Mild Ischemic Stroke Research Articles

Recovery of post-stroke cognitive and motor deficiencies by Shuxuening injection via regulating hippocampal BDNF-mediated Neurotrophin/Trk Signaling

A mild ischemic stroke may cause both debilitating locomotor and cognitive decline, for which the mechanism is not fully understood, and no therapies are currently available. In this study, a nonfatal stroke model was constructed in mice by a modified middle cerebral artery occlusion (MCAO) procedure, allowing an extended recovery period up to 28 days. The extended MCAO model successfully mimicked phenotypes of a recovery phase post-stroke, including locomotor motor and cognitive deficiencies, which were effectively improved after Shuxuening injection (SXNI) treatment. Tissue slices staining showed that SXNI repaired brain injury and reduced neuronal apoptosis, especially in the hippocampus CA3 region. Transcriptomics sequencing study revealed 565 differentially expressed genes (DEGs) in the ischemic brain after SXNI treatment. Integrated network pharmacological analysis identified Neurotrophin/Trk Signaling was the most relevant pathway, which involves 15 key genes. Related DEGs were further validated by RT-PCR. Western-blot analysis showed that SXNI reversed the abnormal expression of BDNF, TrkB, Mek3 and Jnk1after stroke. ELISA found that SXNI increased brain level of p-Erk and Creb. At sub-brain level, the expression of BDNF and TrkB was decreased and GFAP was increased on the hippocampal CA3 region in the post-stroke recovery phase and this abnormality was improved by SXNI. In vitro experiments also found that oxygen glucose deprivation reduced the expression of BDNF and TrkB, which was reversed by SXNI. In summary, we conclude that SXNI facilitates the recovery of cognitive and locomotor dysfunction by modulating Neurotrophin/Trk Signaling in a mouse model for the recovery phase of post-ischemic stroke.

Risk Factors and Imaging Mechanisms of Fatigue After Mild Ischemic Stroke: An Exploratory Study From a Single Chinese Center.

Objective: To explore the biochemical risk factors and imaging mechanisms of post fatigue after mild ischemic stroke among a Chinese population.Methods: Forty consecutive patients with mild ischemic stroke within onset of 14 ± 2 days were enrolled between March and June 2018. The clinical information, scale data, biomarkers in peripheral venous blood, and imaging data during hospitalization and follow-up period were collected.Results: Patient age (range 34–78) was positively correlated with the prevalence of fatigue (p = 0.009). Both blood norepinephrine and serotonin levels during hospitalization were negatively correlated to the prevalence of post-stroke fatigue (model 1 p = 0.009 and model 2 P = 0.043, respectively). Infarct of right cerebral hemisphere is positively correlated with the occurrence of fatigue after mild ischemic stroke (p = 0.020). Compared to non-fatigue patients, amplitude of low-frequency fluctuation (ALFF) was lower in several areas of brain in stroke patients with fatigue, including the right orbital inferior frontal, right inner orbital frontal, right frontal, right triangular frontal inferior, right anterior and lateral cingulate, and right medial frontal gyruses. Analysis of the difference in functional connectivity between the fatigue and non-fatigue groups found no cluster.Conclusions: Frontal lobe-related neural pathways may play an essential role in the regulation of fatigue after mild ischemic stroke. Abnormal neural circuits may reduce the levels of neurotransmitters such as serotonin and norepinephrine and lead to post-stroke fatigue.

Protocatechudehyde improves mitochondrial energy metabolism through the HIF1α/PDK1 signaling pathway to mitigate ischemic stroke-elicited internal capsule injury

