The most affected health domains after ischemic stroke

Home and workforce reintegration one year after thrombectomy in acute stroke patients

INTRODUCTION

Endovascular thrombectomy (EVT) combined with intravenous thrombolysis is the current standard treatment for acute large-vessel occlusion stroke. Beyond clear clinical benefits in the acute and post-acute phases, comprehensive evaluations of long-term outcomes, including home and workforce reintegration, remain limited. This study aimed to assess home and workforce reintegration 1 year post-EVT in a cohort of acute stroke patients and explore their association with health-related quality of life (HRQoL).

PATIENTS AND METHODS

We conducted a prospective observational study of 404 patients undergoing EVT at a tertiary university medical center between October 2019 and December 2021. Patients' functional outcomes were evaluated using the modified Rankin Scale (mRS), and HRQoL was assessed via the European Quality of Life Five Dimension Scale (EQ-5D). Data on occupational and living status were collected through standardized telephone interviews at 3- and 12-months post-treatment.

RESULTS

Of 357 patients with 12-month follow-up data, 33.6% had a favorable outcome (mRS 0-2). Among stroke survivors, the rate of home reintegration without nursing care was 42.1%, and workforce reintegration among previously employed patients was 43.3% at 12 months. Both outcomes were significantly associated with improved HRQoL. Lower neurological deficits and younger age were predictive of successful home and workforce reintegration.

DISCUSSION AND CONCLUSION

One year post-EVT, approximately 40%-50% of acute stroke patients successfully reintegrate into home and work settings. These findings underscore the need for ongoing support tailored to improving long-term reintegration and quality of life for stroke survivors.

DATA ACCESS STATEMENT

The data supporting the findings of the study are available from the corresponding author upon reasonable request and in accordance to European data privacy obligations.

Predictive utility of self-efficacy in early stroke rehabilitation

INTRODUCTION

A biopsychosocial approach entailing person-centered factors provides valuable insight to post-stroke rehabilitation potential. The consideration of an individual's belief in their capabilities, known as self-efficacy, may prove especially informative in the inpatient rehabilitation setting where motor learning often occurs.

OBJECTIVE

To assess the predictive utility of self-efficacy in functional independence status change during inpatient rehabilitation.

METHODS

Individuals with stroke admitted to an inpatient rehabilitation facility (IRF) completed an assessment battery near IRF admission and discharge involving motor assessments, participant-reported self-efficacy (Stroke Self-Efficacy Questionnaire), and functional independence status evaluation (sum of self-care and mobility Quality Indicators (QI) from the IRF-Patient Assessment Instrument). Linear regression was performed to determine the predictive performance of self-efficacy on QI change during IRF stay while accounting for age, time post-stroke, and IRF length of stay. Regression procedures were repeated for separate subgroups based on initial motor impairment level.

RESULTS

Thirty individuals with stroke (14 females, age = 67.0 ± 9.80 years, 10.4 ± 3.46 days post-stroke) were enrolled. Self-efficacy at IRF admission explained a significant percentage of variance in QI Change for the cohort (R2 = 30.7%, p = .001) and for the moderate to severe motor impairment subgroup (n = 12; R2 = 49.9%, p = .010). After accounting for confounders, self-efficacy remained a significant predictor for the cohort (n = 30) model.

DISCUSSION

Findings generated from this work support the predictive utility of self-efficacy in early post-stroke motor recovery. The inclusion of self-efficacy in a multi-faceted evaluation framework may therefore optimize rehabilitation outcomes by providing therapists with additional knowledge to better tailor an individual's care.

Intraindividual variability in post-stroke cognition and its relationship with activities of daily living and social functioning: an ecological momentary assessment approach

INTRODUCTION

Ecological momentary assessment (EMA) is a methodological approach to studying intraindividual variation over time. This study aimed to use EMA to determine the variability of cognition in individuals with chronic stroke, identify the latent classes of cognitive variability, and examine any differences in daily activities, social functioning, and neuropsychological performance between these latent classes.

METHODS

Participants (N = 202) with mild-to-moderate stroke and over 3-month post-stroke completed a study protocol, including smartphone-based EMA and two lab visits. Participants responded to five EMA surveys daily for 14 days to assess cognition. They completed patient-reported measures and neuropsychological assessments during lab visits. Using latent class analysis, we derived four indicators to quantify cognitive variability and identified latent classes among participants. We used ANOVA and Chi-square to test differences between these latent classes in daily activities, social functioning, and neuropsychological performance.

RESULTS

The latent class analysis converged on a three-class model. The moderate and high variability classes demonstrated significantly greater problems in daily activities and social functioning than the low class. They had significantly higher proportions of participants with problems in daily activities and social functioning than the low class. Neuropsychological performance was not statistically different between the three classes, although a trend approaching statistically significant difference was observed in working memory and executive function domains.

DISCUSSION

EMA could capture intraindividual cognitive variability in stroke survivors. It offers a new approach to understanding the impact and mechanism of post-stroke cognitive problems in daily life and identifying individuals benefiting from self-regulation interventions.

Modelling anticoagulation and health-related quality of life in those with atrial fibrillation: a secondary analysis of AFFIRM

Associations of anticoagulation with primary endpoints in longitudinal studies are impacted by selection bias and time-varying covariates (e.g. comorbidities). We demonstrate how time-varying covariates and selection bias influence association estimates between anticoagulation and health-related quality of life (HRQoL) in patients with atrial fibrillation. We performed a secondary analysis of the Atrial Fibrillation Follow-up Investigation of Rhythm Management trial quality of life substudy. Dichotomized warfarin use was ascertained at the study baseline, 2 months later, and annually for up to 6 years. HRQoL was measured at every time point using a self-reported ordinal 5-point Likert-scale (lower score and lower odds ratio represents better health-related quality of life). Static and time-varying covariates were ascertained throughout the study period. Confounder-adjusted generalized mixed model and generalized estimating equation regressions were used to demonstrate traditional association estimates between anticoagulation and HRQoL. Inverse probability of treatment and censorship weights were used to ascertain the influence of time-varying confounding and selection bias. Age-stratified analysis (age ≥ 70 years) evaluated for effect modification. 656 individuals were included in the analysis, 601 on warfarin at baseline. The association of warfarin use with better HRQoL over time strengthened when accounting for time-varying confounding and selection bias (OR 0.30, 95% CI 0.14-0.55) compared to traditional analyses (OR 0.61, 95% CI 0.38-0.97), and was most pronounced in those ≥ 70 years upon stratified analysis. Anticoagulation is associated with higher HRQoL in patients with atrial fibrillation, with time-varying confounding and selection bias likely influencing longitudinal estimates in anticoagulation-HRQoL research.

Pharmacotherapy to Improve Cognitive Functioning After Acquired Brain Injury: A Meta-Analysis and Meta-Regression

Cognitive impairments, common sequelae of acquired brain injury (ABI), significantly affect rehabilitation and quality of life. Currently, there is no solid evidence-base for pharmacotherapy to improve cognitive functioning after ABI, nevertheless off-label use is widely applied in clinical practice. This meta-analysis and meta-regression aims to quantitatively aggregate the available evidence for the effects of pharmacological agents used in the treatment of cognitive impairments following ABI. We conducted a comprehensive search of Embase, Medline Ovid, and Cochrane Controlled Trials Register databases for randomized controlled and crossover trials. Meta-analytic effects were calculated for each pharmaceutical agent and targeted neuromodulator system. Cognitive outcome measures were aggregated across cognitive domains. Of 8,216 articles, 41 studies (4,434 patients) were included. The noradrenergic agent methylphenidate showed a small, significant positive effect on cognitive functioning in patients with traumatic brain injury (TBI; k = 14, d = 0.34, 95% confidence interval: 0.12-0.56, P = 0.003). Specifically, methylphenidate was found to improve cognitive functions related to executive memory, baseline speed, inhibitory control, and variability in responding. The cholinergic drug donepezil demonstrated a large effect size, albeit based on a limited number of studies (k = 3, d = 1.68, P = 0.03). No significant effects were observed for other agents. Additionally, meta-regression analysis did not identify significant sources of heterogeneity in treatment response. Our meta-analysis supports the use of methylphenidate for enhancing cognitive functioning in patients with TBI. Although donepezil shows potential, it warrants further research. These results could guide clinical decision making, inform practice guidelines, and direct future pharmacotherapeutic research in ABI.

Exploring patients' experience using PROMs within routine post-discharge follow-up assessment after stroke: a mixed methods approach

BACKGROUND

Patient Reported Outcomes Measures (PROMs) are being used increasingly to measure health problems in stroke clinical practice. However, the implementation of these PROMs in routine stroke care is still in its infancy. To understand the value of PROMs used in ischemic stroke care, we explored the patients' experience with PROMs and with the consultation at routine post-discharge follow-up after stroke.

METHODS

In this prospective mixed methods study, patients with ischemic stroke completed an evaluation questionnaire about the use of PROMs and about their consultation in two Dutch hospitals. Additionally, telephone interviews were held to gain in-depth information about their experience with PROMs.

RESULTS

In total, 63 patients completed the evaluation questionnaire of which 10 patients were also interviewed. Most patients (82.2-96.6%) found completing the PROMs to be feasible and relevant. Half the patients (49.2-51.6%) considered the PROMs useful for the consultation and most patients (87.3-96.8%) reported the consultation as a positive experience. Completing the PROMs provided 51.6% of the patients with insight into their stroke-related problems. Almost 75% of the patients found the PROMs useful in giving the healthcare provider greater insight, and 60% reported discussing the PROM results during the consultation. Interviewed patients reported the added value of PROMs, particularly when arranging further care, in gaining a broader insight into the problems, and in ensuring all important topics were discussed during the consultation.

