Prognostic Factors of Functional Outcome Assessed by Using the Modified Rankin Scale in Subacute Ischemic Stroke

MLC901 in hypoxic-ischemic brain injury patients: A double-blind, randomized placebo-controlled pilot study

BACKGROUND

Hypoxic-ischemic brain injury (HIBI) is a disabling consequence of cardiopulmonary resuscitation, which has no direct treatment except supportive care. Many studies have used pharmacological agents to reduce or stop this disability. MLC901 is a traditional Chinese medicine showing neuroprotective and regenerative effects on focal and global ischemia in previous animal and human studies. We designed an experimental, randomized, double-blind, placebo-controlled study to analyze MLC901 efficacy in HIBI patients.

METHODS

In a randomized, placebo-controlled trial, 35 patients with HIBI were randomly designated to receive either MLC901 or placebo capsules 3 times per day over 6 months. We assessed the 2 groups by modified Rankin Scale and Glasgow Outcome Scale at baseline, and follow-up visits in 3rd month, and 6th-month after injury.

RESULTS

Thirty-one patients completed this study. There was no significant difference in baseline characteristics between the 2 groups as regards age, gender, time of resuscitation, the interval between injury and start of the intervention, and the length of intensive care unit stay. Both the placebo and intervention groups improved during the investigation. However, the Glasgow Outcome Scale and modified Rankin Scale scales were significantly improved in the MLC901 group compared to the placebo after 6 months (P < .05) with close to no adverse effects. No major side effect was reported.

CONCLUSION

MLC901 has shown, compared to placebo, a statistically better improvement at 6 months in neurological functions of patients with HIBI.

The Study of the Association of Polymorphisms in LSP1, GPNMB, PDPN, TAGLN, TSPO, and TUBB6 Genes with the Risk and Outcome of Ischemic Stroke in the Russian Population

To date, there has been great progress in understanding the genetic basis of ischemic stroke (IS); however, several aspects of the condition remain underexplored, including the influence of genetic factors on post-stroke outcomes and the identification of causative loci. We proposed that an analysis of the results obtained from animal models of brain ischemia could be helpful. To this end, we developed a bioinformatic approach for exploring single-nucleotide polymorphisms (SNPs) in human orthologs of rat genes expressed differentially after induced brain ischemia. Using this approach, we identified and analyzed 11 SNPs from 6 genes in 553 Russian individuals (331 patients with IS and 222 controls). We assessed the association of SNPs with the risk of IS and IS outcomes. We found that the SNPs rs858239 (GPNMB), rs907611 (LSP1), and rs494356 (TAGLN) were associated with different parameters of IS functional outcomes. In addition, the SNP rs1261025 (PDPN) was associated significantly with IS itself (p = 0.0188, recessive model). All these associations were demonstrated for the first time. Analysis of the literature suggests that they should be characterized as being inflammation related. This supports the pivotal role of inflammation in both the incidence of stroke and post-stroke outcomes. We believe the findings reported here will help with stroke prognosis in the future.

An exploratory descriptive cohort study of 90-day prognosis after acute ischaemic stroke with mechanical thrombectomy

AIM

To evaluate the relationship between nursing assessment findings at discharge and acute ischaemic stroke (AIS) patient prognosis after mechanical thrombectomy (MT).

METHODS

We analysed the characteristics of 144 AIS patients with MT treatment admitted to a university affiliated teaching hospital in Chengdu, Sichuan Province China, from January 2020 to December 2020. The modified Rankin Scale (mRS) score was used to assess outcomes 90-days after discharge. Exploratory analyses were undertaken using IBM SPSS Statistics (Version 26.0).