Ethnopharmacological relevanceThe internal capsule is vulnerable to ischemia, and mild ischemic stroke often results in lesion of the internal capsule, manifested as contralateral hemiplegia. Protocatechudehyde (PCA), a potential neuroprotective agent, has shown therapeutic effects in the study of a variety of nervous system diseases, including ischemic stroke. Aim of the studyThe aim of this study was to evaluate the effects of PCA on cerebral ischemia reperfusion (CI/R)-elicited internal capsule injury and to elucidate the role of mitochondrial energy metabolism in the underlying mechanism of neuroprotective effects on ischemic stroke. Materials and methodsA rat tMCAO model was established to investigate the therapeutic effects of intravenous PCA (20, 40, and 80 mg/kg, once per day, continued for 7 days) on CI/R-induced internal capsule injury and the regulation of PCA on molecules related to mitochondrial energy metabolism. In vitro, an OGD/R model of PC12 cells was established to further verify the therapeutic mechanism of PCA. ResultsResults showed that PCA dose-dependently attenuated neurological deficit, reduced cerebral infarction, alleviated histopathological damage, and improved mitochondrial ultrastructure of the internal capsule after CI/R. Moreover, PCA reversed the upregulation of HIF1α, PDK1 and pPDHA1 expression induced by CI/R and significantly increased the content of acetyl-CoA, ATP, and the activity of ATP synthase. In vitro, PCA treatment promoted cell survival, inhibited apoptosis, attenuated the dissipation of mitochondrial membrane potential in OGD/R-treated PC12 cells, and these therapeutic effects were reversed by the combination of cobalt chloride (CoCl2), a specific pharmacological inducer of HIF1a expression. ConclusionsThese results indicate that PCA exerts a protective effect against CI/R-induced internal capsule injury and improves mitochondrial energy metabolism in the internal capsule, and the mechanism is associated with the inhibition of HIF1α/PDK1 signaling pathway.

Sources of systematic error in DCE-MRI estimation of low-level blood-brain barrier leakage.

Dynamic contrast-enhanced (DCE) -MRI with Patlak model analysis is increasingly used to quantify low-level blood-brain barrier (BBB) leakage in studies of pathophysiology. We aimed to investigate systematic errors due to physiological, experimental, and modeling factors influencing quantification of the permeability-surface area product PS and blood plasma volume vp , and to propose modifications to reduce the errors so that subtle differences in BBB permeability can be accurately measured. Simulations were performed to predict the effects of potential sources of systematic error on conventional PS and vp quantification: restricted BBB water exchange, reduced cerebral blood flow, arterial input function (AIF) delay and error. The impact of targeted modifications to the acquisition and processing were evaluated, including: assumption of fast versus no BBB water exchange, bolus versus slow injection of contrast agent, exclusion of early data from model fitting and correction. The optimal protocol was applied in a cohort of recent mild ischaemic stroke patients. Simulation results demonstrated substantial systematic errors due to the factors investigated (absolute PS error ≤ 4.48 × 10-4 min-1 ). However, these were reduced (≤0.56 × 10-4 min-1 ) by applying modifications to the acquisition and processing pipeline. Processing modifications also had substantial effects on in-vivo normal-appearing white matter PS estimation (absolute change ≤ 0.45 × 10-4 min-1 ). Measuring subtle BBB leakage with DCE-MRI presents unique challenges and is affected by several confounds that should be considered when acquiring or interpreting such data. The evaluated modifications should improve accuracy in studies of neurodegenerative diseases involving subtle BBB breakdown.

Relationship between fasting blood glucose and subsequent vascular events in Chinese patients with mild ischaemic stroke: a cohort study.

ObjectiveTo characterise the relationship between fasting blood glucose (FBG) and the incidence of subsequent vascular events (SVE) during the 6 months following a mild ischaemic stroke (MIS) in Chinese patients.MethodsData from patients with MIS were retrospectively analysed. The primary endpoint was an SVE during the 6-month follow-up period. The participants were allocated to three groups (tertiles), according to their FBG concentration.ResultsOf the 260 participants, 51 (19.6%) reported an SVE during the follow-up period. The incidence of SVE significantly differed among the tertiles of FBG. The odds ratio (OR) was 2.361 (95% confidence interval [CI]: 1.551–3.594) for FBG as a continuous variable and that for FBG categorised according to tertile was 13.30 (95% CI: 3.519–50.322) in the fully adjusted model. Curve fitting showed that the incidence of SVE gradually increased with increasing FBG, with the highest tertile showing the highest mean incidence (46.7%; 95% CI: 16.2%–79.9%). In addition, participants with or without diabetes mellitus, hypertension, headache, dizziness, mild cognitive impairment or anterior circulation artery lesion showed similar associations between FBG and the incidence of SVE.ConclusionFBG is an independent predictor of 6-month SVE risk in Chinese patients with MIS.

Intravenous thrombolysis in Chinese patients with mild acute ischemic stroke.

