke as well, human studies with transcutaneous VNS should be less challenging than protocols that involve invasive VNS and could be the proof of concept that neuromodulation represents the very first therapeutic approach in the ultra-early management of stroke.

Slow-Paced Breathing and Autonomic Function in People Post-stroke

Purpose: To determine if acute slow breathing at 6 breaths/min would improve baroreflex sensitivity (BRS) and heart rate variability (HRV), and lower blood pressure (BP) in adults after stroke. Methods: Twelve individuals completed two randomized study visits where they performed a 15-min bout of breathing exercises at 6 breaths/min (slow) and at 12 breaths/min (control). Continuous BP and heart rate (HR) were measured throughout, and BRS, BRS response to elevations in blood pressure (BRSup), BRS response to depressions in blood pressure (BRSdown), and HRV were calculated and analyzed before (pre), during, and after (post) breathing exercises. Results: BRS increased from pre to post slow breathing by 10% (p = 0.012), whereas BRSup increased from pre to during slow breathing by 30% (p = 0.04). BRSdown increased from pre to post breathing for both breathing conditions (p < 0.05). HR (control: Δ - 4 ± 4; slow: Δ - 3 ± 4 beats/min, time, p < 0.01) and systolic BP (control: Δ - 0.5 ± 5; slow: Δ - 6.3 ± 8 mmHg, time, p < 0.01) decreased after both breathing conditions. Total power, low frequency power, and standard deviation of normal inter-beat intervals (SDNN) increased during the 6-breaths/min condition (condition × time, p < 0.001), whereas high frequency increased during both breathing conditions (time effect, p = 0.009). Conclusions: This study demonstrated that in people post-stroke, slow breathing may increase BRS, particularly BRSup, more than a typical breathing space; however, paced breathing at either a slow or typical breathing rate appears to be beneficial for acutely decreasing systolic BP and HR and increasing HRV.

Early rehabilitation after stroke: relationship between the heart rate variability and functional outcome

Aims

Impaired autonomic nervous system regulation is frequently observed in patients with stroke. The aim of this prospective study was to evaluate the impact of cardiac autonomic tone on functional outcome after the early post‐stroke rehabilitation.

Methods and results

One hundred and three consecutive patients (67 ± 11 years, body mass index (BMI) 27.1 ± 5.4 kg/m², 64% men) with ischaemic (84% of patients) and haemorrhagic stroke were studied. Depressed heart rate variability (HRV), as a surrogate marker of increased sympathetic tone, was defined by the standard deviation of NN intervals < 100 ms and HRV triangular index ≤ 20 assessed from a 24 h Holter electrocardiogram at admission to rehabilitation (23 ± 16 days after stroke). Twenty‐two per cent of patients had depressed HRV at baseline and were comparable with patients with normal HRV with regard to their functional [Barthel Index (BI), modified Rankin Scale (mRS), and Rivermead Motor Assessment (RMA)] and biochemical status. After a 4‐week follow‐up, 70% of patients with depressed HRV showed a cumulative functional disability, defined by mRS ≥ 4, BI ≤ 70, and RMA ≤ 5, in contrast to patients with normal HRV (35%, P = 0.003). Patients with depressed HRV showed a worse functional status by BI (−16%, P < 0.001), RMA (−12%, P < 0.05), and mRS (+16%, P < 0.01), compared with patients with normal HRV. Cumulative functional disability was associated with depressed HRV (odds ratio 4.25, 95% confidence interval 1.56–11.54, P < 0.005) after adjustment for age, sex, and body mass index (odds ratio 4.6, 95% confidence interval 1.42–14.97, P < 0.05).

Conclusions

The presence of autonomic cardiovascular dysregulation in patients with subacute stroke was associated with adverse functional outcome after the early post‐stroke rehabilitation.

