Comprehensive Stroke Unit Research Articles

Atrial imaging and cardiac Rhythm In cryptogenic Embolic Stroke: the ARIES study

Abstract Background One of the underlying causes of cryptogenic stroke is an unknown cardioembolic etiology, and the most frequent is atrial fibrillation (AF). It is not unusual to find non-sustained (<30 s) "microfibrillatory" atrial tachycardias (nsAT) or frequent atrial ectopic beats (AE) during the work-up but its pathological significance remains uncertain. Purpose Our aim is to analyze the risk of developing AF or nsAT in patients with cryptogenic stroke and compare their atrial function using advanced echocardiography and their clinical outcome during the follow-up. Methods The ARIES study (Atrial imaging and cardiac Rhythm In cryptogenic Embolic Stroke) is an observational, prospective study in patients admitted for recent cryptogenic stroke in a comprehensive Stroke Unit. We analyze the frequency of detecting AF and nsAT in two 30-day ECG records with a wearable device and we compare echocardiographic signs of left atrial (LA) dysfunction according to rhythm classification: AF, high-burden nsAT/AE (>2 nsAT/24 hours or >3.000 AE/24 hours respectively) and normal sinus rhythm (NSR). Finally, we evaluate stroke recurrence and mortality at 12-months and report changes in classification of stroke etiology during the follow-up. Results In total prolonged rhythm study (1st and 2nd 1-month wearable EKG), AF was found in 35 (32.1%) patients, high-burden nsAT/AE in 27 patients (24.8%) and normal rhythm was found in 47 patients (43.1%). Patients with AF compared with patients with NSR presented higher values in LA volume (69.9±21.8 vs 49.4±26.5, p<0.001) , LA index volume (38.8±11.2 vs 27.3±11.8 ml/m2, p<0.001), 3D LA index volume (50.6±17.2 vs 34.0±15.4 ml/m2, p<0.001), 3D-telediastolic LA volume (89.5±27.7 vs 66.8 ±31.9 ml/m2, p=0.002), 3D-telesistolic LA volume (43.6±15.3 vs 25.3±17.4 ml/m2, p <0.001), lower rates of LA ejection fraction (50 ±14.6 vs 62.7±11.8, p=0.001) and LA strain in reservoir (22.0±8.6 vs 30.4±10.5, p<0.001) and contraction (10.5±8.18 vs 17.1±7.5, p<0.001). After multivariable regression analysis (age, HTA and CHASDS2VASC) all the differences remained significative. High-burden nsAT/AE and NSR patients presented significant differences in LA index volume (33.4±12.4 vs 27.3±11.8 ml/m2, p=0.043) and LA strain in reservoir (26.6±12.5) vs 31.0±10.1, p=0.034) that disappeared after multivariate regression analysis. There were no significant differences in ischemic recurrence or mortality between the three groups. Conclusions In patients with cryptogenic stroke, we registered a high rate of AF and high-burden nsAT/AE. AF patients showed notable alterations in LA volume, LA function and reservoir and contraction strain, while patients with high-burden nsAT/AE showed less structural alteration in echocardiography without difference in stroke recurrence among groups.

Predictors of functional outcome after stroke: Sex differences in older individuals.

Sex differences in stroke are well documented, with females being older at onset, with more severe strokes and worse outcomes than males. Females receive less comprehensive stroke unit treatment. Similarly, older individuals receive poorer quality care than younger ones. There is limited research on sex differences in factors that impact 3-month poststroke functional outcome in people older than 80 years. This register-based and cross-sectional study analyzed data from two stroke quality registers in Sweden from 2014 through 2019. The study included patients aged ≥80 with a diagnosis of ischemic or hemorrhagic stroke. Sociodemographic features, prestroke condition, stroke severity on admission (National Institutes of Health Stroke Scale [NIHSS]), stroke unit care, rehabilitation plans, and 3-month poststroke functional outcome measured with the modified Rankin Scale were analyzed. Ordinal regression analyses stratified by sex were conducted to assess sex differences in factors that impact poststroke functional outcome 3 months after the stroke. A total of 2245 patients were studied with the majority (59.2%) being females. Females experienced more severe strokes (NIHSS median 4 vs. 3, p = 0.01) and were older at stroke onset than males (87.0 vs. 85.4, p < 0.001). Females were also less independent prestroke (69.9% vs. 77.4%, p < 0.001) and a higher proportion of females lived alone (78.2% vs. 44.2%, p < 0.001). Males received intravenous thrombolysis more often than females (16.3% vs. 12.0%, p = 0.005). Regarding 3-month functional outcome, males benefited more from thrombolysis (odds ratio [OR] 0.52, 95% confidence interval [CI] 0.30-0.83), whereas females benefited more from thrombectomy (OR 0.40, 95% CI 0.20-0.71). Stroke care should be adapted to sex disparities in older individuals, while clinicians should be aware of these sex disparities. Further research could clarify the mechanisms behind these disparities and lead to a more personalized approach to stroke care of the older population.