BackgroundMild stroke accounts for more than a half of all stroke patients, and short-term outcomes after treatment with intravenous (IV) recombinant tissue plasminogen activator (rtPA) have not been fully investigated in this group.MethodsOur study investigated short-term outcomes and predictors for a favorable functional outcome at discharge in mild stroke patients with IV rtPA. 6,752 mild stroke patients in the China Stroke Center Alliance with a clinical diagnosis of acute ischemic stroke, within 4.5 hours from symptom onset, with a baseline National Institutes of Health Stroke Scale score ≤5 and received rt-PA treatment were included in this retrospective analysis. Univariable and multivariable analyses were performed to identify factors independently associated with a favorable functional outcome.ResultsOnly 18.5% had an unfavorable functional outcome at discharge, 91.1% were discharged home, 89.9% could ambulate independently, 95.9% had a length of stay of 3 days or longer and 1.9% had sICH. A multivariable Logistic regression model identified that age >80 years [adjusted odds ratio (aOR): 1.57 (1.1–2.25)], diabetes mellitus [aOR: 1.35 (1.16–1.58)], 3–4.5 h time window [aOR: 1.43 (1.26–1.63)] and NIHSS score [3 vs. 0, aOR: 1.49 (1.05–2.11); 4 vs. 0, aOR: 2.36 (1.68–3.33); 5 vs. 0, aOR: 2.51 (1.77–3.56)] were independent risk factors for mRS >2 with hospital region, hospital level and hypertension as covariates.ConclusionsOur findings suggest that tPA is safe and effective in mild stroke patients with age ≤80 within the 3 hour time window and in those without diabetes mellitus, further studies are needed to confirm the findings.

The effect of modifiable stroke risk factors on systemic thrombolytic therapy in patients with acute stroke

Introduction. Systemic thrombolytic therapy (STT) is an effective and accessible method of reperfusion treatment for ischaemic stroke. However, it is not yet evident how the risk factors preceding ischaemic stroke affect disease progression and outcome, as well as the efficacy of STT. The study aimed to examine the results of STT in stroke patients, depending on their risk factors, severity of those risk factors, and the success in managing them at the prehospital stage. Materials and methods. We examined 229 patients who underwent SST, of whom 201 survived and 28 died. The presence of hypertension, type 2 diabetes mellitus, atrial fibrillation, or metabolic syndrome, as well as blood sugar level, lipid panel results, and body mass index were assessed. Results. Ischaemic stroke subtype, the length of time from symptom onset to start of STT, or the presence of hypertension did not have a statistically significant effect on 28-day mortality. Patient age, NIHSS score, presence/absence of type 2 diabetes mellitus and atrial fibrillation, modified Rankin Scale score, blood sugar level, body mass index, and the presence of metabolic syndrome had a statistically significant influence on 28-day mortality. Data from the survived 201 patients were used to analyze the correlation between risk factors and functional recovery after ischaemic stroke. For patients with moderate and mild ischaemic stroke, statistically significant inverse correlations were found for age, blood sugar level, and body mass index. Conclusion. An inverse correlation was found between 28-day mortality and age, severity of neurological impairment, blood sugar level at onset, body mass index, and the presence of the metabolic syndrome. The ‘obesity paradox’ was not identified in regard to survival, but patients with hypercholesterolemia had more significant regression of neurological symptoms and better functional recovery. Receiving statins and having a target cholesterol level were not found to have a positive effect on patient recovery in the first 28 days after disease onset, likely because of greater severity of the overall vascular disease. For citation: Kotov S.V., Isakova E.V., Kolchu I.G., Belkina S.N. [The effect of modifiable stroke risk factors on systemic thrombolytic therapy in patients with acute stroke]. Annals of clinical and experimental neurology. 2021; 15(1): 21–31. (In Russ.). https://doi.org/10.25692/ACEN.2021.1.3

Efficacy Analysis of Intravenous Thrombolysis with Alteplase in the Treatment of Acute Mild Ischemic Stroke

Efficacy Analysis of Intravenous Thrombolysis with Alteplase in the Treatment of Acute Mild Ischemic Stroke

30 Informant-Reported Decline Associates with Silent Acute Stroke Lesions and Worse Small Vessel Disease in Mild Stroke Patients

