Assessment Of Stroke Patients Research Articles

SAFE Medication Management for Patients With Physical Impairments of Stroke, Part Two.

Part one of this series addressed impairments of stroke affecting motor skills. This second article focuses on the sensory impairments of stroke as they affect medication management: vision, hearing, memory and thinking, communication, and emotional disturbances. Each impairment is discussed, and possible interventions are proposed. Every patient is an individual and requires variable care plans. Interventions and strategies, such as tools for assessment, practice tips, and assistive devices, aid patients, families, and their caregivers in practicing safe medication management. Development of a comprehensive care plan will assist the patient to return as close to previous capabilities as possible. Patient outcomes and successes are variable. The rehabilitation nurse uses observation, skills, and experience to assess stroke patients' needs and develop strategies to assist the patient in managing their medications. Involving patient, family, and caregivers in the teaching of SAFE (Systematic, Accurate, Functional, Effective) medication management increases safety, decreases the number of adverse drug events, and prevents hospitalizations.

A smartphone-centric system for the range of motion assessment in stroke patients.

The range of motion (ROM) in stroke patients is often severely affected. Poststroke rehabilitation is guided through the use of clinical assessment scales for the rROM. Unfortunately, these scales are not widely utilized in clinical practice as they are excessively time-consuming. Although commercial motion-capture systems are capable of providing the information required for the assessments, most systems are either too costly or lack the convenience required for assessments to be conducted on a daily basis. This paper presents the design and implementation of a smartphone-based system for automated motor assessment using low-cost off-the-shelf inertial sensors. The system was used to automate a portion of the upper-extremity Fugl-Meyer assessment (FMA), which is widely used to quantify motor deficits in stroke survivors. Twelve out of 33 items were selected, focusing mainly on joint angle measurements of the upper body. The system has the ability to automatically identify the assessment item being conducted, and calculate the maximum respective joint angle achieved. Preliminary results show the ability of this system to achieve comparable results to goniometer measurements, while significantly reducing the time required to conduct the assessments. The portability and ease-of-use of the system would simplify the task of conducting range-of-motion assessments.

The assessment and treatment of postural disorders in cerebellar ataxia: A systematic review

Gait and balance disorders are often major causes of handicap in patients with cerebellar ataxia. Although it was thought that postural and balance disorders in cerebellar ataxia were not treatable, recent studies have demonstrated the beneficial effects of rehabilitation programs. This article is the first systematic review on the treatment of postural disorders in cerebellar ataxia. Nineteen articles were selected, of which three were randomized, controlled trials. Various aetiologies of cerebellar ataxia were studied: five studies assessed patients with multiple sclerosis, four assessed patients with degenerative ataxia, two assessed stroke patients and eight assessed patients with various aetiologies. Accurate assessment of postural disorders in cerebellar ataxia is very important in both clinical trials and clinical practice. The Scale for the Assessment and Rating of Ataxia (SARA) is a simple, validated measurement tool, for which 18 of the 40 points are related to postural disorders. This scale is useful for monitoring ataxic patients with postural disorders. There is now moderate level evidence that rehabilitation is efficient to improve postural capacities of patients with cerebellar ataxia – particularly in patients with degenerative ataxia or multiple sclerosis. Intensive rehabilitation programs with balance and coordination exercises are necessary. Although techniques such as virtual reality, biofeedback, treadmill exercises with supported bodyweight and torso weighting appear to be of value, their specific efficacy has to be further investigated. Drugs have only been studied in degenerative ataxia, and the level of evidence is low. There is now a need for large, randomized, controlled trials testing rehabilitation programs suited to postural and gait disorders of patients with cerebellar ataxia.