Stroke Outcome Prediction by Blood Pressure Variability, Heart Rate Variability, and Baroreflex Sensitivity

Background and Purpose- Poststroke autonomic dysfunction portended an unfavorable prognosis. We investigated whether blood pressure variability (BPV), heart rate variability, and baroreflex sensitivity might predict stroke functional outcome. Methods- We calculated BPV, heart rate variability, baroreflex slope, and baroreflex effectiveness index from a 5-minute beat-to-beat blood pressure and heart rate monitoring within 7 days from the stroke onset. We compared the parameters between patients with a good outcome (modified Rankin Scale score, 0-2) and those with a poor outcome. Results- Among 142 patients (mean age, 63.9±10.2 years; 88.0% men), functional outcome was good in 112 (78.9%) and poor in 30 (21.1%). There were significant differences in admission National Institutes of Health Stroke Scale, prior stroke, high-frequency systolic BPV, low/high-frequency ratio of BPV, baroreflex sensitivity-up, and baroreflex sensitivity-total between the 2 groups (all P<0.05). In multivariate analysis, National Institutes of Health Stroke Scale (OR, 1.672 [95% CI, 1.316-2.125]; P<0.001), low/high-frequency ratio of systolic BPV (OR, 0.493 [95% CI, 0.250-0.973]; P=0.041), and baroreflex effectiveness index-down (OR, 0.958 [95% CI, 0.924-0.992]; P=0.017) independently predicted a poor functional outcome. Conclusions- A decreased low/high-frequency ratio of systolic BPV and impaired baroreflex sensitivity predicted an unfavorable stroke outcome, in addition to the established prognostic factor such as the National Institutes of Health Stroke Scale.

Cardiac Autonomic Derangement is Associated with Worse Neurological Outcome in the Very Early Phases of Ischemic Stroke

BACKGROUND

Acute ischemic stroke (AIS) is associated with autonomic dysfunction. We evaluated the prognostic value of heart rate variability (HRV) and the role of stroke localization and reperfusion treatment (RT) on autonomic control.

METHODS

Patients with AIS and sinus rhythm were enrolled in the emergency department. Autonomic parameters were recorded at the onset and after a potential RT. Neurological deficit was assessed using the National Institute of Health Stroke Scale (NIHSS) at the onset and residual disability with modified Rankin Scale (mRS) at 3 months. Two analyses were used to assess HRV. Low frequency (LF) and high frequency (HF) are, respectively, markers of sympathetic and respiratory vagal modulation in spectral analysis. Symbolic analysis provides pattern with no variation (0V%) as an index of sympathetic modulation and pattern with two like variations (2LV%) and pattern with two unlike variations (2UV%) as markers of vagal modulation.

RESULTS

We enrolled 41 patients. Twenty-seven underwent RT. A prevalent parasympathetic modulation was found in patients with NIHSS ≥14. The group with mRS 3-6 exhibited a higher 2UV% and lower 0V%. Right-sided strokes were associated with a higher respiratory vagal control. RT had no effects on HRV parameters.

CONCLUSIONS

In the very early phases of AIS, a decreased 0V% and an increased 2UV% may reflect a loss of sympathetic oscillation, predicting a poorer 3 month-outcome.

The spleen may be an important target of stem cell therapy for stroke

Stroke is the most common cerebrovascular disease, the second leading cause of death behind heart disease and is a major cause of long-term disability worldwide. Currently, systemic immunomodulatory therapy based on intravenous cells is attracting attention. The immune response to acute stroke is a major factor in cerebral ischaemia (CI) pathobiology and outcomes. Over the past decade, the significant contribution of the spleen to ischaemic stroke has gained considerable attention in stroke research. The changes in the spleen after stroke are mainly reflected in morphology, immune cells and cytokines, and these changes are closely related to the stroke outcomes. Autonomic nervous system (ANS) activation, release of central nervous system (CNS) antigens and chemokine/chemokine receptor interactions have been documented to be essential for efficient brain-spleen cross-talk after stroke. In various experimental models, human umbilical cord blood cells (hUCBs), haematopoietic stem cells (HSCs), bone marrow stem cells (BMSCs), human amnion epithelial cells (hAECs), neural stem cells (NSCs) and multipotent adult progenitor cells (MAPCs) have been shown to reduce the neurological damage caused by stroke. The different effects of these cell types on the interleukin (IL)-10, interferon (IFN), and cholinergic anti-inflammatory pathways in the spleen after stroke may promote the development of new cell therapy targets and strategies. The spleen will become a potential target of various stem cell therapies for stroke represented by MAPC treatment.

Heart rate variability is associated with outcome in spontaneous intracerebral hemorrhage

PURPOSE

Autonomic imbalance as measured by heart rate variability (HRV) has been associated with poor outcome after stroke. Observations on HRV changes in intracerebral hemorrhage (ICH) are scarce. Here, we aimed to investigate HRV in ICH as compared to a control group and to explore associations with stroke severity, hemorrhage volume and outcome after ICH.