Abstract Introduction Small vessel disease (SVD) commonly causes stroke and dementia. Early clinical predictors of disease progression are lacking. We aimed to determine whether informant reports of chronic cognitive/functional decline, prerequisites for dementia diagnosis, are associated with (a)baseline SVD burden, measured by Fazekas scores and (b)SVD change, measured by incident subcortical Diffusion-weighted Imaging (DWI) lesions. Method We prospectively recruited patients with mild ischaemic stroke, performed diagnostic MRI, and invited participants to repeat MRI 3- to 6-monthly. Informants completed the Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE) prior to baseline visit, a 16-item questionnaire which assesses patients’ cognitive and functional decline in the preceding ten years. Scores range from 1–5: a score above 3.3 has high sensitivity/specificity for dementia post-stroke. We conducted linear regression with IQCODE as the dependent variable, adjusting for age, sex, baseline MoCA, disability (modified Rankin Scale). Results We recruited 106 participants (mean age 67 years;range 40–86;33% female). Ninety-three informant questionnaires were returned. IQCODE associated with baseline Fazekas score; Fazekas 6 (β = 0.28, p = 0.04) vs. Fazekas 3 (β = 0.03, p = 0.67), R2 = 0.11, adjusted for age, sex, baseline MoCA, disability. Incident DWI lesions were common (15/106; 14/15 subcortical; no active embolic sources; median 67 days post-stroke). Four were asymptomatic, two reported stroke-like symptoms and nine had neuropsychiatric/non-focal symptoms. IQCODE was higher in those with a new lesion vs. without (β = 0.21, p = 0.02), R2 = 0.09, while age (β = −0.004, p = 0.19), MoCA (β = −0.006, p = 0.56) and disability (β = 0.06, p = 0.2) were not. Conclusions Higher SVD burden and incident, mostly “silent” stroke lesions associate more strongly with informant concerns of cognitive/functional decline than age or objective cognitive tests. These findings are novel in an ischaemic stroke population and the first to assess IQCODE/SVD progression. Future work should determine whether combining informant reports with imaging features of small vessel disease improves early detection of dementia.

Abstract P210: Cognitive Testing During Mild Acute Ischemic Stroke Predicts Return to Work, Driving, and Good Functional Outcome at 3 Months

Introduction: Many patients after a mild ischemic stroke (IS) do not return to work or driving. Cognitive testing is commonly done to assess long-term cognitive impairment after IS. However, inpatient cognitive testing during the acute period of mild IS may also be a predictor for workforce reengagement and functional outcome. Methods: At our comprehensive stroke center, we prospectively enrolled previously working adults age <65 years who were diagnosed with first-ever IS, had a prestroke modified Rankin Scale (mRS) ≤1 and NIHSS ≤3. Testing performed within 1 week of IS included the Montreal Cognitive Assessment (MOCA), Clock Drawing Test, Trail Making Tests A and B, Backward Digit Span Test, and Hospital Anxiety and Depression Scale (HADS). Other data obtained included age, gender, years of education, occupation (blue collar or white collar), stroke location (cortical, subcortical, or posterior fossa), stroke laterality, and presence of white matter disease on imaging. Outcome measures assessed at 3 months post stroke included return to work, return to driving, and mRS ≤1. In a logistic regression analysis, we performed both univariate and multivariate analyses. Multivariate analysis was completed on variables p ≤0.05 in the univariate analysis. Results: Of 40 total IS patients enrolled (median [IQR] age 55 [46-60] years; 22.5% female), 36 completed 3-month follow up. 58% returned to work, 78% returned to driving, and 72% had mRS of 0-1 at 3 months. In multivariate analysis, a single point increase in the Clock Drawing Test score increased the odds of return to work by 3.79 (95% CI, 1.10-14.14) and return to driving by 6.74 (95% CI, 1.22-37.23). MOCA and HADS were both associated with mRS ≤1. Conclusion: Clock Drawing Test in the acute period after mild IS may predict early return to work and driving at 3 months. MOCA and HADS may also predict good functional outcome. These tools can potentially be used for prognosis and identifying those who may benefit from further interventions.

