Epidemiology of stroke

Effects of Subtalar Joint Mobilization with Movement on Muscle Strength, Balance, Functional Performance, and Gait Parameters in Patients with Chronic Stroke: A Single-Blind Randomized Controlled Study

BACKGROUND

Losses in muscle strength, balance, and gait are common in patients with chronic stroke (CS). Ankle joint movements play a key role in this population to maintain a sufficient level of functional activity. The aim of this study was to investigate the effects of the subtalar joint (STJ) mobilization with movement (MWM) technique on muscle strength, balance, functional performance, and gait speed (GS) in patients with CS.

METHODS

Twenty-eight patients with CS were randomly divided into the control group (n = 14) and the STJ MWM group (n = 14). A 30-min neurodevelopmental treatment program and talocrural joint MWM were applied to both groups. Also, STJ MWM was applied to the STJ MWM group. The patients were treated 3 days a week for 4 weeks. Ankle dorsiflexion and plantarflexion muscle strength, Berg Balance Scale, Timed Up and Go test, and GS were evaluated before and after treatment.

RESULTS

Berg Balance Scale and Timed Up and Go test scores, dorsiflexion and plantarflexion muscle strength, and GS improved in both groups after the treatment sessions (P < .05), but the improvements were greater in the STJ MWM group compared with the control group (P < .05).

CONCLUSIONS

According to these results, STJ MWM together with neurodevelopmental treatment and talocrural joint MWM can increase ankle muscle strength, balance, functional performance, and GS on the affected leg in patients with CS.

Effects of Action Observation Therapy with Limited Visual Attention on Walking Ability in Stroke Patients

In this study, we compared the effects of action observation therapy (AOT) on the walking ability of stroke patients between videos with limited visual attention (body part videos) and a video with the whole body (whole body video). We employed a crossover design and conducted 3 AOT sessions (body part videos, whole body video and a scenery video) for 11 stroke patients. The evaluation items were the 10-m walking time and number of steps, cadence, trunk and knee joint angles during walking, and the timed up and go test (TUGT). After body part videos, the 10-m walking time, trunk and knee joint angles and TUGT significantly improved, suggesting them to be an efficient AOT method.

Hypertensive Crisis in Acute Cerebrovascular Diseases Presenting at the Emergency Department: A Narrative Review

Hypertensive crisis, defined as an increase in systolic blood pressure >179 mmHg or diastolic blood pressure >109 mmHg, typically causes end-organ damage; the brain is an elective and early target, among others. The strong relationship between arterial hypertension and cerebrovascular diseases is supported by extensive evidence, with hypertension being the main modifiable risk factor for both ischemic and hemorrhagic stroke, especially when it is uncontrolled or rapidly increasing. However, despite the large amount of data on the preventive strategies and therapeutic measures that can be adopted, the management of high BP in patients with acute cerebrovascular diseases presenting at the emergency department is still an area of debate. Overall, the outcome of stroke patients with high blood pressure values basically depends on the occurrence of hypertensive emergency or hypertensive urgency, the treatment regimen adopted, the drug dosages and their timing, and certain stroke features. In this narrative review, we provide a timely update on the current treatment, debated issues, and future directions related to hypertensive crisis in patients referred to the emergency department because of an acute cerebrovascular event. This will also focus greater attention on the management of certain stroke-related, time-dependent interventions, such as intravenous thrombolysis and mechanic thrombectomy.

Hypertensive Crisis in Acute Cerebrovascular Diseases Presenting at the Emergency Department: A Narrative Review

Hypertensive crisis, defined as an increase in systolic blood pressure >179 mmHg or diastolic blood pressure >109 mmHg, typically causes end-organ damage; the brain is an elective and early target, among others. The strong relationship between arterial hypertension and cerebrovascular diseases is supported by extensive evidence, with hypertension being the main modifiable risk factor for both ischemic and hemorrhagic stroke, especially when it is uncontrolled or rapidly increasing. However, despite the large amount of data on the preventive strategies and therapeutic measures that can be adopted, the management of high BP in patients with acute cerebrovascular diseases presenting at the emergency department is still an area of debate. Overall, the outcome of stroke patients with high blood pressure values basically depends on the occurrence of hypertensive emergency or hypertensive urgency, the treatment regimen adopted, the drug dosages and their timing, and certain stroke features. In this narrative review, we provide a timely update on the current treatment, debated issues, and future directions related to hypertensive crisis in patients referred to the emergency department because of an acute cerebrovascular event. This will also focus greater attention on the management of certain stroke-related, time-dependent interventions, such as intravenous thrombolysis and mechanic thrombectomy.

Does Hip Bone Density Differ between Paretic and Non-Paretic Sides in Hemiplegic Stroke Patients? and Its Relationship with Physical Impairment

Background

Bone loss after stroke escalates the risk of fractures, mainly in the hip, leading to further disability in individuals with stroke. We aimed to investigate the skeletal effect of bone mineral density (BMD) based on the duration of onset of stroke, compare the BMD of the paretic and non-paretic sides, and elucidate the relationship between BMD and disability variables.

Methods

The 31 male hemiplegic stroke patients between 20 and 70 years of age with cerebral infarction or hemorrhage were considered in this study. Subacute and chronic cases included 13 and 18 patients with lag time from the onset of 1 to 6 months and beyond 6 months, respectively. BMD in the lumbar, paretic, and non-paretic hip as well as the disability variables were analyzed retrospectively.

Results

The subacute group showed a significant reduction in the femoral neck BMD on the paretic side compared to that on the non-paretic side based on T-scores (P=0.013). Bone loss was significantly correlated with lower limb muscle strength and overall physical impairment (P<0.05). The chronic group demonstrated significant reduction in femur neck and total femur BMD on the paretic side compared to that on the non-paretic side based on T-scores (P=0.002 and P<0.001, respectively). T-scores of BMD in the chronic phase were not significantly associated with the clinical parameters.

Conclusions

Early screening of bilateral hip BMD in the early stages after stroke, monitoring, and timely implementation of prevention strategies are important to minimize subsequent bone loss and prevent possible complications in patients who experience stroke.

Dose-Response Effect of Daily Rehabilitation Time on Functional Gain in Stroke Patients

OBJECTIVE

To demonstrate the effect of daily treatment time on recovery of functional outcomes and how each type of rehabilitation treatment influences the improvement of subgroups of functional outcomes in stroke patients.