METHODS

We examined the autonomic modulation using frequency domain analysis of HRV during the acute phase of the ICH and in a healthy age- and hypertension-matched control group. Hematoma volume, intraventricular extension, initial stroke severity and baseline demographic, clinical parameters as well as mortality and functional outcome were included in the analysis.

RESULTS

47 patients with ICH and 47 age- and hypertension matched controls were analyzed. ICH patients showed significantly lower total high frequency band (HF) and low frequency band (LF) powers (p = 0.01, p < 0.001), higher normalized HF power (p = 0.03), and lower LF/HF ratio (p < 0.001) as compared to the controls. Autonomic parameters showed associations with stroke severity (p = 0.004) and intraventricular involvement (p = 0.01) and predicted poor outcome independently (p = 0.02).

CONCLUSIONS

Autonomic changes seems to be present in acute ICH and are associated with poor outcome independently. This may have future monitoring and therapeutic implications.

Beta-blocker therapy is not associated with mortality after intracerebral hemorrhage

BACKGROUND

Beta-blocker therapy has been suggested to have neuroprotective properties in the setting of acute stroke; however, the evidence is weak and contradictory. We aimed to examine the effects of pre-admission therapy with beta-blockers (BB) on the mortality following spontaneous intracerebral hemorrhage (ICH).

METHODS

Retrospective analysis of the Helsinki ICH Study database.

RESULTS

A total of 1013 patients with ICH were included in the analysis. Patients taking BB were significantly older, had a higher premorbid mRS score, had more DNR orders, and more comorbidities as atrial fibrillation, hypertension, diabetes mellitus, ischemic heart disease, and heart failure. After adjustment for age, pre-existing comorbidities, and prior use of antithrombotic and antihypertensive medications, no differences in in-hospital mortality (OR 1.1, 95% CI 0.8-1.7), 12-month mortality (OR 1.3, 95% CI 0.9-1.9), and 3-month mortality (OR 1.2, 95% CI 0.8-1.7) emerged.

CONCLUSION

Pre-admission use of BB was not associated with mortality after ICH.

Linear and nonlinear parameters of heart rate variability in ischemic stroke patients

INTRODUCTION

Cardiovascular system presents cortical modulation. Post-stroke outcome can be highly influenced by autonomic nervous system disruption. Heart rate variability (HRV) analysis is a simple non-invasive method to assess sympatho-vagal balance.

OBJECTIVES

The purpose of this study was to investigate cardiac autonomic activity in ischemic stroke patients and to asses HRV nonlinear parameters beside linear ones.

METHODS

We analyzed HRV parameters in 15 right and 15 left middle cerebral artery ischemic stroke patients, in rest condition and during challenge (standing and deep breathing). Data were compared with 15 age- and sex-matched healthy controls.

RESULTS

There was an asymmetric response after autonomic stimulation tests depending on the cortical lateralization in ischemic stroke patients. In resting state, left hemisphere stroke patients presented enhanced parasympathetic control of the heart rate (higher values for RMSSD, pNN50 and HF in normalized units). Right hemisphere ischemic stroke patients displayed a reduced cardiac parasympathetic modulation during deep breathing test. Beside time and frequency domain, using short-term ECG monitoring, cardiac parasympathetic modulation can also be assessed by nonlinear parameter SD1, that presented strong positive correlation with time and frequency domain parameters RMSSD, pNN50, HFnu, while DFA α1 index presented negative correlation with the same indices and positive correlation with the LFnu and LF/HF ratio, indicating a positive association with the sympatho-vagal balance.

CONCLUSIONS

Cardiac monitoring in clinical routine using HRV analysis in order to identify autonomic imbalance may highlight cardiac dysfunctions, thus helping preventing potential cardiovascular complications, especially in right hemisphere ischemic stroke patients with sympathetic hyperactivation.

Association between cardiac autonomic control and cognitive performance among patients post stroke and age-matched healthy controls-an exploratory pilot study