Abstract P4: Predictors of Outcomes in Patients With Mild Ischemic Stroke Symptoms: Results From the Mild and Rapidly Improving Stroke Study (mariss)

Background: Although most strokes present with mild symptoms, these have been poorly represented in clinical trials. The objective is to describe multidimensional outcomes, identify predictors of worse outcomes and explore the effect of thrombolysis in this population. Methods: This prospective observational study included patients with ischemic stroke or TIA presenting with stroke symptoms and a baseline NIHSS 0-5 within 4.5 hours from symptom onset. The primary outcome was a 90-day modified Rankin Scale (mRS) 0-1; secondary outcomes included good outcomes in the Barthel Index, Stroke Impact Scale-16 (SIS-16) and European Quality of Life. Multivariable models were created to determine predictors of outcomes and the effect of alteplase. Results: A total of 1765 participants were included from 100 Get With The Guidelines (GWTG)-Stroke participating hospitals (age 65 + 14, 42% women, final diagnosis ischemic stroke 90%, TIA 10%, 57% received alteplase). At 90 days, 37% were disabled and 25% not independent. Worse outcomes were noted for older individuals, women, non-Hispanic Blacks and Hispanics, Medicaid, smokers, those with diabetes, atrial fibrillation, prior stroke, higher baseline NIHSS, visual field defects, arm and leg weakness. Similar outcomes were noted for the alteplase-treated and the untreated groups. Alteplase treated patients were younger (64 + 13 vs. 67 + 1.4) with a higher NIHSS (2.9 + 1.4 vs. 1.7 + 1.4). After adjusting for age, sex, race-ethnicity, and baseline NIHSS, we did not identify an effect of alteplase on the primary outcome but did find an effect on SIS-16 in the restricted sample of baseline NIHSS 3-5. Very few symptomatic hemorrhages were recorded (3/999). Conclusions: A large proportion of stroke patients presenting with a low NIHSS have a disabled outcome. Baseline predictors of worse outcomes are described. An effect of alteplase on outcomes was not identified in the overall cohort but an indication of efficacy was noted in the NIHSS 3-5 subgroup.

Leukocyte Biomarkers for the Differential Diagnosis of Mild Acute Ischemic Stroke, Transient Ischemic Attack, and Stroke Mimic.

IntroductionThe differential diagnosis of transient ischemic attack (TIA) versus mild acute ischemic stroke (AIS) during the initial presentation to the emergency department is often difficult, as the diagnosis of both TIA and AIS relies on the presence of focal neurologic signs. As such, roughly 50% of patients with transient or mild neurologic deficits have an uncertain diagnosis prior to neuroimaging. Biomarkers, particularly leukocyte biomarkers, may be used by clinicians to diagnose mild AIS prior to neuroimaging, and this study is the first to describe the use of leukocyte biomarkers for the differentiation of mild AIS, TIA, and stroke mimic.MethodsWe performed a retrospective chart review of patients discharged from a local hospital with a discharge diagnosis of either TIA or AIS. Past medical history and complete blood cell count with differential upon admission were collected for all subjects. Statistical analyses were performed to compare immune cell parameters between the two groups. For all comparisons, logistic regression analysis was used to assess the effect of confounding variables, such as age, gender, and medical history for each study variable.ResultsOf all the immune parameters assessed in this study, the neutrophil percentage was the only significant biomarker that significantly differed between study groups. After adjustment for confounding variables using stepwise logistic regression, mild AIS patients were 5.3 times more likely than TIA cases to have a neutrophil percentage above the normal range.ConclusionOur results suggest that clinicians may utilize neutrophil percentage as an additional piece of information that may aid in their diagnosis of mild AIS versus TIA.

Intravenous Thrombolysis and Endovascular Thrombectomy in Acute Ischemic Stroke with Minor Symptom

More than 50% of all patients with ischemic stroke initially present with mild symptoms. Despite the mild clinical presentation, a high percentage of these patients develop stroke progression with consequent disability, recurrent stroke, or death at follow-up. Intravenous thrombolysis with recombinant tissue plasminogen activator within 4.5 hours has been proven to be an effective treatment for acute ischemic stroke, but the risk-benefit ratio of this therapeutic approach remains still unclear in patients with mild stroke. Many patients with mild stroke are frequently excluded from thrombolysis. Large artery occlusion is an important predictor of early neurological deterioration or poor outcomes in patients with mild ischemic stroke. However, current guidelines do not recommend endovascular thrombectomy in patients with National Institutes of Health Stroke Scale score of <6 points. Some previous retrospective cohort studies have reported that endovascular thrombectomy showed promising results in cases of acute mild ischemic stroke with large vessel occlusion. Treatment decisions in patients with mild ischemic stroke should be individualized depending on clinical and radiological features. In this review, we discuss the prognosis of mild strokes, efficacy of intravenous thrombolysis and endovascular thrombectomy, and the role of neurovascular imaging in treatment decision making in this patient population.