METHODS

We conducted a retrospective study in 168 patients who were admitted to the Department of Rehabilitation Medicine between 2015 and 2016. Patients who experienced their first-ever stroke and unilateral lesions were included. All patients underwent conventional rehabilitation treatment, and each treatment was administered one to two times a day depending on individual and treatment room schedules. Based on the mean daily treatment time, patients were divided into two groups: a high-amount group (n=54) and low-amount group (n=114). Outcomes were measured through the Korean version of Modified Barthel Index (MBI), FuglMeyer Assessment of the upper extremity, Trunk Impairment Scale (TIS), and Berg Balance Scale (BBS) scores on admission and at discharge.

RESULTS

The functional change and scores at discharge of MBI, TIS, and BBS were greater in the high-amount group than in the low-amount group. Among various types of rehabilitation treatments, occupational therapy training showed significant correlation with MBI, TIS, and BBS gain from admission to discharge.

CONCLUSION

The amount of daily mean treatment in post-stroke patients plays an important role in recovery. Mean daily rehabilitation treatment time seems to correlate with improved balance and basic activities of daily living after stroke.

Smoking cessation, weight gain, and risk of stroke among postmenopausal women

The relationship between smoking cessation, concurrent weight gain, and stroke events is not yet understood. Thus, we examined the association between smoking cessation and subsequent stroke risk and whether the association was modified by concurrent weight gain. In 2017, we analyzed data from 109,498 postmenopausal US women enrolled in the Women's Health Initiative from 1993 to 1998. Women with a history of cancer or cardiovascular disease events were excluded. The median length of follow-up time was 14.01 years. Variables of primary focus were smoking cessation, weight change, and clinically confirmed incident cases of hemorrhagic and ischemic stroke. Hazard ratios were estimated for stroke incidences (all, ischemic, and hemorrhagic) associated with smoking cessation using Cox regression. The exposure-outcome relationship of smoking cessation and risk of stroke was evaluated for effect modification by weight change. Recent quitters between baseline and year 3 had a significantly lower risk for all stroke and ischemic stroke, but not hemorrhagic stroke, when compared to the reference group of continuing smokers. In the multivariable-adjusted model for ischemic stroke, the hazard ratio for recent quitters was 0.66 (95% CI: 0.46, 0.95). In the model for hemorrhagic stroke, the hazard ratio for recent quitters was 0.76 (95% CI: 0.36, 1.61). The association between recent quitting and stroke risk was not significantly modified by weight change. Smoking cessation was associated with a significant reduction in stroke risk. The benefit of smoking cessation on the risk of stroke was not attenuated by concurrent weight gain.

Genetic variation of the intestinal fatty acid-binding protein 2 gene in carotid atherosclerosis

The alanine (A) to threonine (T) substitution at codon 54 of the intestinal fatty acid-binding protein 2 (FABP2) has been associated with dyslipidaemia and other characteristics of the metabolic syndrome, which in turn is a risk factor for cerebrovascular disease. The aim of this study was to investigate whether the A54T polymorphism in the FABP2 gene is associated with internal carotid artery (ICA) stenosis in stroke patients. Swedish subjects initially diagnosed with acute cerebrovascular disease (n = 196) that had been assessed with ultrasound of the carotid arteries were identified and grouped depending on whether a stenosis was found. The subjects were genotyped for the A54T polymorphism using a PCR-RFLP method. In a multivariate logistic-regression analysis, where known risk factors for atherosclerosis were fixed (diabetes, systolic blood pressure, age and smoking), having the FABP2 T allele was a significant risk factor for ICA stenosis (odds ratio 2.9; 95% confidence interval, 1.1-7.7; p = 0.04) together with diabetes (odds ratio 4.9; 95% confidence interval, 1.8-14; p < 0.01). Age, smoking and blood pressure did not reach statistical significance. In conclusion, our result supports the hypothesis that the FABP2 A54T polymorphism is associated with ICA stenosis.

Epidemiology of stroke in Shiraz, Iran

BACKGROUND

Stroke is the main cause of physical disability and the second leading cause of death worldwide. Two-thirds of all strokes occur in the developing countries. Despite being preventable, stroke is increasingly becoming a major health issue in these countries. The aim of this study was to evaluate the epidemiology of stroke in Shiraz, Iran, one of the main referral centers in the southwestern part of Iran.

METHODS

A cross-sectional study was conducted on all stroke patients admitted to the Namazee Hospital, affiliated to Shiraz University of Medical Sciences, between August 2010 and January 2011. Patients' demographic data, atherosclerosis risk factors, type of stroke, drug history, outcomes, and neurological signs were recorded. Chi-square test, Kolmogorov-Smirnov test, t-test, and Mann-Whitney U-test were used to analyze the data.

RESULTS

A total of 305 patients with stroke, aged 27-97 years (mean ± SD = 68.33 ± 12.99), 269 patients (88.2%) had ischemic stroke (IS) and 36 (11.8%) had hemorrhagic stroke (HS). 133 patients (43.6%) were men and 172 (56.4%) were women. 11.4% of the patients with IS and 40.6% with HS died during hospitalization, causing 12.1% death in all stroke patients [Odds ratio (Or) = 5.34, 95% Confidence intervals (CI) = 2.35-12.11]. Hypertension, ischemic heart disease, diabetes, and recurrent stroke were the most common risk factors.

CONCLUSION

This study provides evidence that the epidemiology of stroke in the southwestern part of Iran may be similar to other places. However, it seems necessary and helpful to design a registration system for patients with stroke in Shiraz Namazee Hospital.

Differences in cortical activation between observing one's own gait and the gait of others: a functional near-infrared spectroscopy study

Using functional near-infrared spectroscopy, we investigated cortical activation while participants observed their own gait and the gait of others. Further, we compared the vividness of motor imagery induced by observing one's own and the gait of others. Participants were instructed to perform a gait observation task. The task had two conditions: observing video clips of one's own walking and observing video clips of other individuals walking. After observing the videos, the participants were asked to evaluate the vividness of the mental image of the observed gait on a visual analog scale. When observing one's own gait, the right dorsal premotor cortex and the superior parietal lobule were activated, whereas when observing the gait of others, the left inferior parietal lobule was activated. Observing one's own gait induced imagery that was significantly more vivid than that induced when viewing the gait of others. We suggest that observing one's own gait generates a representation of one's own body in the brain and induces more vivid gait imagery.