Associations between autonomic nervous system health and cognitive performance have been described in different populations. Autonomic disturbances are a common phenomenon in patients post stroke. Little is known about the relationship between post stroke disturbances of the autonomic nervous system and the commonly occurring disturbances of cognitive functions revealed by victims of stroke. To assess the association between heart rate variability (HRV) and cognitive performance among patients post ischemic stroke and healthy age-matched controls, 13 patients post first-ever ischemic stroke aged 40-80 years and 15 age-matched healthy controls were evaluated. HRV was monitored during sustained handgrip, while breathing at a rate of six breaths per minute, while performing the serial-3 subtraction task sitting at rest, and while cycling. Patients post stroke had greater error rate in the serial-3 subtraction task, and lower HRV (both at rest and during task performance) relative to healthy controls (at rest 26 ms [10-53] vs. 43 ms [29-88]). The HRV of stroke patients showed less sensitivity to changes in testing conditions, and also failed to show the correlation with cognitive performance exhibited by the healthy subjects. Stroke patients experience autonomic nervous system dysfunction in parallel to their motor and cognitive impairments. Too often only the latter receive appropriate treatment consideration in the rehabilitation setting. The current results, and earlier research, point to the importance of focusing clinical attention to the status of the autonomic nervous system, as amelioration of its functioning is likely to enhance motor and cognitive functioning as well.

Heart Rate Variability in Patients with Acute Ischemic Stroke at Different Stages of Renal Dysfunction: A Cross-sectional Observational Study

Background:

Renal function is associated with mortality and functional disabilities in stroke patients, and impaired autonomic function is common in stroke, but little is known regarding its effects on stroke patients with renal dysfunction. This study sought to evaluate the association between autonomic function and stroke in patients with renal dysfunction.

Methods:

This study comprised 232 patients with acute ischemic stroke consecutively enrolled from February 2013 to November 2014 at Guangdong Provincial Hospital of Chinese Medicine in China. All patients recruited underwent laboratory evaluation and 24 h Holter electrocardiography (ECG). Autonomic function was measured based on the heart rate variability (HRV) using 24 h Holter ECG. Renal damage was assessed through the estimated glomerular filtration rate (eGFR), and stroke severity was rated according to the National Institutes of Health Stroke Scale (NIHSS). The Barthel index and modified Rankin score were also determined following admission. All the clinical covariates that could potentially affect autonomic outcome variables were adjusted with linear regression.

Results:

In the patients with a mild or moderate decreased eGFR, the values for the standard deviation of the averaged normal-to-normal RR interval (SDANN) index (P = 0.022), very low frequency (VLF) (P = 0.043), low frequency (LF) (P = 0.023), and ratio of low-to-high frequency power (LF/HF) (P = 0.001) were significantly lower than those in the patients with a normal eGFR. A multinomial linear regression indicated that eGFR (t = 2.47, P = 0.014), gender (t = −3.60, P < 0.001), and a history of hypertension (t = −2.65, P = 0.008) were the risk factors of LF/HF; the NIHSS score (SDANN index: t = −3.83, P < 0.001; VLF: t = −3.07, P = 0.002; LF: t = −2.79, P = 0.006) and a history of diabetes (SDANN index: t = −3.58, P < 0.001; VLF: t = −2.54, P = 0.012; LF: t = −2.87, P = 0.004) were independent factors for the SDANN index, VLF, and LF; the Oxfordshire Community Stroke Project (t = −2.38, P = 0.018) was related to the SDANN index.

Conclusions:

Autonomic dysfunction is aggravated with the progression of eGFR stage in patients with acute ischemic stroke; the eGFR is an independent factor of LF/HF in the adjusted models. Stroke severity and a history of diabetes are more significantly associated with HRV in patients with acute ischemic stroke at different stages of renal dysfunction.

MODULAÇÃO AUTONÔMICA DA FREQUÊNCIA CARDÍACA E CAPACIDADE FUNCIONAL AERÓBICA EM HEMIPARÉTICOS

RESUMO Introdução: Tem sido observado que indivíduos acometidos por acidente vascular encefálico (AVE) apresentam, além dos danos físicos, diminuição da capacidade aeróbica e alteração da modulação autonômica da frequência cardíaca, sendo estes importantes fatores para o aparecimento de doenças cardíacas e arritmias. Objetivo: Investigar os efeitos crônicos do AVE sobre a capacidade aeróbica (VO2pico) e os índices de variabilidade da frequência cardíaca (VFC), e se existe correlação entre essas duas variáveis. Métodos: Foram avaliados 11 indivíduos do sexo masculino, com idade entre 55 e 65 anos, acometidos por lesão cerebrovascular há pelo menos seis meses, e todos com hemiparesia. Foram realizadas as seguintes avaliações: teste de capacidade aeróbica máxima; registro dos intervalos R-R e cálculo dos índices da VFC (RMSSD, pNN50, AF, BF e a razão BF/AF). Para comparação entre VO2pico previsto e obtido utilizou-se o teste t de Student não pareado. Para testar a hipótese de correlação entre os índices de VFC e o VO2pico utilizou-se o teste de correlação de Pearson. Resultados: VO2pico (mL.kg-1.min-1) previsto e obtido, respectivamente = 32,15 ± 1,87 e 16,12 ± 5,51; índices da VFC: RMSSD (ms) = 28,69 ± 26,78; pNN50 (%) = 8,76 ± 12,62; AF (u.n.) = 51,96 ± 22,4; BF (u.n.) = 48,04 ± 22,49. O VO2pico correlacionou-se negativamente com os índices RMSSD, pNN50 e AF e positivamente com o índice BF (p < 0,05). Conclusão: Na fase crônica do AVE, variabilidade da frequência cardíaca encontra-se normal e os indivíduos com menor capacidade aeróbica apresentam maior modulação parassimpática e menor simpática, provavelmente em consequência da maior exigência física nas atividades de vida diária.

