Age and Functional Outcome After Stroke

Improvements in activities of daily living among patients with brain tumors are associated with age, baseline physical function, duration of rehabilitation, and tumor recurrence but not type

Genetic testing has improved the accuracy of diagnosis of brain tumors, and treatment is now tailored to the type of brain tumor. In contrast, the factors that influence the improvement in independence in activities of daily living (ADLs) following rehabilitation have not been clarified, particularly the role of tumor type. In this retrospective cohort study of 358 participants, we analyzed changes in the Functional Independence Measure (FIM) from pre-rehabilitation to post-rehabilitation provided in an acute care hospital. Multiple regression was used to determine whether FIM gain is associated with age, gender, preadmission Karnofsky Performance Status (KPS), number of rehabilitation days, average duration of daily therapy (min/day), and tumor recurrence and type (WHO grade 1, 2, 3, and 4 gliomas; primary central nervous system lymphomas; and metastatic brain tumors). The results showed that older age (β -0.183), tumor recurrence (β -0.137), preadmission KPS < 80 (β -0.180), and higher baseline total FIM score (β -0.470) were associated with lower FIM gain whereas the average duration of daily therapy (β 0.153) was associated with higher FIM gain. Brain tumor type was not associated with FIM gain. Improved independence in ADLs is more influenced by demographic, functional status, and treatment factors than differences in brain tumor type.

Influence of Age on the Success of Neurorehabilitation

There is a general understanding that older adults suffering from a stroke have poorer outcomes and might benefit less from neurorehabilitation. This narrative review analyzes the conflicting evidence for the effect of aging on the success of neurorehabilitation after a stroke. While there is convincing evidence that functional outcomes are negatively impacted by age, functional gains made during rehabilitation are less clearly impacted, and the effect of age seems to be related to other factors such as prestroke independence and therapy intensity, as well as the population studied. There is no evidence that would justify withholding high-intensity neurorehabilitation on the sole basis of age.

Clinical Characteristics and Risk Factors of First-Ever Stroke in Young Adults: A Multicenter, Prospective Cohort Study

Stroke in young adults has catastrophic consequences and has increased in prevalence, contrary to the trends of most other diseases. This study aimed to determine the major characteristics and risk factors for stroke in younger adults compared with older adults. From the Korean Stroke Cohort for Functioning and Rehabilitation, 10,584 patients with first-ever stroke between August 2012 and March 2015 were enrolled retrospectively and divided into younger (age ≤ 45) and older groups (age > 45). The clinical characteristics and risk factors of stroke were compared between the younger and older groups. The younger group comprised 915 patients (8.6%). The proportion of hemorrhage strokes in the younger group (42.3%) was significantly higher than in the older group (20.0%) (p < 0.001). Obesity, current smoking, and heavy alcohol consumption were significantly more common risk factors in the younger group than in the older group for all stroke types, whereas hypertension, diabetes mellitus, hyperlipidemia, atrial fibrillation, and coronary heart disease were significantly more frequent in the older group (both p < 0.001). The major risk factors in the younger group may be lifestyle-related. Therefore, increasing awareness of lifestyle-related risk factors may be necessary to prevent stroke in young adults.

Post-ischemia common carotid artery occlusion worsens memory loss, but not sensorimotor deficits, in long-term survived stroke mice

Ischemic stroke in rodents is usually induced by intraluminal occlusion of the middle cerebral artery (MCA) via the external carotid artery (ECA) or the common carotid artery (CCA). The latter route requires permanent CCA occlusion after ischemia, and here, we assess its effects on long-term outcomes. Transient occlusion of MCA and CCA was performed at normal body temperature. After 90minutes of ischemia, mice were randomized to permanent CCA occlusion or no occlusion (control group). Body weight, and motor and sensory functions, ie, pole test, adhesive tape removal, and elevated plus maze, were evaluated at 24hours, and at 7 and 28 days after stroke. Infarct volume, apoptosis, and activation of astrocytes and microglia were assessed at 4 weeks by an investigator blinded to groups. The Morris water maze test was performed at 3 weeks in the second experiment. One mouse died at 4 days, and the other mice survived with persistent neurologic deficits. CCA-occluded mice exhibited delayed turn on the pole at 24hours and decreased responses to the von Frey filament, and spent more time on the pole at 7 and 28 days than the control group. Infarction, hemispheric atrophy, glial activation, and apoptotic neuronal death were present in all mice, and no intra-group difference was found. However, CCA-occluded mice had a significantly poorer performance in the Morris water maze compared to the control group, which showed an adverse effect of post-ischemia CCA occlusion on cognition. Thus, the model selection should be well considered in preclinical efficacy studies on stroke-induced vascular dementia and stroke with Alzheimer's disease.

Young individuals with stroke in rehabilitation: a cohort study

Stroke in younger populations is a public health crisis and the prevalence is rising. Little is known about the progress of younger individuals with stroke in rehabilitation. Characterization of the course and speed of recovery is needed so that rehabilitation professionals can set goals and make decisions. This was a cohort study with data extracted from electronic medical records. Participants were 408 individuals diagnosed with stroke who participated in inpatient rehabilitation in an urban, academic medical center in the USA. The main predictor was age which was categorized as (18-44, 45-64, 65-74 and 75+). Outcomes included baseline-adjusted discharge functional independence measure (FIM) scores and FIM efficiency. In linear regression models for FIM scores, the reference category was the youngest age group. The oldest group was discharged with significantly lower FIM total (B = -8.84), mobility (B = -4.13), self-care (B = -4.07) and cognitive (B = -1.57) scores than the youngest group after controlling for covariates. The 45-64 group also finished with significantly lower FIM total (B = -6.17), mobility (B = -2.61) and self-care (B = -3.01) scores than youngest group. FIM efficiencies were similar for all ages in each of the FIM scales. Younger individuals with stroke make slightly greater functional gains compared to older individuals with stroke, but other factors, such as admission scores, are more important and the rates of recovery may be similar.

Description and Functional Outcomes of a Novel Interdisciplinary Rehabilitation Program for Hospitalized Patients With COVID-19

OBJECTIVES

The aims of the study were to describe an interdisciplinary inpatient rehabilitation program for patients recovering from COVID-19 and to evaluate functional outcomes.

DESIGN

This is an analysis of retrospective data captured from the electronic health record of COVID-19 patients admitted to the rehabilitation unit (N = 106). Rehabilitation approaches are described narratively. Functional gain was evaluated using the Activity Measure for Postacute Care 6 Clicks, basic mobility and daily activities.