Impact of recanalisation by mechanical thrombectomy in mild acute ischemic stroke with large anterior vessel occlusion.

The net clinical benefit of mechanical thrombectomy (MT) in patients presenting acute anterior circulation ischemic stroke with large-vessel occlusion (AIS-LVO) and mild neurological deficit is uncertain. To investigate efficacy and safety of MT in patients with acute AIS-LVO and mild neurological deficit by evaluating i) the influence of recanalisation on three-month outcome and ii) mortality, symptomatic intracerebral hemorrhage (sICH) and procedural complications. We included consecutive patients with acute AIS-LVO and National Institute of Stroke Scale (NIHSS) score<8, treated by MT at Lille University Hospital. Recanalisation was graded according to modified thrombolysis in cerebral infarction (mTICI) score, mTICI 2b/2c/3 being considered successful. We recorded procedural complications and classified intra-cerebral hemorrhages (ICH) and sICH according with European Cooperative Acute Stroke Study (ECASS) and ECASS2 criteria. Three-month outcome was evaluated by modified Rankin scale (mRS). Excellent and favourable outcomes were respectively defined as mRS 0-1 and 0-2 (or similar to pre-stroke). We included 95 patients. At three months, 56 patients (59. 0%) achieved an excellent outcome and 69 (72, 6%) a favourable outcome, both being more frequent in patients with successful recanalisation than in patients without (excellent outcome 71, 1% versus 10, 5%, P<0.001 and favourable outcome 82.9% versus 31.6%, P<0.001). The difference remained unchanged after adjustment for age and pre-MT infarct volume. Similar results were observed in patients with pre-MT NIHSS ≤5. Death occurred in five patients (5.3%), procedural complications in 12 (12.6%), any ICH in 38 (40.0%), including 3 (3.2%) sICH. Achieving successful recanalisation appears beneficial and safe in acute AIS-LVO patients with NIHSS<8 before MT.

Physical Activity Monitoring Using a Fitbit Device in Ischemic Stroke Patients: Prospective Cohort Feasibility Study.

BackgroundContinuous tracking of ambulatory activity in real-world settings using step activity monitors has many potential uses. However, feasibility, accuracy, and correlation with performance measures in stroke patients have not been well-established.ObjectiveThe primary study objective was to determine adherence with wearing a consumer-grade step activity monitor, the Fitbit Charge HR, in home-going ischemic stroke patients during the first 90 days after hospital discharge. Secondary objectives were to (1) determine accuracy of step counts of the Fitbit Charge HR compared with a manual tally; (2) calculate correlations between the Fitbit step counts and the mobility performance scores at discharge and 30 days after stroke; (3) determine variability and change in weekly step counts over 90 days; and (4) evaluate patient experience with using the Fitbit Charge HR poststroke.MethodsA total of 15 participants with recent mild ischemic stroke wore a Fitbit Charge HR for 90 days after discharge and completed 3 mobility performance tests from the National Institutes of Health Toolbox at discharge and Day 30: (1) Standing Balance Test, (2) 2-Minute Walk Endurance Test, and (3) 4-Meter Walk Gait Speed Test. Accuracy of step activity monitors was assessed by calculating differences in steps recorded on the step activity monitor and a manual tally during 2-minute walk tests.ResultsParticipants had a mean age of 54 years and a median modified Rankin scale score of 1. Mean daily adherence with step activity monitor use was 83.6%. Mean daily step count in the first week after discharge was 4376. Daily step counts increased slightly during the first 30 days after discharge (average increase of 52.5 steps/day; 95% CI 32.2-71.8) and remained stable during the 30-90 day period after discharge. Mean step count difference between step activity monitor and manual tally was –4.8 steps (–1.8%). Intraclass correlation coefficients for step counts and 2-minute walk, standing balance, and 4-meter gait speed at discharge were 0.41 (95% CI –0.14 to 0.75), –0.12 (95% CI –0.67 to 0.64), and 0.17 (95% CI –0.46 to 0.66), respectively. Values were similarly poor at 30 days.ConclusionsThe use of consumer-grade Fitbit Charge HR in patients with recent mild stroke is feasible with reasonable adherence and accuracy. There was poor correlation between step counts and gait speed, balance, and endurance. Further research is needed to evaluate the association between step counts and other outcomes relevant to patients, including patient-reported outcomes and measures of physical function.

