Severe stroke: patient profile and predictors of favorable outcome.

Summary.  Background:  Severe stroke carries high rates of mortality and morbidity. The aims of this study were to determine the characteristics of patients who initially presented with severe ischemic stroke, and to identify acute and subacute predictors of favorable clinical outcome in these patients. Methods:  An observational cohort study, Acute Stroke Registry and Analysis of Lausanne (ASTRAL), was analyzed, and all patients presenting with severe stroke - defined as a National Institute of Health Stroke Scale score of ≥ 20 on admission - were compared with all other patients. In a multivariate analysis, associations with demographic, clinical, pathophysiologic, metabolic and neuroimaging factors were determined. Furthermore, we analyzed predictors of favorable outcome (modified Rankin scale score of ≤ 3 at 3 months) in the subgroup of severe stroke patients. Results:  Of 1915 consecutive patients, 243 (12.7%) presented with severe stroke. This was significantly associated with cardio-embolic stroke mechanism (odds ratio [OR] 1.74, 95% confidence interval [CI] 1.19-2.54), unknown stroke onset (OR 2.35, 95% CI 1.14-4.83), more neuroimaging signs of early ischemia (mostly computed tomography; OR 2.65, 95% CI 1.79-3.92), arterial occlusions on acute imaging (OR 27.01, 95% CI 11.5-62.9), fewer chronic radiologic infarcts (OR 0.43, 95% CI 0.26-0.72), lower hemoglobin concentration (OR 0.97, 95% CI 0.96-0.99), and higher white cell count (OR 1.05, 95% CI 1.00-1.11). In the 68 (28%) patients with favorable outcomes despite presenting with severe stroke, this was predicted by lower age (OR 0.94, 95% CI 0.92-0.97), preceding cerebrovascular events (OR 3.00, 95% CI 1.01-8.97), hypolipemic pretreatment (OR 3.82, 95% CI 1.34-10.90), lower acute temperature (OR 0.43, 95% CI 0.23-0.78), lower subacute glucose concentration (OR 0.74, 95% CI 0.56-0.97), and spontaneous or treatment-induced recanalization (OR 4.51, 95% CI 1.96-10.41). Conclusions:  Severe stroke presentation is predicted by multiple clinical, radiologic and metabolic variables, several of which are modifiable. Predictors in the 28% of patients with favorable outcome despite presenting with severe stroke include hypolipemic pretreatment, lower acute temperature, lower glucose levels at 24 h, and arterial recanalization.

Frequency of MELAS main mutation in a phenotype-targeted young ischemic stroke patient population

Mitochondrial diseases, predominantly mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS), may occasionally underlie or coincide with ischemic stroke (IS) in young and middle-aged individuals. We searched for undiagnosed patients with MELAS in a target subpopulation of unselected young IS patients enrolled in the Stroke in Young Fabry Patients study (sifap1). Among the 3291 IS patients aged 18-55 years recruited to the sifap1 study at 47 centers across 14 European countries, we identified potential MELAS patients with the following phenotypic features: (a) diagnosed cardiomyopathy or (b) presence of two of the three following findings: migraine, short stature (≤165 cm for males; ≤155 cm for females), and diabetes. Identified patients' blood samples underwent analysis of the common MELAS mutation, m.3243A>G in the MTTL1 gene of mitochondrial DNA. Clinical and cerebral MRI features of the mutation carriers were reviewed. We analyzed blood samples of 238 patients (177 with cardiomyopathy) leading to identification of four previously unrecognized MELAS main mutation carrier-patients. Their clinical and MRI characteristics were within the expectation for common IS patients except for severe hearing loss in one patient and hyperintensity of the pulvinar thalami on T1-weighted MRI in another one. Genetic testing for the m.3243A>G MELAS mutation in young patients with IS based on phenotypes suggestive of mitochondrial disease identifies previously unrecognized carriers of MELAS main mutation, but does not prove MELAS as the putative cause.