Autonomic dysfunction in first ever ischemic stroke: Prevalence, predictors and short term neurovascular outcome

OBJECTIVES

Central autonomic dysfunction(AD) is reported post-stroke. Very few studies have looked at its impact on neurovascular outcome. We sought to study the prevalence and predictors of autonomic dysfunction in patients with first ever acute ischemic stroke and its impact on discharge and short term outcome.

PATIENTS AND METHODS

Consecutive patients who presented between 2-4 weeks post stroke were prospectively recruited. Study period was April 2012-March 2014 (2 years). Subjects underwent clinical autonomic function testing using Ewing's battery at bedside and 24h Holter analysis for heart rate variability(HRV). HRV parameters studied included both time domain and frequency domain measures. Neurological and cardiovascular outcomes were assessed at discharge,3 months and 1year.

RESULTS

Of 101 patients of mean age 63yrs, 72% were men.Majority had moderate to severe strokes at onset (Mean NIHSS-13.9,MRS-3.1). Clinical bedside autonomic testing criteria were comparable to Holter detected dysautonomia in our study population (p value 0.3). Clinical autonomic dysfunction had a positive association with male gender whereas onset stroke severity and Insular involvement were associated with significantly higher incidence of autonomic dysfunction with both methodology. Those with autonomic dysfunction had more stroke severity at discharge, which was independent of onset severity. Increasing age, hemispheric laterality or presence of comorbidities had no impact on post-stroke dysautonomia.

CONCLUSIONS

Insular involvement and higher disability at onset are associated with greater incidence of autonomic dysfunction post-stroke. Those with AD had higher chance of infarct expansion and in hospital cardiovascular complications and poorer outcome at 1year, independent of onset stroke severity.

Changes of deceleration and acceleration capacity of heart rate in patients with acute hemispheric ischemic stroke

Background and purpose

Autonomic dysfunction is common after stroke, which is correlated with unfavorable outcome. Phase-rectified signal averaging is a newly developed technique for assessing cardiac autonomic function, by detecting sympathetic and vagal nerve activity separately through calculating acceleration capacity (AC) and deceleration capacity (DC) of heart rate. In this study, we used this technique for the first time to investigate the cardiac autonomic function of patients with acute hemispheric ischemic stroke.

Methods

A 24-hour Holter monitoring was performed in 63 patients with first-ever acute ischemic stroke in hemisphere and sinus rhythm, as well as in 50 controls with high risk of stroke. DC, AC, heart rate variability parameters, standard deviation of all normal-to-normal intervals (SDNN), and square root of the mean of the sum of the squares of differences between adjacent normal-to-normal intervals (RMSSD) were calculated. The National Institutes of Health Stroke Scale (NIHSS) was used to assess the severity of stroke. We analyzed the changes of DC, AC, SDNN, and RMSSD and also studied the correlations between these parameters and NIHSS scores.

Results

The R–R (R wave to R wave on electrocardiogram) intervals, DC, AC, and SDNN in the cerebral infarction group were lower than those in controls (P=0.003, P=0.002, P=0.006, and P=0.043), but the difference of RMSSD and the D-value and ratio between absolute value of AC (|AC|) and DC were not statistically significant compared with those in controls. The DC of the infarction group was significantly correlated with |AC|, SDNN, and RMSSD (r=0.857, r=0.619, and r=0.358; P=0.000, P=0.000, and P=0.004). Correlation analysis also showed that DC, |AC|, and SDNN were negatively correlated with NIHSS scores (r=−0.279, r=−0.266, and r=−0.319; P=0.027, P=0.035, and P=0.011).

