Symptomatic intracranial haemorrhage after intra-arterial thrombolysis in acute ischaemic stroke: assessment of 294 patients treated with urokinase

BACKGROUND: The PROACT II trial showed that intra-arterial thrombolysis (IAT) is effective for treatment of acute ischaemic stroke attributable to M1 and M2 segment occlusions. Incidence of symptomatic intracranial haemorrhage (sICH) was 10%. OBJECTIVE: To evaluate the risk and predictors of sICH after IAT by using urokinase in a large number of patients presenting with the whole spectrum of cerebral vessel occlusions. METHODS: 294 patients with stroke treated with intra-arterial urokinase were retrospectively analysed. The risk of sICH as well as bleeding characteristics were assessed. Demographic and radiological data, time to treatment, urokinase dose, recanalisation rates, stroke aetiology and severity were analysed for predictors. RESULTS: sICH occurred in 14 of 294 (4.8%) patients. The median National Institute of Health Stroke Scale score of all patients was 15. All but one sICH were located in the infarcted brain tissue, and no sICH occurred in patients with peripheral vessel occlusions (M3 or M4 segments of the middle cerebral artery). Poor collaterals (p = 0.001), early signs of ischaemia on computed tomography (p = 0.003), higher urokinase dose (p = 0.019), lower recanalisation rate (p = 0.02) and higher diastolic blood pressure on admission (p = 0.04) were found to be correlated with sICH on univariate analysis. On multivariate analysis, poor collaterals (p = 0.004), urokinase dose (p = 0.021) and early signs on computed tomography (p = 0.026) remained predictors of sICH. CONCLUSIONS: With regard to the whole spectrum of cerebral vessel occlusions, an incidence of <5% sICH after IAT is distinctly low. This result underlines the important role of IAT in the treatment of acute stroke.

Effects of care pathways on stroke care practices at regional hospitals

Background: Our previous work identified deficiencies in stroke care practices at regional hospitals in comparison to standards suggested by published stroke care guidelines. These deficiencies might be improved by the implementation of clinical pathways. The aim of this study was to assess changes in acute stroke care practices following the implementation of stroke care pathways at four regional Queensland hospitals. Methods: The medical records of two cohorts of 120 patients with a discharge diagnosis of stroke or transient ischaemic attack were retrospectively audited before and after implementation of stroke care pathways to identify differences in the use of acute interventions, investigations and secondary prevention strategies. Results: Following pathway implementation there were clinically important, but not statistically significant, increases in the rates of swallow assessment, allied health assessment (significant for occupational therapy, P = 0.04) and use of deep vein thrombosis prevention strategies (also significant, P = 0.006). Fewer patients were discharged on no anti-thrombotic therapy (statistically significant in the subgroup of patients with atrial fibrillation, P = 0.02). Only 37% of the patients audited were actually enrolled on the pathway. Among this subgroup there were significant increases in the rates of swallow assessment (first 24 h, P = 0.01; any time during admission, P = 0.0001), allied health assessments (all P < 0.05), estimation of blood glucose level (P = 0.0015) and the use of deep vein thrombosis prevention strategies (P = 0.0003). Conclusion: Stroke care pathways appear to improve the process of care. Whether this influences outcomes such as mortality, functional and neurological recovery, the incidence of complications, length of stay or the cost of care was beyond the scope of this study and will require further examination.