Abstract W P264: Perception of Educational Benefits of Online National Institute of Health Stroke Scale Training by Nursing Staffs

Background: Primary Stroke Center at University Medical Center (UMC) in Lubbock, Texas requires nursing staffs who are directly caring for stroke patients to obtain NIHSS training by certification via an online training program by NINDS and/or AHA. One of quality improvement programs by UMC is to evaluate the compliance and reliability of neurologic assessment of stroke patients by nursing staff. Purposes: The purpose of this study is to evaluate the current perception and effectiveness of online training for quality improvement. Methods: We performed survey on licensed staff members in the Emergency Department (ED), Medical Intensive Care Units (MICUS) and one Medical Surgical Unit (MSU) to determine perception on the effectiveness of the current online education (OE) and on the inter-rater reliability between staffs and units. Results: 164 nurses completed the survey: 81 from ED, 63 from MICU, and 20 from MSU. 55% of staff rated the OE as excellent, 33% as good, and 12% as poor. 42% believed inter-rater reliability was excellent, 32% as good and 19% rated the intra-rater reliability as poor. Regarding how comfortable they were with performing the NIHSS exam, 11% rated themselves as poor, 29% as good, and 65% as excellent. The staffs performed three NIHSS exam (range 0– 40) on average after their training. Extinction and inattention, limb ataxia, dysarthria, and language were felt most difficult to assess, which was similar to previous studies. The majority of group which rated inter-rater reliability as poor worked at the ED and MICU. Some of the suggestions include hands-on training with standardized patient, hands-on training of intubated patients with simulation, regular onsite and online education, and enjoyable education materials. Conclusions: In conclusion, NIHSS online training is an effective way to train nursing staffs but additional and regular educations are needed after the initial online training. Based on the evaluation data, Stroke Program at UMC is developing NIHSS training program utilizing standardized patients in simulation and will implement in education for quality improvement in clinical practice and inter-rater reliability.

Abstract T P196: The Feasibility of iPad Technology for Remote Stroke Assessment Within a Moving Ambulance

Several regional telestroke systems now exist to remotely assess stroke patients at community hospitals via wireless technology in order to decrease the time between stroke onset and treatment. More recently, mobile applications have been studied yet the wireless technology was not sufficient to support reliable audiovisual transmission. This study assessed the feasibility of remote stroke assessment via an iPad within a moving ambulance. Connectivity, quality of transmission, and interrater agreement were examined. Using routes between five spoke rural community hospitals and a telemedicine hub hospital in Fort Wayne, Indiana (radius of approximately 45 miles), two blinded, certified NIH Stroke Scale (NIHSS) raters conducted 30 stroke assessments on a standardized patient. An iPad was mounted within an ambulance and the standardized patient was examined by both in-person and remote assessors. The study demonstrated feasibility in 84% of the assessments with kappa coefficient analysis demonstrating strong interrater agreement for subscales with the exceptions of Best Language and Motor Right Leg. The assessors’ total NIHSS scores were found to have an 88% agreement to the expected scores. When compared to the expected NIHSS scores, subscales showed strong agreement, except moderate agreement in the Best Language subscale. The results of this feasibility study demonstrate that remote NIHSS assessments based within a moving ambulance were feasible. This success rate supports further study of the application in a real, live clinical setting.