CONCLUSIONS

Completing PROMs appears to be feasible for patients with stroke attending post-discharge consultation; the vast majority of patients experienced added value for themselves or the healthcare provider. We recommend that healthcare providers discuss the PROM results with their patients to improve the value of PROMs for the patient. This could also improve the willingness to complete PROMs in the future.

Association of socioeconomic status and poststroke cognitive function: A systematic review and meta-analysis

BACKGROUND

Stroke survivors are at high risk of coping with cognitive problems after stroke. In recent decades, the relationship between socioeconomic status (SES) and health-related outcomes has been a topic of considerable interest. Learning more about the potential impact of SES on poststroke cognitive dysfunction is of great importance.

OBJECTIVE

The purpose of this systematic review and meta-analysis was to summarize the association between SES and poststroke cognitive function by quantifying the effect sizes of the existing studies.

METHOD

We searched studies from PubMed, Ovid, Embase, Cochrane, Scopus, and PsychINFO up to January 30th 2024 and the references of relevant reviews. Studies reporting the risk of poststroke cognitive dysfunction as assessed by categorized SES indicators were included. The Newcastle-Ottawa scale and the Agency for Healthcare Research and Quality were used to evaluate the study quality. Meta-analyses using fixed-effect models or random-effect models based on study heterogeneity were performed to estimate the influence of SES on cognitive function after stroke, followed by subgroup analyses stratified by study characteristics.

RESULTS

Thirty-four studies were eligible for this systematic review and meta-analysis. Of which, 19 studies reported poststroke cognitive impairment (PSCI) as the outcome, 13 reported poststroke dementia (PSD), one reported both PSCI and PSD, and one reported vascular cognitive impairment no dementia. The findings showed that individuals with lower SES levels had a higher risk of combined poststroke cognitive dysfunction (odds ratio (OR) = 1.91, 95% confidence interval (CI) = 1.59-2.29), PSCI (OR = 2.09, 95% CI = 1.57-2.78), and PSD (OR = 1.95, 95% CI = 1.48-2.57). Subgroup analyses stratified by SES indicators demonstrated the protective effects of education and occupation against the diagnoses of combined poststroke cognitive dysfunction, PSCI, and PSD.

CONCLUSIONS

Stroke survivors belonging to a low SES are at high risk of poststroke cognitive dysfunction. Our findings add evidence for public health strategies to reduce the risk of poststroke cognitive dysfunction by reducing SES inequalities.

Fatigue in patients with acquired brain damage

Fatigue is a complex, multidimensional syndrome that is prevalent in patients with acquired brain damage and has a negative impact on the neurorehabilitation process. It presents from early stages after the injury, and may persist over time, regardless of whether sequelae have resolved. Fatigue is conditioned by upper neuronal circuits, and is defined as an abnormal perception of overexertion. Its prevalence ranges from 29% to 77% after stroke, from 18% to 75% after traumatic brain injury, and from 47% to 97% after brain tumours. Fatigue is associated with factors including female sex, advanced age, dysfunctional families, history of specific health conditions, functional status (eg, fatigue prior to injury), comorbidities, mood, secondary disability, and the use of certain drugs. Assessment of fatigue is fundamentally based on such scales as the Fatigue Severity Scale (FSS). Advances have recently been made in imaging techniques for its diagnosis, such as in functional MRI. Regarding treatment, no specific pharmacological treatment currently exists; however, positive results have been reported for some conventional neurorehabilitation therapies, such as bright light therapy, neurofeedback, electrical stimulation, and transcranial magnetic stimulation. This review aims to assist neurorehabilitation professionals to recognise modifiable factors associated with fatigue and to describe the treatments available to reduce its negative effect on patients.

Longitudinal Association of Health Satisfaction With Functional Status and Income Satisfaction in Stroke Survivors

IMPORTANCE

Although cross-sectional studies have reported the relationships among performance of activities of daily living (ADLs), income satisfaction, and health satisfaction, longitudinal associations in stroke survivors remain unclear.

OBJECTIVE

To examine the effects of ADL function and income satisfaction on health satisfaction over time in stroke survivors.

DESIGN

Retrospective longitudinal study designs with latent growth curve models (LGMs) to control for time-varying and time-invariant covariates.

SETTING

Community.

PARTICIPANTS

A total of 198 stroke survivors.

OUTCOMES AND MEASURES

Self-reported ADL performance, income satisfaction, and health satisfaction.

RESULTS

The average age of participants was 70.68 yr (SD = 8.09; 107 men, 91 women). Each LGM showed that an increase in ADL score (standardized β = 0.116∼0.296, all ps < .05) and income satisfaction (standardized β = 0.513∼0.726, all ps < .001) positively predicted health satisfaction over time, even after controlling for time-varying annual income, demographics, and behavioral characteristics. The fit results of all LGMs were within the acceptable range: χ2(47) = 66.378, p = .0327; χ2(47) = 57.742, p = .1355; root-mean-square error of approximation, <0.08; comparative fit index and Tucker-Lewis index, >0.90; standardized root-mean-square residual, <0.05.

CONCLUSIONS AND RELEVANCE

Because ADLs are significant modifiable health satisfaction factors, occupational therapy practitioners would need to focus more closely on ADL training in clinical settings. Furthermore, referring those clients to appropriate vocational rehabilitation to improve their income satisfaction would be necessary. Plain-Language Summary: This study recognizes the unique challenges and opportunities that arise when stroke survivors are preparing to return to their communities by emphasizing the significance of ADL training and income satisfaction during this stage of recovery. The study suggests that the therapeutic use of ADL training and income satisfaction could increase health satisfaction for stroke survivors. Therefore, comprehensive ADL training, as an occupational therapy intervention, could be crucial for stroke survivors who are preparing to return to their community from a clinical setting. Furthermore, connecting with vocational rehabilitation could also be important for improving income satisfaction for stroke survivors who are preparing to return to a community.

Quality of Life in Patients with Excellent 3-Month Clinical Outcome after First-Ever Ischemic Stroke: A Time to Redefine Excellent Outcome?

INTRODUCTION

Ischemic stroke (IS) may have impact on long-term health-related quality of life (HRQoL) even in the patients with good clinical outcome, and tools mostly used for the assessment of outcome may underestimate or not reflect all relevant sequels after IS. We aimed to analyze HRQoL in the patients with excellent outcome after IS.

METHODS

We analyzed consecutive IS patients enrolled in the prospective FRAILTY study (ClinicalTrials.gov: NCT04839887) with excellent 3-month clinical outcome (score 0-1 in modified Rankin Scale [mRS]). Stroke Impact Scale (SIS) version 3.0 and Hospital Anxiety and Depression Scale (HADS) were used for the HRQoL, anxiety, and depression assessments, and subgroup comparisons were performed according to NIHSS score (0, ≥1), age (50<, ≥50 years), and sex.

RESULTS

In total, 158 patients (55.7% men, mean age 60.3 ± 13.4 years) were analyzed, and 72.2% of them had score 0 in mRS. The overall lowest median scores were found in the SIS domain "emotion," "strength," and "participation." Patients with NIHSS ≥1 had lower scores in all SIS domains except "emotions" and "mobility." Patients ≥50 years had lower score in "mobility" (p = 0.004) and females in domain of "social participation" (p = 0.044). No differences were found among all subgroups in HADS anxiety and depression. Age, NIHSS score, and depression were found negative predictors for the physical domains of HRQoL.

DISCUSSION/CONCLUSIONS

Despite excellent 3-month clinical outcome after IS, patients had affected substantially their HRQoL, especially those with NIHSS ≥1. Patients ≥50 years had more affected "mobility" and females "social participation."

Participation in daily life activities at two months after stroke predicts long-term health-related quality of life

BACKGROUND

After stroke, many patients experience problems with participation in daily activities. Improving participation is the main goal in stroke rehabilitation. However, the longitudinal relationship between participation and health-related quality of life (HRQoL) remains unclear.

OBJECTIVES

This study aimed to examine (1) the predictive value of participation at two months on long-term HRQoL and (2) the longitudinal relationship between participation and HRQoL.

METHODS

In this multicenter, prospective cohort study, patients were assessed at two and 12 months after stroke. Participation was measured with the Restriction subscale of the Utrecht Scale for Evaluation of Rehabilitation - Participation. HRQoL was assessed with the three-level version of the EuroQoL five dimensions questionnaire index score.

RESULTS

This study included 291 patients. Mean age was 66.6 ± 12.4 years, 64.3% were male and mean National Institutes of Health Stroke Scale (NIHSS) was 2.5 ± 2.9. Multivariable linear regression, adjusted for demographic characteristics, stroke characteristics, physical and cognitive impairment, showed that a higher level of participation at two months correlated with a higher HRQoL at one year (B = .004; 95% CI =.002-.005). Patients whose participation improved had a greater increase in HRQoL, compared to patients without improvement (0.080 ± .21 versus -.054 ± .21; p < .001).

CONCLUSIONS

The level of participation at two months post-stroke predicts HRQoL at one year. Improvement in participation during the first year after stroke is associated with improvement in HRQoL. We recommend including the assessment of participation in daily activities at follow-up visits.

Strategy-training post-stroke via tele-rehabilitation: a pilot randomized controlled trial

PURPOSE

Long-term limitations in social participation are common after stroke. Whether these can be attenuated through a tele-rehabilitation approach is unknown. We were particularly interested in examining transfer of learning effects which could result in broader improvements in social participation.