RESULTS

Interdisciplinary approaches were implemented to address the medical, physical, communication, cognitive, and psychosocial needs of COVID-19 patients. COVID-19 patients exhibited significant improvements in basic mobility (Activity Measure for Postacute Care for basic mobility, P < 0.001, Cohen d = 1.35) and daily activities (Activity Measure for Postacute Care for daily activities, P < 0.001, Cohen d = 1.06) from admission to discharge. There was an increase in ambulatory distance as well as the percentage of the patients who were able to breathe on room air. At discharge, fewer patients required supplemental oxygen on exertion. Eighty percent of the patients were discharged home after an average length of stay of 17 days. Greater functional improvement was associated with younger age, longer intubation duration, and participation in psychotherapy, but not a history of delirium during hospitalization.

CONCLUSIONS

Early rehabilitation is associated with improved mobility and independence in activities of daily living after COVID-19.

Adiposity and Outcome After Ischemic Stroke: Obesity Paradox for Mortality and Obesity Parabola for Favorable Functional Outcomes

BACKGROUND AND PURPOSE

A survival advantage among individuals with higher body mass index (BMI) has been observed for diverse acute illnesses, including stroke, and termed the obesity paradox. However, prior ischemic stroke studies have generally tested only for linear rather than nonlinear relations between body mass and outcome, and few studies have investigated poststroke functional outcomes in addition to mortality.

METHODS

We analyzed consecutive patients with acute ischemic stroke enrolled in a 60-center acute treatment trial, the NIH FAST-MAG acute stroke trial. Outcomes at 3 months analyzed were (1) death; (2) disability or death (modified Rankin Scale score, 2-6); and (3) low stroke-related quality of life (Stroke Impact Scale<median). Relations with BMI were analyzed univariately and in multivariate models adjusting for 14 additional prognostic variables.

RESULTS

Among 1033 patients with acute ischemic stroke, average age was 71 years (±13), 45.1% female, National Institutes of Health Stroke Scale 10.6 (±8.3), and BMI 27.5 (±5.6). In both unadjusted and adjusted analysis, increasing BMI was linearly associated with improved 3-month survival (P=0.01) odds ratios in adjusted analysis for mortality declined across the BMI categories of underweight (odds ratio, 1.7 [CI, 0.6-4.9]), normal (odds ratio, 1), overweight (0.9 [CI, 0.5-1.4]), obese (0.5, [CI, 0.3-1.0]), and severely obese (0.4 [CI, 0.2-0.9]). In unadjusted analysis, increasing BMI showed a U-shaped relation to poststroke disability or death (modified Rankin Scale score, 2-6), with odds ratios of modified Rankin Scale score, 2 to 6 for underweight, overweight, and obese declined initially when compared with normal weight patients, but then increased again in severely obese patients, suggesting a U-shaped or J-shaped relation. After adjustment, including for baseline National Institutes of Health Stroke Scale, modified Rankin Scale score 2 to 6 was no longer related to adiposity.

CONCLUSIONS

Mortality and functional outcomes after acute ischemic stroke have disparate relations with patients' adiposity. Higher BMI is linearly associated with increased survival; and BMI has a U-shaped or J-shaped relation to disability and stroke-related quality of life. Potential mechanisms including nutritional reserve aiding survival during recovery and greater frequency of atherosclerotic than thromboembolic infarcts in individuals with higher BMI.

Effect of intensive rehabilitation on improvement of activity of daily living after intracerebral hemorrhage: a retrospective observational study

Between 2008 and 2012, the intensity of rehabilitation therapy for the recovery phase of stroke was gradually increased at our hospital in line with the policy of Japan's National Insurance System. Training hours increased from 0.8 to 2.5 hours/day without introducing any new techniques, programs, or equipment. The aim of this study was to investigate the effectiveness of the increased intensity of rehabilitation on the improvement of activity of daily living of patients with intracerebral hemorrhage. We retrospectively compared patient outcomes for the periods 2013-2017 (N = 162) and 2003-2007 (N = 116) using the gain in Barthel Index as an indicator of improvement in activity of daily living. The median (interquartile range) gain was significantly higher in 2013-2017 than in 2003-2007 [30 (20-45) vs. 15 (5-30); P < 0.001]. A stratified analysis showed that this improvement was independent of sex, the patient's Barthel Index on admission, or the side of the brain lesion, but it varied with age or time to admission from onset of the disease. These results, based on a considerable difference in the intensity of rehabilitation between the two periods, support the consensus that increased time spent on rehabilitation results in better functional outcome in post-stroke patients. The results also suggest that age and the timing of starting rehabilitation are important factors to examine the effectiveness of intense rehabilitation in patients with intracerebral hemorrhage.

A Retrospective Cohort Comparing Left and Right Middle Cerebral Artery Ischemic Stroke Functional Outcomes in Acute Inpatient Rehabilitation

BACKGROUND

To date, no large population studies compare left and right middle cerebral artery (MCA) strokes and corresponding patient performance in acute rehabilitation as measured by the Functional Independence Measure (FIM).

OBJECTIVE

To compare granular performance data using the six FIM subcategories between left and right MCA territory strokes. This may foster development of individualized rehabilitation programs and affect rehabilitation policy based on phenotypic variations.

DESIGN

Retrospective cohort study.

SETTING

Inpatient rehabilitation facilities, using Uniform Data System for Medical Rehabilitation data from 2015 to 2017.

PATIENTS

Individuals with MCA strokes admitted to inpatient rehabilitation facilities (n = 38 812).

MAIN OUTCOME MEASURES

Mean FIM efficiency and FIM gain within the six FIM subcategories (self-care, sphincter control, transfers, locomotion, communication, and social cognition) were compared between left and right MCA strokes. All were stratified by admission FIM severity categories (<40, 40-80, >80). The study also examined length of stay and percentage discharged to home.

RESULTS

Mean FIM efficiency was significantly higher for left MCA strokes compared to right MCA strokes. Left MCA strokes with admission FIM <40 and 40-80 had significantly higher FIM efficiencies within the majority of FIM subcategories. However, left and right MCA strokes with admission FIM > 80 did not display any significant differences. Overall, patients with left MCA strokes were discharged to home at a significantly higher percentage. Patients with left MCA strokes with admission FIM 40-80 had on average a 2-day shorter length of stay than those with right MCA strokes.