Prognostic value of cortically induced motor evoked activity by TMS in chronic stroke: caveats from a very revealing single clinical case

Background: We report the case of a chronic stroke patient (62 months after injury) showing total absence of motor activity evoked by transcranial magnetic stimulation (TMS) of spared regions of the left motor cortex, but near-to-complete recovery of motor abilities in the affected hand. Case presentation: Multimodal investigations included detailed TMS based motor mapping, motor evoked potentials (MEP), and Cortical Silent period (CSP) as well as functional magnetic resonance imaging (fMRI) of motor activity, MRI based lesion analysis and Diffusion Tensor Imaging (DTI) Tractography of corticospinal tract (CST). Anatomical analysis revealed a left hemisphere subinsular lesion interrupting the descending left CST at the level of the internal capsule. The absence of MEPs after intense TMS pulses to the ipsilesional M1, and the reversible suppression of ongoing electromyographic (EMG) activity (indexed by CSP) demonstrate a weak modulation of subcortical systems by the ipsilesional left frontal cortex, but an inability to induce efficient descending volleys from those cortical locations to right hand and forearm muscles. Functional MRI recordings under grasping and finger tapping patterns involving the affected hand showed slight signs of subcortical recruitment, as compared to the unaffected hand and hemisphere, as well as the expected cortical activations. Conclusions: The potential sources of motor voluntary activity for the affected hand in absence of MEPs are discussed. We conclude that multimodal analysis may contribute to a more accurate prognosis of stroke patients.

GABA(A) alpha-1 subunit mediated desynchronization of elevated low frequency oscillations alleviates specific dysfunction in stroke:a case report

The paradoxical effects of the hypnotic imidazopyridine zolpidem, widely reported in persistent vegetative state, have been replicated recently in brain-injured and cognitively impaired patients. However, the neuronal mechanisms underlying these benefits are yet to be demonstrated. We implemented contemporary neuroimaging methods to investigate sensorimotor and cognitive improvements, observed in stroke patient JP following zolpidem administration.

The role of miRNAs in stroke

Stroke is currently one of the leading causes of death and disability worldwide. Despite recent advances in the treatment of stroke there is a major unmet clinical need for novel therapeutics for intervention. miRNAs are small coding RNAs which act to post-transcriptionally inhibit expression of genes. Emerging evidence has supported the view that miRNAs play an important role in the development and progression of ischaemic stroke, although understanding remains relatively poor. This research uses several models to investigate the effects of miRNAs in the context of stroke in vivo and in vitro, as well as assessment of patient serum samples in order to identify biomarkers for stroke. miR-29b was found to be significantly upregulated in SHRSP rat brain peri-infarct at 72h following stroke, and downregulated in ischaemic core at 24h and 72h following stroke, whilst miR-29c was significantly downregulated in remainder tissue at 24h following stroke and in infarct at 72h following stroke. The upreglation of miR-29b at 72h corresponded to a significant downregulation of miR-29 target genes MMP2, MMP9 and TGF-β1 in peri-infarct tissue at 72h following stroke. Modulation of miR-29b and miR-29c was achieved in a rat neuronal cell line but suppression of genes of interest was not observed following oxygen glucose deprivation. Several candidate miRNAs were then identified by microRNA Openarray analysis in stroke patient serum samples. Validation of these miRNAs was not demonstrated in the population studied, but assessment of these miRNAs in rat serum and isolated exosomes demonstrated that several of these miRNAs were significantly altered in SHRSP rats following stroke. Finally miR-21 was demonstrated to be significantly upregulated in SHRSP rat peri-infarct following stroke. This was associated with a change in miR-21 localization as determined by in situ hybridization. Modulation of miR-21 via the use of CAG-miR-21 mice demonstrated no difference in infarct size as measured by T2 -weighted MRI scan nor was any difference present in behavioural tests versus wild type. KO of miR-21 resulted in a reduction of survival rate compared with wild type. This thesis demonstrates that miR-29 and miR-21 are modulated following stroke in animal models, and these are potential candidates for therapeutic intervention in the future. Analysis of clinical samples has illustrated difficulties in the identification of serum miRNA profiles and suggests that looking at the exosomal component of serum may provide better information regarding miRNA profiles after stroke.

Reabilitação no internamento hospitalar: prospectiva na dinâmica de actores - Implementação da governação clínica num hospital E.P.E.

Mestrado em Intervenção Sócio-Organizacional na Saúde - Área de especialização: Políticas de Administração e Gestão de Serviços de Saúde.