Conclusion

Both DC and AC of heart rate decreased in patients with hemispheric infarction, reflecting a decrease in both vagal and sympathetic modulation. Both DC and AC were correlated with the severity of stroke.

Heart Rate Variability Is Associated with Motor Outcome 3-Months after Stroke

OBJECTIVES

The primary objective of this paper was to determine whether heart rate variability (HRV) acquired upon admission to inpatient rehabilitation is associated with motor outcome 3 months after stroke. The secondary objective of this paper was to determine whether HRV shows a strong association with the motor outcome 3 months after stroke in individuals with severe initial motor impairments.

METHODS

We recruited 13 patients with acute stroke from an acute inpatient rehabilitation hospital. A Holter monitor was placed upon admission and Fugl-Meyer Upper Extremity and Lower Extremity Subscales were used to assess the movement of the affected upper and lower extremities 3 months after admission. The standard deviation of R-R intervals was used to quantify HRV.

RESULTS

A Spearman rank correlation revealed a strong positive and significant correlation between HRV upon admission and movement of the affected upper extremity (r = .70, P = .01) and affected lower extremity (r = .60, P = .03) at 3 months. For patients with severe initial motor impairments, HRV showed a strong positive association with the movement of the affected upper (r = .61, P = .04) and lower (r = .70, P = .04) extremities at 3 months.

CONCLUSION

HRV is strongly associated with motor outcome after stroke and provides a promising marker to explore the mechanisms associated with motor recovery after stroke.

Cardiac autonomic dysfunction in chronic stroke women is attenuated after submaximal exercise test, as evaluated by linear and nonlinear analysis

Background

We evaluated cardiac autonomic modulation in women with chronic ischemic stroke (at least 4 years post-stroke) at rest and in response to submaximal exercise test.

Methods

Fourteen post-stroke women (S group) and 10 healthy women (C group) participated in this study. Autonomic modulation (using linear and nonlinear analysis), blood pressure and metabolic variables at rest were evaluated immediately after the exercise test and during the recovery period (20 min). All participants underwent submaximal exercise test on cycle ergometer with gas analysis.

Results

At rest, the S group displayed higher lactate concentration, systolic (SBP) and diastolic blood pressure (DBP) values when compared to C group. Furthermore, the S group had lower heart rate variability (HRV) in time domain (SDNN: S = 30 ± 5 vs. 40 ± 8 ms; rMSSD: S = 14 ± 2 vs. C = 34 ± 3 ms), decreased high frequency band of pulse interval (S = 8.4 ± 2 vs. 33.1 ± 9 %) and 2V pattern of symbolic analysis (S = 17.3 ± 1 vs. 30 ± 3 %) (both indicators of cardiac vagal modulation) when compared to C group. Immediately after exercise, S group presented higher values of lactate, SBP, DBP and double product when compared to C group, as well as decreased heart rate recovery (HRR) measured at the first, second and third minutes. At recovery time, all HRV parameters in time and frequency domains improved in the S group; however, HF band remained lower when compared to C group.

Conclusions

After the exercise test, women with chronic stroke presented reduced heart rate variability, reduced cardiac vagal modulation, as well as reduced HRR, while displayed an improvement of heart rate variability and cardiac vagal modulation when compared to their baseline. These results reinforce the importance of a physically active lifestyle for cardiovascular autonomic disorders observed in chronic stroke women.

Potential Interactions between the Autonomic Nervous System and Higher Level Functions in Neurological and Neuropsychiatric Conditions

The autonomic nervous system (ANS) maintains the internal homeostasis by continuously interacting with other brain structures. Its failure is commonly observed in many neurological and neuropsychiatric disorders, including neurodegenerative and vascular brain diseases, spinal cord injury, and peripheral neuropathies. Despite the different underlying pathophysiological mechanisms, ANS failure associates with various forms of higher level dysfunctions, and may also negatively impact on patients’ clinical outcome. In this review, we will discuss potential relationships between ANS and higher level dysfunctions in a selection of neurological and neuropsychiatric disorders. In particular, we will focus on the effect of a documented fall in blood pressure fulfilling the criteria for orthostatic hypotension and/or autonomic-reflex impairment on cognitive performances. Some evidence supports the hypothesis that cardiovascular autonomic failure may play a negative prognostic role in most neurological disorders. Despite a clear causal relationship between ANS involvement and higher level dysfunctions that is still controversial, this might have implications for neuro-rehabilitation strategies aimed at improving patients’ clinical outcome.