Does the speed of the treadmill influence the training effect in people learning to walk after stroke? A double-blind randomized controlled trial

OBJECTIVE

To compare the effectiveness of high-speed treadmill training and progressive treadmill training for stroke patients.

DESIGN

A double-blind, randomized controlled trial.

SETTING

Inpatient rehabilitation hospital.

PARTICIPANTS

A total of 61 ambulatory stroke patients.

INTERVENTIONS

Patients in both groups underwent treadmill training for 30 minutes with conventional intervention. The progressive training group (n = 31) was trained to walk on a treadmill with a stepwise increase of speed over the treatment period. The high-speed training group (n = 30) trained to begin at 1.2-1.3 m/s, which is faster than the mean speed of stroke patients. All participants underwent 20 training sessions for five weeks.

MAIN MEASURES

Timed up-and-go test, 10-m walk test, 6-minute walk test, and both step lengths and cadence.

RESULTS

There were significant improvements in the results of the timed up-and-go test (-1.96 vs. -5.02 seconds), 10-m walk test (0.30 vs. 0.47 m/s), 6-minute walk test (38.35 vs. 64.40 m), and in the step length of the affected side (0.14 vs. 0.19 m) and the unaffected side (0.10 vs. 0.12 m) in the high-speed training group compared with those in the progressive training group (p < 0.05). Step width was not changed in either group (p > 0.05).

CONCLUSION

These results suggest that high-speed training is an effective method for improving the walking ability of stroke patients.

Gravity-supported exercise with computer gaming improves arm function in chronic stroke

OBJECTIVE

To investigate the effect of 4 to 6 weeks of exergaming with a computer mouse embedded within an arm skate on upper limb function in survivors of chronic stroke.

DESIGN

Intervention study with a 4-week postintervention follow-up.

SETTING

In home.

PARTICIPANTS

Survivors (N=13) of chronic (≥6 mo) stroke with hemiparesis of the upper limb with stable baseline Fugl-Meyer assessment scores received the intervention. One participant withdrew, and 2 participants were not reassessed at the 4-week follow-up. No participants withdrew as a result of adverse effects.

INTERVENTION

Four to 6 weeks of exergaming using the arm skate where participants received either 9 (n=5) or 16 (n=7) hours of game play.

MAIN OUTCOME MEASURE

Upper limb component of the Fugl-Meyer assessment.

RESULTS

There was an average increase in the Fugl-Meyer upper limb assessment score from the beginning to end of the intervention of 4.9 points. At the end of the 4-week period after the intervention, the increase was 4.4 points.

CONCLUSIONS

A 4- to 6-week intervention using the arm skate significantly improved arm function in survivors of chronic stroke by an average of 4.9 Fugl-Meyer upper limb assessment points. This research shows that a larger-scale randomized trial of this device is warranted and highlights the potential value of using virtual reality technology (eg, computer games) in a rehabilitation setting.

Impact of metabolic syndrome components on incident stroke subtypes: a Chinese cohort study

Limited evidence is available on the risk differences in the development of stroke subtypes in relation to particular clustering patterns of the metabolic syndrome (MetS) components. A follow-up study of a Chinese cohort involving 10,292 individuals was performed to assess the roles of cluster patterns of the MetS components in the prediction of incident stroke subtypes. During follow-up, there were 161 incident cases of ischemic strokes and 41 incident cases of hemorrhagic strokes. Among MetS components, only the hypertensive trait was associated with significantly elevated risks of both ischemic and hemorrhagic strokes. Furthermore, MetS with hypertension as components was associated with increased risk of ischemic and hemorrhagic strokes (adjusted hazards ratio (95% confidence interval) was 2.96 (1.94-4.50) and 2.93 (1.25-6.90), respectively) as compared with those who had neither hypertension nor MetS. Notably, as the number of the MetS components increased, the risk of ischemic stroke significantly and dose-dependently increased. This implies a cumulative effect of MetS components in elevating the risk of ischemic stroke. These findings suggest that MetS comprises heterogenous clusters with respect to the risk of developing the subtype of stroke.

Intra-arterial thrombolysis in acute ischemic stroke: a review of pharmacologic approaches

Ischemic stroke is a major public health problem worldwide. The potential to cure stroke patients with intravenous thrombolytic therapy has evolved to the use of intra-arterial thrombolytic agents. Fewer than 200 patients have been enrolled in randomized trials of intra-arterial therapy. In this article the authors have reviewed the literature listed in MEDLINE and EMBase, and searched relevant articles to examine the role of fibrinolytic agents in acute interventional stroke therapy. Only English language articles reporting five or more patients were included. Outcomes were defined at 90 days. Good outcome was defined on the modified Rankin Scale. Symtpomatic hemorrhage was defined as hemorrhage in the setting of clinical deterioration in the first 24 to 48 h. The search identified 57 studies of which 44 reported usable data. Only three randomized trials were reported. Of a total of 1140 patients, most (73%) were treated open-label with urokinase (Abbokinase, Abbott Laboratories). The best outcomes were reported in case series and slightly worse outcomes were reported in clinical trials. Overall, it was not possible to distinguish whether one agent was superior to the others. There is a paucity of published evidence on intra-arterial therapy for acute ischemic stroke. Alteplase (Activase, Genentech Inc.) is currently the drug of choice simply because it is available and it is the current intravenous standard. Further trials and developments are anticipated.

Investigating the association between influenza vaccination and reduced stroke risk

Acute infections, mainly of the respiratory tract, have consistently been demonstrated to considerably increase the risk of stroke. At present, prospective interventional trials are lacking and there is no proof of the effectiveness of any therapeutic anti-infective strategy in stroke prevention. However, some new evidence from observational studies lends support to the idea that influenza vaccination may contribute importantly to fighting stroke. Although final proof of efficacy is still missing, patients with previous cerebral ischemia and subjects of any age at high risk of stroke should be encouraged to receive annual influenza vaccination.

The effects of action observational training on walking ability in chronic stroke patients: a double-blind randomized controlled trial

Objective:

To investigate the effect of action observational training on walking ability with chronic stroke patients.

Design:

A double-blind randomized controlled trial.

Setting:

Inpatient rehabilitation hospital.

Participants:

Thirty chronic stroke patients.