METHODS

We adapted a strategy training rehabilitation approach (tele-CO-OP) for remote delivery. Participants with chronic stroke were randomized to receive the intervention (EXPT) or to a wait list (Control). Feasibility and acceptability were measured via attendance scores, satisfaction with the training and therapist evaluation of engagement with the training. The primary outcome measure was the Canadian Occupational Performance Measure (COPM), a standardized semi-structured interview which elicits difficulties in day-to-day life.

RESULTS

Seventeen participants were randomized. Tele-CO-OP was found to be feasible and acceptable: participants reported high satisfaction and engagement, and missed few sessions. Large effect sizes for transfer of learning effects were observed in favor of receiving tele-CO-OP vs being waitlisted. Significant benefits were also conferred to the Control group following receipt of tele-CO-OP. The intervention also appeared to improve mood.

CONCLUSIONS

This exploratory study demonstrates the feasibility and acceptability of tele-CO-OP and provides preliminary evidence for transfer of learning effects to untrained everyday social participation activities. Trial registration number: NCT02724813.

Stroke survivors' preferences on assessing patient-reported outcome measures

BACKGROUND

To assess quality of life and unmet needs after stroke, patient-reported outcome measures (PROMs) have gained increasing attention. However, patients' perspectives on assessing PROMs remain unclear, potentially hindering implementation into clinical practice. Therefore, this study explored patients' preferences on assessing PROMs after ischemic stroke.

METHODS

A paper-based questionnaire was sent to stroke survivors treated at the Department of Neurology, University of Leipzig, Germany. Health-related quality of life (HRQoL, EQ-5D-5L) and preferences regarding different aspects of data collection to assess PROMs were investigated and linked to socio-demographic and medical characteristics.

RESULTS

158 persons were contacted and 80 replies were subsequently analyzed. Mean age was 70.16 years and mean HRQoL was 68.79 (visual analogue scale with a theoretical maximum of 100). Participants showed positive attitudes towards PROMs as they saw potential to improve care of other patients (n = 66/79; 83.54%) or to improve their own situation (n = 53/74; 71.62%). Participants preferred an annual interview after stroke (n = 39/80; 48.75%) and would preferably spend 15-30 min (n = 41/79; 51.90%) to answer a written survey (n = 69/80; 86.25%). The initially treating clinic was preferred as initiator of such surveys (n = 43/79; 54.43%). Stratification revealed that participants with more than 1 h of daily digital media usage preferred email as way of communication.

CONCLUSIONS

For the first time, this study showed individual preferences on assessing PROMs after ischemic stroke, focusing on the way, time interval, duration, and initiation site of surveys. These insights might help to successfully implement PROMs after stroke and subsequently detect unmet needs and deficits in stroke care.

Associations of effort-reward imbalance at work and quality of life among workers after stroke: a one-year longitudinal study in Thailand

Stroke incidence is increasing among working-age population, but the role of psychosocial stress in the workplace in predicting quality of life (QoL) after stroke onset is understudied. This longitudinal study aimed to investigate the relationship between work stress, measured by the effort-reward imbalance (ERI) model, and QoL over one-year period among 103 Thai workers who had experienced a stroke. The study evaluated the effort (E)-reward (R) ratio and over-commitment, the extrinsic and intrinsic components of the ERI model, before discharge; QoL was repeatedly measured at baseline, six months, and 12 months after discharge, respectively, using the Short Form Version 2 (SF-12v2) indicators of physical and mental health composite scores. Generalized estimating equations were used to examine longitudinal relationships between work stress at baseline and QoL over one year by testing the hypotheses that E-R ratio and over-commitment would have direct effects on QoL, and potential moderating effects of over-commitment on E-R ratio and QoL. The results supported the ERI model partially, as over-commitment was significantly associated with poor mental health (coefficient - 8.50; 95% CI: -13.79, -3.20) after adjusting baseline sociodemographic, behavioral, and clinical characteristics, while the E-R ratio was not significantly associated with physical or mental health; the interaction between the E-R ratio and over-commitment was also not significant. These findings suggest that more attention should be paid to workers' personal coping skills and ability to handle work-related problems and prioritize interventions that address over-commitment to promote long-term mental health among workers with stroke.

Changes in gene expression and neuroinflammation in the hippocampus of rats with poststroke cognitive impairment

Poststroke cognitive impairment (PSCI) often occurs during the stroke recovery period and greatly increases the difficulty of rehabilitation. Activation of neuroinflammation and long-term changes in gene expression patterns in the hippocampus could be essential in the development of PSCI. Therefore, this study aimed to identify neuroinflammation and changes in gene expression patterns in the hippocampus in rats with PSCI. Rats underwent transient middle cerebral artery occlusion (tMCAO) or sham surgery. The infarct volume was measured on day 3 after surgery. The Morris water maze (MWM) test was used to assess cognitive function. Microglial activation and white matter (WM) lesions in the hippocampus were evaluated on day 28 after surgery. In addition, we compared differentially expressed genes (DEGs) in the hippocampus between tMCAO group rats and sham group rats by RNA sequencing. Then, Gene Ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG), and protein-protein interaction (PPI) network analyses were conducted to investigate these DEGs. The results showed that the tMCAO group rats showed extensive infarction and cognitive dysfunction compared with the sham group rats. Microglial activation and WM damage were obvious in the hippocampus of tMCAO group rats. We found 43 DEGs by RNA sequencing: 29 genes with upregulated expression and 14 genes with downregulated expression. The GO analysis indicated that DEGs were mainly involved in cell proliferation and differentiation, cholesterol synthesis, and metabolism. The KEGG pathway analysis suggested that the DEGs were significantly enriched in intestinal immune network for IgA production and steroid biosynthesis. Acta2, Calb2, and Cxcl12 were notable in the PPI analysis. Our results suggest that microglial activation and WM damage are maintained in rats with PSCI. The mechanism may be related to the regulation of steroid biosynthesis, intestinal immunity, and potential key genes such as Acta2, Calb2, and Cxcl12 in the hippocampus.

Impact of acute symptomatic seizures and their management on patient-reported outcomes after stroke

OBJECTIVE

Acute symptomatic seizures (ASyS) after stroke are not uncommon. However, the impact of ASyS and its management with anti-seizure medications (ASMs) on patient-reported outcome measures (PROMs) remains poorly investigated. The objective of our study is to evaluate the association between PROMs and ASyS and ASMs following stroke.

METHODS

We performed a retrospective cohort study of all stroke patients who underwent inpatient continuous EEG (cEEG) monitoring performed due to suspected ASyS, including the ones with observed convulsive ASyS, from 04/01/2012 to 03/31/2018, who completed PROMs within 6 months of hospital discharge. Patient-reported outcome measures, including one Neuro-QoL and six PROMIS v1.0 domain scales, were completed by patients as the standard of care in ambulatory stroke clinics. Since ASMs are sometimes used without clearly diagnosed ASyS, we performed group comparisons based on ASM status at discharge, irrespective of their ASyS status. T-tests or Wilcoxon rank sum tests compared continuous variables across groups and chi-square tests or Fisher's exact tests were used for categorical variables.

RESULTS

A total of 508 patients were included in the study [mean age 62.0 ± 14.1 years, 51.6% female; 244 (48.0%) ischemic stroke, 165 (32.5%) intracerebral hemorrhage, and 99 (19.5%) subarachnoid hemorrhage]. A total of 190 (37.4%) patients were discharged on ASMs. At the time of the first PROM, conducted a median of 47 (IQR = 33-78) days after the suspected ASyS, and 162 (31.9%) were on ASMs. ASM use was significantly higher in patients diagnosed with ASyS. Physical Function and Satisfaction with Social Roles and Activities were the most affected health domains. Patient-reported outcome measures were not significantly different between groups based on ASyS (electrographic and/or convulsive), ASM use at hospital discharge, or ASM status on the day of PROM completion.

SIGNIFICANCE

There were no differences in multiple domain-specific PROMs in patients with recent stroke according to ASyS status or ASM use suggesting the possible lack of the former's sensitivity to detect their impact. Additional research is necessary to determine if there is a need for developing ASyS-specific PROMs.

Association of Income with Post-Stroke Cognition and the Underlying Neuroanatomical Mechanism

OBJECTIVE

To investigate the association between income and post-stroke cognition at 3 months, and the underlying neuroanatomical mechanism.

METHODS

Patients with first-ever ischemic stroke were enrolled and analyzed. Baseline information on income and neuroimaging measurements with predictive values for post-stroke cognitive impairment (PSCI) were collected within 7 days of the admission. Three months after the index stroke, all participants underwent a detailed neuropsychological test battery. The associations between income and PSCI and between income and brain structural measurements were investigated.

RESULTS

A total of 294 patients were recruited for this study. Lower income was independently associated with poor cognitive performance on Stroop tests, Clinical Dementia Rating, Boston Naming Test, and Verbal Fluency Test. Regarding neuroimaging parameters, lower income was associated with a lower total brain volume (TBV)/total intracranial volume (TICV) ratio (p = 0.004).

CONCLUSIONS

Lower income is associated with an increased chance of post-stroke cognitive decline, particularly in executive function and language domains. Since global brain atrophy (measured by TBV/TICV ratio) is a strong predictor for PSCI, its correlation with income may help explain the neuroanatomical mechanism between income and post-stroke cognition.

Patient-Reported Quality of Life After Intravenous Alteplase for Stroke in the WAKE-UP Trial

BACKGROUND AND OBJECTIVES

Intravenous alteplase improves functional outcome after acute ischemic stroke. However, little is known about the effects on self-reported health-related quality of life (HRQoL).