CONCLUSIONS

Overall, patients with left MCA ischemic strokes had shorter length of stays, higher FIM efficiencies, and larger FIM gains than those with right MCA strokes. These results allow clinicians to counsel patients regarding functional gains based on diagnosis and to tailor rehabilitation programs to impairments encountered in left and right MCA territories. Including laterality of stroke and admission functional status would also improve algorithms for determining reimbursement.

A Meta-Analysis of Neuropsychological Predictors of Outcome Following Stroke and Other Non-Traumatic Acquired Brain Injuries in Adults

A number of cognitive abilities have been reported to predict outcome following a non-traumatic acquired brain injury (ABI) in adults. However, the results are inconsistent. Furthermore, the unique and combined capacity of these cognitive abilities to predict ABI outcome has not been evaluated. Consequently, we employed meta-analysis and multiple regression to evaluate the capacity of various neuropsychological domains to predict two separate outcome variables in adults: (1) activities of daily living; and (2) quality of life. Based on the activities of daily living meta-analysis (N = 2384), we estimated the following significant bivariate effects: memory (r = .31, 95% CI: .20/.41]), language (r = .33, 95% CI:.26/.40), attention (r = .38, 95% CI: .30/.46]), executive functions (r = .29, 95% CI: .19/.39]), and visuospatial abilities (r = .41, 95% CI: .34/ .48). Based on the quality of life meta-analysis (N = 1037), we estimated the following significant bivariate effects: memory (r = .12, 95% CI: .03/.20]), language (r = .19, 95% CI: .06/ .32), attention (r = .30, 95% CI: .16/.44]), executive functions (r = .24, 95% CI: .12/.37) and visuospatial/constructional abilities (r = .30, 95% CI: .14/.46). Meta-analytic structural equation modelling (metaSEM) identified two significant, unique predictors of activities of daily living, attention and visuospatial abilities, and the model accounted for 21% of the variance (multiple R² = .21, 95%CI: .16/.26). For the corresponding quality of life metaSEM, no statistically significant unique predictors were identified, however, a significant multiple correlation was observed, multiple R² = .11 (95%CI: 04/.18). We conclude that practitioners may be able to predict, with some degree of accuracy, functional outcome following a stroke and other non-traumatic ABI in adults. We also provide some critical commentary on the nature and quality of the measures used in this area of research to represent the cognitive dimensions of interest.

Prediction of the Lethal Outcome of Acute Recurrent Cerebral Ischemic Hemispheric Stroke

Background and objectives. Stroke-induced mortality is the third most common cause of death in developed countries. Intense interest has focused on the recurrent ischemic stroke, which rate makes up 30% during first 5 years after first-ever stroke. This work aims to develop criteria for the prediction of acute recurrent cerebral ischemic hemispheric stroke (RCIHS) outcome on the basis of comprehensive baseline clinical, laboratory, and neuroimaging examinations. Materials and Methods. One hundred thirty-six patients (71 males and 65 females, median age 74 (65; 78)) with acute RCIHS were enrolled in the study. All patients underwent a detailed clinical and neurological examination using National Institutes of Health Stroke Scale (NIHSS), computed tomography of the brain, hematological, and biochemical investigations. In order to detect the dependent and independent risk factors of the lethal outcome of the acute period of RCIHS, univariable and multivariable regression analysis were conducted. A receiver operating characteristic (ROC) analysis with the calculation of sensitivity and specificity was performed to determine the prediction variables. Results. Twenty-five patients died. The independent predictors of the lethal outcome of acute RCIHS were: Baseline NIHSS score (OR 95% CІ 1.33 (1.08-1.64), p = 0.0003), septum pellucidum displacement (OR 95% CI 1.53 (1.17-2.00), p = 0.0021), glucose serum level (OR 95% CI 1.28 (1.09-1.50), p = 0.0022), neutrophil-to-lymphocyte ratio (OR 95% CI 1.11 (1.00-1.21), p = 0.0303). The mathematical model, which included these variables was developed and it could determine the prognosis of lethal outcome of the acute RCIHS with an accuracy of 86.8% (AUC = 0.88 ± 0.04 (0.88-0.93), p < 0.0001).

Time series analysis of ambient air pollution effects on dynamic stroke mortality

This study aims to examine the correlations between air pollution and dynamic stroke mortality, which is defined as the daily real-time number of deaths from stroke. Death data were obtained from daily medical records of 7230 incidents from the Center for Disease Control and Prevention in the Longquanyi District of China from 2016 to 2017. Air pollution data were obtained from environmental monitoring stations in the Longquanyi District. Time series analysis using generalized additive Poisson regression models was applied, and single-pollutant and two-pollutant adjusted models were utilized. Furthermore, categories based on gender, age, and meteorological factors were considered in the analysis. The results indicated that PM2.5, PM10, O₃ , and CO had significant effects on dynamic stroke mortality, which were stronger for older people and during the cold season. This study helps hospital managers, patients, and governments seeking to prevent and control the effects of air pollution on the risks of stroke.

The association between effectiveness of clinical supervision of allied health professionals and improvement in patient function in an inpatient rehabilitation setting

Purpose: Clinical supervision is widely accepted as an important element of practice for allied health professionals to ensure a high quality of patient care. However, it is unknown whether effective clinical supervision of allied health professionals improves patients' outcomes. This study investigated whether effective clinical supervision of allied health professionals is associated with improved patient functional independence. Methods: A prospective longitudinal study design and multi-level regression analysis were used to explore the association between effective clinical supervision and patient functional independence. The effectiveness of clinical supervision was assessed using the Manchester Clinical Supervision Scale. Functional improvement in patients treated by allied health professionals was measured utilising the mobility and self-care subscales of the functional independence measure.Results: Physiotherapists (n = 27) and occupational therapists (n = 26) in inpatient rehabilitation were recruited and the medical records of their patients (n = 1846) audited. The effectiveness of clinical supervision of physiotherapists was positively associated with improvement in personal care. Therapist variables accounted for less than 2.5% of the variation in patient improvement in functional independence.Conclusions: Effectiveness of a reflective model of clinical supervision of physiotherapists and occupational therapists was not associated with an improvement in their patients' mobility or personal care, respectively.Implications for rehabilitationEffective clinical supervision of physiotherapists and occupational therapists using a reflective model of practice is a poor predictor of improved functional independence in rehabilitation inpatients.Patient variables, such as the intensity of therapy, were more important predictors of patient functional improvement than effective clinical supervision.Initiatives aimed at increasing intensity of therapy will likely have a greater effect on improving patient functional independence compared with initiatives aimed at improving the effectiveness of clinical supervision using a reflective model of practice.Initiatives to improve the effectiveness of clinical supervision in improving quality of care could explore the use of a direct model of practice where supervisors directly observe and support supervisees during patient treatment sessions.