Interventions:

Patients in both groups underwent treadmill training for 30 minutes. The action observational training group ( n = 15) watched a video of treadmill walking actions taken at various speeds before treadmill training for 10 minutes. The control group ( n = 15) watched a nature video unrelated to gait training for the same amount of time. All participants received training five times a week for a period of four weeks.

Main measures:

Timed up and go test, 10-metre walk test, 6-minute walk test and maximal flexed knee angle in the swing phase during walking.

Results:

There were significant improvements in timed up and go test (–4.47 vs. –2.47 seconds), 10-m walk test (0.35 vs. 0.16 m/s), 6-minute walk test (93.13 vs. 32.53 m) and maximal flexed knee angle in the swing phase during walking (7.11 vs. 4.58 degrees) in the action observational training group compared with the control group ( P < 0.05). Small to huge effect sizes of 1.27, 0.57, 2.34 and 0.37 were observed for timed up and go test, 10-m walk test, 6-minute walk test, and maximal flexed knee angle in the swing phase during walking, respectively.

Conclusion:

These results suggest that action observational training is an effective method for improvement of the walking ability in chronic stroke patients.

Estimation of spatio-temporal parameters for post-stroke hemiparetic gait using inertial sensors

This paper represents the first step in developing an inertial sensor system that is capable of assessing post-stroke gait in terms of walking speed and temporal gait symmetry. Two inertial sensors were attached at the midpoint of each shank to measure the accelerations and angular velocity during walking. Despite the abnormalities in hemiparetic gait, the angular velocity of most of the testing subjects (12 out of 13) exhibited similar characteristics as those from a healthy population, enabling walking speed estimation and gait event detection based on the pendulum walking model. The results from a standardized 10-meter walk test demonstrated that the IMU-based method has an excellent agreement with the clinically used stopwatch method. The gait symmetry results were comparable with previous studies. The gait segmentation failed when the angular velocity deviates significantly from the healthy groups' profile. With further development and concurrent validations, the inertial sensor-based system may eventually become a useful tool for continually monitoring spatio-temporal gait parameters post stroke in a natural environment.

Use of assistive technology in cognitive rehabilitation: exploratory studies of the opinions and expectations of healthcare professionals and potential users

OBJECTIVE

To provide recommendations for the successful implementation of Assistive Technology (AT) in cognitive rehabilitation by investigating the attitudes towards AT of professionals, individuals with acquired brain injury (ABI) and their caregivers in two exploratory studies.

METHOD

A total of 147 professionals in cognitive rehabilitation filled out a web-based survey. Fifteen patients with ABI and 14 caregivers were interviewed.

RESULTS

Most professionals were willing to use AT in the future, although only 27% used AT currently in a treatment setting. Professionals with AT experience were more positive than those without about the potential of AT and their own ability to use it in their treatment programmes. Most patients and caregivers were positive about using AT in the future, still, only a minority currently used AT. Refusal to reimburse AT devices by health insurance companies appeared an important barrier for a more widespread use.

CONCLUSIONS

Although enthusiasm about AT was evident in both studies, a lack of progress in the implementation of AT was noted. This could be improved by promoting knowledge and hands-on experience of professionals who work in rehabilitation centres. More evidence on the efficacy of AT is required to improve coverage of AT devices by insurance companies.

Development of a parametric kinematic model of the human hand and a novel robotic exoskeleton

This paper reports the integration of a kinematic model of the human hand during cylindrical grasping, with specific focus on the accurate mapping of thumb movement during grasping motions, and a novel, multi-degree-of-freedom assistive exoskeleton mechanism based on this model. The model includes thumb maximum hyper-extension for grasping large objects (~> 50 mm). The exoskeleton includes a novel four-bar mechanism designed to reproduce natural thumb opposition and a novel synchro-motion pulley mechanism for coordinated finger motion. A computer aided design environment is used to allow the exoskeleton to be rapidly customized to the hand dimensions of a specific patient. Trials comparing the kinematic model to observed data of hand movement show the model to be capable of mapping thumb and finger joint flexion angles during grasping motions. Simulations show the exoskeleton to be capable of reproducing the complex motion of the thumb to oppose the fingers during cylindrical and pinch grip motions.

Stroke Incidence and Survival in Ludwigshafen am Rhein, Germany

Background and Purpose— Considerable locoregional differences in stroke incidence exist even within countries. Based on data from a statewide stroke care quality monitoring project, we hypothesized a high stroke incidence mainly among younger age groups in the industrial city of Ludwigshafen am Rhein, Germany. To test this hypothesis and to provide data on stroke incidence and case-fatality rates, a population-based stroke register was initiated.

Methods— The Ludwigshafen Stroke Study is a prospective ongoing population-based stroke register among the 167 906 inhabitants of Ludwigshafen am Rhein. Starting on January 1, 2006, standard definitions and multiple overlapping methods of case ascertainment were used to identify all patients with incident stroke or transient ischemic attack.

Results— In 2006 and 2007, 1231 cases with stroke or transient ischemic attack including 725 patients with first-ever stroke were identified. The crude annual incidence rate per 1000 for first-ever stroke was 2.16 (95% CI 2.10 to 2.32). After age adjustment to the European population, incidence for first-ever stroke was 1.46 (95% CI 1.35 to 1.57; men: 1.63; 95% CI 1.46 to 1.81; women: 1.29; 95% CI 1.15 to 1.43). Crude annual incidence rates per 1000 were 1.86 for ischemic stroke, 0.19 for intracerebral hemorrhage, 0.05 for subarachnoid hemorrhage, and 0.05 for undetermined stroke. Case-fatality rates for first-ever stroke were 13.6%, 16.4%, and 23.2% at Days 28, 90, and 365, respectively.

Conclusions— High crude incidence rates in our study reflect the rising burden of stroke in our aging population. Age-adjusted incidence rates were somewhat higher than those reported by recent studies from Western Europe, mainly due to higher incidence in subjects <65 years.

[Stroke and atrial fibrillation]

Approximately 80% of all strokes are ischemic, the remaining being hemorrhagic. The major reason for cerebral ischemia is occlusion of a cerebral artery by a cardiac thrombus in a patient with atrial fibrillation. This article focuses on the therapeutic management of patients with cerebral ischemia due to atrial fibrillation and is based on the guidelines of the German Society of Neurology and the European Stroke Organization: Patients with cerebral ischemia and atrial fibrillation require oral anticoagulation with an INR of 2.0-3.0. After a TIA (transient ischemic attack) or minor ischemic stroke, anticoagulation can be initiated within the first week after the stroke. Combination therapy of aspirin and clopidogrel is less effective than oral anticoagulation.