METHODS

WAKE-UP was a multicenter, randomized, placebo-controlled trial of MRI-guided intravenous alteplase in stroke with unknown onset time. HRQoL was assessed using the EuroQol five-dimensional questionnaire (EQ-5D) at 90 days, comprising the EQ-5D index and the EQ visual analogue scale (VAS). Functional outcome was assessed by the modified Rankin Scale (mRS). We calculated the effect of treatment on EQ-5D index and EQ VAS using multiple linear regression models. Mediation analysis was performed on stroke survivors to explore the extent to which the effect of alteplase on HRQoL was mediated by functional outcome.

RESULTS

Among 490 stroke survivors, the EQ-5D index was available for 452 (92.2%), of whom 226 (50%) were assigned to treatment with alteplase and 226 (50%) to placebo. At 90 days, mean EQ-5D index was higher, reflecting a better health state, in patients randomized to treatment with alteplase than with placebo (0.75 vs 0.67) with an adjusted mean difference of 0.07 (95% CI 0.02-0.12, p = 0.005). In addition, mean EQ VAS was higher with alteplase than with placebo (72.6 vs 64.9), with an adjusted mean difference of 7.6 (95% CI 3.9-11.8, p < 0.001). Eighty-five percent of the total treatment effect of alteplase on the EQ-5D index was mediated using the mRS score while there was no significant direct effect. By contrast, the treatment effect on the EQ VAS was mainly through the direct pathway (60%), whereas 40% was mediated by the mRS.

DISCUSSION

Assessment of patient-reported outcome measures reveals a potential benefit of intravenous alteplase for HRQoL beyond improvement of functional outcome.

TRIAL REGISTRATION INFORMATION

ClinicalTrials.gov number, NCT01525290; EudraCT number, 2011-005906-32.

A novel digital approach for post-stroke cognitive deficits: a pilot study

BACKGROUND

Cognitive dysfunctions after a brain stroke have a huge impact on patients' disability and activities of daily living. Prism adaptation (PA) is currently used in patients with right brain damage to improve lateralized spatial attentional deficits. Recent findings suggest that PA could also be useful for rehabilitation of other cognitive functions.

OBJECTIVE

In the present study, we tested for the efficacy on cognitive rehabilitation of a novel device in which the procedure of prism adaptation is digitized and followed by cognitive training of attention and executive functions using serious games.

METHODS

Thirty stroke patients were randomly assigned to two groups: an experimental group of 15 patients, which performed the experimental rehabilitation training using the novel device in 10 consecutive daily sessions; a control group of 15 patients, which performed the routine cognitive training in 10 consecutive daily sessions. Both groups were tested before and after the rehabilitation program on neuropsychological tests (digit and spatial span forward and backward, attentional matrices, Stroop task) and on functional scales (Barthel index and Beck Anxiety Index).

RESULTS

The main results showed that only patients who received the experimental rehabilitation training improved their scores on tests of digit span forward, spatial span backward, attentional matrices and Stroop. Moreover, patients of the experimental but not of the control group showed a significant correlation between improvement on some tasks (mainly spatial span backward) and improvement on activities of daily living as well as with reduction of anxiety levels.

CONCLUSIONS

These results suggest that combining digital PA with cognitive training using serious games may be added in clinical settings for cognitive rehabilitation of stroke patients, with beneficial effects extending in promoting independency in activities of daily living and reduction of psychiatric symptoms.

Higher comorbidity burden is associated with lower self-reported quality of life after stroke

Introduction

This study assesses the association of comorbidity burden and polypharmacy with self-reported quality of life after stroke.

Patients and methods

We performed a post-hoc analysis of a prospective, single-center, observational study of outcome evaluation by patient-reported outcome measures in stroke clinical practice. Consecutive patients with acute ischemic stroke (AIS) were enrolled and self-reported health-related quality of life (HrQoL) was assessed 90 days after acute stroke using the Patient-reported Outcomes Measurement Information System 10-Question Short-Form (PROMIS-10). Comorbidities at baseline were assessed by the Charlson Comorbidity Index (CCI). Polypharmacy was defined as medication intake of ≥5 at baseline. We used linear regression analysis to study the association of CCI, polypharmacy and other clinical covariates with HrQoL after stroke.

Results

Of 781 patients (median age 76 years, 48.4% female) enrolled, 30.2% had a CCI Score ≥2, and 31.5% presented with polypharmacy. At follow up, 71 (9.1%) had died. In 409 (52.4%) reached for outcome evaluation, Global Physical Health T-Score was 43.8 ± 10 and Global Mental Health T-Score was 43.5 ± 8.76, indicating lower HrQoL than the average population. A CCI Score ≥2, higher NIHSS Score, female sex, dependency on others for dressing, toileting and mobility before index stroke, atrial fibrillation and hypertension were independent predictors of worse physical and mental health outcomes, while polypharmacy was not.

Conclusion

In patients with AIS, high comorbidity burden and polypharmacy are frequent. Comorbidity burden at admission is independently associated with worse self-reported physical and mental health three months after stroke.

Orthotic Research Initiative for Outcomes aNalysis (ORION I): predictors of PROMIS PF for stroke survivors seeking orthotic intervention

PURPOSE

Ankle-foot orthoses (AFOs) are used to improve physical performance measures of physical function (PF) post-stroke; however, the perception of improved PF of this population has not been described. The purpose of this study was to identify the predictors of self-reported PF of individuals seeking orthotic intervention post-stroke.

MATERIALS AND METHODS

A retrospective analysis of 237 patients at a nationwide orthotic services provider in the United States was conducted to characterize PF using the Patient-Reported Outcome Measures Information System®. A backward stepwise multiple regression was conducted to identify demographic characteristics predictive of self-reported PF.

RESULTS

The mean T-score of PF of the sample was 30.8 (±6.5), two standard deviations below the US general population mean, indicating significant impairment. The regression model explained approximately 15% (R = 0.411) of the variance in PF of the sample. Self-reported PF was worse for individuals requiring more supportive assistive devices (β = 0.270, p = 0.001), those with more recent ankle problems (β = -0.167, p = 0.035), and those with greater living assistance (β = -0.139, p = 0.089).

CONCLUSIONS

These results improve understanding of the factors that contribute to impaired self-reported PF of stroke survivors in need of AFO intervention.Implications for rehabilitationAnkle-foot orthoses (AFOs) are often used to improve physical performance measures of physical performance (PF) during stroke rehabilitation.Our data indicate that the self-reported PF of AFO users is severely impaired.Level of assistance, time since ankle and foot problems began, and living assistance status are important clinical characteristics to consider when planning AFO intervention for this population.

Emerging Limb Rehabilitation Therapy After Post-stroke Motor Recovery

Stroke, including hemorrhagic and ischemic stroke, refers to the blood supply disorder in the local brain tissue for various reasons (aneurysm, occlusion, etc.). It leads to regional brain circulation imbalance, neurological complications, limb motor dysfunction, aphasia, and depression. As the second-leading cause of death worldwide, stroke poses a significant threat to human life characterized by high mortality, disability, and recurrence. Therefore, the clinician has to care about the symptoms of stroke patients in the acute stage and formulate an effective postoperative rehabilitation plan to facilitate the recovery in patients. We summarize a novel application and update of the rehabilitation therapy in limb motor rehabilitation of stroke patients to provide a potential future stroke rehabilitation strategy.

[Long-term consequences of stroke]

The treatment of stroke has significantly improved over the past two decades, resulting in reduced mortality and morbidity in high-income countries. However, strokes remain the third leading cause of mortality and disability worldwide. In addition to acute care and the prevention of risk factors, treatment of the various persisting disabilities that impact the daily activities and quality of life of patients also remain important. Motor and language deficits affect everyday life most obviously. Other deficits may involve complex movements, sensory, and cognitive functions. Patients also often suffer from anxiety, fatigue, and depression.Established ergotherapeutic, physiotherapeutic, and logopedic programs exist for motor and language deficits for in-patient treatment as well as in the ambulatory setting. The diagnosis and treatment of cognitive impairments and behavioral disorders, however, are largely confined to the early rehabilitation phase. Despite indications of a long-term impairment of quality of life due to cognitive deficits and behavioral disorders, previous study results speak against drug-based antidepressant therapy in in-patient rehabilitation. Individual patient-reported outcomes, supported by screening for cognitive deficits and consideration of individual risk factors and coping strategies, could further improve the treatment of stroke and its long-term burden.

The use of PROMIS measures in clinical research in stroke patients, a systematic literature review

Objective

To systematically describe the use and outcomes of Patient-Reported Outcomes Measurement Information System (PROMIS) measures in clinical studies in populations with stroke.

Data Sources

A systematic search on the use of PROMIS measures in clinical stroke studies in 9 electronic databases.

Study Selection

Studies had to be original, reporting on outcome data using PROMIS measures in populations with stroke (ischemic and/or hemorrhagic), from January 1st, 2007. Initially, 174 unique studies met the inclusion criteria. In 2 steps, titles, abstracts and full-text articles were screened for eligibility (2 authors independently).

Data Extraction

From the selected articles, study characteristics, type of PROMIS measures, and its outcomes were extracted by 2 authors independently. The authors discussed their views to achieve consensus. A third author was consulted if necessary.

Data Synthesis

In total, 27 studies (24,366 patients) were included, predominantly from the United States (22); most study populations were hospital-based (20); the number of patients ranged from 30-3283. In general, patients had no or mild symptoms (median modified Rankin scale 1). Two different generic PROMIS measures were reported (PROMIS Global Health, PROMIS 29) and 9 PROMIS measures focusing on specific domains (sleep, pain, physical functioning, self-efficacy, satisfaction with social roles, depression, anxiety, cognition, fatigue). These match the International Classification of Functioning, Disability, and Health (ICF) domains mentioned in the Core Set for Stroke. The measures were administered 1-55 months after stroke. Outcome data are provided. Pooling of data was not achieved because of a large variety in study characteristics (inclusion criteria, follow-up moments, data processing).