Prevalence and Impact of Medical Complications on Clinical Outcomes in Acute Ischemic Stroke Patients After Endovascular Therapy – Data From a Comprehensive Stroke Unit in China

ObjectiveWe aim to assess the incidence and impact of in-hospital medical complications (MCs) on clinical outcomes in acute ischemic stroke (AIS) patients after endovascular therapy (EVT). MethodsAIS patients who underwent EVT were consecutively recruited from January 2019 to July 2022. The primary outcome was a poor 3-month functional outcome, defined as a modified Rankin Scale score (mRS) of 3-6. The safety variables were symptomatic intracerebral hemorrhage (sICH) and mortality at seven and 30 days. ResultsA total of 306 (50.1%) patients experienced at least one of the MCs. The most common MC was pneumonia (42.6%). Multivariate analysis revealed that the setting of MCs was an independent predictor of a poor 3-month functional outcome (adjusted odds ratio [aOR] 4.40, 95% confidence interval [CI] 3.01-6.42; P<0.001). In the subgroup analysis, this trend was significant, especially in the patients aged 60 to75 years (aOR 5.87, 95% CI 3.45-9.97; P<0.001) or with baseline NIHSS (≤16) (aOR 5.05, 95% CI 2.84-9.01; P<0.001). For individuals, cardiac events (aOR 8.56, 95% CI 4.05-18.09; P<0.001), pneumonia (aOR 5.08, 95%CI 3.42-7.55; P<0.001), and gastrointestinal bleeding (GIB) (aOR 6.12, 95%CI 3.40-11.01; P<0.001) were independently associated with the poor 3-month outcome. The setting of MCs was independently associated with sICH (aOR 2.11, 95% CI 1.22-3.64; P=0.007) and mortality at 30 days (aOR 2.11, 95% CI 1.22-3.64; P=0.007) after adjustment, but not with mortality at seven days. ConclusionsMCs in AIS patients after EVT have a high incidence, despite successful reperfusion, adversely affecting clinical outcomes and increasing short-term mortality.

Determining ischemic stroke subtype: an improved algorithm and its use in a comprehensive stroke unit

Objective ‒ to implement a inified algorithm for determining an ischemic cerebral stroke (ICS) etiological subtype and evaluate the results of its use in patients who were admitted to a comprehensive stroke unit (CSU).Materials and methods. The study enrolled 689 patients with ICS (43.4 % women, 56.6 % men; median age 68.1 years (59.7–75.5)) who in 2010 to 2018 were admitted to a hospital unit where the structure and processes correspond to the principles of CSU. The participants’ age, gender, National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale scores were analyzed. All patients underwent an initial workup that included neuroimaging, vascular imaging, a cardiologist’s exam and a set of laboratory tests, and an advanced evaluation, at his physician discretion. All ICS was assigned to one of the four etiological subtypes: cardioembolic, atherosclerotic, lacunar or other. Results. According to the proposed algorithm, 294 (42.7 %) cases were assigned to cardioembolic subtype, 282 (40.9 %) to atherosclerotic subtype, 52 (7.5 %) to lacunar subtype and 61 (8.9 %) to ischemic cerebral stroke unknown etiology. Differences in the shown frequency of the main etiological ICS subtypes compared to the results of epidemiological studies are due to the greater severity of ICS in our sample: baseline median NIHSS total score was 10 (6–17), and median modified Rankin scale score was 4 (3–5), and, on the other hand, to in-depth assessment using modern diagnostic technologies and a longer length of stay that allowed for the tests to be completed.Conclusions. Thorough evaluation and the use of a unified algorithm based on causal etiological classifications allow to successfully determine an ICS subtype in the CSU patients with low proportion of ICS of unknown etiology, which is the key to effective secondary prevention.

Stroke-associated pneumonia risk estimation in patients admitted to a comprehensive stroke unit at different phases after stroke