Factores preditores do estado de saúde em indivíduos vítimas de AVC

Apesar dos inúmeros avanços ao nível da prevenção e intervenção perante o acidente vascular cerebral, este continua a ser a condição mais prevalente e com grande impacto na sociedade, com alterações significativas no estado de saúde destes indivíduos. Estudar os factores preditores da variabilidade no estado de saúde poderá contribuir para a melhoria da qualidade dos cuidados. Objectivos (i) Analisar o constructo explicativo de factores pessoais, factores relacionados com o AVC e com tratamento realizado (fisioterapia), bem como nível de deficiência, grau de incapacidade e percepção sobre grau de recuperação no estado de saúde dos indivíduos. Material e métodos Efectuou-se um estudo de nível II, tipo descritivo – correlacional, de corte transversal, levado a efeito em 378 indivíduos com diagnóstico de AVC que se encontravam a efectuar tratamento de fisioterapia. A recolha de dados foi efectuada através de um questionário estruturado e elaborado que enquadra as variáveis sócio-demográficas, clínicas e de tratamento, e das medidas: Chedoke-McMaster Stroke Assessment (CMSA) e Questionário de Avaliação do Impacto do Acidente Vascular Cerebral (SIS). Para a identificação dos factores explicativos da variabilidade de resultado (dimensões do estado de saúde) recorreu-se à Regressão Linear Múltipla (RLM) com a aplicação do método de análise stepwise. Resultados (i) os indivíduos encontram-se afectados em múltiplas dimensões do estado de saúde, com piores pontuações ao nível da funcionalidade da mão, força, participação social, actividades de vida diária e mobilidade; (ii) surgem como factores explicativos o sexo, a idade e os anos de escolaridade, sendo que, de entre os factores relacionados com o tratamento de fisioterapia, apenas o número de sessões realizadas aduz valor preditivo na variabilidade para a dimensão comunicação do estado de saúde; (iii) a localização da lesão e as complicações no internamento aduzem capacidade preditora na variação do estado de saúde, em praticamente todos os domínios; (iv) são relevantes em termos preditivos a deficiência e a incapacidade, sendo que quanto maior o seu grau, menor será o perfil de estado de saúde; (v) o valor preditivo observado é sempre mais elevado quando se olha para os domínios físicos do estado de saúde (força, AVD, mobilidade e funcionalidade da mão – R2adj entre 0,516 e 0,742, p<0,001) do que para os restantes domínios. Nestes últimos, releva sobretudo o maior valor explicativo registado para o domínio participação social (R2adj de 0,410) e o menor para o domino emoção (R2adj de 0,124). Conclusão Pelos valores preditivos encontrados para a deficiência e incapacidade, importa no tratamento do doente pós AVC olhar para as limitações de actividade e restrições de participação encontrados (CIF) já que com as alterações neste domínio se conseguem alterações significativas do estado de saúde.

Diminution de la performance motrice du membre ipsilatéral au site de l’accident vasculaire cérébral lors de tâches bilatérales

Suite à un accident vasculaire cérébral (AVC), des déficits au membre controlatéral et ipsilatéral à la lésion cérébrale sont observés chez les personnes avec un AVC. La performance du membre ipsilatéral est déterminée par l’importance de la sévérité clinique du membre controlatéral ainsi que par l’adéquation du traitement bihémisphérique des informations sensori-motrices. L’objectif de la présente étude est de comparer la performance motrice de la main ipsilatérale lors de diverses tâches nécessitant un niveau plus ou moins complexe de traitement de l’information chez une clientèle hémiplégique ayant une faible sévérité clinique. Les résultats démontrent que les forces de pinces entre le pouce et l’index du membre ipsilatéral sont modulées et anticipées adéquatement chez les personnes avec un AVC ayant une faible sévérité clinique tel que démontré par des scores de cinq ou plus au Chedoke-McMaster Stroke Assessment (modules bras et main). La performance motrice du membre ipsilatéral lors de l’exécution d’une tâche de coordination bilatérale est comparable à celle du membre dominant des sujets sains lorsque la tâche est réalisée sans interaction entre les membres supérieurs (deux objets) et elle est perturbée lorsqu’elle implique une action coordonnée et réciproque des membres supérieurs sur un même objet. Ces personnes, ayant une bonne récupération motrice, ont donc une problématique centrale d’intégration et de traitement de l’information sensori-motrice lorsqu’il y a une complexification de la tâche à réaliser. Ces résultats suggèrent donc que les cliniciens devraient porter une attention plus particulière aux activités unilatérales et de coordination bilatérales lors le l’exécution de tâches complexes nécessitant un niveau d’intégration sensori-motrice élevé.