RESULTS

At 90-days, 47.9% (n = 69) had a good prognosis (mRS ≤ 2) including 22.2%(n = 32) fully recovered patients. There were 5 (3.5%) deceased patients and 48.6% (n =70) of patients had a poor prognosis (mRS ≥ 3). In univariate analysis, clinical prognosis correlated with the need for inpatient endotracheal intubation (p = 0.02), nasogastric tube (p＜0.001), indwelling urinary catheter (p＜0.001), central venous catheter (p = 0.03), health knowledge needs of pressure injury prevention (p = 0.03), National Institute of Health Stroke Scale (NIHSS) score (p＜0.001) and Activities of Daily Living (ADL) score (p＜0.001) at the time of discharge from hospital. The average hospitalisation time of the 144 patients was 12[IQR, 9-25] days, and the average cost of hospitalisation was $Y$21291.93 (SD 9165.01).

CONCLUSION

Almost half of the surviving patients had a poor prognosis. In our country, this surgery and rehabilitation impose a significant financial burden that needs to be addressed. However, the longer length of hospital stay and higher costs at discharge may be contributing factors to worse outcomes. The outcomes of comprehensive nursing assessment of the patients, including nursing needs, activities of daily living, and neurological function, can predict their outcome.

IMPACT STATEMENT

We recommend a comprehensive nursing assessment at discharge that predicts patient outcomes and can be used for subsequent targeted interventions. The prognosis of patients with acute ischaemic stroke after mechanical thrombectomy is poor, and the financial burden needs to be considered.

Internet-based information sharing with stroke patient families in a rehabilitation hospital during the COVID-19 pandemic: A case-control study

BACKGROUND

The spread of COVID-19 has affected stroke rehabilitation. Given that inpatient visits are restricted in most institutions, alternative ways of providing information to family members are imperative. Informing families about patients' rehabilitation progress via the Internet may help involve families in the rehabilitation process, enhance patients' motivation to continue rehabilitation, and contribute overall to patients' improvement in activities of daily living (ADL).

OBJECTIVE

We aimed to investigate the feasibility of an Internet-based rehabilitation information sharing (IRIS) intervention for families of stroke patients at a rehabilitation hospital and to examine the effect of IRIS on patients' ADL improvement.

METHODS

In this case-control study, participants were inpatients at a rehabilitation hospital between March 2020 and April 2021. The intervention group (ICT group) included patients and families who requested IRIS, which consisted of a progress report on patients' rehabilitation using text, photos, and movies. Those who did not receive Internet-based information were included in the non-ICT group. The control group, matched with the ICT group based on a 1:1 propensity score, was selected from the non-ICT group. The covariates for calculating the propensity score were patients' age, sex, and motor and cognitive scores on the Functional Independence Measure (FIM) at admission. The main outcome was the degree of ADL improvement during hospitalization. Multiple regression analysis (forced entry method) was performed to confirm the impact of ICT use on ADL improvement. The independent variables were the presence of intervention, length of hospital stay, and the number of days from onset to hospitalization.

RESULTS

Sixteen groups of patients and families participated in the IRIS. The mean age of patients was 78.6±7.2 and 78.6±8.2 years in the ICT and control groups, respectively. The median total FIM difference was 28.5 (interquartile range 20.3-53.0) and 11.0 (2.8-30.0) in the ICT and control groups, respectively, and the ICT group showed significant improvement in ADL function (p=.02). In the multiple regression analysis of the ICT and control groups, the unstandardized regression coefficients and 95% confidence intervals were 11.97 (0.09 to 23.84) for ICT use. These results indicate that ICT use was independently and significantly associated with improvement in ADL.

CONCLUSIONS

This study examined the effect of IRIS on family members to improve ADL in hospitalized stroke patients. The results showed that IRIS promotes improvement of patients' ADL regardless of age, sex, and motor and cognitive functions at admission, and length of hospital stay.

Functional Independence predicts patients with stroke more likely to be discharged to the community after inpatient rehabilitation

BACKGROUND

Functional domain predictors of discharge destination following inpatient rehabilitation for stroke have not been thoroughly identified.

OBJECTIVES

1) Determine the relationships between intrinsic variables (demographic; comorbidities; functional independence at admission to and at discharge from an inpatient rehabilitation facility (IRF)) and discharge to home. 2) Determine cut scores for Functional Independence Measure® (FIM) subscales and domains that predict discharge to the community.