Predictors of Good Outcome After Endovascular Therapy for Vertebrobasilar Occlusion Stroke

BACKGROUND AND PURPOSE

Endovascular therapy is increasingly used in acute ischemic stroke treatment and is now considered the gold standard approach for selected patient populations. Prior studies have demonstrated that eventual patient outcomes depend on both patient-specific factors and procedural considerations. However, these factors remain unclear for acute basilar artery occlusion stroke. We sought to determine prognostic factors of good outcome in acute posterior circulation large vessel occlusion strokes treated with endovascular therapy.

METHODS

We reviewed our prospectively collected endovascular databases at 2 US tertiary care academic institutions for patients with acute posterior circulation strokes from September 2005 to September 2015 who had 3-month modified Rankin Scale documented. Baseline characteristics, procedural data, and outcomes were evaluated. A good outcome was defined as a 90-day modified Rankin Scale score of 0 to 2. The association between clinical and procedural parameters and functional outcome was assessed.

RESULTS

A total of 214 patients qualified for the study. Smoking status, creatinine levels, baseline National Institutes of Health Stroke Scale score, anesthesia modality (conscious sedation versus general anesthesia), procedural length, and reperfusion status were significantly associated with good outcomes in the univariate analysis. Multivariate logistic regression indicated that only smoking (odds ratio=2.61; 95% confidence interval, 1.23-5.56; P=0.013), low baseline National Institutes of Health Stroke Scale score (odds ratio=1.09; 95% confidence interval, 1.04-1.13; P<0.0001), and successful reperfusion status (odds ratio=10.80; 95% confidence interval, 1.36-85.96; P=0.025) were associated with good outcome.

CONCLUSIONS

In our retrospective case series, only smoking, low baseline National Institutes of Health Stroke Scale score, and successful reperfusion status were associated with good outcome in patients with posterior circulation stroke treated with endovascular therapy.

Functional outcomes by age after inpatient stroke rehabilitation in Saudi Arabia

Background

Among various risk factors, age has been identified as a nonmodifiable risk factor for stroke that influences functional outcomes after inpatient stroke rehabilitation in the developed world as well as in Saudi Arabia (SA). The demand for inpatient stroke rehabilitation services increases with population aging and stroke incidence; however, these services are limited in SA.

Objective

To examine functional outcomes by age after inpatient stroke rehabilitation in SA.

Patients and methods

Data from 418 patients with stroke who underwent inpatient stroke rehabilitation at the King Fahad Medical City-Rehabilitation Hospital, Riyadh, SA, between November 2008 and December 2014 were collected from electronic medical records. According to the patients’ age, we classified participants into two groups: adults, aged <65 years (n=255), and older adults, aged ≥65 years (n=163). All patients’ functional statuses at admission and discharge from inpatient stroke rehabilitation were assessed using the functional independence measure (FIM) scale.

Results

The mean age was 59.9 years (SD =9.4). Older adults had significantly smaller changes in functional outcome from admission to discharge on both the total FIM (23 [SD =15.9]) and the motor FIM (21 [SD =15.4]), and they were significantly less independent (36%) compared to adults. In the adjusted models, older adults had significantly lower scores than adults, by 11 points (p<0.0001) for the total FIM score and by 10 points (p<0.0001) for the motor FIM subscale score. There was no significant change with age in the cognitive FIM subscale score.

Conclusion

After inpatient stroke rehabilitation, older adults had limited functional outcomes or were less independent than adults. However, the clinical relevance of this finding is questionable, so there is currently no justification to deny patients access to intensive stroke rehabilitation solely because of advanced age. Future large-scale research is needed to confirm rehabilitation outcomes by including confounders such as social support, socioeconomics, comorbidities, and the patient’s opinion after rehabilitation.

Stroke patients and long-term training: is it worthwhile? A randomized comparison of two different training strategies after rehabilitation

Objective : To find out if there were any differences in improvement and maintenance of motor function, activity of daily living and grip strength between patients with first-ever stroke receiving two different strategies of physical exercise during the first year after stroke.

Design : A longitudinal randomized controlled stratified trial.

Setting : Rehabilitation institutions, community, patients' homes and nursing homes.

Subjects : Seventy-five male and female first-time-ever stroke patients: 35 in an intensive exercise group and 40 in a regular exercise group.

Intervention : The intensive exercise group received physiotherapy with focus on intensive exercises in four periods during the first year after stroke. The regular exercise group patients were followed up according to their subjective needs during the corresponding year.

Main outcome measures : Motor Assessment Scale, Barthel Index of Activities of Daily Living, and grip strength.

Results : Both groups improved significantly up to six months when function stabilized. The groups did not differ significantly on any test occasions. The difference of improvement from admission to discharge was significant in favour of the intensive exercise group, in the Motor Assessment Scale total score (intensive exercise group 7.5; regular exercise group 1.7, P = 0.01), and in the Barthel Index of Activities of Daily Living total score (17.4 versus 8.9, P = 0.04).

Conclusion : Motor function, activities of daily living functions and grip strength improved initially and were maintained during the first year after stroke in all patients irrespective of exercise regime. This indicates the importance of motivation for regular exercise in the first year following stroke, achieved by regular check-ups.

Pilot randomized controlled trial to assess the impact of additional supported standing practice on functional ability post stroke

Objective: To investigate whether provision of additional standing practice increases motor recovery and mobility post stroke.

Design: A pilot randomized controlled trial.

Setting: A stroke rehabilitation unit in the UK.

Participants: Seventeen participants, seven women and ten men, age range 51—92 admitted to the unit 6—58 days post stroke.

Intervention: Each participant was randomly allocated into a control (conventional physiotherapy) or treatment (conventional therapy plus an additional session of standing practice) group. The period of intervention ranged from 14 to 28 days dependent upon length of stay on the unit.

Outcome measures: The Gross Functional Tool Section of the Rivermead Motor Assessment, the Trunk Control Test and the Berg Balance Scale were used on admission to the study, at weekly intervals during the intervention, and at 12 weeks (after discharge).