Controle autonômico do coração e fração de ejeção na fase crônica do acidente vascular encefálico

Introdução: Sujeitos acometidos por acidente vascular encefálico (AVE) podem apresentar alterações na estrutura e função do coração e na modulação autonômica.Objetivo: Verificar função autonômica e cardíaca sistólica em homens após AVE, e se estas variáveis estão associadas.Métodos: Foram avaliados oito homens, com idade entre 55 e 65 anos, acometidos por lesão cerebrovascular há pelo menos seis meses e todos com hemiparesia. Foram realizadas as seguintes avaliações: 1) Ecocardiografia, para avaliar a função cardíaca sistólica. 2) Registro da frequência cardíaca (FC) e dos intervalos R-R (IRR), batimento a batimento, para avaliação do controle neural do coração. Esses dados foram analisados no domínio da frequência, por meio das análises dos seguintes componentes espectrais: alta frequência; baixa frequência e a razão BF/AF. Foi aplicado o teste de correlação de Pearson (p ≤ 0,05).Resultados: Características demográficas, antropométricas e fisiológicas: Idade = 58,62 ± 2,88 anos; IMC = 27,41 ± 5,33 kg/m2 ; BF = 61,78 ± 26,79 (un); AF = 38,23 ± 26,79 (un); BF/AF = 3,41 ± 3,38; FE = 0,65 ± 0,04. Não houve correlação estatisticamente significativa entre os índices espectrais BF e AF com fração de ejeção e a presença de fatores de risco para AVE.Conclusão: No presente estudo, a fração de ejeção do ventrículo esquerdo encontra-se normal e o controle neural do coração pode estar normal ou não, mesmo na presença de fatores de risco para o AVE.

Heart rate variability and functional outcome in ischemic stroke: a multiparameter approach

BACKGROUND AND PURPOSE

Heart rate variability (HRV) as a measure of autonomic function might provide prognostic information in ischemic stroke. However, numerous difficulties are associated with HRV parameters assessment and interpretation, especially in short-term ECG recordings. For better understanding of derived HRV data and to avoid methodological bias we simultaneously recorded and analyzed heart rate, blood pressure and respiratory rate.

METHODS

Seventy-five ischemic stroke patients underwent short-term ECG recordings. Linear and nonlinear parameters of HRV as well as beat-to-beat blood pressure and respiratory rate were assessed and compared in patients with different functional neurological outcomes at 7th and 90th days.

RESULTS

Values of Approximate, Sample and Fuzzy Entropy were significantly lower in patients with poor early neurological outcome. Patients with poor 90-day outcome had higher percentage of high frequency spectrum and normalized high frequency power, lower normalized low frequency power and lower low frequency/high frequency ratio. Low frequency/high frequency ratio correlated negatively with scores in the National Institutes of Health Stroke Scale and modified Rankin Scale (mRS) at the 7th and mRS at the 90th days. Mean RR interval, values of blood pressure as well as blood pressure variability did not differ between groups with good and poor outcomes. Respiratory frequency was significantly correlated with the functional neurological outcome at 7th and 90th days.

CONCLUSION

While HRV assessed by linear methods seems to have long-term prognostic value, complexity measures of HRV reflect the impact of the neurological state on distinct, temporary properties of heart rate dynamic. Respiratory rate during the first days of the stroke is associated with early and long-term neurological outcome and should be further investigated as a potential risk factor.

Investigation of changes in body composition, metabolic profile and skeletal muscle functional capacity in ischemic stroke patients: the rationale and design of the Body Size in Stroke Study (BoSSS)

BACKGROUND

Stroke is steadily increasing in prevalence. Muscle tissue wasting and functional changes are frequently observed in stroke, but this has not been studied in detail yet. There is a lack of data to support guideline recommendations on how to target muscle wasting in stroke patients. We hypothesise that pathophysiological metabolic profiles and muscle functional and structural impairment are developing in stroke patients, which are associated with stroke severity and outcome after stroke.