Necessidades em cuidados paliativos do doente pós-AVC

Relatório de Prática Clínica apresentado à Escola Superior de Saúde Dr. Lopes Dias do Instituto Politécnico de Castelo Branco para cumprimento dos requisitos necessários à obtenção do grau de Mestre em Cuidados Paliativos, realizada sob a orientação científica do Professora Doutora Ana Paula Gonçalves Antunes Sapeta, do Instituto Politécnico de Castelo Branco.

Health at a glance: Europe 2012.

This second edition of Health at a Glance: Europe presents a set of key indicators of health and health systems in 35 European countries, including the 27 European Union member states, 5 candidate countries and 3 EFTA countries. The selection of indicators is based largely on the European Community Health Indicators (ECHI) shortlist, a list of indicators that has been developed by the European Commission to guide the development and reporting of health statistics. It is complemented by additional indicators on health expenditure and quality of care, building on the OECD expertise in these areas. Contents: Introduction 12 Chapter 1. Health status 15 1.1. Life expectancy and healthy life expectancy at birth 1.2. Life expectancy and healthy life expectancy at age 65 1.3. Mortality from all causes 1.4. Mortality from heart disease and stroke 1.5. Mortality from cancer 1.6. Mortality from transport accidents 1.7. Suicide 1.8. Infant mortality 1.9. Infant health: Low birth weight 1.10. Self-reported health and disability 1.11. Incidence of selected communicable diseases 1.12. HIV/AIDS 1.13. Cancer incidence 1.14. Diabetes prevalence and incidence 1.15. Dementia prevalence 1.16. Asthma and COPD prevalence Chapter 2. Determinants of health 49 2.1. Smoking and alcohol consumption among children 2.2. Overweight and obesity among children 2.3. Fruit and vegetable consumption among children 2.4. Physical activity among children 2.5. Smoking among adults 2.6. Alcohol consumption among adults 2.7. Overweight and obesity among adults 2.8. Fruit and vegetable consumption among adults Chapter 3. Health care resources and activities 67 3.1. Medical doctors 3.2. Consultations with doctors 3.3. Nurses 3.4. Medical technologies: CT scanners and MRI units 3.5. Hospital beds 3.6. Hospital discharges 3.7. Average length of stay in hospitals 3.8. Cardiac procedures (coronary angioplasty) 3.9. Cataract surgeries 3.10. Hip and knee replacement 3.11. Pharmaceutical consumption 3.12. Unmet health care needs Chapter 4. Quality of care 93 Care for chronic conditions 4.1. Avoidable admissions: Respiratory diseases 4.2. Avoidable admissions: Uncontrolled diabetes Acute care 4.3. In-hospital mortality following acute myocardial infarction 4.4. In-hospital mortality following stroke Patient safety 4.5. Procedural or postoperative complications 4.6. Obstetric trauma Cancer care 4.7. Screening, survival and mortality for cervical cancer 4.8. Screening, survival and mortality for breast cancer 4.9. Screening, survival and mortality for colorectal cancer Care for communicable diseases 4.10. Childhood vaccination programmes 4.11. Influenza vaccination for older people Chapter 5. Health expenditure and financing 117 5.1. Coverage for health care 5.2. Health expenditure per capita 5.3. Health expenditure in relation to GDP 5.4. Health expenditure by function. 5.5. Pharmaceutical expenditure 5.6. Financing of health care 5.7. Trade in health services Bibliography 133 Annex A. Additional information on demographic and economic context 143 Most European countries have reduced tobacco consumption via public awareness campaigns, advertising bans and increased taxation. The percentage of adults who smoke daily is below 15% in Sweden and Iceland, from over 30% in 1980. At the other end of the scale, over 30% of adults in Greece smoke daily. Smoking rates continue to be high in Bulgaria, Ireland and Latvia (Figure 2.5.1). Alcohol consumption has also fallen in many European countries. Curbs on advertising, sales restrictions and taxation have all proven to be effective measures. Traditional wine-producing countries, such as France, Italy and Spain, have seen consumption per capita fall substantially since 1980. Alcohol consumption per adult rose significantly in a number of countries, including Cyprus, Finland and Ireland (Figure 2.6.1).This resource was contributed by The National Documentation Centre on Drug Use.