[Risk factors, etiology and prognosis in patients older than 80 years old with ischemic stroke]

INTRODUCTION

The aim of this study was to analyze differences between patients aged 80 years or less and those aged more than 80 years old a hospital series of ischemic stroke.

MATERIAL AND METHODS

We performed a retrospective review of all patients with ischemic stroke or transient ischemic attack requiring admission to the Neurology Service of the Dr. Negrín University Hospital of Gran Canaria (Spain) between January 1, 2004 and December 31, 2006. Data were gathered on hypertension, diabetes mellitus (DM), hyperlipidemia, ischemic cardiopathy (IC), atrial fibrillation (AF), the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification, as well as the National Institutes of Health (NIH) scale and the modified Rankin scale (mRS) at discharge.

RESULTS

A total of 850 patients were included. Age was >80 years in 106 (12.4%) and was <80 years in 744 (87.6%). In the group aged>80 years, 43.4% were men and 56.6% were women (64.1% men and 35.9% women in the group aged<80 years). Hypertension was present in 81.1% of patients aged>80 years (68.1% in those aged<80 years); previous DM was found in 29.2% (39.3% in the group aged<80 years); hyperlipidemia was present in 26.4% (40.2% in the group aged<80); IC was found in 16.9% (15.8% in the group aged<80); AF was found in 40% (20.9% in the group aged<80 years). In the group of patients aged>80 years, 23.6% had atherothrombotic stroke (19.3% in those aged<80 years); 38.7% were cardioembolic (19.3% in the group aged<80 years); 10.4% were lacunar (22.6% in the group aged<80 years); and 24.5% was of undetermined origin (28.6% in the group aged<80 years). The mRS at discharge was <or=2 in 73.8% of patients aged<80 years and in 55.7% of those aged>80 years.

CONCLUSIONS

Ischemic stroke in patients over 80 years old leads to certain differences in relation to risk factors, stroke etiology and stroke severity.

Geographic hierarchies of diagnostic practice style in cerebrovascular disease

Diagnostic practice style describes the ways in which physicians diagnose information about disease. Like practice style effects in general, diagnostic practice style effects may emerge as the result of training, inter-personal relationships between professionals, medical enthusiasm for particular diagnoses and patient-physician interactions. In this study we analyze the ways in which patterns of diagnostic practice style associated with cerebrovascular disease varies at different socio-geographical scales in the province of Alberta, Canada. We use hierarchical linear models to partition a measure of diagnostic practice style into four levels of observation: the physician level, the facility level, the municipality level and the regional (census division) level. We model a variety of fixed effects related to physician attributes, their practice, the facilities they work in and the municipalities within which their facilities operate. Our results suggest that attributes related to physicians and the facilities and municipalities in which they work all contribute to patterns of diagnostic practice style. Physicians working in rural and urban municipalities have different practice style patterns even after controlling for the types of facilities they work in, their professional medical specialization and their workload. Similar to other research, our results reveal that physicians have different diagnostic practice styles with members of the same sex than members of the opposite sex. Geographic variations in diagnostic practice style may obscure changes in the epidemiology of cerebrovascular disease in rural communities, and provide indirect evidence that the quality and/or timeliness of diagnosis may be worse in rural Alberta.

Trends in mortality from different subtypes of stroke in the population of Belgrade (Serbia)

OBJECTIVE

To estimate trends in mortality due to different stroke subtypes in the population of Belgrade during the period 1989-2003.

PATIENTS AND METHODS

Mortality data for stroke were compiled from material of the Municipal Institute of Statistics. Stroke mortality rates were standardized by world standard population. Linear regression coefficient in time trend analysis of mortality rates was assessed by Fisher's test.

RESULTS

In Belgrade, 1989-2003, the highest values of mortality rates were for ischemic stroke in both sexes: 50.1/100,000-men, and 39.9/100,000-women. The mortality rate from subarachnoid hemorrhage (SAH) was lower in men (3.9/100,000) compared to women (5.3/100,000). For intracerebral hemorrhage (ICH), the death rate was 3.1 times higher than that for SAH. Stroke due to hemorrhage was a more common cause of death than ischemic stroke for both sexes in all age groups up to 59. In older age, ischemic stroke became the more frequent cause of death. The time trends of stroke mortality rates in the Belgrade population during the period 1989-2003 showed that the most excessive statistically significant increase in death rates was related to ICH in both sexes. The death rates from SAH had increasing tendency in both sexes, especially in women (p=0.017). Upward trends were observed for ischemic stroke mortality rates too, with statistical significance in men (p=0.048).

CONCLUSION

Further research is needed to explain the causes of the increasing burden of stroke in Serbia. Since different profiles of risk factors play a role in the etiology of different stroke subtypes, these facts should be taken into account in the creation of both prevention and management strategies.

Predictors of in-hospital mortality for intracerebral hemorrhage: a hospital-based study in Pakistani adults

INTRODUCTION

Intracerebral hemorrhages (ICHs) comprise 5% to 30% of all strokes with a case fatality rate of 30% to 50%. With an increasing elderly population, nontraumatic ICH is likely to present as a recurring medical emergency in Pakistan. There is scarce documentation in Pakistan regarding the predictors for mortality in patients with ICH that can guide physicians in their management. We conducted a hospital-based study to determine the predictors of in-hospital mortality from ICH in patients admitted to a tertiary care facility.

MATERIALS AND METHODS

We reviewed case records of patients above 17 years admitted to The Aga Khan University Hospital, Karachi, Pakistan, between July 1995 and December 1997, with the primary diagnosis of ICH confirmed on computed tomography scanning. Clinical and risk factors were also evaluated.

RESULTS

The data of 221 patients was analyzed. Seventy-one (32%) patients died during hospital stay, half of whom died during the first 2 days of hospitalization. Patients who died during hospital stay were more likely on admission to have intraventricular extension of the primary hemorrhage (odds ratio = 10.6, P < .01), a Glasgow Coma Score less than 12 on admission (odds ratio = 4.8, P < .01), and a systolic blood pressure greater than or equal to 180 mm Hg (odds ratio = 2.7, P = .03).