Results: Of the 17 participants recruited, three withdrew from the additional intervention group citing fatigue as a barrier and 15 completed the study.

Participants completing additional standing practice demonstrated higher scores in all motor measures at week 12, but this difference was not statistically significant. There was a statistically significant difference ( P < 0.05) in the changes in Berg Balance score when comparing week 1 with week 12, in support of the group receiving extra standing practice.

Conclusions: A larger study is required to establish the value of additional standing practice after stroke. This pilot demonstrates that the Gross Functional Tool Section of the Rivermead Motor Assessment and the Berg Balance Scale would be useful in such a study. Fatigue may be a significant barrier to ability to participate in more intensive programmes so screening participants for severe fatigue may be useful.

Development and Validation of Prognostic Indices for Recovery of Physical Functioning Following Stroke: Part 1

OBJECTIVE

To develop a prognostic index using Functional Independence Measure grades and stages that would enable clinicians to determine the likelihood of achieving a level of minimum assistance with physical functioning after a stroke. Grades define varying levels of physical function, and stages define varying levels of cognitive functioning.

DESIGN

Retrospective cohort study.

SETTING

Veterans Affairs Medical Centers throughout the United States.

PARTICIPANTS

Veterans with a diagnosis of a new stroke discharged between October 1, 2006, and September 30, 2008, who were below physical grade IV (requiring minimal assistance) at initial rehabilitation assessment.

MAIN OUTCOME MEASURE

Achievement of physical grade IV or above at final rehabilitation assessment.

RESULTS

Physical grade IV was reached by 25.8% of participants who were initially below this grade. Seven variables remained independently predictive of physical grade IV after adjustment. These variables were assigned the following points: age, ≤69 years = 2, 70-79 years = 1, ≥80 years = 0; initial physical grade, I = 0, II = 3, III = 4; initial cognitive stage, I or II = 0, III = 2, IV or V = 3, VI or VII = 4; absence of renal failure = 1; no serious nutritional compromise = 3; the type of rehabilitation services received, consultative = 0, comprehensive = 4; and recovery time between admission and discharge physical grade assessment, 1-2 days = 0, 3-7 days = 4, and ≥8 days = 5. The area under the receiver operating characteristic curve was 0.84 and 0.83 for the point system in the derivation and validation cohorts, respectively. The Hosmer-Lemeshow statistic was not significant (P = .93) in the derivation cohort, indicating that the regression model demonstrated adequate fit. The proportions of patients recovered to physical grade IV in the first (score ≥9), second (score = 10-12), third (score = 13-15), and fourth (score >15) score quartiles were 2.72%, 11.38%, 28.96%, and 60.34%, respectively.

CONCLUSION

By using a simple tool, clinicians can forecast the likelihood of recovery to or above the physical grade IV benchmark by the conclusion of rehabilitation services during the acute stroke hospitalization.

Prevalence of self-reported stroke and disability in the French adult population: a transversal study

In France, the prevalence of stroke and the level of disability of stroke survivors are little known. The aim of this study was to evaluate functional limitations in adults at home and in institutions, with and without self-reported stroke. A survey named “the Disability Health survey” was carried out in people's homes (DHH) and in institutions (DHI). Medical history and functional level (activities-of-daily-living, ADL and instrumented-activities-of-daily-living IADL) were collected through interviews. The modified Rankin score (mRS) and the level of dependence and disability were compared between participants with and without stroke. 33896 subjects responded. The overall prevalence of stroke was 1.6% (CI95% [1.4%–1.7%]). The mRS was over 2 for 34.4% of participants with stroke (28.7% of participants at home and 87.8% of participants in institutions) versus respectively 3.9%, 3.1% and 71.6% without stroke. Difficulty washing was the most frequently reported ADL for those with stroke (30.6% versus 3% for those without stroke). Difficulty with ADL and IADL increased with age but the relative risk was higher below the age of 60 (17 to 25) than over 85 years (1.5 to 2.2), depending on the ADL. In the overall population, 22.6% of those confined to bed or chair reported a history of stroke. These results thus demonstrate a high national prevalence of stroke. Older people are highly dependent, irrespective of stroke history and the relative risk of dependence in young subjects with a history of stroke is high compared with those without.

Stroke in young women: An interpretative phenomenological analysis

Stroke among adults of working age is increasing. We aimed to explore the experience of stroke among young women in Ireland. In total, 12 women (aged between 18 and 50 years) participated in semi-structured interviews. Data were analysed using interpretative phenomenological analysis. Four super-ordinate themes were identified: stroke as an illness of later life ('obviously it's for older people'), post-stroke selves, a desire for peer support and the impact of stroke on relationships. Findings indicate the importance of addressing the specific needs of younger stroke patients from admission to recovery through provision of inclusive all-age acute stroke services with tailored rehabilitation.

Does age matter? Age and rehabilitation of visual field disorders after brain injury

Homonymous visual field disorders (HVFD) are frequent and disabling consequences of acquired brain injury, particularly in older age. Their rehabilitation is therefore of great importance. Compensatory oculomotor therapy has been found to be effective in improving the associated functional impairments in reading and visual exploration. But older age is commonly considered to adversely affect practice-dependent functional plasticity and, thus, functional and rehabilitation outcome after acquired brain injury. The effect of age in the compensatory treatment of HVFD, however, has never been investigated hitherto. It remains unknown whether age determines not only patients' functional impairments but also the rehabilitation outcome and the required amount of treatment. We therefore present the first study to determine the effect of age in 38 patients with HVFD receiving compensatory oculomotor treatment for their reading and visual exploration impairments. We investigated whether older patients with HVFD (1) show more pronounced impairments and less spontaneous adaptation, (2) show lesser compensatory treatment-related improvement in reading and visual exploration, and (3) require a higher amount of treatment than younger patients. Our main finding is that older patients achieve the same treatment-induced improvements in reading and visual exploration with the same amount of treatment as younger patients; severity of functional impairment also did not differ between older and younger patients, at least in reading. Age does not seem to be a critical factor determining the functional and rehabilitation outcome in the compensatory treatment of HVFD. Older age per se is not necessarily associated with a decline in practice-dependent functional plasticity and adaptation. To the contrary, the effectiveness of compensatory treatment to reduce the functional impairments to a similar extent in younger and older patients with HVFD adds to the growing evidence for a life-long potential for adaptation to the adverse effects of brain injury.