Causas de no trombolisis en ataque cerebrovascular

Introducción. El ataque cerebrovascular (ACV) ocupa el primer lugar en frecuencia entre todas las enfermedades neurológicas de la vida adulta, y el tercer lugar como causa más frecuente de muerte. Se aprobó para el manejo agudo, la terapia con activador del plasminógeno tisular recombinante (t-PA) en las primeras 4,5 horas después del inicio de los síntomas, demostrando mayor sobrevida y menos niveles de discapacidad. Sin embargo solo el 5-10% de pacientes reciben este manejo. Por estas razones es necesario conocer que factores se asocian con la no intervención terapéutica. Objetivo. Describir los factores asociados con la no trombolisis en pacientes con ataque cerebrovascular en un hospital de IV nivel en Bogotá, Colombia. Métodos. Estudio analítico de corte transversal, en un centro de cuarto nivel en Bogotá entre enero de 2009 y enero de 2011. Resultados. Se encontraron 178 pacientes en un promedio de edad de 65,9 años (DE± 10 años) con una relación hombre-mujer 1:1, la principal causa de no trombolisis fue la ventana mayor a 4.5 horas, 33,7% (n=60), 26,4% por cambios en imágenes diagnosticas, y 14% por puntajes leves o severos en las escala National Institute of Health Stroke Scale (NIHSS), historia quirúrgica 7.3% y laboratorios 4.5%. El tiempo promedio de atención fue 23 minutos (DE ± 21 min) para la activación del código de ACV, 39 minutos para valoración por neurología (DE ± 25 min), 46 minutos (DE ± 19,1 min) para toma de paraclínicos, 66 minutos para toma de imágenes y 97 minutos para trombolisis (DE ± 21min, DE ± 17 min, respectivamente). Se realizó trombolisis en 17 pacientes, 9,6%. No se encontró asociación significativa entre cultura de organización con trombolisis ni de tiempos de atención con trombolisis. Conclusiones. La principal razón de no trombolisis, fue la ventana mayor a 4.5 horas, no se encontró relación entre cultura de organización institucional con trombolisis. El tiempo promedio de trombolisis fue de 90 minutos. Deben instaurarse medidas para reducir el tiempo de llegada al hospital, y los tiempos de atención en urgencias. Deben realizarse nuevas evaluaciones del código ACV posterior a las estrategias de mejoría.

Efectividad del tratamiento con neurofeedback en trastornos del estado del ánimo, ansiedad y fibromialgia: una revisión de literatura

El neurofeedback es una técnica no invasiva en la que se pretende corregir, mediante condicionamiento operante, ondas cerebrales que se encuentren alteradas en el electroencefalograma. Desde 1967, se han conducido numerosas investigaciones relacionadas con los efectos de la técnica en el tratamiento de alteraciones psicológicas. Sin embargo, a la fecha no existen revisiones sistemáticas que reúnan los temas que serán aquí tratados. El aporte de este trabajo es la revisión de 56 artículos, publicados entre los años 1995 y 2013 y la evaluación metodológica de 29 estudios incluidos en la revisión. La búsqueda fue acotada a la efectividad del neurofeedback en el tratamiento de depresión, ansiedad, trastorno obsesivo compulsivo (TOC), ira y fibromialgia. Los hallazgos demuestran que el neurofeedback ha tenido resultados positivos en el tratamiento de estos trastornos, sin embargo, es una técnica que aún está en desarrollo, con unas bases teóricas no muy bien establecidas y cuyos resultados necesitan de diseños metodológicamente más sólidos que ratifiquen su validez.