stroke is one of the leading causes of death and acquired disability among adults worldwide. Various complications frequently occur in patients with stroke and can significantly increase the risk for poor outcomes. Stroke-associated pneumonia, with the rate of up to 15%, is considered the most common serious medical complication in stroke patients. The aim of the study was to determine the independent predictors of the stroke-associated pneumonia in patients admitted to a comprehensive stroke unit at different time from stroke onset, as well as to develop a prognostic model for stroke-associated pneumonia risk estimation. Medical complications, including stroke-associated pneumonia, were documented in patients with clinical diagnosis of intraparenchymal cerebral stroke at admission and during their stay on the comprehensive stroke unit in 2010 to 2018. The workup at admission included assessment using the National Institutes of Health Stroke Scale and the modified Rankin scale. The diagnosis of stroke-associated pneumonia was made by specialists, in accordance with Centers for Disease Control recommendations. Qualitative variables are displayed as numbers and percentages, quantitative variables are displayed using the median (interquartile range). The method of logistic regression models was used to quantitatively assess the impact of characteristics on the PSP risk. The analysis was carried out using the package MedCalc v. 19.1. The study enrolled 539 patients, 309 (57.3%) men and 230 (42.7%) women. Median age of the patients was 66.0 years (57.9-75.1). Among the participants 101 (18.7%) were diagnosed with intracerebral hemorrhage, and 438 (81.3%) were diagnosed with ischemic stroke. Median initial National Institutes of Health Stroke Scale total score was 11 (6–18), median baseline modified Rankin scale score was 4 (3–5). Majority (64.1%) individuals were admitted within the first 30 days from onset, while 194 (35.9%) patients presented later. History of medical complications before the admission was present in 192 (35.6%) of the study participants, while during our in-hospital stay they occurred in 103 (19.1%) of the patients. The rate of new medical complications at the unit was significantly lower (p&lt;0.001) than prior to the admission. The diagnosis of stroke-associated pneumonia before the admission was established in 20 (3.7%), and during our in-patient treatment was made in 7 (1.3%) subjects (p&lt;0.001). Independent predictors of the stroke-associated pneumonia development were older age (odds ratio 1.11; 95% confidence interval 1.02-1.21, on average, for each additional year, p=0.02) and history of stroke-associated pneumonia at admission (odds ratio 12.2; 95 % confidence interval 2.0-72.4, p=0.006). Excellent sensitivity (85.7%), good specificity (75.0%) and area under the operating characteristic curve of 0.86 (95% confidence interval 0.83 – 0.89) for the developed prognostic model based on these of two variables, indicate their strong association with the risk of stroke-associated pneumonia during a comprehensive stroke unit stay. Therefore, stroke patients frequently develop medical complications at various stroke phases. The risk of stroke-associated pneumonia is higher in older patients and, especially, in those with stroke-associated pneumonia history. The lower rate of medical complications, in particular stroke-associated pneumonia, observed during in-hospital stay compared to the period prior to the admission may indicate the benefits of comprehensive stroke unit.

Предиктори потреби у сторонній допомозі у повсякденному житті серед пацієнтів, які перебували на стаціонарному лікуванні в інтегрованому інсультному блоці

Актуальність. Інсульт залишається провідною причиною інвалідності, але якісна медична допомога може поліпшити результати лікування. Мета дослідження: визначити предиктори збереження потреби у сторонній допомозі у пацієнтів з інсультом, які виписані з інтегрованого інсультного блоку (ІІБ). Матеріали та методи. Учасниками дослідження стали пацієнти з мозковим інсультом, які у 2010–2018 рр. перебували на стаціонарному лікуванні в Інсультному центрі (ІЦ), що розташований у багатопрофільній лікарні та функціонує за принципами ІІБ. Усі пацієнти були ретельно обстежені та отримували належне лікування, у кожного з них при надходженні та перед випискою було проведено оцінювання за основними інсультними шкалами. Дані пацієнтів проспективно вносились до спеціального реєстру. Як результат лікування розглядали прикінцеву оцінку за індексом Бартел (ІБ): при ІБ ≥ 85 балів ефект лікування вважався досягнутим, у разі ІБ ≤ 80 балів — недосягнутим. Для оцінки ступеня впливу 40 факторних ознак на ймовірність неповного функціонального відновлення був використаний метод побудови та аналізу логістичних моделей регресії. Результати. У дослідження були включені 677 пацієнтів віком від 20 до 95 років (медіана — 65,9 року), із них 271 (40,4 %) жінка. У 80,8 % пацієнтів був діагностований ішемічний, а у 19,2 % — геморагічний інсульт. Медіана оцінки за NIHSS при надходженні становила 10 балів. Терміни госпіталізації до ІЦ коливались від &lt; 24 год (17,5 % пацієнтів) до понад 180 днів (17,2 % пацієнтів), 59,7 % учасників були госпіталізовані протягом перших 30 днів від початку захворювання. Згідно з результатами однофакторного аналізу, статистично значущий зв’язок з ризиком недосягнення ефекту лікування мали 27 факторних ознак, зокрема тип та підтип інсульту, вік, наявність фібриляції передсердь, інсульт в анамнезі, тяжкий неврологічний дефіцит, когнітивні порушення та значна функціональна неспроможність при госпіталізації, окремі неврологічні порушення (пригнічення свідомості, дисфагія, геміанопсія, геміпарез) та підвищений рівень маркерів запалення (С­реактивний білок, швидкість осідання еритроцитів) у крові. Відповідно до результатів багатофакторного аналізу, сильний та незалежний зв’язок з ризиком недосягнення бажаного ефекту лікування мали вік пацієнта (відношення шансів (ВШ) 1,06; 95% довірчий інтервал (ДІ) 1,03–1,10 в середньому на кожен додатковий рік; р &lt; 0,001), повторний інсульт (ВШ 2,8; 95% ДІ 1,3–6,2; р = 0,01), початкові оцінки за ІБ (ВШ 0,97; 95% ДІ 0,95–0,98 в середньому при зменшенні оцінки на кожний бал; р &lt; 0,001), модифікованою шкалою Ренкіна (ВШ 1,7; 95% ДІ 1,0–2,8 в середньому при збільшенні оцінки на кожний бал; р = 0,05) та індексом мобільності Рівермід (ВШ 0,87; 95% ДІ 0,76–0,99; р = 0,05), а також початкова оцінка сили рук у відповідних розділах NIHSS (ВШ 1,5; 95% ДІ 1,1–1,9 в середньому на кожний додатковий бал; р = 0,003) та пізня госпіталізація до ІЦ (при надходженні пізніше 180 днів від початку захворювання ВШ 9,6; 95% ДІ 3,1–29,4; р &lt; 0,001). Площа під кривою операційних характеристик AUC = 0,95 (95% ДІ 0,93–0,97) свідчить про відмінну узгодженість моделі прогнозування. Висновки. Найбільший вплив на збереження потреби у сторонній допомозі після лікування в ІІБ мають вік пацієнта, тяжкість початкових порушень та період захворювання. Незалежні предиктори збереження функціональної неспроможності можуть допомогти кращому оцінюванню прогнозу та оптимізації прийняття рішень щодо лікувальної тактики.