Conclusions

The PROMIS measures in this review could be relevant from a patient's perspective, covering ICF core set domains for patients with stroke. The large variety in study characteristics hampers comparisons across populations. Many different outcome measures are used to report results of stroke rehabilitation studies.

Leveraging Factors of Self-Efficacy and Motivation to Optimize Stroke Recovery

The International Classification of Functioning, Disability and Health framework recognizes that an individual's functioning post-stroke reflects an interaction between their health condition and contextual factors encompassing personal and environmental factors. Personal factors significantly impact rehabilitation outcomes as they determine how an individual evaluates their situation and copes with their condition in daily life. A key personal factor is self-efficacy-an individual's belief in their capacity to achieve certain outcomes. Self-efficacy influences an individual's motivational state to execute behaviors necessary for achieving desired rehabilitation outcomes. Stroke rehabilitation practice and research now acknowledge self-efficacy and motivation as critical elements in post-stroke recovery, and increasing evidence highlights their contributions to motor (re)learning. Given the informative value of neuroimaging-based biomarkers in stroke, elucidating the neurological underpinnings of self-efficacy and motivation may optimize post-stroke recovery. In this review, we examine the role of self-efficacy and motivation in stroke rehabilitation and recovery, identify potential neural substrates underlying these factors from current neuroimaging literature, and discuss how leveraging these factors and their associated neural substrates has the potential to advance the field of stroke rehabilitation.

The Impact of Sex and Gender on Stroke

Women face a disproportionate burden of stroke mortality and disability. Biologic sex and sociocultural gender both contribute to differences in stroke risk factors, assessment, treatment, and outcomes. There are substantial differences in the strength of association of stroke risk factors, as well as female-specific risk factors. Moreover, there are differences in presentation, response to treatment, and stroke outcomes in women. This review outlines current knowledge of impact of sex and gender on stroke, as well as delineates research gaps and areas for future inquiry.

Longitudinal assessment of depression during the first year after stroke: Dimensionality and measurement invariance

OBJECTIVE

Repeated measurement of depression using summative scores of commonly used depression scales assumes that the construct is unidimensional and invariant across time, but little is known about the validity of these assumptions in stroke patients. The study examined the assumptions during the first year after mild to moderate stroke using the 8-item Patient Health Questionnaire (PHQ-8).

METHODS

Data were obtained from the 2014-2016 Brain Attack Surveillance in Corpus Christi project, a population-based stroke surveillance study with longitudinal follow-up in Texas, United States. Depressive symptoms were assessed with the PHQ-8 at 3, 6, and 12 months post-stroke (n = 648, 542, 533, respectively). Dimensionality of the PHQ-8 was examined using exploratory bifactor analysis and confirmatory factor analysis (CFA). Based on a one-factor CFA model, longitudinal measurement invariance was examined by fitting configural, weak, strong and strict invariance models sequentially.

RESULTS

Mean age was 65.6 (SD = 11.2), half were women, and 56.7% were Mexican American. Reliability measures suggested a generally unidimensional construct (Omega Hierarchical: 0.79-0.86), good internal consistency (Cronbach's alpha: 0.84-0.88) and good temporal stability (intraclass correlation coefficient: 0.838). Configural invariance for equality of item-factor structure (RMSEA = 0.038, CFI = 0.982, WRMR = 0.970) was supported. Partial weak invariance for equality of factor loadings (p = 0.11) was supported by chi-square difference tests, whereas full longitudinal invariance was supported by changes in comparative fit index and root mean square error of approximation.

CONCLUSIONS

The findings suggest the PHQ-8 may be a reasonable tool for repeated measurement of depression in stroke patients, and more research on its longitudinal psychometric properties is needed.

When Should Neuroendovascular Care for Patients With Acute Stroke Be Palliative?

Noncurative surgeries intended to relieve suffering during serious illness or near end of life have been analyzed across palliative settings. Yet sparse guidance is available to inform clinical management decisions about whether, when, and which interventions should be offered when ischemic stroke and other neurological complications occur in patients whose survival is extended by other novel disease-modifying interventions. This case commentary examines key ethical and clinical considerations in palliative neuroendovascular care of patients with acute stroke.

Validity and reliability of the fatigue impact scale in stroke

BACKGROUND

Fatigue is one of the significant problems of post-stroke patients as it causes a decreased quality of life. Although the fatigue impact scale (FIS) is used in stroke, it lacks validation studies.

OBJECTIVE

This study evaluates the psychometric properties of the FIS in patients with stroke.

SUBJECTS AND METHODS

A total of 41 subjects with stroke and 41 control subjects admitted to Physical Medicine and Rehabilitation Department were included. Convergent validity was assessed using the SF-36 vitality (SF-36 v) scale and the fatigue severity scale (FSS). Divergent validity was assessed using the Hospital Anxiety and Depression Scale (HADS).

RESULTS

All subscores of the FIS were significantly higher in the stroke group than in the control group (p < .05). FIS showed excellent internal consistency in stroke patients (Cronbach's alpha = 0.946). There was a negative correlation among FIS and SF-36 v (r = -0.506, p = .001), and a positive correlation between the HADS anxiety score (r = 0.356, p = .026) and the HADS depression score (r = 0.293, p = .071). FIS total scores were weakly correlated with the FSS (r = 0.323, p = 0.039). The test-retest reliability of FIS was good in terms of its cognitive, physical, and psychosocial subscales and total scores, with ICC values of 0.78, 0.73, 0.80, and 0.83, respectively.

CONCLUSION

FIS is a valid and reliable multidimensional scale that sensitively discriminated fatigue in the stroke patients from that in the control subjects.

Fatigue in patients with acquired brain damage

Fatigue is a complex, multidimensional syndrome that is prevalent in patients with acquired brain damage and has a negative impact on the neurorehabilitation process. It presents from early stages after the injury, and may persist over time, regardless of whether sequelae have resolved. Fatigue is conditioned by upper neuronal circuits, and is defined as an abnormal perception of overexertion. Its prevalence ranges from 29% to 77% after stroke, from 18% to 75% after traumatic brain injury, and from 47% to 97% after brain tumours. Fatigue is associated with factors including female sex, advanced age, dysfunctional families, history of specific health conditions, functional status (eg, fatigue prior to injury), comorbidities, mood, secondary disability, and the use of certain drugs. Assessment of fatigue is fundamentally based on such scales as the Fatigue Severity Scale (FSS). Advances have recently been made in imaging techniques for its diagnosis, such as in functional MRI. Regarding treatment, no specific pharmacological treatment currently exists; however, positive results have been reported for some conventional neurorehabilitation therapies, such as bright light therapy, neurofeedback, electrical stimulation, and transcranial magnetic stimulation. This review aims to assist neurorehabilitation professionals to recognise modifiable factors associated with fatigue and to describe the treatments available to reduce its negative effect on patients.

Profiles of patients' self-reported health after acute stroke

BACKGROUND

We aimed to identify groups of patients with similar health status after stroke, assessed by patient reported outcome measures (PROMs), to improve initial risk stratification.

METHODS

In a prospective study, inpatients were recruited during acute stroke treatment. Demographics, history, and cardio-vascular risk factors were assessed at baseline. Self-reported functional status, physical and mental health as well as anxiety and depressive symptoms were assessed 3 and 12 months after stroke and used to identify latent classes. The association of patient characteristics with latent class membership was investigated with multinomial logistic regression.

RESULTS

Of the 650 patients included with a mean age of 75 years and 48% female, 70% had ischemic, 6% hemorrhagic strokes, and 24% transient ischemic attacks. Median NIHSS on admission was 2 (IQR:0,5). Values of PROMs remained comparable at 3 and 12 months. A three-class model was developed, differentiating between patients with mildly (75%), moderately (17%), and severely (8%) impaired self-reported health status. Adjusted for univariately significant baseline characteristics, initial NIHSS distinguished mild- from moderate-, and moderate- from severe-class-membership (p < 0.001). Length of inpatient stay (p < 0.001;OR = 1.1), diabetes (p = 0.021;OR = 1.91), and atrial fibrillation (p = 0.004;OR = 2.20) predicted allocation to the moderately vs. mildly affected class.

CONCLUSIONS

Grading stroke patients by a standard set of PROMs up to 1 year after stroke allows to distinguish the diverse impact of baseline characteristics on differently affected groups. In addition to initial stroke severity, longer inpatient stay, presence of diabetes and atrial fibrillation correlate with greater impairment of self-reported health in the less affected groups.

TRIAL REGISTRATION

http://www.ClinicalTrials.gov ; Unique identifier: NCT03795948 .

Psychometric properties of a patient-reported outcome set in acute stroke patients

OBJECTIVES

Impairments after stroke may affect multiple domains of health-related quality of life (HRQoL). Patient-reported outcome measures (PROMs) have proven valuable in measuring patients' well-being. We examine the psychometric properties of a standard set of PROMs assessing global health, anxiety, and depression, and functioning in a German health care setting.

METHOD

We included inpatients at the Department of Neurology at the University Medical Center Hamburg-Eppendorf, diagnosed with stroke. Following the stroke-specific standard set of the International Consortium for Health Outcome Measurement, we collected demographic and clinical information at baseline, and PROMs for global health (PROMIS-10), three items for self-reported functioning, anxiety, and depression (PHQ-4) at 90 days follow-up. We calculated confirmatory factor analyses to test factorial validity and correlation analyses to test construct validity. We further conducted item and reliability analyses.