METHODS

This study was a secondary analysis of a large, multi-IRF dataset from the Uniform Data System for Medical Rehabilitation. Participants were adults with stroke who were discharged from an IRF in 2019 (n = 92,153).

RESULTS

Correlations with discharge to the community were strongest for discharge FIM scores (r = 0.330 to 0.580), followed by admission FIM scores (r = 0.245 to 0.411), which were stronger than the demographic and comorbidity variables (r = 0.005 to 0.110). Logistic regression analysis indicated 5 of 6 FIM domains (Social Cognition, Self-care, Sphincter, Transfer, and Locomotion) scored at admission and at discharge were predictive of discharge home. Receiver operating characteristic curve analyses determined the best cut point for each domain. For each FIM measure, the area under the curve was greater when the measure was obtained at discharge than it was at admission.

CONCLUSIONS

Clinicians may consider the cut points presented for each domain at admission and at discharge when setting goals or making recommendations for patients with stroke who aspire to a discharge from an IRF to a community setting.

Predicting home discharge after inpatient rehabilitation of stroke patients with aphasia

The early identification of the discharge setting from Inpatient Rehabilitation Facilities is a primary goal in stroke-related research because of its clinical and socio-economic relevance. Several features have been identified as significant predictors of the discharge setting. Within cognitive deficits, aphasia is known to be a common and disabling condition that could influence rehabilitation outcome. However, it is often set as an exclusion criterion in stroke research. This study aims to investigate the predictive power of clinical variables, in particular specific language disturbances and nonlinguistic cognitive deficits, for discharge setting in post-acute stroke patients with aphasia after intensive multidisciplinary rehabilitation. In a sample of 158 patients, demographic, motor, language, and nonverbal cognitive data were retrospectively considered for the prediction of the discharge to home vs. another institutional setting. Univariate analysis identified relevant differences between groups and the significant variables were included in a logistic regression model. The results showed that better functional motor status, absence of dysphagia and unimpaired nonlinguistic cognitive profile independently predict the discharge to home. In particular, nonverbal cognitive functioning seemed to be specifically relevant within the aphasic population. The findings could be helpful for setting up the rehabilitation priorities and an adequate discharge arrangement.

Examination of Genetic Variants Revealed from a Rat Model of Brain Ischemia in Patients with Ischemic Stroke: A Pilot Study

Although there has been great progress in understanding the genetic bases of ischemic stroke (IS), many of its aspects remain underexplored. These include the genetics of outcomes, as well as problems with the identification of real causative loci and their functional annotations. Therefore, analysis of the results obtained from animal models of brain ischemia could be helpful. We have developed a bioinformatic approach exploring single nucleotide polymorphisms (SNPs) in human orthologues of rat genes expressed differentially under conditions of induced brain ischemia. Using this approach, we identified and analyzed nine SNPs in 553 Russian individuals (331 patients with IS and 222 controls). We explored the association of SNPs with both IS outcomes and with the risk of IS. SNP rs66782529 (LGALS3) was associated with negative IS outcomes (p = 0.048). SNPs rs62278647 and rs2316710 (PTX3) were associated significantly with IS (p = 0.000029 and p = 0.0025, respectively). These correlations for rs62278647 and rs2316710 were found only in women, which suggests a sex-specific association of the PTX3 polymorphism. Thus, this research not only reveals some new genetic associations with IS and its outcomes but also shows how exploring variations in genes from a rat model of brain ischemia can be of use in searching for human genetic markers of this disorder.

Personal and social factors that influence physical activity levels in community-dwelling stroke survivors: A systematic review of qualitative literature

OBJECTIVES

To determine the personal and social factors perceived to influence physical activity levels in stroke survivors.

DATA SOURCES

Four electronic databases (MEDLINE, CINAHL, PubMed and Embase) were searched from inception to November 2020, including reference and citation list searches.

STUDY SELECTION

The initial search yielded 1499 papers, with 14 included in the review. Included articles were peer-reviewed, qualitative studies, reporting on the perceived factors influencing physical activity levels of independently mobile community-dwelling adults, greater than 3 months post stroke.

DATA EXTRACTION

Data extracted included location, study aim, design, participant and recruitment information and how data were collected and analysed.