Very Early Cognitive Screening and Self-Reported Feeling of Fatigue Three Months After Stroke.

Stroke is a major cause of disability and the second leading cause of death worldwide. Post-stroke fatigue has been reported as one of the most limiting symptoms after a stroke. Early identification of risk factors for developing post-stroke fatigue is important for providing timely rehabilitation. A correlation has been found between fatigue and cognitive impairment after stroke, but 2 months after stroke at the earliest. In the present study, we examined whether cognitive function screening using the Montreal Cognitive Assessment (MoCA) very early after stroke could explain fatigue 3 months after stroke. A total of 311 stroke patients admitted to a comprehensive stroke unit in Sweden between 2011 and 2016 were included in this longitudinal study. Cognition was screened within 2 days after admission to the stroke unit. Data on self-reported feeling of fatigue were retrieved from Riksstroke’s 3-month follow-up form. The data were analyzed using binary logistic regression. We found that the cognitive function in an acute phase after stroke could not explain self-reported feeling of fatigue in a later stage. The correlation between cognitive impairment and fatigue that has been reported may be detectable no earlier than the subacute phase of stroke. As previous studies have shown that functional outcome, severity of stroke, and sex also correlate with fatigue after stroke, we controlled for these variables in our analysis. In line with previous studies, we found that female patients had higher odds of experiencing fatigue. This is something that health care professionals should be aware of when working with stroke patients.

Acute stroke treatment and outcome in the oldest old (90\u2009years and older) at a tertiary care medical centre in Germany-a retrospective study showing safety and efficacy in this particular patient population

BackgroundStroke is among the most common causes of death and disability worldwide. Despite the relevance of stroke-related disease burden, which is constantly increasing due to the demographic change in industrialized countries with an ageing population and consecutively an increase in age-associated diseases, there is sparse evidence concerning acute stroke treatment and treatment-related outcome in the elderly patient group. This retrospective study aimed at analysing patient characteristics, therapy-related complications and functional outcome in stroke patients aged 90 years or older who underwent acute stroke treatment (i.e. intravenous thrombolysis, mechanical thrombectomy, or both).MethodsWe identified files of all inpatient stays at the Department of Neurology at Saarland University Medical Center (tertiary care level with a comprehensive stroke unit) between June 2011 and December 2018 and filtered for subjects aged 90 years or older at the time of admission. We reviewed patient files for demographic data, symptoms upon admission, (main) diagnoses, comorbidities, and administered therapies. For patients admitted due to acute stroke we reviewed files for therapy-related complications and functional outcome. We compared the modified Rankin scale (mRS) scores upon admission and at discharge for these patients.ResultsWe identified 566 inpatient stays of subjects aged 90 years or older. Three hundred sixty-seven of the 566 patients (64.8%) were admitted and discharged due to symptoms indicative of stroke. Two hundred eleven patients received a diagnosis of ischaemic stroke. These 211 patients were analysed subsequently. Sixty-four patients qualified for acute stroke treatment (intravenous thrombolysis n = 22, mechanical thrombectomy n = 26, intravenous thrombolysis followed by mechanical thrombectomy n = 16) and showed a significant improvement in their functional status as measured by change in mRS score (admission vs. discharge, p 0.001) with 7 (10.9%) observed potentially therapy-related complications (relevant drop in haemoglobin n = 2, subarachnoidal haemorrhage n = 1, cerebral haemorrhage n = 3, extracranial bleeding n = 1). One intravenous thrombolysis was stopped because of an uncontrollable hypertensive crisis. Patients who did not qualify for these treatments (including those declining acute treatment) did not show a change of their functional status between admission and discharge (p 0.064).ConclusionOur data indicate that acute stroke treatment is effective and safe in the oldest old. Age alone is no criterion to withhold an acute intervention even in oldest old stroke patients.