CONCLUSIONS

Our study suggests that Glasgow Coma Score and intraventricular extension are predictors of acute mortality, consistent with published results. Elevated systolic blood pressure at admission, also found to be a predictor of acute mortality from ICH, may be explained alternatively by internal and external stroke-induced stress factors. The actual mechanisms for high admission systolic blood pressure remain unclear.

Stroke mortality in Belgrade, Serbia: age, period, and cohort analyses

OBJECTIVE

To assess the age, period, and cohort effects on stroke mortality in Belgrade, Serbia, between 1989 and 2003.

METHODS

Mortality data for stroke events were obtained from the Municipal Institute of Statistics. The age- and gender-specific mortality rates were calculated for the cohorts of individuals born between 1904-1908 and 1964-1968.

RESULTS

In males, the average mortality rate increased from 80.9/100,000 in 1989-1993 to 111.3/100,000 in 1994-1998, and decreased slightly to 101.8/100,000 in 1999-2003. A similar pattern was observed among females. Stroke mortality risk was strongly related to age in both genders. This age effect was present for both genders, independent of the cohort or time period. The majority of the successive generations in Belgrade had an increased risk of death from stroke in the recent cohorts especially among females.

CONCLUSIONS

Our results suggest the need to improve efforts in the primary and secondary prevention of stroke.

Infection as a risk factor for stroke

Persisting disability requiring professional healthcare or help in daily life activities can be expected in a third to a half of all stroke survivors. It is mainly the elderly that are affected. For the increasingly aging population of Western societies, stroke represents an increasing social and economic burden. Besides the existing therapeutic options, additional treatment and prevention strategies are needed. Traditional risk factors do not explain all clinical and epidemiological features of stroke. Recently, the association between infectious and inflammatory processes and the occurrence of vascular disease has been established. This review summarizes the current evidence of infections as stroke risk factors and of potential anti-infective strategies as future methods of stroke prevention.

Increased cognitive load during simple and complex motor tasks in acute stage after stroke

The aim of this study was to assess the activation of primary motor cortex, prefrontal cortex and parietal cortex during simple and complex motor tasks performed with the hemiparetic and non-hemiparetic hand.

METHODS

Seven patients after stroke in the left brain hemisphere were included in the study. Functional magnetic resonance imaging (fMRI) was performed in the first and third week, and in three patients also three months after the stroke.

RESULTS

Performance of both the simple and the complex tasks with the hemiparetic or non-hemiparetic hand resulted in activations of the motor cortex, prefrontal cortex and parietal cortex in majority of the consecutive fMRI sessions. Three months after the stroke fMRI data revealed reduced activation of primary motor cortex and parietal cortex in the contralesional hemisphere during the performance of the simple task by the hemiparetic hand. During the complex task, the reduction of activation was less prominent.

CONCLUSIONS

Results of the present study suggest that in mildly impaired stroke patients a bilateral activation of prefrontal and parietal cortex may participate in the recovery process from stroke. The potential for measurement of cortical rehabilitation is discussed.

The effect of infections and vaccinations on stroke risk

There is increasing evidence that, in addition to conventional risk factors, acute and chronic infectious diseases increase the risk of stroke. Acute infection, mainly respiratory, and both bacterial and viral infection, represent temporarily active trigger factors for cerebral ischemia. Chronic infectious diseases that may increase the risk of stroke include periodontitis, chronic bronchitis and infections with microbial antigens, such as Helicobacter pylori and Chlamydia pneumoniae. From observational studies, there is evidence that vaccination against influenza is associated with a reduced risk of stroke, myocardial infarction and all-cause mortality. This report provides an overview on the influence of infection on stroke risk and potential anti-infective strategies that may play a future role in stroke prevention.

Effect of Conventional Risk Factors for Excess Cardiovascular Death in Men NIPPON DATA80

BACKGROUND

The present study examined how sex differences in conventional risk factors for cardiovascular disease (CVD), especially smoking, account for excess male mortality from CVD in Japan.

METHODS AND RESULTS

In a 14-year follow-up study, causes of death were ascertained among 10,546 Japanese aged 30 years or older at the baseline. The proportion of the excess male risk of CVD explained by the differences in risk factors was estimated as (HR0-HR1)/(HR0-1), where HR0 is the age-adjusted hazard ratio (men vs women) and HR1 is the age and risk factor-adjusted hazard ratio. The age-adjusted male:female ratios were 1.60 (95% confidence interval (CI), 1.32-1.94) for CVD, 1.75 (95% CI, 1.33-2.30) for stroke, and 1.55 (95% CI, 0.97-2.49) for coronary heart disease. The proportion of excess male risk of CVD explained by smoking was 46% and excess risk explained by all risk factors including smoking was 36%. In men, drinking habits decreased the excess risk of CVD. Except for the association between drinking habits and CVD, the impact of the hazard ratios of conventional risk factors had no sex difference.

CONCLUSIONS

Smoking contributes substantially to excess male mortality from CVD when the smoking rates vary substantially by sex.

Robotic techniques for upper limb evaluation and rehabilitation of stroke patients

This paper presents two robot devices for use in the rehabilitation of upper limb movements and reports the quantitative parameters obtained to characterize the rate of improvement, thus allowing a precise monitoring of patient's recovery. A one degree of freedom (DoF) wrist manipulator and a two-DoF elbow-shoulder manipulator were designed using an admittance control strategy; if the patient could not move the handle, the devices completed the motor task. Two groups of chronic post-stroke patients (G1 n = 7, and G2 n = 9) were enrolled in a three week rehabilitation program including standard physical therapy (45 min daily) plus treatment by means of robot devices, respectively, for wrist and elbow-shoulder movements (40 min, twice daily). Both groups were evaluated by means of standard clinical assessment scales and a new robot measured evaluation metrics that included an active movement index quantifying the patient's ability to execute the assigned motor task without robot assistance, the mean velocity, and a movement accuracy index measuring the distance of the executed path from the theoretic one. After treatment, both groups improved their motor deficit and disability. In G1, there was a significant change in the clinical scale values (p < 0.05) and range of motion wrist extension (p < 0.02). G2 showed a significant change in clinical scales (p < 0.01), in strength (p < 0.05) and in the robot measured parameters (p < 0.01). The relationship between robot measured parameters and the clinical assessment scales showed a moderate and significant correlation (r > 0.53 p < 0.03). Our findings suggest that robot-aided neurorehabilitation may improve the motor outcome and disability of chronic post-stroke patients. The new robot measured parameters may provide useful information about the course of treatment and its effectiveness at discharge.