A Gentle/S approach to robot assisted neuro-rehabilitation

Movement disorders (MD) include a group of neurological disorders that involve neuromotor systems. MD can result in several abnormalities ranging from an inability to move, to severe constant and excessive movements. Strokes are a leading cause of disability affecting largely the older people worldwide. Traditional treatments rely on the use of physiotherapy that is partially based on theories and also heavily reliant on the therapists training and past experience. The lack of evidence to prove that one treatment is more effective than any other makes the rehabilitation of stroke patients a difficult task. UL motor re-learning and recovery levels tend to improve with intensive physiotherapy delivery. The need for conclusive evidence supporting one method over the other and the need to stimulate the stroke patient clearly suggest that traditional methods lack high motivational content, as well as objective standardised analytical methods for evaluating a patient's performance and assessment of therapy effectiveness. Despite all the advances in machine mediated therapies, there is still a need to improve therapy tools. This chapter describes a new approach to robot assisted neuro-rehabilitation for upper limb rehabilitation. Gentle/S introduces a new approach on the integration of appropriate haptic technologies to high quality virtual environments, so as to deliver challenging and meaningful therapies to people with upper limb impairment in consequence of a stroke. The described approach can enhance traditional therapy tools, provide therapy "on demand" and can present accurate objective measurements of a patient's progression. Our recent studies suggest the use of tele-presence and VR-based systems can potentially motivate patients to exercise for longer periods of time. Two identical prototypes have undergone extended clinical trials in the UK and Ireland with a cohort of 30 stroke subjects. From the lessons learnt with the Gentle/S approach, it is clear also that high quality therapy devices of this nature have a role in future delivery of stroke rehabilitation, and machine mediated therapies should be available to patient and his/her clinical team from initial hospital admission, through to long term placement in the patient's home following hospital discharge.

Anhörigvårdare till strokedrabbade personer

Syftet med studien var att beskriva hur anhöriga upplevde att deras dagliga liv påverkades av att vara anhörigvårdare till en strokedrabbad person och vilken effekt riktade sjuksköterskeinterventioner hade för anhörigvårdarna. Studien genomfördes som en litteraturstudie. Databaser som användes var PubMed, Cinahl och Scopus. Resultatet visade att många anhörigvårdare upplevde oro och stress i olika situationer och detta skapade begränsningar i deras dagliga liv. Anhörigvårdarnas psykiska och fysiska hälsa påverkades av att vårda sin anhörig. Relationen mellan anhörigvårdaren och den strokedrabbade upplevdes förändrad efter stroke både till det positiva och det negativa. Anhörigvårdare som fick ett stöd- och utbildningsprogram från sjuksköterskan fick en ökad livskvalité och bättre kunskap kring stroke. Även då praktisk träning kombinerades med stöd- och utbildningsprogram ökade livskvalitén. De anhörigvårdare som fick ett anpassat utskrivningsprogram och sedan fick uppföljning kunde bättre prioritera de dagliga aktiviteterna men deras livskvalité blev inte bättre. Slutsats: Anhörigas dagliga liv påverkades av att vara anhörigvårdare till en strokedrabbad person till både det positiva och negativa. När sjuksköterskeinterventioner gavs ökade anhörigvårdarnas livskvalité, välbefinnande och de gav vård av bättre kvalitet. 

Seleção de categorias da Classificação Internacional de Funcionalidade, Incapacidade e Saúde para avaliação do paciente com acidente vascular cerebral em reabilitação

Stroke represents the first cause of disabilities among adults. Although different professions work together in treatment of stroke patients, all they use different terminologies for the description of the patients problems and it can constitute an impediment in the communication between the staff members. Thus, the multidisciplinary and interdisciplinary work would be facilitated if using a reference common tool, as the new International Classification of Functioning, Disability and Health (ICF). However, the ICF is very extensive and complex and due to its complexity, it has been evidenced the necessity to select its categories to become it more practical. The aim of the study was to investigate which categories of the ICF are more suitable to evaluate and to describe the stroke patient in the view of teachers and municipal public health professionals. It was a descriptive research, which involved 5 professors and 11 professionals of Physiotherapy that have worked at the health public area in Natal / RN. It was used the Delphi Technique in 3 rounds and the Likert Scale to select the categories among the ICF components. As result, from the 362 IFC categories, 94 were selected. The selected categories correspond to rehabilitative characteristics of Stroke patients in the universe of the Physiotherapy performance. The methodology applied was suitable to the studied object emphasizing the necessity of future studies for validation of the chosen categories

Preserved speech abilities and compensation following prefrontal damage.

Lesions to left frontal cortex in humans produce speech production impairments (nonfluent aphasia). These impairments vary from subject to subject and performance on certain speech production tasks can be relatively preserved in some patients. A possible explanation for preservation of function under these circumstances is that areas outside left prefrontal cortex are used to compensate for the injured brain area. We report here a direct demonstration of preserved language function in a stroke patient (LF1) apparently due to the activation of a compensatory brain pathway. We used functional brain imaging with positron emission tomography (PET) as a basis for this study.