Women and Stroke: Different, yet Similar

Background: The impact of gender on acute ischemic stroke, in terms of presentation, severity, etiology, and outcome, is increasingly getting recognized. Here, we analyzed the gender-related differences in etiology and outcome of ischemic stroke in South India. Methods: Patients with first ever ischemic stroke within 1 week of onset presenting to the Comprehensive Stroke Care Centre, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India, were included in our study. Clinical and risk factor profile was documented. The stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS) at onset, and stroke subtype classification was done using Trial of Org 10172 in Acute Ischemic Stroke criteria. The 3-month functional outcome was assessed using the modified Rankin Scale (mRS) with excellent outcome defined as an mRS ≤2. Results: Of the 742 patients, 250 (33.7%) were females. The age, clinical profile, and rate of reperfusion therapies did not differ between the genders. Women suffered more severe strokes (mean NIHSS 9.5 vs. 8.4, p = 0.03). While large artery atherosclerosis was more common in men (21.3% vs. 14.8%, p = 0.03), cardioembolic strokes secondary to rheumatic heart disease were more common in women (27.2% vs. 19.7%, p = 0.02). Men had a better 3-month functional outcome compared to women (68.6% vs. 61.2%, p = 0.04), but was not statistically significant after adjusting for confounders. Conclusion: Our data, from a single comprehensive stroke unit from South India, suggest that stroke in women are different, yet similar in many ways to men. Guideline-based treatment can result in comparable short-term outcomes, irrespective of admission stroke severity.

Adequate access to mechanical thrombectomy during COVID-19 pandemic in lesser Poland Voivodeship in Poland

Many studies have shown that COVID-19 pandemic decreased the access to mechanical thrombectomy (MT) in acute ischemic stroke (AIS) patients. We studied, if the pandemic affected the access to MT in Lesser Poland Voivodeship (LPV) located in southeastern Poland (3.36 million of inhabitants). In LPV patients with AIS are admitted to the nearest stroke unit in the region (15-unit Stroke Network), where intravenous thrombolysis is performed. Those fulfilling the criteria for MT are admitted to the Comprehensive Stroke Unit at the University Hospital in Krakow. We compared the number of MT performed within 12 months before pandemic outburst, from March 2019 to February 2020 with the number of MT performed during pandemic, from March 2020 to February 2021. We also compared the time from stroke onset (SO) to groin puncture (GP) during the two studied periods. 146 had MTs performed during pre-pandemic period and 182 during the pandemic period. The number of MTs in the consecutive months of both periods was similar up to Novembers. The number of MT doubled from December 2020 to January 2021 as compared to the same period of time a year earlier. The mean SO-GP times were similar in both analyzed periods.View Large Image Figure ViewerDownload Hi-res image Download (PPT) In LPV the number of MTs during COVID-19 pandemic was similar or even higher as compared to the corresponding pre-pandemic period. The time of the access to MT was not affected by the COVID-19 pandemic. Our results reflect the efficiency of the local medical system for stroke care, irrespectively of the COVID-19 challenges.

Delayed Comprehensive Stroke Unit Care Attributable to the Evolution of Infection Protection Measures across Two Consecutive Waves of the COVID-19 Pandemic.

We aimed to assess how evidence-based stroke care changed over the two waves of the COVID-19 pandemic. We analyzed acute stroke patients admitted to a tertiary care hospital in Germany during the first (2 March 2020–9 June 2020) and second (23 September 2020–31 December 2020, 100 days each) infection waves. Stroke care performance indicators were compared among waves. A 25.2% decline of acute stroke admissions was noted during the second (n = 249) compared with the first (n = 333) wave of the pandemic. Patients were more frequently tested SARS-CoV-2 positive during the second than the first wave (11 (4.4%) vs. 0; p < 0.001). There were no differences in rates of reperfusion therapies (37% vs. 36.5%; p = 1.0) or treatment process times (p > 0.05). However, stroke unit access was more frequently delayed (17 (6.8%) vs. 5 (1.5%); p = 0.001), and hospitalization until inpatient rehabilitation was longer (20 (1, 27) vs. 12 (8, 17) days; p < 0.0001) during the second compared with the first pandemic wave. Clinical severity, stroke etiology, appropriate secondary prevention medication, and discharge disposition were comparable among both waves. Infection control measures may adversely affect access to stroke unit care and extend hospitalization, while performance indicators of hyperacute stroke care seem to be untainted.

Neurological and medical complications in cerebral stroke patients before hospitalization and during admission to the clinic «oberig» stroke center