Predicting length of stay in patients admitted to stroke rehabilitation with high levels of functional independence

PURPOSE

In Ontario, stroke patients with relatively mild functional deficits are admitted to inpatient rehabilitation programmes. Despite apparently minor impairments, many of these patients remain in rehabilitation for prolonged periods of time. The objective of the present study is to identify variables that predict length of stay (LOS) within this population of high functioning stroke patients.

METHODS

Stroke patients with Functional Independence Measure (FIM™) scores ≥100 admitted to a specialised inpatient rehabilitation programme in Ontario, Canada, from April 2005 to March 2008 were included in this study. Data from the National Rehabilitation Reporting System and chart review were used. Associations with LOS were examined among 25 potential predictor variables using bivariate correlations. Significantly correlated (p <0.002) variables were entered into a multiple linear regression.

RESULTS

Twenty-four percent (n = 134) of patients admitted during the study period were identified as presenting with mild functional deficits. These patients had a mean admission age of 63.5 (SD 14.6) years, a mean admission FIM score of 109.9 (SD 6.6) and a mean LOS of 22.3 (SD 10.5) days. FIM motor and cognitive subscale scores, Mini Mental State Exam scores and five single items assessing orientation, financial independence, and verbal, written and auditory communication ability were significantly correlated with LOS. The regression model, which included all eight variables, explained 60% of the variance associated with LOS (r = 0.80).

CONCLUSIONS

For patients admitted to stroke rehabilitation programmes with mild functional impairment, 60% of the variance in LOS can be explained by a small number of variables indicative of deficits in the areas of motor function, cognition and communication.

Stroke discharges from a rehabilitation unit: 1-year and 5-year domicile outcomes. Function is important

BACKGROUND

Stroke units save lives, reduce disability and increase the chances of the person returning to their own home. Following the introduction of a stroke rehabilitation unit, we assessed the durability of stroke discharges over a 1-year period and predictors of early 'failed' home discharges. Stability of discharge domicile and survival over 5 years was also reviewed.

METHODS

A 6-month cohort of all discharges was followed for 5 years. Changes in domicile, including entry into institutional care, were recorded out to 5 years or until death. Predictors of early (3 months) and later (1 year) discharge stability were assessed.

RESULTS

There were 142 discharges. Fifty-eight (76%) of those who returned home were still at home 12 months later. In contrast, there was a high mortality of dependent patients who were discharged to high dependency care (9 (29%) and 13 (42%) at 3 and 12 months, respectively). The chance of an early failed discharge was associated with lower functional ability on discharge (P= 0.012). Lower function on discharge was also independently associated with death in the next 12 months (P < 0.0001). At 5 years the mortality for the whole sample was 55% (78 of 141) and 38 (61%) of the survivors still lived in the community whereas 24 (39%) resided in institutional care.

CONCLUSION

Functional ability on discharge is a key predictor of ability to remain at home as well as survival and therefore every effort should be made to maximize function.

The psychology of stroke in young adults: the roles of service provision and return to work

Literature about the psychological consequences of stroke in those under 65 is reviewed focussing on services and work. Despite similarities, young and old survivors have different experiences and needs. These are attributable to the effects of stroke on age-normative roles and activities, self-image, and the young person's stage in the life-cycle, especially family and work. "Hidden" cognitive impairments, a disrupted sense of self, and the incongruity of suffering an "older person's" disease are salient. Young survivors benefit from services, but experience lack of congruence between their needs and service philosophy, methods, and aims, and consequently have unmet needs. Employment is psychologically salient, and the evidence about return rates, factors that affect return, and the adequacy of employment-related service provision is reviewed. Specific and general recommendations are made for increasing congruence between young survivors' needs and service provision and also for facilitating their return to work.

Aging exacerbates intracerebral hemorrhage-induced brain injury

Aging may be an important factor affecting brain injury by intracerebral hemorrhage (ICH). In the present study, we investigated the responses of glial cells and monocytes to intracerebral hemorrhage in normal and aged rats. ICH was induced by microinjecting autologous whole blood (15 microL) into the striatum of young (4 month old) and aged (24 month old) Sprague-Dawley rats. Age-dependent relations of brain tissue damage with glial and macrophageal responses were evaluated. Three days after ICH, activated microglia/macrophages with OX42-positive processes and swollen cytoplasm were more abundantly distributed around and inside the hemorrhagic lesions. These were more dramatic in aged versus the young rats. Western blot and immunohistochemistry analyses showed that the expression of interleukin-1beta protein after ICH was greater in aged rats, whereas the expression of GFAP and ciliary neurotrophic factor protein after ICH was significantly lower in aged rats. These results suggest that ICH causes more severe brain injury in aged rats most likely due to overactivation of microglia/macrophages and concomitant repression of reactive astrocytes.

Effect of age, sex, and timing on correction of spastic equinovarus following cerebrovascular accident

BACKGROUND

Spastic equinovarus (SEV) is the most common leg deformity after cerebrovascular accident (CVA). This study reviewed functional outcomes after surgical correction of SEV in a cohort of hemiplegic, post-CVA patients.

METHODS

Sixty-four consecutive post-CVA SEV patients who underwent surgical correction from January 2003 to January 2006 were included. Data parameters included age, sex, duration since CVA, preoperative orthotic and ambulatory requirements, and Viosca ambulation scores. There were 45 females and 19 males. Average age was 54 (range, 24 to 74) years. Average duration from CVA to surgery was 66 (range, 17 to 523) months. Mean followup was 50.1 (range, 12 to 168) weeks. Final outcomes included status of correction, bracing needs, use of assistive devices, and Viosca score. Univariate and multivariate statistical analyses were performed to determine if age, sex, and time from CVA to surgery affected outcome.

RESULTS

All feet were corrected to plantigrade position. Of the 48 patients who used orthoses preoperatively, 27 (56%) continued use while 11 (44%) were brace-free postoperatively. Of the 23 patients that used an ambulatory assistive device preoperatively, 12 (52%) continued use and 11 (47.8%) were free of assistive devices postoperatively. Median Viosca score improved from two (Independent Household Ambulation) to three (Independent Neighborhood Ambulation) (p < 0.001). There was no statistical association between age, sex, CVA chronicity and outcome parameters.

CONCLUSION

These results indicate that surgical correction of SEV is effective in post-CVA patients. Patients demonstrated improvement in ambulation score regardless of age, sex, or duration from CVA to surgery.