DATA SYNTHESIS

Thematic analysis was undertaken to identify meanings and patterns, generate codes and develop themes. Five main themes were identified: (i) Social networks are important influencers of physical activity; (ii) Participation in meaningful activities rather than 'exercise' is important; (iii) Self-efficacy promotes physical activity and physical activity enhances self-efficacy; (iv) Pre-stroke identity related to physical activity influences post-stroke physical activity; and (v) Formal programmes are important for those with low self-efficacy or a sedentary pre-stroke identity.

CONCLUSIONS

Physical activity levels in stroke survivors are influenced by social activities and support, pre-stroke identity, self-efficacy levels and completion of activities that are meaningful to stroke survivors.

Intense Arm Rehabilitation Therapy Improves the Modified Rankin Scale Score: Association Between Gains in Impairment and Function

OBJECTIVE

To evaluate the effect of intensive rehabilitation on the modified Rankin Scale (mRS), a measure of activities limitation commonly used in acute stroke studies, and to define the specific changes in body structure/function (motor impairment) most related to mRS gains.

METHODS

Patients were enrolled >90 days poststroke. Each was evaluated before and 30 days after a 6-week course of daily rehabilitation targeting the arm. Activity gains, measured using the mRS, were examined and compared to body structure/function gains, measured using the Fugl-Meyer (FM) motor scale. Additional analyses examined whether activity gains were more strongly related to specific body structure/function gains.

RESULTS

At baseline (160 ± 48 days poststroke), patients (n = 77) had median mRS score of 3 (interquartile range, 2-3), decreasing to 2 [2-3] 30 days posttherapy (p < 0.0001). Similarly, the proportion of patients with mRS score ≤2 increased from 46.8% at baseline to 66.2% at 30 days posttherapy (p = 0.015). These findings were accounted for by the mRS score decreasing in 24 (31.2%) patients. Patients with a treatment-related mRS score improvement, compared to those without, had similar overall motor gains (change in total FM score, p = 0.63). In exploratory analysis, improvement in several specific motor impairments, such as finger flexion and wrist circumduction, was significantly associated with higher likelihood of mRS decrease.

CONCLUSIONS

Intensive arm motor therapy is associated with improved mRS in a substantial fraction (31.2%) of patients. Exploratory analysis suggests specific motor impairments that might underlie this finding and may be optimal targets for rehabilitation therapies that aim to reduce activities limitations.

CLINICAL TRIAL

Clinicaltrials.gov identifier: NCT02360488.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that for patients >90 days poststroke with persistent arm motor deficits, intensive arm motor therapy improved mRS in a substantial fraction (31.2%) of patients.

Pilot study on comparisons between the effectiveness of mobile video-guided and paper-based home exercise programs on improving exercise adherence, self-efficacy for exercise and functional outcomes of patients with stroke with 3-month follow-up: A single-blind randomized controlled trial

OBJECTIVE

To compare the effectiveness of mobile video-guided home exercise program and standard paper-based home exercise program.

METHODS

Eligible participants were randomly assigned to either experimental group with mobile video-guided home exercise program or control group with home exercise program in a standard pamphlet for three months. The primary outcome was exercise adherence. The secondary outcomes were self-efficacy for exercise by Self-Efficacy for Exercise (SEE) Scale; and functional outcomes including mobility level by Modified Functional Ambulatory Category (MFAC) and basic activities of daily living (ADL) by Modified Barthel Index (MBI). All outcomes were captured by phone interviews at 1 day, 1 month and 3 months after the participants were discharged from the hospitals.

RESULTS

A total of 56 participants were allocated to the experimental group ( n = 27 ) and control group ( n = 29 ) . There were a significant between-group differences in 3-months exercise adherence (experimental group: 75.6%; control group: 55.2%); significant between-group differences in 1-month SEE (experimental group: 58.4; control group: 43.3) and 3-month SEE (experimental group: 62.2; control group: 45.6). For functional outcomes, there were significant between-group differences in 3-month MFAC gain (experimental group: 1.7; control group: 1.0). There were no between-group differences in MBI gain.