Objective ‒ to determine the rate of medical and neurological complications in patients with cerebral stroke (CS) before hospitalization and during in-patient treatment at the Stroke Center (SC), as well as to establish independent predictors for new medical complications at the SC, and to develop an appropriate prognostic model. Materials and methods. The study enrolled 539 patients, 309 (57.3 %) were men and 230 (42.7 %) were women. The age of patients ranged from 20.4 to 95.6 (66.0 [57.9; 75.1]) years. 438 (81.3 %) patients were diagnosed with ischemic stroke (177 (40.4%) ‒ atherothrombotic subtype, 200 (45.7 %) ‒ cardioembolic, 30 (6.9 %) – lacunar, 32 (7.0 %) ‒ stroke of other established or undetermined etiology), 101 (18.7 %) ‒ intracerebral hemorrhage. 109 (20.2%) of the study participants were hospitalized in the hyperacute period, 113 (21.0 %) ‒ in the acute, 199 (36.9 %) ‒ in the early subacute, 36 (6.7 %) ‒ in the late subacute, 82 (15.2%) ‒ in the remote (chronic) period of CS. All patients were evaluated upon admission using the National Institutes of Health Stroke Scale (NIHSS) and the modified Rankin Scale (mRS). The method of construction and analysis of logistic regression models was used to quantify the degree of influence of factor features on the risk of complications. The analysis was performed using the package MedCalc v. 19.1. Results. The total NIHSS score on admission ranged from 0 to 39 (11 [6; 18]). Among the studied patients, 119 (22.1 %) had mild, 218 (40.5 %) – moderate, 114 (21.2 %) – severe, 88 (16.3 %) – very severe CS. Asesed with mRS upon admission, 11 (2.0 %) patients have 0 point, 34 (6.3 %) – 1 point, 58 (10.8 %) – 2 point, 65 (12.1 %) – 3 point,136 (25.2 %) – 4 point, and 235 (43.6 %) – 5 point. Neurological or medical complications before hospitalization occurred in 303 (56.2 %) patients, including 111 (20.6 %) patients with neurological complications and 192 (35.6 %) patients with medical ones. More than one complication was recorded in 52 (9.6 %) persons. The incidence of new neurological and medical complications during the SC stay was significantly lower (p&lt;0.001) than before hospitalization. The independent predictors of new medical complications were CE subtype of IS (OR 2.08; 95 % CI 1.11–3.92), medical complications before admission (OR 2.58; 95 % CI 1.51–4.42), higher initial NIHSS score (OR 1.11; 95 % CI 1.06–1.16 for each additional point), and higher initial mRS (OR 1.62; 95 % CI 1.07–2.48, for each additional point). The predictive model based on the selected set of features has good sensitivity (86.4 %) and moderate specificity (68.4 %). The area under the operating characteristics curve AUC = 0.85 (95 % CI 0.82–0.88), indicates a strong relationship between this set of factorial factors and the risk of medical complications during in-patient treatment at the SC. Conclusions. Before SC admission, complications, mainly medical, occurred in the majo-rity of the patients. A higher rate of medical complications associated with severe CS, greater dependency, older age, and a longer period from CS onset to SC admission. The incidence of complications at the SC was significantly lower than before the admission, which suggests the benefits of care at a Comprehensive Stroke Unit.

Randomized Sham-Controlled Pilot Study of Neurocardiac Function in Patients With Acute Ischaemic Stroke Undergoing Heart Rate Variability Biofeedback.

Background: Neurocardiac dysfunction worsens clinical outcome and increases mortality in stroke survivors. We hypothesized that heart rate variability (HRV) biofeedback improves neurocardiac function by modulating autonomic nervous system activity after acute ischaemic stroke (AIS).Methods: We randomly allocated (1:1) 48 acute ischaemic stroke patients to receive nine sessions of HRV- or sham biofeedback over 3 days in addition to comprehensive stroke unit care. Before and after the intervention patients were evaluated for HRV via standard deviation of normal-to-normal intervals (SDNN, primary outcome), root mean square of successive differences between normal heartbeats (RMSSD), a predominantly parasympathetic measure, and for sympathetic vasomotor and sudomotor function. Severity of autonomic symptoms was assessed via survey of autonomic symptom scale total impact score (TIS) at baseline and after 3 months.Results: We included 48 patients with acute ischaemic stroke [19 females, ages 65 (4.4), median (interquartile range)]. Treatment with HRV biofeedback increased HRV post intervention [SDNN: 43.5 (79.0) ms vs. 34.1 (45.0) ms baseline, p = 0.015; RMSSD: 46.0 (140.6) ms vs. 29.1 (52.2) ms baseline, p = 0.015] and alleviated autonomic symptoms after 3 months [TIS 3.5 (8.0) vs. 7.5 (7.0) baseline, p = 0.029], which was not seen after sham biofeedback (SDNN: p = 0.63, RMSSD: p = 0.65, TIS: 0.06). There were no changes in sympathetic vasomotor and sudomotor function (p = ns).Conclusions: Adding HRV biofeedback to standard stroke unit care led to improved neurocardiac function and sustained alleviation of autonomic symptoms after acute ischaemic stroke, which was likely mediated by a predominantly parasympathetic mechanism.Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT03865225.

Patients' physical activity in stroke units in Latvia and Sweden.

ObjectiveA prospective, observational study to describe levels of physical activity in patients with stroke in a comprehensive stroke unit in Sweden and Latvia, comparing data between countries.MethodsThe study was performed at stroke units in one hospital in Sweden (data were acquired over a 2‐month period in 2017) and two hospitals in Latvia (data were acquired over a 3‐month period between 2016 and 2017). Patients with stroke were observed for 1 min every 10 min. The level of physical activity, location, and the people present were noted at each time‐point.ResultsA total of 27 patients were observed in Latvia and 25 patients in Sweden. Patients from both countries were in bed half of the time and spent the majority of the day in their bedroom and alone. Patients in Sweden had higher physical activity levels, spent more time outside their bedroom and spent more time with rehabilitation specialists and visitors.ConclusionPatients are inactive and alone for a majority of the time during hospitalization at a comprehensive stroke unit in both countries. There are differences in environment in the stroke unit between countries.