[Socio-economic aspects of stroke management]

BACKGROUND

Stroke is the third leading cause of death and the first leading cause of disability in developed and developing countries. It is one of the most demanding public health problems to be faced in the upcoming years, particularly because of population aging.

STATE OF THE ART

New therapeutic advances in the management of acute stroke have changed our perception of this condition and have had a major impact on healthcare organization and subsequently healthcare expenditures. Care required for the stroke victim is costly in both developing countries and in developed countries. Hemmorhagic events are the most costly, but their prevalence in Western countries is lower than ischemic events. Prevalence of ischemic events is higher in Asian countries. The direct costs of stroke, both for primary and secondary events, constitute the larger part of healthcare expenditures. The mean cost of stroke in France is estimated at 18,000 euros for the first 12 months. Disability accounts for 42 percent of the variable cost of stroke. During the first year, the acute phase accounts for 40 percent of the cost, rehabilitation and mid-term hospitalization for 29 percent, and ambulatory care for 8 percent. After 46 months, the cost of ambulatory care exceeds the cost of the first six months of care during and following the acute phase.

CONCLUSION

Any improvement in the primary or secondary prevention of stroke will lead to a decrease in the incidence and prevalence of stroke, and any therapeutic advance capable of reducing disability will consequently reduce the overall cost of stroke.

The FABP2 gene polymorphism in cerebrovascular disease

OBJECTIVE

Earlier studies have shown that the fatty acid binding protein 2 (FABP2) T54 allele is associated with dyslipidemia, which in turn correlates with the incidence of cerebrovascular disease (CVD). To assess whether the FABP2 gene A54T polymorphism is associated with an increased risk of CVD we undertook a case-control study.

MATERIALS AND METHODS

A total of 407 patients diagnosed with acute CVD and 158 control subjects were genotyped for the A54T polymorphism using a PCR-RFLP method.

RESULTS

Allele and genotype frequencies of the FABP2 A54T polymorphism did not differ between subjects with acute CVD (TT, 9.6%; TA, 41.0%; AA, 49.4%) and controls (TT, 7.6%; TA, 41.1%; AA, 51.3%; P = ns) or in the following subgroups of CVD compared with controls: non-cardioembolic infarction (n = 252), intracerebral hemorrhage (n = 23), and cardioembolic infarction (n = 91). In transient ischemic attacks (TIAs) (n = 41) the combined TT and TA genotype frequency (TT + TA, 65.9%) was more frequent than in controls (48.7%) (P = 0.05). Furthermore, the TT genotype was more frequent in non-smoking patients under the age of 70 (n = 77) with a non-cardioembolic infarction (TT, 18.2%) compared with controls (7.6%) (P = 0.024).

CONCLUSIONS

Our findings suggest an involvement of the FABP2 (A54T) gene polymorphism in the pathogenesis of CVD. The FABP2 T54 allele appears to be a genetic susceptibility marker for TIA and non-cardioembolic infarction at younger onset.

The recovery of walking ability and subclassification of stroke

BACKGROUND AND PURPOSE

The recovery of walking after a stroke is a key functional goal for many patients. Reports vary, but approximately 50-80% of patients will regain some degree of walking ability following stroke (Skilbeck et al., 1983). There are few data available to show whether different subclassifications of stroke have distinct patterns of gait recovery. The present paper describes the pattern of walking recovery in a population of stroke patients classified according to the Oxfordshire Community Stroke Project classification (Bamford et al., 1991).

METHOD

A prospective observational study. Stroke patients (n = 238) admitted to the inpatient Stroke Rehabilitation Unit at the Western General Hospital, Edinburgh were initially included, with data for 185 patients ultimately available for analysis. Standardized measures of recovery of 10 steps and a 10-metre walk were used routinely to examine recovery time of walking ability. The main outcome measures consisted of days taken to achieve a 10-step walk, days to achieve a 10-metre walk, and initial and discharge gait velocity over 10 meters.

RESULTS

Eighty-nine per cent of the sample (n = 164) achieved a 10-step walk in a median time of five days and a 10-metre walk in eight days. The median initial gait velocity was 0.45 m/s which improved by discharge to 0.55 m/s. Further analysis by subgroup revealed that subjects sustaining a partial anterior circulation infarct, lacunar infarct or posterior circulation infarct recovered significantly more quickly than those subjects with a total anterior circulation infarct (Kruskal Wallis test for days to achieve 10 steps (H = 22.524, N = 164, df = 3) p < 0.001; Kruskal Wallis test for days to achieve a 10-metre walk (H = 22.586, N = 164, df = 3) p < 0.001.

CONCLUSIONS

An hierarchical pattern of recovery of gait was observed with definite variation between the subclassifications of stroke. It is suggested that further work needs to be undertaken to identify more accurately the factors that may influence the recovery of walking following stroke.

Microalbuminuria and stroke in a British population: the European Prospective Investigation into Cancer in Norfolk (EPIC-Norfolk) population study

OBJECTIVES

To examine the relationship between microalbuminuria and incident stroke in the general population.

DESIGN

Population-based prospective cohort study.

SETTING

Participants were recruited in a primary care setting from 35 participating general practice units in Norfolk, UK.

SUBJECTS AND MAIN OUTCOME MEASURES

The study population consisted of 23,630 individuals aged 40-79 years recruited between 1993 and 1997 for the EPIC-Norfolk Study and followed up for an average of 7.2 years. Random spot urine specimens were collected at baseline and albumin-to-creatinine ratio measured. Participants were categorized into normoalbuminuria, microalbuminuria and macroalbuminuria groups. During follow-up, the main end point was stroke incidence (fatal and nonfatal), ascertained from the UK Office for National Statistics and from the National Health Service Health District database of all hospital admissions.

RESULTS

A total of 246 stroke events occurred during follow-up [crude incidence rate of stroke, 1.5 per 1000 person years (pyrs)]. The age-adjusted incidence of stroke increased significantly across categories of baseline albuminuria (0.9, 1.1 and 1.4/1000 pyrs for tertiles of normoalbuminuria, 2.6/1000 pyrs for microalbuminuria, and 6/1000 pyrs for macroalbuminuria in the total population, P < 0.001 for trend). In all women and men, the multivariate hazard ratio [95% confidence interval (CI)] for stroke associated with microalbuminuria was 1.49 (1.13-2.14) and macroalbuminuria 2.43 (1.11-6.26). After stratifying by stroke subtype, microalbuminuria was only independently predictive of ischaemic stroke, with hazard ratio (95% CI) of 2.01 (1.29-3.31).