RESULTS

In a sample of 487 patients (mean age, SD: 71.1, 12.6; 47% female) with mild and moderate symptoms, model fit for the PROMIS-10 was acceptable for the two-factor and single-factor models. Factor loadings ranged from 0.52 to 0.94. The postulated single-factor model for functioning was saturated with zero degrees of freedom. Factor loadings ranged from 0.90 to 0.96. For the PHQ-4, the two-factor model showed excellent model fit. Factor loadings ranged from 0.78 to 0.87. Internal consistency was acceptable to good. Construct validity was generally confirmed.

CONCLUSIONS

The PROMIS-10 is a valid and reliable instrument to measure HRQoL among German stroke patients. While the PHQ-4 was confirmed as a screening measure for mental disorders, further research is needed on items assessing self-reported functioning. Results are limited to patients showing minimal functional deficits.

Prevalence and Predictors of Fatigue and Neuropsychiatric Symptoms in Patients with Minor Ischemic Stroke

OBJECTIVES

Patients who are victims of a mild stroke are vulnerable to several invisible and neglected neurological sequelae. In parallel, it is known that fatigue and neuropsychiatric symptoms are common complications after a stroke in general. Our aim was to describe the prevalence and the factors associated with these two outcomes after a minor stroke.

MATERIALS AND METHODS

We conducted a prospective observational cohort study that included consecutive patients diagnosed with minor ischemic stroke between 2015 and 2019. Minor stroke was defined as NIHSS < 4 and modified Rankin Scale (mRS) < 2. Patients were followed for 12 months after the index stroke. The primary endpoints included fatigue and neuropsychiatric impairment, which were evaluated with the Fatigue Severity Scale (FSS) and the Hospital Anxiety Depression Scale (HADS), respectively.

RESULTS

A total of sixty patients were followed in our cohort. The mean age was 53.0 (SD 15.0) and 51.7% were male. There were 32 (53.3%) and 25 (41.7%) patients who developed PSF and post-stroke neuropsychiatric symptoms, respectively. The use of antidepressants and statins were associated with post-stroke fatigue, while women and younger patients were more likely to develop neuropsychiatric symptoms after the stroke (p < 0.05). Eighteen (30.0%) patients were diagnosed with both post-stroke fatigue and psychiatric disorders.

CONCLUSIONS

Post-stroke fatigue and neuropsychiatric symptoms are prevalent in minor stroke and should be independently addressed as a part of the recovery goal.

Changes in Health-Related Quality of Life After Transient Ischemic Attack

IMPORTANCE

Numerous studies have found that patients diagnosed with TIA have decreased health-related quality of life, which has been interpreted as suggesting that patients with TIA have residual symptoms after the event. Studies assessing health status in the same patients before and after an event are lacking but may allow a direct determination of the association of TIA with postevent health status.

OBJECTIVE

To examine patient-reported health before transient ischemic attack (TIA) among individuals diagnosed with this event and evaluate change in patient-reported health after the event overall and by TIA characterization subgroups.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was conducted among 236 patients with a clinical diagnosis of TIA from October 2015 to December 2017 in a large US health system that collects a patient-reported outcome measure in ambulatory setting as part of routine care. Included patients had patient-reported global health scale assessments completed as part of routine care before and after a TIA event. Data were analyzed from March through July 2020.

MAIN OUTCOMES AND MEASURES

The main outcome was Patient-Reported Outcome Measurement Information System Global Health (PROMIS GH) scale score before and after TIA. A change of 5 or more points in this score is considered clinically relevant. The secondary outcomes included change in patient-reported global health by clinical impression of the probability of a TIA event, pattern of neurological deficits, and short-term risk of stroke, as assessed by the ABCD2 score.

RESULTS

Among 263 patients who experienced TIA, mean (SD) age was 67.9 (13.4) years and 138 (52.5%) were women. The median (interquartile range) time between patient-reported global health scores was 152 (94-284) days. Mean (SD) baseline patient-reported global physical health and mental health scale summary scores were 43.4 (8.2) and 47.7 (9.7), respectively, and were statistically significantly decreased compared with the general population mean (SD) scores of 50 (10; P < .001) for physical and mental health. The difference between physical health summary score among study participants and the general population was clinically relevant. Mean (SD) summary scores were not statistically significantly different after the event compared with before the event overall (physical health: 44.1 [8.2], for a mean [SE] improvement of 0.65 [0.38] points; P = .09; mental health: 47.4 [9.1], for a mean [SE] worsening of 0.25 [0.38] points; P = .51) or within subgroups.

CONCLUSIONS AND RELEVANCE

These findings suggest that impaired health status among patients diagnosed with TIA reflect, at least in part, an impaired premorbid state of health. This study did not find that TIA events were associated with worsening of health status overall or within subgroups.

Effect of intravenous alteplase on post-stroke depression in the WAKE UP trial

BACKGROUND AND PURPOSE

The aim was to study the effect of intravenous alteplase on the development of post-stroke depression (PSD) in acute stroke patients, and to identify predictors of PSD.

METHODS

This post hoc analysis included patients with unknown onset stroke randomized to treatment with alteplase or placebo in the WAKE-UP trial (ClinicalTrials.gov number, NCT01525290), in whom a composite end-point of PSD was defined as a Beck Depression Inventory ≥10, medication with an antidepressant, or depression recorded as an adverse event. Multiple logistic regression was used to identify predictors of PSD at 90 days. Structural equation modelling was applied to assess the indirect effect of thrombolysis on PSD mediated by the modified Rankin Scale.

RESULTS

Information on the composite end-point was available for 438 of 503 randomized patients. PSD was present in 96 of 224 (42.9%) patients in the alteplase group and 115 of 214 (53.7%) in the placebo group (odds ratio 0.63; 95% confidence interval 0.43-0.94; p = 0.022; adjusted for age and National Institutes of Health Stroke Scale at baseline). Prognostic factors associated with PSD included baseline medication with antidepressants, higher lesion volume, history of depression and assignment to placebo. While 65% of the effect of thrombolysis on PSD were caused directly, 35% were mediated by an improvement of the mRS.

CONCLUSIONS

Treatment with alteplase in patients with acute stroke resulted in lower rates of depression at 90 days, which were only partially explained by reduced functional disability. Predictors of PSD including history and clinical characteristics may help in identifying patients at risk of PSD.

Quality of Life in Physical, Social, and Cognitive Domains Improves With Endovascular Therapy in the DEFUSE 3 Trial

BACKGROUND AND PURPOSE

The DEFUSE 3 (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke 3) randomized clinical trial demonstrated the efficacy of endovascular therapy in treating ischemic stroke 6 to 16 hours after onset, resulting in better functional outcomes than standard medical therapy alone. The objective of this secondary analysis is to analyze the effect of late-window endovascular treatment of ischemic stroke on quality of life (QoL) outcomes.

METHODS

Patients (n=182) who presented between 6 and 16 hours after they were last known to be well with acute anterior circulation ischemic stroke were randomized to endovascular thrombectomy plus standard medical therapy or standard medical therapy alone and followed-up through 90 days poststroke. QoL at day 90 was assessed with the QoL in Neurological Disorders measurement tool.

RESULTS

Of the 146 subjects alive at day 90, 136 (95%) filled out QoL in Neurological Disorders short forms. Patients treated with endovascular therapy had better QoL scores in each domain: mobility, social participation, cognitive function, and depression (P<0.01 for all). Variables other than endovascular therapy that were independently associated with better QoL included lower baseline National Institutes of Health Stroke Scale, younger age, and male sex. The degree to which the modified Rankin Scale captures differences in QoL between patients varied by domain; the modified Rankin Scale score accounted for a high proportion of the variability in mobility (Rs²=0.82), a moderate proportion in social participation (Rs²=0.62), and a low proportion in cognition (Rs²=0.31) and depression (Rs²=0.19).

CONCLUSIONS

Patients treated with endovascular therapy 6 to 16 hours after stroke have better QoL than patients treated with medical therapy alone, including better mobility, more social participation, superior cognition, and less depression. The modified Rankin Scale fails to capture patients' outcomes in cognition and depression, which should therefore be assessed with dedicated QoL tools. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02586415.

The validity of proxy responses on patient-reported outcome measures: Are proxies a reliable alternative to stroke patients' self-report?

PURPOSE

Caregivers, or proxies, often complete patient-reported outcome measures (PROMs) on behalf of patients with stroke. The objective of our study was to assess the validity and responsiveness of proxy-responses compared to patient-responses across multiple domains of health.

METHODS

Stroke patients and their proxies were recruited to complete PROMs between 7/2018-11/2019. PROMs included Neuro-QoL cognitive function, PROMIS physical function, satisfaction with social roles, anxiety, fatigue, pain interference, sleep disturbance, Global Health, and PHQ-9. Internal consistency and convergent validity were compared between patient- and proxy-reported measures. Known-groups validity was assessed across levels of stroke disability. Internal responsiveness was evaluated using paired t-tests for a subset of patients who attended rehabilitation following stroke. Analyses were stratified by patients ≤ 3 vs > 3 months from stroke.

RESULTS

This cross-sectional study included 200 stroke patients (age 62.2 ± 13.3, 41.5% female) and their proxies (age 56.5 ± 13.9, 70% female, 72% spouses). PROMs had high internal consistency and were significantly correlated for patients and proxies. Patient- and proxy-reported measures worsened with increasing stroke disability. For 34 (17%) patients who attended rehabilitation, patients self-reported improvement on 5 domains whereas proxies reported no improvement. Compared to patient self-reports, validity was worse for proxy-reports on patients ≤ 3 months but better > 3 months from stroke.