CONCLUSION

The use of mobile video-guided home exercise program was superior to standard paper-based home exercise program in exercise adherence, SEE and mobility gain but not basic ADL gain for patients recovering from stroke.

Dynamic Alterations of Brain Injury, Functional Recovery, and Metabolites Profile after Cerebral Ischemia/Reperfusion in Rats Contributes to Potential Biomarkers

Cerebral ischemia-reperfusion (I/R) is characterized by initial transient cerebral ischemia followed by reperfusion. Various pathophysiological processes are involved in brain injury and functional recovery during cerebral I/R. There are few studies on dynamic metabolic process after cerebral I/R. The present study was to observe dynamic alteration of brain injury, functional recovery, and metabolites after cerebral I/R in rats and discover potential metabolic markers. The cerebral I/R model was established by middle cerebral artery occlusion (MCAO) for 90 min, following reperfusion in rats. The results of cerebral infarction area, cerebral edema, and behavior test showed that there were dynamic changes in brain injury and functional recovery at different periods after cerebral I/R. Further analysis showed that the brain injury was severe on the first day of cerebral I/R, and there was a significant functional recovery from the 7th day of cerebral I/R, followed by an aggravation trend of brain injury from the days 7 to 28. Furthermore, Matrix-assisted laser desorption ionization mass spectrometry imaging analysis showed that the expression of ATP, glucose, and citric acid on 7th day was the highest during cerebral I/R, which indicated that energy metabolism and oxidative phosphorylation played important roles during cerebral I/R. In addition, the untargeted metabolomic results showed that the level of isocitric acid, the ratio of oxyglutaric acid/glutamic acid, and the level of pyruvic acid associated with the TCA cycle were also the highest on the 7th day during cerebral I/R, which indicated that the transient spontaneous recovery of ischemic brain on the 7th day after ischemia-reperfusion might be related to oxidative phosphorylation and energy metabolism in the brain in this period. In conclusion, the results suggest that some small molecule metabolites participate in the brain injury and functional recovery during cerebral I/R, which is of great significance to the development of therapeutic drugs and diagnostic markers.

The Association Between an Antecedent of Transient Ischemic Attack Prior to Onset of Stroke and Functional Ambulatory Outcome

BACKGROUND

Specific clinical risk factors linked to transient ischemic attack (TIA) could affect functional ambulatory outcome following thrombolytic therapy in patients having ischemic stroke with a prior TIA (TIA-ischemic stroke). This issue was investigated in this study.

METHODS

We retrospectively analyzed data from 6379 ischemic stroke patients of which 1387 presented with an antecedent TIA prior to onset of stroke. We used logistic regression model to identify demographic and clinical risk factors that are associated with functional ambulatory outcome in patients with TIA-ischemic stroke treated with thrombolytic therapy.

RESULTS

In a population of TIA-ischemic stroke who received recombinant tissue plasminogen activator, patients with a history of stroke (odds ratio [OR] = 3.229, 95% confidence interval [CI] = 1.494-6.98, P = .003) were associated with increasing odds of improvement in functional ambulation, while the female gender (OR = 0.462, 95% CI = 0.223-0.956, P = .037) was associated with reducing odds of improvement. In the non-TIA group, dyslipidemia (OR = 1.351, 95% CI = 1.026-1.781, P = .032) and blood glucose (OR = 1.003, 95% CI = 1.0-1.005, P = .041) were associated with the increasing odds of improvement while older patients (OR = 0.989, 95% CI = 0.98-0.999, P = .029) with heart failure (OR = 0.513, 95% CI = 0.326-0.808, P = .004) and higher lipid level (OR = 0.834, 95% CI = 0.728-0.955, P = .009) were associated with reducing odds of improvement in ambulation.

CONCLUSION

In a population of TIA-ischemic stroke with thrombolytic therapy and a clearly defined TIA without focal ischemic injury, regardless of associated clinical risk factors, a TIA prior to a stroke is not associated with reducing odds of improved ambulatory outcome, except in female patients with TIA-ischemic stroke.