CONCLUSION

Microalbuminuria is independently associated with approximately 50% increased risk of stroke in the general population. Microalbuminuria may be useful in identifying those at increased risk of stroke in the general population.

Establishing the reliability of Mobility Milestones as an outcome measure for stroke

Baer GD, Smith MT, Rowe PJ, Masterton L. Establishing the reliability of mobility milestones as an outcome measure for stroke. Arch Phys Med Rehabil 2003;84:977-81.

OBJECTIVE

To establish intrarater, interrater, and test-retest reliability of a standardized measure of mobility, "mobility milestones," incorporating sitting balance, standing balance, and walking ability.

DESIGN

Repeated-measures reliability study by using video data of patients with stroke.

SETTING

Physiotherapy and rehabilitation departments in Scotland.

PARTICIPANTS

Forty physiotherapists recruited from within the Lothian region: 20 senior physiotherapists with at least 3 years of experience working with neurologic patients and 20 staff grade physiotherapists with less than 12 months of experience working with neurologic patients.

INTERVENTION

Videotape comprising 40 clips (36 original clips, 4 repeated clips) of stroke patients of differing levels of ability attempting the mobility milestones was produced. After a short training session in the interpretation and application of the mobility milestones, each physiotherapist viewed the tape separately and scored whether the milestone had been achieved or not. This was repeated at a separate test session 2 weeks later.

MAIN OUTCOME MEASURE

Score for each mobility milestone.

RESULTS

Kappa statistics were used to determine interrater reliability and showed good (.61-.80) to very good (.81-1.0) reliability for 3 of 4 milestones. Intraclass correlation coefficients (ICCs) were used to determine intrarater reliability of the 4 repeated clips and showed 75% of all subjects had high (ICC(2,1)=.91-1.0) reliability. The ICC(2,1) for test-retest reliability showed a similar pattern, with 70% of subjects showing good (.81-.90) or high (.91-1.0) reliability.

CONCLUSIONS

The mobility milestones showed favorable levels of reliability when used by experienced or novice physiotherapists. The milestones can be adopted as a simple clinical outcome measure for use with stroke. Further research is required to establish reliability levels when the measure is used by different rehabilitation professionals.

Stroke epidemiology: a review of population-based studies of incidence, prevalence, and case-fatality in the late 20th century

This overview of population-based studies of incidence, prevalence, mortality, and case-fatality of stroke was based on studies from 1990. Incidence (first stroke in an individual's lifetime) and prevalence were computed by age, sex, and stroke type. Age-standardised incidence and prevalence with the corresponding 95% CI were plotted for each study to facilitate comparisons. The review shows that the burden of stroke is high and is likely to increase in future decades as a result of demographic and epidemiological transitions in populations. The main features of stroke epidemiology include modest geographical variation in incidence, prevalence, and case-fatality among the--predominantly white--populations studied so far, and a stabilisation or reversal in the declining secular trends in the pre-1990s rates, especially in older people. However, further research that uses the best possible methods to study the incidence, risk factors, and outcome of stroke are urgently needed in other populations of the world, especially in less developed countries where the risk of stroke is high, lifestyles are changing rapidly, and population restructuring is occurring.

Apolipoprotein E gene polymorphism in cerebrovascular disease: a case-control study

The association between apolipoprotein E (apo E) polymorphism and stroke has been controversial. So far there are no studies reported on the polymorphism of apolipoprotein E in cerebrovascular diseases in the Asian Indians. A blinded case-control study was therefore undertaken and the apo E genotypes and lipid profile of a total of 120 subjects (63 stroke patients and 57 healthy controls) were done. The frequency distribution of apo E alleles and genotypes were assessed and their relation with the occurrence of stroke in Asian Indian subjects was determined. A significantly high frequency of apo epsilon4 allele (30%) was observed in the stroke patients than the controls (11%) (p < 0.005), and patients with epsilon4 allele had a fourfold higher odds to develop stroke OR (95%CI) 4.2 (1.8-10.1) (p < 0.005). On multivariate analysis, after adjusting for age, triglycerides and hypertension, the association of epsilon4 allele with stroke was found to be no longer statistically significant, OR (95%CI) 1.2 (0.4-4.5) (p = NS). On multiple logistic regression analysis age, OR (95%CI) 1.1 (1.1-1.2) (p < 0.001), and hypertension OR (95%CI) 15.1 (2.6-89.1) (p < 0.005) were found to be independent risk factors for development of stroke. This is the first report to have examined the association of apo E gene polymorphism with stroke in the Asian Indians. This study suggests that apo epsilon4 allele, triglycerides, age and hypertension are the predictors for stroke development.

Reaching-lifting-placing task during standing after stroke: Coordination among ground forces, ankle muscle activity, and hand movement

OBJECTIVE

To investigate the coordination among hand movement, ground forces, and muscle activity in standing stroke patients reaching forward and lifting an object from a table.

DESIGN

Survey.

SETTING

Research laboratory.

PATIENTS

Eight stroke patients and 8 persons serving as controls.

MAIN OUTCOME MEASURE

Symmetry of percentage of body weight (BW) during initial standing, velocity and hand path trajectory, ankle muscle electromyography. Temporal and spatial parameters in percentage of movement time were recorded by using 2 forceplates, 3-dimensional kinematics, and surface electromyography. Motor function, sensory function, and functional performance were also assessed.

RESULTS

Weight distribution during initial standing was significantly higher (57.4% +/- 8.1% BW) on the nonparetic leg. All subjects had preserved the preparatory loading phase, and after onset of hand movement loading shifted to the contralateral leg. Ankle muscle activity onset (lateral gastrocnemius [LG]) occurred after loading. In stroke subjects, LG was consistently activated first in the nonparetic leg, regardless of which arm performed the task. During paretic hand task, the reaching phase was significantly longer and the lifting phase significantly shorter compared with that of the nonparetic hand task and with that of the controls. In the paretic task, the hand path velocity was not bell-shaped; the object lifting was.

CONCLUSIONS

Stroke subjects preserve the coordination between ground forces and hand movement. The lack of spontaneous use of the paretic hand is primarily caused by difficulties of planning the hand trajectory in space, as reflected by temporal and spatial parameters during task performance.