ADMISSION VARIABLES ASSOCIATED WITH INDEPENDENT AMBULATION AT TIME OF DISCHARGE FROM A COMPREHENSIVE STROKE UNIT

The aim: To identify admission variables associated with Functional Ambulation Classification (FAC) 1 to 4 (unable to walk without assistance) at time of discharge (dFAC&lt;5) from a comprehensive stroke unit (CSU). Materials and methods: Patients admitted to CSU at Oberig Clinic, Kyiv, Ukraine, August 01, 2012 to July 31, 2018, were screened for study selection criteria. Association of qualifying patients’ data with FAC score at CSU discharge was retrospectively assessed by univariate and multivariate logistic regression, odds ratios (OR) and 95% confidence intervals (95% CI) using MedCalc v. 19.1. Results: The study cohort (442 of 492 admitted patients) had median age: 65.8 years, gender: 43% female, stroke-type: 84% ischemic strokes, median baseline NIHSS total score: 10. Estimated time from stroke onset to CSU admission was from less-than-24-hours to over-180-days. The univariate logistic regression analysis, revealed 28 variables significantly (p&lt;0.05) related to dFAC&lt;5; while in multivariate analysis only 4 admission variables were significantly (p&lt;0.05) associated with dFAC&lt;5: age (OR= 1.07; 95% CI 1.03-1.10, on average, for each additional year, p&lt;0.001), baseline NIHSS score (OR= 1.15; 95% CI 1.08-1.22, on average, with a 1-point increase in the total score, p&lt;0.001), initial FAC score (OR= 0.40; 95% CI 0.31–0.52, on average, with a 1-point decrease in the score, p&lt;0.001), and very late CSU admission (over 180 days; OR= 5.7; 95% CI 1.9–17.1, p=0.002). Conclusions: Four admission variables may be independently associated with dFAC&lt;5 and provide opportunity for improving CSU outcomes and mitigating risk for inability to ambulate without assistance after CSU discharge.

Influence of the amount of rehabilitation and the disease phase on recovering independence in patients with cerebral stroke

Objective ‒ to determine independent predictors and develop a prognostic model for asses-sing the likelihood of lack of a good outcome (dependence) in cerebral stroke patients with severe disabilities who were admitted to a comprehensive stroke unit in a subacute or chronic phase.Materials and methods. A retrospective observational study enrolled patients with a verified cerebral stroke, who were admitted to the Stroke Center (SC) over 2010‒2018 in the early subacute (from Day 8 to Day 90 from onset), the late subacute (from Day 91 to Day 180 from onset) or chronic (after 180 days from onset) phase of the disease and had severe disabilities upon admission (i.e. a modified Rankin scale (mRS) 4 or 5). There were included 290 patients (38.7 % of women) aged from 20.4 to 91.2 years (median ‒ 64.9 years, interquartile range ‒ 56.6‒74.6). Care in the SC was provided in accordance with guidelines and included active interdiscipli-nary rehabilitation. The restoration of independence in daily living at discharge was considered a good outcome (mRS 0‒2). We assessed the relationship of the risk of failure to achieve a good outcome with five clinical variables: age, sex, stroke period, and baseline mRS score and the amount (dose) of rehabilitation (total time of physical therapy, ergotherapy or mechanotherapy).Results. 81 (28.0 %) participant had intracerebral hemorrhage, whereas 209 (72.0 %) had cerebral infarction. The total National Institutes of Health stroke scale (NIHSS) score on admission ranged from 1 to 36 (median 14 points, interquartile range 10–20). While 188 (64.8 %) of the patients were hospitalized to the SC during the early subacute, 34 (11.8 %) and 68 (23.4 %) study participants were admitted only in the late subacute and chronic phase of stroke, respectively. In the analysis of generalized linear regression models, three features had a significant relationship with a decrease in the mRS score: sex, time from stroke onset to SC admission, and the total time of mechanotherapy. According to the multivariate analysis, four factors were significantly associated with a need for assistance in activities of daily living at SC discharge: the risk of dependence was significantly (p = 0.004) lower in men, was directly depended on the initial mRS score and the time elapsed from the estimated stroke onset to the SC admission, but was inversely related to the amount (dose) of certain rehabilitation interventions (the odds ratio of not achieving a good outcome was 0.93 (95 % CI 0.89‒0.97) for every additional 100 minutes of mechanotherapy). The logistic regression model based on the selected set of features turned out to be adequate (χ2 = 60.7 at 7 degrees of freedom, p &lt;0.001). The area under the curve of operational characteristics AUC = 0.82 (95 % CI 0.77‒0.86) indicates good internal prognostic model agreement, and its sensitivity and specificity were good with 76.1 % (95 % CI 70.1‒81.4 %) and 75.0 % (95 % CI 61.6‒85.6 %), respectively.Conclusions. In a cohort of patients with cerebral stroke, independent predictors of dependency after in-patient rehabilitation were identified and a predictive model was developed to assess the likelihood of a good treatment outcome. If its external validity is confirmed in other settings, the developed model may be useful for optimizing treatment strategies and providing patients and their families with prognostic evaluations.