METHODS

The Body Size in Stroke Study (BoSSS) is a prospective, longitudinal observation study that will explore associations between the metabolic profile, body tissue wasting and particular metabolic and functional changes in skeletal muscle tissue in stroke patients. Consecutive patients with acute stroke (n = 150) will be enrolled due to lacunar or territorial ischemic infarct in the area of the middle cerebral artery. Patients will be studied at annual intervals after 12 and 24 months. For comparison, healthy controls of similar age and patients with chronic heart failure will be used as control groups. The main objective is to study changes in body composition in stroke patients. Secondary, the study will focus on changes in insulin sensitivity of adipose tissue and skeletal muscle. Furthermore, measurements of endothelial function and peripheral blood flow will provide insight in the vascular regulation in stroke patients.

CONCLUSION

This study will be the largest observational study providing insights into the metabolic and functional changes of muscle tissue in patients with acute ischemic stroke. The new data will increase our understanding of the pathophysiologic tissue wasting in stroke disease and help to develop new therapeutic strategies.

Heart rate variability

Heart rate variability (HRV) provides indirect insight into autonomic nervous system tone, and has a well-established role as a marker of cardiovascular risk. Recent decades brought an increasing interest in HRV assessment as a diagnostic tool in detection of autonomic impairment, and prediction of prognosis in several neurological disorders. Both bedside analysis of simple markers of HRV, as well as more sophisticated HRV analyses including time, frequency domain and nonlinear analysis have been proven to detect early autonomic involvement in several neurological disorders. Furthermore, altered HRV parameters were shown to be related with cardiovascular risk, including sudden cardiac risk, in patients with neurological diseases. This chapter aims to review clinical and prognostic application of HRV analysis in diabetes, stroke, multiple sclerosis, muscular dystrophies, Parkinson's disease and epilepsy.

Parasympathetic activity correlates with early outcome in patients with large artery atherosclerotic stroke

To evaluate the associations between autonomic function and early stroke outcome in different subtypes of cerebral infarct, 24 patients with acute large artery atherosclerotic infarction (LAA), 26 patients with acute lacunar infarction (LAC), and 19 control subjects were prospectively recruited. Stroke outcome by the National Institute of Health Stroke Score (NIHSS) and heart rate variability (HRV) by power spectral analysis were recorded. The LAA group had lower high-frequency power (HF, P=0.017), lower normalized HF (P=0.002), higher normalized low-frequency power (LF%, P=0.016), and higher ratio of LF to HF (P=0.003) than both the LAC and control groups. Multivariate regression analysis in the LAA group showed that HF significantly correlated with early outcome (standardized coefficient=-0.486, P=0.016), and HF less than 3.9 [ln(ms(2))] was an independent risk factor for NIHSS≥4 at seventh day after admission (odd ratio=6.00, 95% confidence interval 1.02-35.37, P=0.048). There was no significant correlation between any HRV parameter and early stroke outcome in the LAC group. There were different autonomic function properties between LAA and LAC groups, and depressed parasympathetic modulation was associated with worse early outcome in patients with LAA.

Preliminary findings of the effects of autonomic dysfunction on functional outcome after acute ischemic stroke

BACKGROUND AND PURPOSE

Impaired autonomic function is common in the acute poststroke phase but little is known about its effects on functional outcome after acute ischemic stroke. This study sought to investigate the impact of autonomic dysfunction by Ewing's classification on functional outcome 2 months after acute ischemic stroke.

METHODS

34 consecutive acute ischemic stroke patients within 7 days after onset were enrolled. On admission, autonomic function was assessed by Ewing's battery tests. Stroke severity was assessed by the National Institutes of Health Stroke Scale (NIHSS), autonomy in activities of daily living by the Barthel Index (BI), and global disability by the modified Rankin Scale (mRS). BI and mRS were also evaluated 2 months after ischemic stroke onset.

RESULTS

On admission, eight patients were diagnosed as minor autonomic dysfunction and 26 patients as relatively severe autonomic dysfunction. The prevalence of relatively severe autonomic dysfunction in ischemic stroke patients was 76.5%. There were no significant differences in baseline characteristics between the minor and severe autonomic dysfunction groups. 2 months after stroke onset, the mean BI score of patients with minor autonomic dysfunction and severe autonomic dysfunction increased from 76.3±15.3 on admission to 95.0±7.1, 66.5±15.2 on admission to 74.8±15.9 respectively. The mean BI score after 2-month stroke onset and the change in BI from admission to 2-month outcome (delta BI) in patients with severe autonomic dysfunction were lower than those in patients with minor autonomic dysfunction (all P<0.05).

CONCLUSIONS

Autonomic dysfunction occurs in acute stroke patients. Relatively severe autonomic dysfunction is related to an unfavorable functional outcome in patients with acute ischemic stroke.