CONCLUSIONS

Both patient- and proxy-reported PROMs demonstrated strong validity. Only patient-reported PROMs were responsive to change, and proxies had worse validity for patients ≤ 3 months from stroke but better validity for patients > 3 months from stroke. These findings justify the utilization of proxy responses in stroke patients > 3 months from stroke.

Patient Reported Outcomes Measurements Information System in Stroke Patients in Full and Shortened Format

Introduction: The modified Rankin Scale (mRS) after 90 days documents outcome in stroke patients, but focusses only on activities of daily living. Here we studied stroke outcome beyond these activities by the Dutch-Flemish version of the Patient Reported Outcomes Measurement Information System (PROMIS) questionnaire. Patients and Methods: We documented the mRS at day 90 in stroke patients who filled out a questionnaire on pain intensity and seven PROMIS domains: physical function, ability to participate in social roles, anxiety, fatigue, depression, sleep disturbance, pain interference. In a subgroup of patients this questionnaire was reduced to one overall question per PROMIS domain. We correlated these findings with the mRS. Results: We received 102 questionnaires and identified physical function as the most affected PROMIS domain. The strongest correlation with mRS was found for the health domains of physical function (ρs = 0.70, p < 0.001) and ability to participate in social roles (ρs = 0.61, p < 0.001). The other domains with substantial proportions of patients with worse scores compared to the general population (19-44%) correlated weakly with the mRS. We identified a strong correlation between the single question per health domain and the overall score per PROMIS domain. Discussion and Conclusion: PROMIS better reflects the overall health status of stroke patients beyond functional outcome as measured by the mRS. Simplification of the questionnaire with a single question per PROMIS domain could potentially replace the full questionnaire, but needs further validation.

Brief Psychosocial Intervention to Address Poststroke Depression May Also Benefit Fatigue and Sleep-Wake Disturbance

PURPOSE

This study aimed to determine if brief psychosocial/behavioral therapy directed to reduce poststroke depression would decrease fatigue and improve sleep-wake disturbance.

DESIGN

A preplanned secondary data analysis from a completed clinical trial was conducted.

METHODS

One hundred participants received usual care, in-person intervention, or telephone intervention. Depression, fatigue, and sleep-wake disturbance were measured at entry, 8 weeks, 21 weeks, and 12 months following the intervention.

FINDINGS

Fatigue (within: p = .042, between: p = .394), sleep disturbance (within: p = .024, between: p = .102), and wake disturbance (within: p = .004, between: p = .508) decreased over the 12 months in the intervention groups, but not in the control group. This difference was clinically meaningful for wake disturbance and approached the clinically important difference for fatigue.

CONCLUSIONS/CLINICAL RELEVANCE

Reduction in wake disturbance was consistent with clinically meaningful difference standards for patient-reported outcomes, warranting further research in larger samples.

Health-Related Quality of Life in Stroke Survivors in Relation to the Type of Inpatient Rehabilitation in Serbia: A Prospective Cohort Study

Background and objectives: Health-related quality of life after stroke is an important public health issue. The objective of the study was to investigate the relationship between the perceived health-related quality of life in stroke survivors in relation to the type of inpatient rehabilitation. Materials and Methods: Using a random selection method out of a total of 688 patients, every fourth survivor who had a stroke in the period from 1 January 2017 to 31 December 2019 was selected from the admission protocol of the Clinic for Rehabilitation and Physical Medicine of the Clinical Centre Niš, Serbia. A total of 160 first-ever stroke survivors were included (80 underwent additional inpatient rehabilitation and 80 underwent only inpatient rehabilitation in a tertiary health institution) in a twelve-month prospective study. The EuroQuol-5 Dimension (EQ5D) questionnaire and Stroke Impact Scale were used for the assessment. Multivariate linear regression analysis was done. Results: Multivariate linear regression analysis showed that additional inpatient rehabilitation from six up to eight weeks after discharge was significantly associated with better self-reported health condition by 3.9 times (from 1.9 to 8.2), significantly decreased the ranks of EQ5D by 1.78 times (from 1.02 to 3.11), and showed a higher health-related quality of life. We determined a significant increase of strength, emotions, mobility, and participation role in survivors who underwent additional inpatient rehabilitation compared with those who did not. Conclusions: There was a significant difference in health-related quality of life perceived by stroke survivors who underwent additional hospital rehabilitation in relation to those who underwent only inpatient rehabilitation.

Magnitude and Variability of Stroke Patient-Proxy Disagreement Across Multiple Health Domains

OBJECTIVES

To quantify the extent and variability of bias introduced when caregivers, or proxies, complete patient-reported outcome measures (PROM) on behalf of stroke patients.

DESIGN

Cross-sectional survey study conducted between July 2018 and November 2019.

SETTING

Ambulatory clinic of a cerebrovascular center or rehabilitation unit.

PARTICIPANTS

A consecutive sample of stroke patients (N=200) and their proxies who were able and willing to complete PROMs. Proxies completed PROMs as they believed the patient would answer.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

PROMs included Neuro-QoL cognitive function, PROMIS physical function, social role satisfaction, anxiety, fatigue, pain interference, sleep disturbance, Patient Health Questionnaire-9 translated to PROMIS Depression, and PROMIS Global Health.

RESULTS

The study included 200 stroke patients (age, 62.2±13.3; 41.5% women) and their proxies (age 56.5±13.9; 70% women, 72% spouses). Proxies reported worse functioning and more symptoms across all PROM domains compared with patients (average difference, 0.3-3.0 T score points). Reliability between dyad responses was moderate across all domains (intraclass correlation coefficients (2,1), 0.49-0.76) and effect sizes were small (d=0.04-0.35). Cognitive function, anxiety, and depression had the lowest agreement, whereas physical function, pain, and sleep had the highest agreement based on the Bland-Altman method. At the individual level, a large proportion of dyads had meaningfully different scores across domains (range, 40%-57%; dyads differed >5 T score points). Few predictors of disagreement were identified through multinomial regression models.

CONCLUSIONS

At the aggregate level, small differences were detected between stroke patient-proxy pairs, with lower agreement on more subjective domains. At the individual level, a large proportion of dyads reported meaningfully different scores on all domains, affecting the interpretability of proxy responses on PROMs in a clinical setting.

Patient-reported, health-related, quality of life after stroke thrombectomy in clinical practice

OBJECTIVE

To determine patient-reported health-related quality of life (HRQOL) after stroke thrombectomy in clinical practice and to identify predictors of better HRQOL by analyzing data of 504 consecutive patients treated in a large university stroke center.

METHODS

All patients with stroke treated by thrombectomy (June 2015-October 2018) were prospectively enrolled in this observational study. At 90 days, functional outcome was assessed by the modified Rankin Scale (mRS) and patient-reported HRQOL was assessed by the EuroQol Group 5-Dimension (EQ-5D) self-report questionnaire, consisting of 5 health domains. The EQ-5D utility index (EQ-5D-I) score (-0.594 to 1.00, with higher values indicating better HRQOL) was calculated. Linear regression analysis was applied to identify predictors of better HRQOL (higher EQ-5D-I score).

RESULTS

Of 504 patients (median age 76 years, 51.8% female), the mean EQ-5D-I score was 0.39 (SD 0.44). The proportion of stroke survivors who reported complaints in the different domains decreased from 66% in Usual Activities to 57% in Mobility, 50.4% in Self-Care, 41.7% in Pain/Discomfort, and 40.8% Anxiety/Depression. Lower age, lower prestroke mRS score, lower baseline NIH Stroke Scale score, higher Alberta Stroke Program Early CT Score, concomitant thrombolysis therapy, and a successful recanalization were independent predictors of better HRQOL.

CONCLUSIONS

Patient-reported HRQOL provides a more comprehensive assessment of stroke outcome than the mRS score. Health domains involving motor function most frequently showed complaints in HRQOL after stroke thrombectomy, while a large proportion of patients did not report any complaints across the different health domains. Predictors of better HRQOL closely match the predictors of better functional outcome measured by the mRS in other thrombectomy studies.

Health-related quality of life 90 days after stroke assessed by the International Consortium for Health Outcome Measurement standard set

BACKGROUND AND PURPOSE

Stroke has detrimental effects in multiple health domains not captured by routine scales. The International Consortium for Health Outcome Measurement has developed a standardized set for self-reported assessment to overcome this limitation. The aim was to assess this set in acute stroke care.

METHODS

Consecutive patients with acute ischaemic stroke, transient ischaemic attack or intracerebral hemorrhage were enrolled. Demographics, living situation and cardiovascular risk factors were collected from medical records and interviews. The Patient-reported Outcomes Measurement Information System 10-Question Short Form (PROMIS-10) and the Patient Health Questionnaire-4 (PHQ-4) were conducted 90 days after admission. Linear and logistic regression analyses were used to identify predictors of outcome. The study is registered at ClinicalTrials.gov, NCT03795948.

RESULTS

In all, 1064 patients were enrolled; mean age was 71.6 years, 51% were female, and median National Institutes of Health Stroke Scale (NIHSS) on admission was 3. Diagnosis was acute ischaemic stroke in 74%, transient ischaemic attack in 20% and intracerebral hemorrhage in 6%. 673 patients were available for outcome evaluation at 90 days; of these 90 (13%) had died. In survivors, t scores of PROMIS-10 physical and mental health were 40.3 ± 6.17 and 44.3 ± 8.63, compared to 50 ± 10 in healthy populations. 16% reported symptoms indicating depression or anxiety on the PHQ-4. Higher NIHSS, prior stroke and requiring help pre-stroke predicted lower values in physical and mental health scores. Higher NIHSS and diabetes were associated with anxiety or depression.