Neuropsychological assessment and cerebral vascular disease: The new standards

Vascular cognitive impairment (VCI) includes vascular dementia (VaD), vascular mild cognitive impairment (VaMCI) and mixed dementia. In clinical practice, VCI concerns patients referred for clinical stroke or cognitive complaint. To improve the characterization of VCI and to refine its diagnostic criteria, an international group has elaborated a new standardized evaluation battery of clinical, cognitive, behavioral and neuroradiological data which now constitutes the reference battery. The adaption of the battery for French-speaking subjects is reported as well as preliminary results of the on-going validation study of the GRECOG-VASC group [Clinical Trial NCT01339195]. The diagnostic accuracy of various screening tests is reviewed and showed an overall sub-optimal sensitivity (<0.8). Thus, the general recommendation is to perform systematically a comprehensive assessment in stroke patients at risk of VCI. Furthermore,the use of a structured interview has been shown to increase the detection of dementia. In addition to the well known NINDS-AIREN criteria of VaD, criteria of VCI have been recently proposed which are based on the demonstration of a cognitive disorder by neuropsychological testing and either history of clinical stroke or presence of vascular lesion by neuroimaging suggestive of a link between cognitive impairment and vascular disease. A memory deficit is no longer required for the diagnosis of VaD as it is based on the cognitive decline concerning two or more domains that affect activities of daily living. Both VaMCI and VaD are classified as probable or possible. These new criteria have yet to be validated. Considerable uncertainties remain regarding the determinant of VCI, and especially the lesion amount inducing VCI and VaD. The interaction between lesion amount and its location is currently re-examined using recent techniques for the analysis of MRI data. The high frequency of associated Alzheimer pathology is now assessable in vivo using amyloid imaging. The first studies showed that about a third of patients with VaD due to small vessel disease or with poststroke dementia have amyloid PET imaging suggestive of AD. These new techniques will examine the interaction between vascular lesions and promotion of amyloid deposition. Although results of these on-going studies will be available in few years, these data indicate that efforts should be done in clinical practice to reduce underdiagnosis of VCI; VCI should be examined using a specific protocol which will be fully normalized soon for French-speaking patients; the sub-optimal sensitivity of screening tests prompts to use a structured interview to grade Rankin scale and to perform systematically a comprehensive assessment in stroke patients at risk of VCI; poststroke dementia occurring after 3 months poststroke may be preventable by treatment of modifiable vascular risk factors and secondary prevention of stroke recurrence according to recent recommendations.

응급구급대원에서 뇌졸중 조기증상 인지 및 환자평가 향상을 위한 교육 필요성

Results: The results showed that 63.2% of those surveyed had completed the required educational programs on stroke during the past year. The level of awareness about early symptoms of stroke and assessment of stroke patients' condition was relatively high for women, those who were 30 years under, low position people, emergency service practitioners, emergency medical technicians, and people who have completed education, respectively. It was also turned out that 82.8% of those surveyed took stroke patients to the nearest hospitals first so that they could receive appropriate treatment. The level of awareness about early symptoms of stroke and assessment of stroke patients' condition in people who have completed education were higher than non-complete. The level of awareness about early symptoms of stroke was positively correlated with confidence, satisfaction and appropriateness in treatment of stroke patients. Conclusions: These results strongly suggest that it is necessary to operate specialized educational programs to enhance EMTs' appropriate awareness of the early symptoms of stroke and assessment of stroke patient's condition.

Agreement between ambulance nurses and physicians in assessing stroke patients

If an ambulance nurse could bypass the emergency department (ED) and bring suspected stroke patients directly to a CT scanner, time to thrombolysis could be shortened. This study evaluates the level of agreement between ambulance nurses and emergency physicians in assessing the need for a CT scan, and interventions and monitoring beforehand, in patients with suspected stroke and/or a lowered level of consciousness. From October 2008 to June 2009, we compared the ambulance nurses' and ED physicians' judgement of 200 patients with stroke symptoms. Both groups answered identical questions on patients' need for a CT scan, and interventions and monitoring beforehand. There was poor agreement between ambulance nurses and ED physicians in judging the need for a CT scan: κ = 0.22 (95% confidence interval (CI), 0.06-0.37). The nurses' ability to select the same patients as the physician for a CT scan had a sensitivity of 84% (95% CI, 77-89) and a specificity of 37% (95% CI, 23-53). Agreement concerning the need for interventions and monitoring was also low: κ = 0.32 (95% CI, 0.18-0.47). In 18% of cases, the nurses considered interventions before a CT scan unnecessary when the physicians' deemed them necessary. Additional tools to support ambulance nurses decisions appear to be required before suspected stroke patients can be taken directly to a CT scanner.