Risk factor profile associated with major ischemic stroke subtypes in patients managed in a comprehensive stroke unit

Objective — to determine risk factor profiles associated with major ischemic stroke (IS) subtypes in patients managed in a comprehensive stroke unit (CSU).Methods and subjects. 612 patients with IS (mean age 68.1 years, 44.4 % of women) admitted CSU in 2011 — 2018 were enrolled in a retrospective observational study. Patients’ medical history included detailed information about risk factors, and all necessary auxiliary investigations were carried out according to current guidelines, which allowed us to determine the subtype of IS. The c2 criterion was used to compare qualitative indicators in major IS subtypes (posterior comparison was performed using the Marascuilo method), and the Kruskal‑Wallis test was used to compare the quantitative indicators (posterior comparison was performed according to the Dunn’s test). All statistical analysis was performed in MedCalc v. 19.2 software.Results. Risk factors were highly prevalent in IS patients: 86.5 % had arterial hypertension (AH), 59.9 % were elderly or old, 41.1 % had hyperlipidemia, 37.1 % had atrialfibrillation (AF), 30.3 % had diabetesmellitus (DM), and 24.7 % were smokers. 254 patients were assigned to atherothrombotic (AT), 270 to cardioembolic (CE), and 35 to lacunar (LI) subtypesof IS, whereas 53 subjects were diagnosed with IS of otheretiology. In 369 (60.3 %) patients, AH was uncontrolled (only 31 % of the study participants were taking antihypertensive drugs regularly), 163 (60.4 %) patients with CE had not taken anticoagulants. AT was significantly (p &lt; 0.05) associated with AH, smoking, and malesex, CE correlated with older age, female sex, and high rate of AF, while individuals with LI had higher levels of total and low density lipoproteincholesterol. Significant relationships of IS subtypes with the duration of AH or DM, cholesterolor high densityl ipoproteincholesterol levels, obesity, control of AH or a family history of stroke were not found.Conclusions. High prevalence and poor control of risk factors in IS patients was documented, and risk factor profiles associated with major IS subtypes were determined. Identification of the sub patterns may contribute to the further improvement of stroke prevention strategies in Ukraine.

Temporal sustainability of guideline based door-to-needle times for intravenous thrombolysis for acute ischemic stroke

BackgroundDoor to needle (DTN) time provides valuable insight into stroke care workflow and is a performance indicator of an acute stroke unit. The aim of the current study was to ascertain whether a door to needle time of less than 60 min can be achieved for intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) and maintained long term in a comprehensive stroke unit. MethodsPatients with AIS treated with IVT in the stroke unit formed the study group. Demographic and clinical characteristics including door to imaging (DTI) time, DTN time, and 3 month functional outcome were abstracted. Pairwise comparison was done of yearly median DTI and DTN times with Bonferroni correction. ResultsOver a period of 6 years a total of 196 patients with mean age of 61.5 ± 13.1 years and median (IQR) NIHSS 11 (8–16) underwent IVT. The median DTI time and DTN time over the study period was 15 (12–21) minutes and 40 (30–50) minutes respectively. A total of 90.1%, 69.4% and 29.1% patients received IVT within 60 min, 45 min and 30 min respectively. On pairwise comparison of the median yearly DTN Year 2016 and 2017 were lower compared to most of the earlier years (p < 0.0001). Good functional outcome (mRS ≤ 2) was noted in 68.7% patients at 3 months follow-up. ConclusionIt is possible to sustainably reduce DTN time for IVT in AIS to well below the current 60 min benchmark with hospital system training and teamwork.

Levels of physical activity in acute stroke patients treated at a stroke unit: A prospective, observational study.

A prospective, observational study to describe levels of physical activity in patients with stroke on day 2 and day 5 or 6 after admission to a comprehensive stroke unit in Sweden. The study was performed at the stroke unit at Sahlgrenska University Hospital during a period of 4 months between 2017 and 2018. Consecutive patients with stroke were observed for 1 min every 10 min while the multidisciplinary team was at work. The level of physical activity, location and the people present were noted at each time-point. A total of 46 patients were observed on day 2, of whom 29 were observed a second time on day 5 or 6. Patients were in bed half of the time and engaged in upright activity for less than 10% of day 2. Patients spent 73% of day 2 in the bedroom and 56% of this day alone. Over time, there was a significant shift of 10% from "in bed" activity to "sitting" (p §lt;0.001). Patients are physically inactive, alone and in their rooms for a majority of the time during the first days at a comprehensive stroke unit. There is some increase in physical activity during the first week after admission.

Olle Höök Lectureship 2019: The changing world of stroke rehabilitation.

The paper presents a summary of the Olle Höök lecture, which was presented at the Baltic North-Sea Forum in Oslo, Sweden, in October 2019. The paper aims to provide a worldwide picture of stroke, developments in this field, and the evolution of stroke rehabilitation. It sets out the background to, evidence for, and content of the comprehensive stroke unit. The paper also describes some rehabilitation techniques based on neurophysiology, the use of robotics, and the evidence level for interventions. Organization of the stroke care chain and different aspects of rehabilitation during its trajectory are described. However, the need for rehabilitation is often not met, due to restricted and unevenly distributed resources. With increasing knowledge of neurophysiology and evidence from meta-analyses, the content of stroke rehabilitation will continue to evolve.