Predictive factors of functional gain in long-term stroke survivors admitted to a rehabilitation programme

PRIMARY OBJECTIVE

To assess factors that may influence functional gain of patients with chronic sequelae of stroke.

RESEARCH DESIGN

Prospective study of 290 stroke patients consecutively admitted to a rehabilitation setting.

METHODS AND PROCEDURES

Functional Independence Measure Scale (FIM) was used to assess functional capacity. Functional improvement registered during hospitalization (FIM-gain score) was compared to demographic data, stroke sub-type, vascular risk factors, motor deficit, visual hemineglect, aphasia, level of response and sphincter control. FIM-gain score was classified as high-gain (=22) and low-gain (<22).

MAIN OUTCOMES AND RESULTS

Two hundred and fifty-two patients who had no prior rehabilitation and were capable of completing the rehabilitation programme were studied (average age 58.4+/-13.9 years; 42.9% women). The mean time from stroke onset to admission was 271.5 days. Average FIM score at admission was 58.8 and at discharge was 81.6. Average FIM Gain was 23.6. The 38% patients admitted later than 6 months after stroke had an average FIM Gain of 19 vs 26 for patients admitted prior to 6 months. Significant predictors of functional improvement were time from stroke onset, age, sitting balance and level of responsiveness.

CONCLUSION

The functional improvement scores in persons with stroke beginning a rehabilitation programme at a later stage are 73% of the scores obtained by patients beginning treatment in the first 6 months. FIM score improvement can be predicted by time since stroke onset, age, sitting balance and level of responsiveness.

Functional Outcomes of Cancer Patients in an Inpatient Rehabilitation Setting

Introduction: Cancer is the leading cause of death and the second most common cause of hospitalisation in Singapore. Significant functional gains are achievable with cancer rehabilitation yet there are no formal cancer rehabilitation programmes in Singapore. This study aims to describe the demographics, clinical characteristics, complications and functional outcomes of cancer patients undergoing comprehensive inpatient rehabilitation at our unit and compare these with non-cancer patients. It also seeks to compare these data within sub-groups of the cancer cohort. Materials and Methods: This is a prospective cohort study. The Department of Rehabilitation Medicine database was reviewed for the period between 1 July 2002 and 31 December 2006. One thousand seven hundred and fifty patients had complete records, of which 58 are cancer patients. The primary outcome measures were the discharge total Functional Independence Measure (FIM), FIM gain and FIM efficiency. Other outcome measures included the length of rehabilitation stay, discharge destination, complication rates, rate of transfer back to the referring unit, the length of survival of the cancer patients upon discharge and the durability of the functional improvement made. Results: The mean age of the cancer patients was 57.4 ± 16.1 years and 62% were male. The mean admission total FIM was 70.9 ± 18.0 and the total discharge FIM was 86.2 ± 18.3. The average FIM gain was 15.3 ± 11.6 and the mean efficiency was 0.867 ± 0.806. This improvement is highly significant, and there is no statistical difference in FIM gain or efficiency between the cancer and non-cancer cohort, or between the cancer sub- groups. The length of stay was similar in cancer and non-cancer cohorts but cancer patients with spinal metastasis and those who underwent concomitant radiotherapy stayed longer. There were good rates of discharge home, transfer back, survivorship and durability in functional gains. Conclusion: Cancer patients benefit as much as non-cancer patients in undergoing a rehabilitation programme. More patients should be admitted to such programmes and these programmes should be better structured and refined. Key words: Complications, Durability, Efficiency, Radiotherapy

Process skill rather than motor skill seems to be a predictor of costs for rehabilitation after a stroke in working age; a longitudinal study with a 1 year follow up post discharge

BACKGROUND

In recent years a number of costs of stroke studies have been conducted based on incidence or prevalence and estimating costs at a given time. As there still is a need for a deeper understanding of factors influencing these costs the aim of this study was to calculate the direct and indirect costs in a younger (<65) sample of stroke patients and to explore factors affecting the costs.

METHODS

Fifty-eight patients included in a study of home rehabilitation and followed for 1 year after discharge from the rehabilitation unit, were interviewed about their use of health care services, assistance, medications and assistive devices. Costs (defined as the cost for society) were calculated. A linear regression of cost and variables of functioning, ability, community integration and health-related quality of life was done.

RESULTS

Inpatient care contributed substantially to the direct cost with a mean length of stay of 92 days. Rehabilitation during the first year constituted of an average of 28 days in day clinics, 38 physiotherapy sessions and 20 occupational therapy sessions. The total direct mean cost was 80 020 euro and the indirect cost 35 129 euro. The direct costs were influenced by the process skill (the ability to plan and perform a given task and to adapt when needed) and presence of aphasia. Indirect costs for informal care giving increased for patients with a lower health-related quality of life as well as a low score on home integration.

CONCLUSION

Costs are high in this group of young (< 65 years) stroke patients compared to other studies, partly due to the length of the stay and partly to loss of productivity.

Results From a Prospective Acute Inpatient Rehabilitation Database: Clinical Characteristics and Functional Outcomes using the Functional Independence Measure

Introduction: Rehabilitation improves functional outcomes, but there is little data on the profiles and outcomes of patients undergoing inpatient rehabilitation in Singapore. The aims of this paper were to document the clinical characteristics and functional outcomes, using the Functional Independence Measure (FIM), of all patients admitted to an inpatient rehabilitation unit in a tertiary teaching hospital, and to identify and analyse factors significantly associated with better discharge functional scores and higher functional gains. Materials and Methods: In this prospective cohort study over a 4-year period, clinical and functional data for 1502 patients admitted consecutively to the Singapore General Hospital inpatient rehabilitation unit were charted into a custom-designed rehabilitation database. The primary outcome measures were the discharge total FIM scores, FIM gain and FIM efficiency. Multiple linear regression analysis was used to identify independent variables associated with better discharge FIM scores and FIM gain. Results: The mean age was 61.3 ± 15.0 years and 57.2% of the patients were male. Stroke (57.9%) followed by spinal cord injury (9.7%) were the most common diagnoses. The average rehabili-tation length of stay was 21.5 ± 19.0 days. The mean admission total FIM score was 70.3 ± 23.2 and the mean discharge total FIM score was 87.3 ± 23.0, with this gain being highly significant (P <0.001). The mean FIM gain was 17.0 ± 13.4 and FIM efficiency was 0.95 ± 0.90 points/day. Factors associated with better functional outcomes were higher admission motor and cognitive FIM scores, male gender, a longer rehabilitation length of stay and the use of acupuncture. Factors associated with poorer functional outcomes were older age, clinical deconditioning, ischaemic heart disease, depression, pressure sores and the presence of a domestic worker as a caregiver. Conclusions: The FIM is an easy-to-use, standardised and robust general measure of functional disability. Multiple demographic, clinical and socio-cultural variables are associated with the primary functional outcomes and should be taken into account in rehabilitation and discharge planning. Nevertheless, rehabilitation improves functional outcomes across a wide range of diagnoses. Further research should be aimed at evaluating long-term disability post-discharge from inpatient rehabilitation and translating these findings into improving rehabili-tation and healthcare resource utilisation. Key words: Database, Functional Independence Measure, Functional outcomes, Rehabilitation,