Comprehensive and Rapid Assessment of Carotid Plaques in Acute Stroke Using a New Single Sweep Method for Three‐Dimensional Carotid Ultrasound

We describe a 68-year-old man with acute stroke in whom the newly developed single sweep method for three-dimensional (3D) carotid ultrasound provided a rapid and comprehensive assessment of atherosclerotic plaque burden in the internal carotid artery. The two-dimensional duplex carotid scan diagnosed 50-69% stenosis, and with the three-dimensional method, the markedly hypoechogenic plaque (total volume 1.42 mL) was shown to occupy 77% of the total arterial volume (1.84 mL), consistent with severe lesion. The ultrasound findings were confirmed by computed tomographic angiography and subsequent carotid endarterectomy. The new single sweep 3D carotid ultrasound has the potential to become a valuable clinical tool in the assessment of stroke patients.

Functional electrical stimulation based on a normal walking pattern for improving lower extremity function early after cerebral infarction

Objective To observe the effects of functional electrical stimulation (FES) based on a normal walking pattern on the lower extremity function of subjects early after cerebral infarction.Methods Twenty patients with cerebral infarction aged (59.7 ± 10.1) years (range 45-80) who were hospitalized and within 3 months (31.1 ± 19.3 days) after the onset were randomly assigned to an FES group (n =11) or a placebo stimulation group (n =9).All subjects in both groups received standard medical and rehabilitation treatment.In addition,the FES group received FES and the placebo group received sham-FES without current output.The daily stimulation and shamstimulation sessions lasted for 30 min,5 d/week for 3 weeks.All of the subjects in the two groups were assessed using the Fugl-Meyer assessment (FMA),postural assessment for stroke patients (PASS),the Berg balance scale (BBS),functional ambulation categories (FACs) and the modified Barthel index (MBI).Results After 3 weeks of treatment,FMA,PASS,BBS and MBI scores had all improved significantly compared with before treatment in both groups,but the FES group showed significantly better improvement.After treatment the average FAC results of both groups had improved,and there was no significant difference between the two groups.At the same time,the research revealed the expected significant correlations among the FMA,PASS,BBS and MBI results.Conclusion FES based on a normal walking pattern can improve lower extremity motor function early after cerebral infarction,improve balance,and improve ability in the activities of daily living. Key words: Functional electrical stimulation; Cerebral infarction; Lower extremities

Abstract TP288: Introduction of a 24/7 Acute Care Nurse Practitioner-Based Stroke Code Team Improved Compliance with Time Targets

Introduction: An on-site stroke team improves access to IV tPA and speeds assessment of acute stroke patients. The impact of an acute care nurse practitioner (ACNP)-based team to provide 24/7 on-site stroke coverage was studied at a Primary Stroke Center that previously lacked on-site coverage around-the-clock. Hypothesis: We hypothesized that the introduction of 24/7 on-site coverage by an ACNP-based acute stroke team would improve compliance with time targets for rapid assessment of stroke patients. Methods: A single Primary Stroke Center in Honolulu, HI prospectively collected data on acute stroke code activations for the Get With the Guidelines - Stroke clinical database over a 33-month period. We retrospectively analyzed data for consecutive periods of 19 months before and 14 months after introduction of a 24/7 on-site acute stroke code team that included an ACNP as first responder. Data included patient characteristics, target times, and tPA utilization. Results: During the 19-month period prior to ACNP coverage, 200 acute stroke code activations occurred. The mean age of patients was 67.6 years, 51.5% were male, and the mean initial NIH stroke scale score was 15.3 +/- 5.1. Acute ischemic stroke was diagnosed in 47% of acute stroke code activations and 36.2% of those were treated with IV tPA. During the 14-month period after ACNP coverage began, the number of stroke code activations increased to 276. The mean age of patients was 67.5 years, 44.6% were male, and the mean initial NIH stroke scale score was 12.4 +/- 7.2. Acute ischemic stroke was diagnosed in 53.3% of acute stroke code activations and 33.3% of those were treated with IV tPA. After the intervention, door-to-CT-completion time improved from 45.2 +/- 30.1 to 37.8 +/- 20/8 minutes (p=0.192), door-to-lab-result time improved from 42.2 +/- 11.4 to 34.0 +/- 12.4 minutes (p=0.003), and door-to-needle time improved from 60.8 +/- 30.2 to 55.1 +/- 24.3 minutes (p=0.367). After the intervention, compliance with the 60-minute target door-to-needle time improved from 62.1% to 72.3% (p=0.247). Conclusions: Introduction of 24/7 on-site ACNP coverage as first responder for acute stroke code activations resulted in modest improvement of compliance with target times for assessment of acute stroke patients.