Stroke admission rates before, during and after the first phase of the COVID-19 pandemic

BackgroundThere was a significant decrease in stroke admissions during the first phase of the COVID-19 pandemic. There are concerns that stroke patients have not sought medical attention and in the months after the lockdown suffer recurrent severe strokes. The aims of this study were to investigate how stroke admission rates and distributions of severity varied before, during and after the lockdown in a representative Norwegian hospital population.MethodsAll patients discharged from Akershus University Hospital with a diagnosis of transient ischemic attack (TIA) or acute stroke from January to September 2020 were identified by hospital chart review.ResultsWe observed a transient decrease in weekly stroke admissions during lockdown from an average of 21.4 (SD 4.7) before to 15.0 (SD 4.2) during and 17.2 (SD 3.3) after (p < 0.011). The proportion of mild ischemic and haemorrhagic strokes was also lower during lockdown with 66% before, 57% during and 68% after (p = 0.011).ConclusionThe period of COVID-19 lockdown was associated with a temporary reduction in total admissions of strokes. In particular, there were fewer with TIA and mild stroke. Given the need to prevent the worsening of symptoms and risk of recurrence, it is necessary to emphasise the importance to seek medical care even in states of emergency.

Stroke memory rehabilitation (SMaRT) programme for mild ischemic stroke: Preliminary findings

AbstractBackgroundThere are 6000‐7000 stroke survivors yearly in Singapore with about 40% being at risk for post‐stroke cognitive impairment (PSCI). Stroke Memory Rehabilitation (SMaRT) programme was designed to reduce the incidence of PSCI, facilitate transition back to the community, improve the mood and quality of life of patients with mild ischemic strokes. We report the preliminary outcomes of the program.MethodParticipants who attended the programme from April 2018 to Dec 2019 were included in this study. Each patient attended 8 two‐hour sessions over 8 weeks, focusing on cognitive processes (episodic memory, executive function and visuospatial function); healthy lifestyle habits, relaxation techniques and goal setting. All patients were administered neuropsychological assessments and questionnaires pre‐programme, 8 weeks and 6 months post‐programme. Paired sample t‐tests were applied to evaluate the changes in scores over the four time points on each outcome measure, subject to Bonferroni correction for family‐wise errors.Result156 participants (mean age=63.53 years, SD=9.63; mean education=9.95 years SD=4.18, 65.4 % male). Significant improvements in all outcome measures were observed from pre‐programme to all other time points. Cognitive scores significantly improved from pre to post‐programme and pre to 6 months post‐programme on the Montreal Cognitive Assessment (24.52 to 25.36; p&lt;.001 and 25.05 to 25.98; p&lt;.001 respectively); Visual Cognitive Assessment Test (VCAT) Score (22.67 to 24.14; p&lt;.001 and 22.63 to 24.92; p&lt;.001). Scores for Trail Making Test‐A only significantly shortened from pre‐ to 6 months post‐programme (52.00 to 45.52; p&lt;.001). Depression levels significantly reduced on the Geriatric Depression Scale (4.01 to 3.29; p=.001 and 3.46 to 2.33; p&lt;.001). Activities of daily living measured on the NEADL significantly improved (52.24 to 55.15; p&lt;.001 and 52.48 to 56.27; p&lt;.001). Quality of life (DemQOL) also significantly improved (88.77 to 91.88; p=.006 and 91.83 to 95.52; p&lt;.001).ConclusionPreliminary findings demonstrate encouraging improvement in global cognition, executive function, quality of life, depression and activities of daily living from pre‐programme to 8 weeks and 6 months post‐programme. A multi‐approach structured cognitive rehabilitation programme for stroke survivors may thus be useful in preventing post‐stroke dementia.