Outcomes in total knee arthroplasty patients after inpatient rehabilitation: influence of age and gender

OBJECTIVES

To examine age and gender effects on outcomes after inpatient rehabilitation in primary total knee arthroplasty (TKA) and revision TKA patients.

DESIGN

This retrospective, comparative study was conducted in a 50-bed, university-affiliated rehabilitation hospital. Patients included primary TKA patients (n = 286) and revision TKA patients (n = 138) placed into one of three age brackets: <60 yrs, 60-70 yrs, or >70 yrs. Measurements included length of stay (LOS), FIM scores, hospital charges, and discharge disposition location.

RESULTS

FIM scores improved from admission to discharge in both primary and revision patients (P = 0.015). LOS was shorter in primary than revision patients (8.3 vs. 10.4 days, P = 0.001), and the LOS was longest in patients >70 yrs compared with those <60 or 60-70 yrs (10.6 vs. 8.7 and 8.8 days, respectively; P = 0.004). FIM efficiency was greater in primary than in revision TKA patients (3.68 vs. 2.77 points/day, P = 0.001), and greater for men than women in each age bracket regardless of TKA type (3.68 vs. 2.78 points/day, P = 0.001). Total hospital charges were lower for men than women for both TKA types ($9,656 +/- 823 vs. $11,544 +/- 1,359; P = 0.015), and were highest in patients >70 yrs of age (P = 0.015).

CONCLUSIONS

Primary and revision TKA patients make improvements in functional independence during inpatient rehabilitation. Although FIM gains were similar among age and gender groupings, FIM efficiency is lowest in women. Despite similar daily hospital costs among the groups, slower progress with functional gains (decreased FIM efficiency) increases the LOS and total hospital charges, especially in older women.

Effects of Day Hospital Rehabilitation After Stroke

OBJECTIVE

We sought to evaluate with 3 relevant, reliable, and valid measurement instruments the effect of 6 to 8 weeks of day hospital rehabilitation (DHR) after stroke on physical and cognitive functions and self-rated health and health-related quality of life, possible relationships among these variables, and direct costs of the rehabilitation period.

DESIGN

We conducted a prospective follow-up study of DHR in a university hospital with pretreatment and posttreatment assessments.

PATIENTS

In all, 52 consecutive patients aged 18 to 60 years with first-ever stroke occurring in the mean 6 months before study start comprised the study group.

METHODS

We conducted assessments using Functional Independence Measure, Medical Outcomes Study 36-item Short Form, and EuroQol.

RESULTS

Significant improvements occurred in physical and cognitive functions (P < .0001) and self-rated health and health-related quality of life (P < .0001 for both physical and mental component summaries and P < .0001 for the EuroQol). Improvements correlated inversely with baseline scores (P = .026-P < .0001 for different variables). Improvements in self-rated health and health-related quality of life were not related to improvements in physical and cognitive functions. Direct costs were estimated at about 12,000 euros or $14,500 per patient for the treatment period.

CONCLUSION

During the 6 to 8 weeks of DHR, there is significant improvement in physical and cognitive functions and self-rated health and health-related quality of life, which are not related significantly to each other. Improvements are greater in patients with more severe impairment of physical and cognitive functions and self-rated health and health-related quality of life at baseline.

Clinical Characteristics and Rehabilitation Outcomes of Patients With Posterior Cerebral Artery Stroke

OBJECTIVES

To describe the demographics, clinical profile, and functional outcomes in posterior cerebral artery (PCA) stroke and to identify factors associated with functional change during rehabilitation and discharge disposition.

DESIGN

Retrospective study of patients with PCA stroke admitted to a rehabilitation hospital over an 8-year period.

SETTING

Free-standing urban rehabilitation hospital in the United States.

PARTICIPANTS

Eighty-nine consecutive patients with PCA stroke (48 men, 41 women; mean age, 71.5y) met inclusion criteria.

INTERVENTION

Inpatient multidisciplinary comprehensive rehabilitation program.

MAIN OUTCOME MEASURES

Demographic, clinical, and discharge disposition information were collected. Functional status was measured using the FIM instrument, recorded at admission and discharge. The main outcome measures were the discharge total FIM score, the change in total FIM score (DeltaFIM), and the discharge disposition. Multiple and logistic regression analyses were performed to identify factors associated with the main outcome measures.

RESULTS

The most common impairments were motor paresis (65%), followed by visual field defects (54%) and confusion or agitation (43%). The mean discharge total FIM score +/- standard deviation was 88.3+/-28.2. The mean DeltaFIM was 23.3+/-16.4. Fifty-five (62%) patients were discharged home. On multiple regression analysis, higher admission total FIM score, longer length of stay (LOS), and a rehabilitation stay free of interruptions were associated with higher discharge total FIM score and greater DeltaFIM. Absence of diabetes mellitus and younger age were also associated with higher discharge total FIM scores, and male sex had greater DeltaFIM. On logistic regression analysis, younger patients, higher discharge FIM scores, presence of a caregiver, and the nonnecessity for 24-hour support were associated with a discharge to home.

CONCLUSIONS

Motor, visual, and cognitive impairments are common in PCA stroke, and good functional gains are achievable after comprehensive rehabilitation. Higher admission FIM scores, longer LOS, and younger and male patients were associated with better functional outcomes. Most patients were discharged home, particularly those with caregivers and those for whom 24-hour support was not required. Further research should aim at the development of functional outcome measures of greater breadth and sensitivity to visual and cognitive deficits and should compare PCA stroke outcomes with outcomes of strokes in other vascular territories.