Physiotherapists’ and occupational therapists’ perceptions of the assessment of stroke patients for musculoskeletal rehabilitation in the UK national health service

Background and Purpose: This exploratory study focused on the assessment of stroke patients for musculoskeletal rehabilitation in the United Kingdom National Health Service. It was the first phase of research on developing telerehabilitation for the assessment of patients who have had a stroke. The assessment of stroke patients for musculoskeletal rehabilitation is currently performed at the therapist’s discretion using different outcome measures. When looking at the Department of Health’s “National Clinical Guidelines for Stroke”, it is stated that there are a variety of outcome measures, yet no particular one is recommended. It is specified that each rehabilitation sector should select its own methodologies. Aim: The aim of this exploratory study was to understand physiotherapists’ and occupational therapists’ perspectives of the strengths and weaknesses of current rehabilitative assessment of stroke patients in the UK National Health Service. Methods: This study had 2 parts, non-participant observation with 2 therapists and 3 patients, and 10 semi-structured interviews with 5 physiotherapists and 5 occupational therapists to identify current practice, problem areas, and what types of improvements could be made. Interviews were transcribed and analyzed using thematic coding. Results: Seven emergent themes were identified portraying how outcome measures are currently not being used in a standardized way within National Health Service hospitals. This means that the feedback provided to patients, therapists and healthcare commissioners is limited. Therapists are currently performing more informal assessments each time a patient begins therapy and concerns are shown with these methods of assessment, including subjectivity, standardization issues and time. Interviewed therapists were clear that they believed that change is required within this field. Conclusions: This study raises concerns about the methodologies used for the assessment of stroke patients for rehabilitative purposes in the United Kingdom National Health Service.

CT perfusion-guided patient selection for endovascular recanalization in acute ischemic stroke: a multicenter study

BackgroundThe treatment of acute ischemic stroke is traditionally centered on time criteria, although recent evidence suggests that physiologic neuroimaging may be useful. In a multicenter study we evaluated the use...

The exploration of the optimal evaluation method and extraction time of acute stroke patients with indwelling gastric tube

Objective To explore the optimal evaluation method and extraction time of acute stroke patients with indwelling gastric tube.Methods From October 2009 to October 2011,300 cases of stroke patients with swallowing dysfunction,were randomly divided into 2 groups.The control group of 156 cases took the prescribed extraction method,while nursing staff took bedside water swallowing test(Bed-side Water Swallowing Test) for a week to 156 patients with indwelling gastric tube for swallowing assessment in the test group,to determine whether to extract.The extraction time,once again placing tube rate,respiratory tract infections,aspiration,gastrointestinal infections,upper digestive tract hemorrhage and main nuritional index of 2groups were compared.Results Compared to control group,gastric tube indwelling time of test group was obviously shortened,again catheterization rate was significantly lower in infection of the respiratory tract,gastrointestinal infections,upper digestive tract hemorrhage were lower,indwelling gastric tube main nutrition index was higher,with significant differences(P＜ 0.05).Conclusions The swallowing assessment in stroke patients with indwelling gastric tube through bedside swallowing water test to identify extraction time,can reduce the incidence of complications,shorten the indwelling gastric tube time,increase oral feeding opportunities,enhance nutrition supply,and improve the nurses' enthusiasm. Key words: Stroke; Indwelling gastric tube; Extraction; Timing