November 2020 Stroke Highlights.

November 2020 Stroke Highlights.

The effect of head positioning on cerebral hemodynamics: Experiences in mild ischemic stroke

Background and purposeIt is generally agreed that optimal head positioning is an important consideration in acute stroke management regime. However, there is limited literature investigating the effect of head positioning changes on cerebrovascular physiology in acute ischemic stroke (AIS). We aim to assess cerebral autoregulation (CA) and associated hemodynamic responses during gradual head positioning (GHP) changes, between AIS and controls. MethodsCerebral blood flow velocity (CBFV, transcranial Doppler), blood pressure (BP, Finometer) and end-tidal CO2 (capnography) were recorded between lying flat (0°) and sitting up (30°) head position, in 16 controls (8 women, mean age 57 ± 16 yrs) and 15 AIS patients (7 women, 69 ± 8 yrs). AIS patients carried out three visits at 13.3 ± 6.9 h, 4.8 ± 3.2 days and 93.9 ± 11.5 days from symptom onset, respectively. ResultsAIS patients were significantly hypertensive (p = 0.005), hypocapnic (p < 0.001), and had lower CBFV (p = 0.02) compared to controls, in both head positions. When comparing 5-min FLAT to SIT head position, reductions in BP (both AIS and controls, p < 0.001) and CBFV (controls only: dominant hemisphere p = 0.001 and non-dominant hemisphere p = 0.05) were demonstrated. Of note, a reduction in autoregulation index was observed in AIS, after 5-min SIT head positioning, at all 3 visits (p = 0.018).Conclusion: Key hemodynamic changes were demonstrated when the head position changes from 5-min FLAT to SIT head position (GHP) in mildly affected stroke patients. Importantly, these were associated with non-significant changes in CBFV but reduced measures of CA following AIS, which may be relevant in determining the optimal head position and the ideal timing of mobilisation.Clinical Trial Registration – URL: http://www.clinicaltrials.gov.Unique Identifier: NCT02932540

Reperfusion Therapy Frequency and Outcomes in Mild Ischemic Stroke in the United States.

More than half of patients with acute ischemic stroke have minor neurological deficits; however, the frequency and outcomes of reperfusion therapy in regular practice has not been well-delineated. Analysis of US National Inpatient Sample of hospitalizations with acute ischemic stroke and mild deficits (National Institutes of Health Stroke Scale [NIHSS] score 0-5) from October 1, 2016, to December 31, 2017. Patient- and hospital-level characteristics associated with use and outcome of reperfusion therapies were analyzed. Primary outcomes included excellent discharge disposition (discharge to home without assistance); poor discharge disposition (discharge to facility or death); in-hospital mortality; and radiological intracranial hemorrhage. Among 179 710 acute ischemic stroke admissions with recorded NIHSS during the 15-month study period, 103 765 (57.7%) had mild strokes (47.3% women; median age, 69 [interquartile range, 59-79] years; median NIHSS score of 2 [interquartile range, 1-4]). Considering reperfusion therapies among strokes with documented NIHSS, mild deficit hospitalizations accounted for 40.0% of IVT and 10.7% of mechanical thrombectomy procedures. Characteristics associated with IVT and with mechanical thrombectomy utilization were younger age, absence of diabetes, higher NIHSS score, larger/teaching hospital status, and Western US region. Excellent discharge outcome occurred in 48.2% of all mild strokes, and in multivariable analysis, was associated with younger age, male sex, White race, lower NIHSS score, absence of diabetes, heart failure, and kidney disease, and IVT use. IVT was associated with increased likelihood of excellent outcome (odds ratio, 1.90 [95% CI, 1.71-2.13], P<0.001) despite an increased risk of intracranial hemorrhage (odds ratio, 1.41 [95% CI, 1.09-1.83], P<0.001). In national US practice, more than one-half of acute ischemic stroke hospitalizations had mild deficits, accounting for 4 of every 10 IVT and 1 of every 10 mechanical thrombectomy treatments, and IVT use was associated with increased discharge to home despite increased intracranial hemorrhage.