Depression and its assessment among stroke patients and their caregivers

Approximately one-third of stroke patients experience depression. Stroke also has a profound effect on the lives of caregivers of stroke survivors. However, depression in this latter population has received little attention. In this study the objectives were to determine which factors are associated with and can be used to predict depression at different points in time after stroke; to compare different depression assessment methods among stroke patients; and to determine the prevalence, course and associated factors of depression among the caregivers of stroke patients. A total of 100 consecutive hospital-admitted patients no older than 70 years of age were followed for 18 months after having their first ischaemic stroke. Depression was assessed according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R), Beck Depression Inventory (BDI), Hamilton Rating Scale (HRSD), Visual Analogue Mood Scale (VAMS), Clinical Global Impression (CGI) and caregiver ratings. Neurological assessments and a comprehensive neuropsychological test battery were performed. Depression in caregivers was assessed by BDI. Depressive symptoms had early onsets in most cases. Mild depressive symptoms were often persistent with little change during the 18-month follow-up, although there was an increase in major depression over the same time interval. Stroke severity was associated with depression especially from 6 to 12 months post-stroke. At the acute phase, older patients were at higher risk of depression, and a higher proportion of men were depressed at 18 months post-stroke. Of the various depression assessment methods, none stood clearly apart from the others. The feasibility of each did not differ greatly, but prevalence rates differed widely according to the different criteria. When compared against DSM-III-R criteria, sensitivity and specificity were acceptable for the CGI, BDI, and HRSD. The CGI and BDI had better sensitivity than the more specific HRSD. The VAMS seemed not to be a reliable method for assessing depression among stroke patients. The caregivers often rated patients depression as more severe than did the patients themselves. Moreover, their ratings seemed to be influenced by their own depression. Of the caregivers, 30-33% were depressed. At the acute phase, caregiver depression was associated with the severity of the stroke and the older age of the patient. The best predictor of caregiver depression at later follow-up was caregiver depression at the acute phase. The results suggest that depression should be assessed during the early post-stroke period and that the follow-up of those at risk of poor emotional outcome should be extended beyond the first year post-stroke. Further, the assessment of well-being of the caregivers of stroke patients should be included as a part of a rehabilitation plan for stroke patients.

Brief neuropsychological assessment of adults post-stroke in the left hemisphere

The neuropsychological assessment investigates cognitive deficits to improve the diagnosis, the prognosis and the rehabilitation of patients. In Brazil, stroke is a major cause of hospitalization and the leading cause of mortality and disability. The stroke in the left hemisphere (LH) is associated with different degrees of loss of language and other cognitive impairments, for example, in the memory. We compared the performance in brief neuropsychological tasks of the left hemisphere poststroke patients, without moderate or severe aphasia, with healthy controls. A list of 135 patients was selected based on inclusion criteria. The study included 15 patients with left stroke, paired by sex, age and education to 30 neurologically healthy adults. The data resulting from application of the Neupsilin Brief Neuropsychological Assessment Instrument were analyzed with the nonparametric Mann-Whitney U. Adults with LH stroke showed a significant reduction in performance when compared to healthy controls on language, working memory and ideomotor praxis, results also found in other studies of patients with left hemisphere stroke

Assessment of beginners' front-crawl stroke efficiency

Efficiency in front-crawl stroke has been inferred primarily by means of the analysis of arm actions, specifically, stroke frequency and stroke length. The objective of the present study was to investigate whether swimming efficiency could be better assessed in children still learning the front-crawl stroke by analyzing the movement pattern as a whole. Forty-two children enrolled in private swimming programs volunteered to participate in the study. The task consisted of swimming 30 m as fast as possible. Three experts analyzed the movement pattern of the participants using a checklist. Both stroke frequency and stroke length were calculated. The correlation coefficients between the time taken to swim and both the stroke frequency and stroke length were not significant, but the total and components of the checklist scores were. Results indicate that the swimming efficiency of children learning the front-crawl stroke can be better assessed by analyzing their whole movement pattern.