High-Intensity Focused Ultrasound (HIFU) for Dissolution of Clots in a Rabbit Model of Embolic Stroke

It is estimated that only 2–6% of patients receive thrombolytic therapy for acute ischemic stroke suggesting that alternative therapies are necessary. In this study, we investigate the potential for high intensity focused ultrasound (HIFU) to initiate thrombolysis in an embolic model of stroke. Iron-loaded blood clots were injected into the middle cerebral artery (MCA) of New Zealand White rabbits, through the internal carotid artery and blockages were confirmed by angiography. MRI was used to localize the iron-loaded clot and target the HIFU beam for treatment. HIFU pulses (1.5 MHz, 1 ms bursts, 1 Hz pulse repetition frequency, 20 s duration) were applied to initiate thrombolysis. Repeat angiograms and histology were used to assess reperfusion and vessel damage. Using 275 W of acoustic power, there was no evidence of reperfusion in post-treatment angiograms of 3 rabbits tested. In a separate group of animals, 415 W of acoustic power was applied and reperfusion was observed in 2 of the 4 (50%) animals treated. In the last group of animals, acoustic power was further increased to 550 W, which led to the reperfusion in 5 of 7 (∼70%) animals tested. Histological analysis confirmed thatthe sonicated vessels remained intact after HIFU treatment. Hemorrhage was detected outside of the sonication site, likely due to the proximity of the target vessel with the base of the rabbit skull. These results demonstrate the feasibility of using HIFU, as a stand-alone method, to cause effective thrombolysis without immediate damage to the targeted vessels. HIFU, combined with imaging modalities used to identify and assess stroke patients, could dramatically reduce the time to achieve flow restoration in patients thereby significantly increasing the number of patients which benefit from thrombolysis treatments.

Assessing Stroke Patients for Rehabilitation During the Acute Hospitalization: Findings From the Get With The Guidelines–Stroke Program

ObjectiveTo examine the frequency and determinants of an assessment for rehabilitation during the hospitalization for acute stroke. DesignProspective cohort of patients admitted with acute stroke in the Get With The Guidelines–Stroke (GWTG-Stroke) program from January 8, 2008, to March 31, 2011. SettingAcute hospitals (n=1532) in the United States participating in the GWTG-Stroke program. ParticipantsAdults with a stroke diagnosis (N=616,982) from a GWTG-Stroke–participating acute hospital. InterventionsNot applicable. Main Outcome MeasureDocumentation of an assessment for rehabilitation services during the acute hospitalization. ResultsOverall, almost 90% of stroke patients had documentation of an acute assessment for rehabilitation. In multivariable analysis, patients significantly more likely to be assessed for rehabilitation were younger, male, black or of other nonwhite races (Asian, American Indian, Alaska Native, Native Hawaiian, or Pacific Islander) when compared with white, independently ambulating before admission, and admitted from the community. Patients who received a stroke consult, cared for in a stroke unit, and treated in the northeast region of the United States were also more likely to be assessed. ConclusionsThere is evidence that rehabilitation was considered for 90% of acute stroke patients in this sample. Future research is needed to examine what assessments are conducted and by whom, and how these are used to determine the appropriate level of rehabilitation care for their needs.

Abstract 3468: Correlation of the Miami Emergency Neurologic Deficit (MEND) Exam Performed in the Field by Paramedics with an Abnormal NIHSS and Final Diagnosis of Stroke for Patients Airlifted from the Scene.