CONCLUSIONS

Integrated in the routine of acute stroke care, systematic assessment of patient-reported outcomes reveals impairments in physical and mental health. Main predictors are severity of stroke symptoms and comorbidities such as hypertension and diabetes.

Clinical Symptom Profiles After Mild-Moderate Stroke

Background

There is heterogeneity in the severity of domains affected in patients with stroke, resulting in differences in health‐related quality of life (hrQoL). Identifying different clinical profiles of stroke patients may provide a means for selecting patients for tailored interventions to improve hrQoL.

Methods and Results

This was an observational study of 496 patients with ischemic stroke or intracerebral hemorrhage seen in a cerebrovascular clinic from October 12, 2015, through June 11, 2018, who completed patient‐reported outcome measures using Patient‐Reported Outcome Measurement Information System (PROMIS) tools within 1 month of stroke. Latent profile analysis identified groups based on PROMIS domain scores—pain, depression, cognitive function, fatigue, social role satisfaction, and physical function—as well as clinician‐reported modified Rankin Scale (mRS). Five distinct profiles were identified. Group 1 (“excellent hrQoL,” n=106) had fewer symptoms in all domains than the general population. Group 2 (“disabled with mixed hrQoL,” n=17) had fewer symptoms than the general population in all domains except social role satisfaction and physical function, despite having moderate disability (median mRS score: 3). Group 3 (“mild limitations with average hrQoL,” n=189) had scores similar to the general population for all domains and minimal disability (median mRS score: 1). Group 4 (“mild limitations with poor hrQoL,” n=152) also had a median mRS score of 1 but had worse scores than group 3 on all domains. Group 5 (“disabled with poor hrQoL,” n=32) had worse symptoms than patients in the other profiles and a median mRS score of 3.

Conclusions

Patients with recent stroke have distinct clinical symptom profiles, even with similar levels of clinician‐reported disability. Symptom profiles provide a means of understanding patterns of outcomes in patients with stroke.

Look closer: The multidimensional patterns of post-stroke burden behind the modified Rankin Scale

Background

The utility-weighted modified Rankin Scale, representing patient perspectives of quality of life, is a newly proposed measure to improve the interpretability of the modified Rankin Scale. Despite obvious advantages, such weighting imperfectly reflects the multidimensional patterns of post-stroke burden.

Aims

To investigate multidimensional patterns of post-stroke burden formed by individual domains of Assessment of Quality of Life and Barthel Index for each modified Rankin Scale category.

Methods

In the A Very Early Rehabilitation Trial (n = 2104), modified Rankin Scale scores and modified Rankin Scale-stratified Barthel Index scores of Self-care and Mobility, and Assessment of Quality of Life scores of Independent Living, Senses, Mental Health and Relationships were collected at three months. The multivariate relationship between individual Assessment of Quality of Life and Barthel Index domains, and modified Rankin Scale was investigated using random effects linear regression models with respective interaction terms.

Results

Of 2104 patients, simultaneously collected Assessment of Quality of Life, Barthel Index and modified Rankin Scale scores at three months were available in 1870 patients. While individual Assessment of Quality of Life and Barthel Index domain scores decreased significantly as modified Rankin Scale increased (p < 0.0001), the patterns of decrease differed by domains (p < 0.0001). Patients with modified Rankin Scale 0–1 had the largest post-stroke burden in the Mental Health and Relationship domains, while patients with modified Rankin Scale >3 showed the greatest burden in Independent Living, Mobility and Self-care domains.

Conclusions

Across the modified Rankin Scale, individual domains are varyingly impacted demonstrating unique patterns of post-stroke burden, which facilitates appropriate assessment, articulation and interpretation of the modified Rankin Scale and utility-weighted modified Rankin Scale.

Acupuncture for post-stroke insomnia: A protocol for systematic review and meta-analysis

BACKGROUND

Post-stroke insomnia (PSI) is a significant complication of stroke, which often affects patients in various aspects. Acupuncture has fewer side effect and is increasingly used to treat PSI. The purpose of this study is to summarize the efficacy and safety of acupuncture for PSI.

METHODS

We will perform a comprehensive electronic searching, including PubMed, Embase, Cochrane Library, WangFang Database, China National Knowledge Infrastructure, Chinese Scientific Journal Database, Chinese Biomedical Literature Database, from inception to July 2020. We will also manually retrieve references, and contact lead authors. Randomized clinical trials (RCTs) of acupuncture for PSI will be included, regardless of whether blind method and allocation concealment are used. The outcomes of interest include: Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), efficacy standards of Chinese medicine, relapse rate after follow-up, adverse events, quality of life. To assess the risk of bias, we will use the Cochrane risk assessment tool. RevMan 5.3 software will be used to conduct data synthesis. The evidence quality of each outcome will be appraised according to Grades of Recommendation, Assessment, Development, and Evaluation (GRADE).

RESULTS

The results will be published in a peer-reviewed journal.

CONCLUSION

This study will provide a high-quality evidence to evaluate the efficacy and adverse reactions of acupuncture for PSI.

PROSPERO REGISTRATION NUMBER

CRD42020157865.

Psychosocial Sequelae of Stroke in Working-Age Adults: A Pilot Study

OBJECTIVE

Few prospective studies have examined psychosocial symptoms in young adult stroke survivors. The purpose of this pilot study was to examine the feasibility of methods to assess and describe the presence of symptoms and their characteristics in young adult stroke survivors.

METHODS

A prospective descriptive design using PROMIS and NeuroQoL patient-reported outcomes was used. Stroke survivors aged 18 to 65 years admitted for acute ischemic stroke completed baseline measures before hospital discharge; the same measures were collected by telephone interview 6 months later.

RESULTS

Thirty patients were recruited, and 18 (60%) completed follow-up measures. There was wide variability in scores across patients for each patient-reported outcome that persisted at 6 months. NeuroQoL cognitive function was the only patient-reported outcome to have a statistically significant change from baseline to 6 months (P = .045).

CONCLUSIONS

It is feasible to recruit and retain young adult stroke survivors in a prospective study. Wide variability in scores across patients suggests different trajectories of recovery in the first 6 months after stroke. Neuroscience nurses can assess for these symptoms and provide individualized interventions to aid in self-management of burdensome symptoms.

Opposing Associations of Stress and Resilience With Functional Outcomes in Stroke Survivors in the Chronic Phase of Stroke: A Cross-Sectional Study

Stroke survivors report significant levels of psychological distress post stroke. To date, most studies conducted have focused on the relationship between psychological stress and functional outcomes in the acute phase of stroke. However, no studies had considered the role of stress over the chronic phase, where stress may continue to exert negative effects on cognitive and psychological processes. Further, the role of potentially modulatory variables, such as psychological resilience, on stroke outcomes has been understudied. The purpose of this study was to consider the relationships between stress and resilience with functional outcomes in long-term survivors of stroke. People (N = 70) who had experienced a stroke between 5 months and 28 years ago were included in the cross-sectional study, along with age-matched controls (N = 70). We measured stress using both the Perceived Stress Scale and biological markers, and resilience using both the Brief Resilience Scale and the Connor-Davidson Resilience Scale. Stroke outcomes were assessed using the Stroke Impact Scale. We found that, compared with age-matched controls, stroke survivors reported greater levels of perceived stress, and lower levels of resilience. In stroke survivors, both perceived stress and resilience were independently associated with stroke outcomes in linear regression models. In particular, these relationships were observed for cognitive outcomes including mood, memory, and communication. The association between stress and stroke outcome did not differ across time post stroke. Given that resilience is a modifiable psychological construct, future research may consider whether strategies directed at enhancing resilience may improve recovery from stroke.

Australia and New Zealand Clinical Trials Registry: ACTRN12617000736347.

Sleep-related symptoms in patients with mild stroke

STUDY OBJECTIVES

Treatable sleep-related conditions are frequent in stroke patients, although their prevalence across stroke types and ideal method for screening is not clear. The objectives of this study were to evaluate the prevalence of sleep disturbance across different stroke types and identify approaches to the collection of sleep-related measures in clinical practice.

METHODS

We performed an observational cohort study of 2,213 patients with ischemic stroke, intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), or transient ischemic attack seen in a cerebrovascular clinic February 17, 2015 through July 5, 2017 who completed at least one of the following sleep-related questionnaires: Patient-Reported Outcomes Measurement Information System (PROMIS) sleep disturbance, Insomnia Severity Index (ISI), Sleep Apnea Probability Scale (SAPS), and sleep duration. Prevalence of abnormal scores were calculated using the following thresholds: PROMIS sleep disturbance ≥ 55, ISI ≥ 15, SAPS score ≥ 0.50, and sleep duration fewer than 6 or more than 9 hours. Sensitivity, specificity, and positive and negative predictive values of PROMIS sleep disturbance T-score ≥ 55 to identify patients with moderate-severe insomnia (ISI ≥ 15) were computed.

RESULTS

In the cohort, 28.6% patients (624/2183) had PROMIS sleep disturbance score ≥ 55, 17.6% (142/808) had ISI ≥ 15, and 61.3% (761/1241) had a positive SAPS screen. The frequency of abnormal sleep scale scores was similar across time periods and stroke types. The sensitivity and specificity of PROMIS sleep disturbance T-score ≥ 55 to identify patients with ISI ≥ 15 were 0.89 (95% confidence interval 0.83-0.94) and 0.81 (95% confidence interval 0.78-0.84), respectively.

CONCLUSIONS

The prevalence of sleep-related symptoms in patients with mild stroke are similar across stroke types and time periods after stroke. Potential approaches to screening for sleep disturbance in stroke patients are provided.