Assessment of post-stroke fatigue: the fatigue scale for motor and cognitive functions

Post-stroke fatigue (PSF) is an important but still controversial issue since knowledge on its nature is still humble. The aim of the present study was to characterize PSF beyond the subacute phase.

Longitudinal polysomnographic assessment from acute to subacute phase in infratentorial versus supratentorial stroke

Background: Regulation of sleep and sleep-related breathing resides in different brain structures. Vascular lesions can be expected to differ in their consequences on sleep depending on stroke topography. However, studies addressing the differences in sleep and sleep-related breathing depending on stroke topography are scarce. The aim of the present investigation was to compare the sleep and sleep-related breathing of patients with supratentorial versus infratentorial stroke. Methods: This study was part of the prospective multicenter study SAS-CARE-1 (Sleep-Disordered Breathing in Transient Ischemic Attack (TIA)/Ischemic Stroke and Continuous Positive Airway Pressure (CPAP) Treatment Efficacy (SAS-CARE); NCT01097967). We prospectively included 14 patients (13 male, age 66 ± 6 years) with infratentorial lesions and 14 patients (14 male, age 64 ± 7 years) with supratentorial lesions, matched for age and stroke severity. Polysomnography was recorded in all during the acute phase within 9 days after stroke onset and 3 months later. Results: During the acute phase after stroke, patients with infratentorial lesions had significantly more sleep-related breathing disorders than patients with supratentorial lesions with an apnea-hypopnea index >20 observed in 8 (57%) patients with infratentorial stroke and in only 2 (14%) patients with supratentorial stroke. Sleep-related breathing improved from the acute to the subacute phase (3 months), albeit remaining elevated in a significant proportion of subjects. Sleep parameters did not differ between the two patient groups but there was a general improvement of sleep from the acute to the subacute phase which was comparable for both patient groups. Although stroke severity was mild, recovery after 3 months was worse in patients with infratentorial stroke with 12 of 14 patients with supratentorial stroke being symptom free (NIHSS = 0), while this was the case for only 6 of 14 patients with infratentorial stroke. Conclusions: Patients with infratentorial lesions are at an increased risk for sleep-related breathing disorders, which are frequent in this group. Monitoring of sleep-related breathing is therefore especially recommended in patients with infratentorial stroke. Because of the absence of reliable differences in sleep parameters between the two patient groups, polygraphy, with reduced diagnostic costs, rather than polysomnography could be considered. The higher prevalence of sleep-related breathing disorders and the poorer recovery of patients with infratentorial lesions suggest that early treatment interventions should be considered.

Assessment of carotid calcifications on panoramic radiographs in relation to other used methods and relationship to periodontitis and stroke: a literature review

OBJECTIVES To assess the literature on carotid calcifications defined from panoramic radiographs (PMX) and concurrent diagnosis of stroke and periodontitis. MATERIALS AND METHODS A literature search screening for publications using search terms such as PMX and carotid calcification, stroke and periodontitis was performed in November 2012. RESULTS A total of 189 articles were retrieved, among which 30 were included in the review. The sensitivity for PMX findings of carotid calcifications (CC) compared to a diagnosis by Doppler sonography varied between 31.1-100%. The specificity for PMX findings of carotid calcifications compared to a diagnosis by Doppler sonography varied between 21.4-87.5%. Individuals with CC findings from PMX have more periodontitis and risk for stroke. CONCLUSIONS There is a shortage of well-designed studies in older dentate individuals assessing the associations between periodontitis and radiographic evidence of CC and in relation to stroke or other cardiovascular diseases. STATEMENT OF CLINICAL RELEVANCE: Carotid calcifications are prevalent in patients with periodontitis and such individuals may have an increased risk for stroke. The absence of signs of carotid calcification on panoramic radiographs is indicative of no calcification of carotid arteries.