Introduction Early recognition and rapid transport to a stroke center by prehospital providers is essential in the care of stroke patients. In this study, prehospital providers were trained to perform the Miami Emergency Neurologic Deficit (MEND) exam as part of an 8-hour comprehensive course, Advanced Stroke Life Support (ASLS ® ). The MEND exam was devised to facilitate communication between healthcare providers throughout the continuum of care for stroke patients. It can provide a baseline exam in the prehospital setting, and then be used by nurses for initial evaluation and subsequent exams in the ED, ICU or hospital floor. The MEND exam incorporates all three components of the Cincinnati Prehospital Stroke Scale (CPSS) and six additional components from the NIHSS (level of consciousness, orientation, commands, visual fields, gaze, leg motor, limb ataxia, sensation). The exam takes less than 2 minutes and requires no tools, making it ideal for the Prehospital environment. Purpose Determine the correlation of the MEND exam completed by a prehospital provider on scene to the initial NIHSS performed by the neurologist at the receiving facility, and the final diagnosis. Methods All prehospital providers from three Fire Rescue agencies participated in the training (96 EMT-P, 68 EMT, 5 RN). The Prehospital providers conducted the CPSS, and if abnormal, placed the helicopter team on standby. They then completed the MEND exam and communicated their findings to a receiving hospital stroke neurologist. We retrospectively reviewed the MEND exam performed by the prehospital providers to determine the correlation with the same components of the initial NIHSS at the hospital. While the NIHSS assigned a numerical value to those specific components, the MEND exam did not. Additionally, we examined the final discharge diagnosis to determine how many patients had a stroke or transient ischemic attack (TIA). Results From Sept. 2008 to June 2011, 51 patients met the criteria of having both a MEND exam and NIHSS completed. There were 32 males (63%) and 19 females (37%) with a median age of 67 years (44-98 years). The average NIHSS score was 9 (range 0-30). 90.2% (46 of 51) of patients had an NIHSS that correlated to the findings on the MEND (95% C.I. 90.1-90.3). Of the 5 remaining patients, 1 completely recovered on the flight (diagnosed with a TIA), and 3 had a NIHSS score of 0 and were diagnosed with other conditions. Stroke or TIA was diagnosed in 40 patients (78.4%). Of 37 strokes, 32 were ischemic (86.5%) and 5 hemorrhagic (13.5%). The 11 patients not diagnosed with a stroke had several other pathologies (e.g. seizure, hypertensive crisis, viral encephalitis, complex migraine). Conclusion The MEND exam completed in the Prehospital setting correlated well with the initial NIHSS performed at the receiving facility. The MEND exam is a valuable tool when assessing stroke patients and determining need for air transport.

Abstract 89: Fatigue and Anxiety in Patients Following Stroke and TIA.

Introduction. Up to 60% of patients report fatigue in the 6 months following acute stroke but the cause of this is poorly understood. Previous studies have reported a correlation with depression however the majority of fatigued subjects are not depressed and the majority of depressed subjects are not fatigued. We hypothesised that the association between fatigue and depression may not be direct and that it may be due to the enhanced level of arousal associated with anxiety disorder. Methods: Data was reviewed from four previous studies performed to identify associations of fatigue in stroke patients. All studies were performed in cognitively intact, independent (Modified Rankin Score &lt;3) stroke patients by trained clinicians. Assessments of fatigue (Fatigue Severity Score), Anxiety and Depression (Hospital Anxiety and Depression Scale) were performed on all or subgroups of patients in all 4 studies. The FSS is a 9 item scale predominantly evaluating physical manifestations of fatigue. A score&gt;4 is indicative of severe fatigue. The Hospital Anxiety and Depression Scale is a simple fourteen item questionnaire (seven questions on symptoms of anxiety (HADS-A) and seven depression (HADS-D) based). Each question may be scored between 0 and 3. A score in either subset &lt;8 is considered normal, between 8 and 10 borderline abnormal and &gt;10 definitely abnormal. Results: Data on 94 patients were included in the assessment. 57 (61%) were male and median age was 68 years (range 44-90 years). Mean FSS was 3.6 and 38 subjects (40.4%) had an FSS &gt;4. Mean HADS-A score was 6.4, 14 (14.9%) subjects had a HADS-A &gt;10 and 21 (22.3%) had a score 8-10. Mean HADS-D score was 4.4, 6 (6.4%) subjects had a score &gt;10 and 10 (10.6%) had a HADS-D between 8 and 10. FSS correlated strongly with both HADS-A (r=0.57 (95% ci 0.42-0.69) p&lt;0.0001 and HADS-D (r=0.51 (95% ci 0.34-0.64) p&lt;0.0001). Positive predictive value (PPV) for an FSS&gt;4 for possible anxiety (HADS-A &gt;7) was 0.61. (PPV) for an FSS&gt;5 for possible anxiety was 0.73. Negative predictive value for a FSS&lt;/=4 for HADS-A &lt;8 was 0.79. PPV for an FSS&gt;4 for possible depression (HADS-D &lt;7) was 0.32 and NPV was 0.93. PPV for an FSS of &gt;6 for both HADS-A and HADS-D was 0.87. Conclusion: Post stroke fatigue is strongly correlated with both anxiety and depression in patients with stroke but the prevalence of symptoms of anxiety is higher. It is worthwhile assessing stroke patients complaining of fatigue for evidence of anxiety disorder.