Robotic Outcome Assessment in a Non-Human Primate Model of Middle Cerebral Artery Stroke

Stroke is a prevalent disorder with immense socioeconomic impact. A variety of chronic neurological deficits result from stroke. In particular, sensorimotor deficits are a significant barrier to achieving post-stroke independence. Unfortunately, the majority of pre-clinical studies that show improved outcomes in animal stroke models have failed in clinical trials. Pre-clinical studies using non-human primate (NHP) stroke models prior to initiating human trials are a potential step to improving translation from animal studies to clinical trials. Robotic assessment tools represent a quantitative, reliable, and reproducible means to assess reaching behaviour following stroke in both humans and NHPs. We investigated the use of robotic technology to assess sensorimotor impairments in NHPs following middle cerebral artery occlusion (MCAO). Two cynomolgus macaques underwent transient MCAO for 90 minutes. Approximately 1.5 years following the procedure these NHPs and two non-stroke control monkeys were trained in a reaching task with both arms in the KINARM exoskeleton. This robot permits elbow and shoulder movements in the horizontal plane. The task required NHPs to make reaching movements from a centrally positioned start target to 1 of 8 peripheral targets uniformly distributed around the first target. We analyzed four movement parameters: reaction time, movement time (MT), initial direction error (IDE), and number of speed maxima to characterize sensorimotor deficiencies. We hypothesized reduced performance in these attributes during a neurobehavioural task with the paretic limb of NHPs following MCAO compared to controls. Reaching movements in the non-affected limbs of control and experimental NHPs showed bell-shaped velocity profiles. In contrast, the reaching movements with the affected limbs were highly variable. We found distinctive patterns in MT, IDE, and number of speed peaks between control and experimental monkeys and between limbs of NHPs with MCAO. NHPs with MCAO demonstrated more speed peaks, longer MTs, and greater IDE in their paretic limb compared to controls. These initial results qualitatively match human stroke subjects’ performance, suggesting that robotic neurobehavioural assessment in NHPs with stroke is feasible and could have translational relevance in subsequent human studies. Further studies will be necessary to replicate and expand on these preliminary findings.

Robotic Outcome Assessment in a Non-Human Primate Model of Middle Cerebral Artery Stroke

Stroke is a prevalent disorder with immense socioeconomic impact. A variety of chronic neurological deficits result from stroke. In particular, sensorimotor deficits are a significant barrier to achieving post-stroke independence. Unfortunately, the majority of pre-clinical studies that show improved outcomes in animal stroke models have failed in clinical trials. Pre-clinical studies using non-human primate (NHP) stroke models prior to initiating human trials are a potential step to improving translation from animal studies to clinical trials. Robotic assessment tools represent a quantitative, reliable, and reproducible means to assess reaching behaviour following stroke in both humans and NHPs. We investigated the use of robotic technology to assess sensorimotor impairments in NHPs following middle cerebral artery occlusion (MCAO). Two cynomolgus macaques underwent transient MCAO for 90 minutes. Approximately 1.5 years following the procedure these NHPs and two non-stroke control monkeys were trained in a reaching task with both arms in the KINARM exoskeleton. This robot permits elbow and shoulder movements in the horizontal plane. The task required NHPs to make reaching movements from a centrally positioned start target to 1 of 8 peripheral targets uniformly distributed around the first target. We analyzed four movement parameters: reaction time, movement time (MT), initial direction error (IDE), and number of speed maxima to characterize sensorimotor deficiencies. We hypothesized reduced performance in these attributes during a neurobehavioural task with the paretic limb of NHPs following MCAO compared to controls. Reaching movements in the non-affected limbs of control and experimental NHPs showed bell-shaped velocity profiles. In contrast, the reaching movements with the affected limbs were highly variable. We found distinctive patterns in MT, IDE, and number of speed peaks between control and experimental monkeys and between limbs of NHPs with MCAO. NHPs with MCAO demonstrated more speed peaks, longer MTs, and greater IDE in their paretic limb compared to controls. These initial results qualitatively match human stroke subjects’ performance, suggesting that robotic neurobehavioural assessment in NHPs with stroke is feasible and could have translational relevance in subsequent human studies. Further studies will be necessary to replicate and expand on these preliminary findings.