A robotic device as a sensitive quantitative tool to assess upper limb impairments in stroke patients: A preliminary prospective cohort study

To compare kinematic indices in age-matched healthy subjects and stroke patients, by evaluating various tasks performed with a robotic device, and to provide an objective and standardized protocol to assess upper limb impairments in stroke patients. A prospective cohort study. Age-matched healthy subjects (n = 10) and stroke patients (n = 10). Various kinematic indices were analysed from 3 randomly assigned tasks performed by the affected arm in stroke patients and the dominant arm in healthy subjects. These tasks, composed of large-amplitude, targeted and geometrical movements, were standardized and performed with the ReaPLAN robotic device. For large-amplitude movements, the stroke patients' path lengths were less constant in amplitude, less rectilinear and less smooth than those for healthy subjects (p < 0.001). For the targeted movements, the stroke patients' path lengths were less rectilinear than those of the healthy subjects (p < 0.001). For the geometrical movements, the stroke patients had greater difficulty making the requested shapes compared with the healthy subjects (p < 0.01). Our study proposes an objective and standardized protocol to assess stroke patients' upper limbs with any robotic device. We suggest that further randomized controlled trials could use this quantitative tool to assess the efficacy of treatments such as robot-assisted therapy.

Automatic Segmentation of Ventricular Cerebrospinal Fluid from Ischemic Stroke CT Images

Accurate segmentation of ventricular cerebrospinal fluid (CSF) regions in stroke CT images is important in assessing stroke patients. Manual segmentation is subjective, time consuming and error prone. There are currently no methods dedicated to extracting ventricular CSF regions in stroke CT images. 102 ischemic stroke CT scans (slice thickness between 3 and 6 mm, voxel size in the axial plane between 0.390 and 0.498 mm) were acquired. An automated template-based algorithm is proposed to extract ventricular CSF regions which accounts for the presence of ischemic infarct regions, image noise, and variations in orientation. First, template VT(2) is registered to the scan using landmark-based piecewise linear scaling and then template VT(1) is used to further refine the registration by partial segmentation of the fourth ventricle. A region of interest (ROI) is found using the registered VT(2). Automated thresholding is then applied to the ROI and the artifacts are removed in the final phase. Sensitivity, dice similarity coefficient, volume error, conformity and sensibility of segmentation results were 0.74 ± 0.12, 0.8 ± 0.09, 0.16 ± 0.11, 0.45 ± 0.39, 0.88 ± 0.09, respectively. The processing time for a 512 × 512 × 30 CT scan takes less than 30 s on a 2.49 GHz dual core processor PC with 4 GB RAM. Experiments with clinical stroke CT scans showed that the proposed algorithm can generate acceptable results in the presence of noise, size variations and orientation differences of ventricular systems and in the presence of ischemic infarcts.