Moderate Stroke Research Articles

A Randomized Controlled Trial to Study the Effectiveness of Interactive, Virtual Tele-Physiotherapy for Improving Motor Function and Quality of Life in Stroke Patients: A Study Protocol

Introduction: Telephysiotherapy (TPT) is provision of physiotherapy services using telecommunication technology such as audio call or video call to facilitate the physiotherapy management of patients within their own homes. In the absence of which the patients may have to discontinue physiotherapy treatment that may result into poor motor outcomes leading to deterioration of the quality of life (QoL).
 Methodology: This is a study protocol designed to study the effectiveness of TPT intervention in Stroke patients. The objective is to study whether TPT is effective for Stroke Rehabilitation in improving motor function and quality of life. An exercise protocol will be administered to patients suffering from mild to moderate stroke those grading less than or equal to 4 on a Modified Rankin Scale (mRS=<4). A total 40 patients will be recruited in the study, divided into 2 groups –Group A and Group B, where Group A will receive the exercise therapy through Tele Physiotherapy & Group B will receive Out-Patient-Based (OPD-based) Physiotherapy. Participants of both the groups will be called to the OPD at the baseline and at the end of 6 weeks intervention. The patients shall be assessed at the baseline and at the end of intervention using Fugl-Meyer Assessment (FMA), Dynamic Gait Index (DGI), Functional Independence Measure (FIM) and Stroke Specific Quality Of Life scale (SS-QOL) to evaluate their motor function, gait, functional status and quality of life respectively.
 Ethical Considerations: Approval from the Institutional Ethics committee of the institute is obtained. Participation in study will be voluntary and only the patients willing to give the written informed consent will be recruited for the study.
 Results: The results of the study will be published and disseminated in peer-reviewed journals.

The Efficacy of Group Acceptance and Commitment Therapy for Preventing Post-Stroke Depression: A Randomized Controlled Trial

Background and purposePost-stroke depression (PSD) is a common psychiatric complication of stroke and is associated with the subsequent prognosis, yet still lacking of enough attention. PSD is preventable, and psychotherapy is an alternative prophylactic treatment which needs more solid evidences to confirm its efficacy. In this study, group Acceptance and Commitment Therapy (G-ACT) was performed in acute stroke patients to see if it can effectively relieve depressive symptoms and improve neurological function. The efficacy was also evaluated in stroke patients of different severity. MethodsOne hundred and four hospitalized patients with acute ischemic stroke were enrolled according to the inclusion criteria and exclusion criteria. After baseline evaluation, they were randomly allocated to the intervention (G-ACT) group and the control (usual care) group. Patients in the control group received routine stroke treatment, while those in the intervention group were given additional G-ACT treatment (5 sessions, 45-55 min/session). Both of the two groups were assessed with 24-item Hamilton Depression Scale (HAMD-24), National Institutes of Health Stroke Scale (NIHSS), and Barthel Index (BI) at baseline, 2 weeks, 1 month, and 3 months follow-up. Patients were further divided into the mild stroke group (NIHSS 0-3) and the moderate stroke group (NIHSS 4-9), HAMD scores at different time points were also assessed. ResultsThe HAMD score of G-ACT group was significantly lower than that of control group at 1 month (p = 0.018) and 3 months follow-up (p = 0.001). As to the NIHSS score, there was no significant difference between the two groups within the follow-up period (p > 0.05). The BI score of the two groups was statistically different at 2 weeks (p = 0.033) and 1 month (p = 0.019), while no difference was shown at 3 months (p = 0.191). In acute phase, the HAMD score of moderate stroke patients was significantly higher than that of mild ones (p < 0.001). After G-ACT treatment, both mild and moderate stroke patients showed lower HAMD score at 3 months follow-up (p = 0.004; p = 0.033). ConclusionsG-ACT seems to be a viable and effective treatment for preventing PSD in the acute phase of stroke, while the efficacy of which on improving neurological deficits needs to be further evaluated.

Changes in PHQ-9 depression scores in acute stroke patients shortly after returning home.

Post-stroke depression is a disabling condition that occurs in approximately one-third of stroke survivors. There is limited information on changes in depressive symptoms shortly after stroke survivors return home. To identify factors associated with changes in post-stroke depressive symptoms during the early recovery period, we conducted a secondary analysis of patients enrolled in a clinical trial conducted during the transition period shortly after patients returned home (MISTT). The Michigan Stroke Transitions Trial (MISTT) tested the efficacy of social worker case management and access to online information to improve patient-reported outcomes following an acute stroke. Patient Health Questionnaire-9 (PHQ-9) scores were collected via telephone interviews conducted at 7 and 90 days post-discharge; higher scores indicate more depressive symptoms. Generalized estimating equations were used to identify independent predictors of baseline PHQ-9 score at 7 days and of changes over time to 90 days. Of 265 patients, 193 and 185 completed the PHQ-9 survey at 7 and 90 days, respectively. The mean PHQ-9 score was 5.9 at 7 days and 5.1 at 90 days. Older age, being unmarried, and having moderate stroke severity (versus mild) were significantly associated with lower 7-day PHQ-9 scores (indicating fewer depressive symptoms). However, at 90 days, both unmarried patients and those with moderate or high stroke severity had significant increases in depressive symptoms over time. In stroke patients who recently returned home, both marital status and stroke severity were associated with depressive symptom scores; however, the relationships were complex. Being unmarried and having higher stroke severity was associated with fewer depressive symptoms at baseline, but both factors were associated with worsening depressive symptoms over time. Identifying risk factors for changes in depressive symptoms may help guide effective management strategies during the early recovery period.

Translation and validation of the stroke impact scale 3.0 into Urdu for Pakistan.

The Stroke Impact Scale version 3.0 (SIS 3.0) is a self-reported outcome measure designed to assess quality of life (QoL) following a stroke. Although the psychometric properties of the SIS 3.0 are identified as superior to the generic QoL scales, it has not been translated and tested in Pakistan. To validate the Urdu version of the SIS 3.0 (USIS 3.0) for Pakistan. A prospective cohort of 116 patients with mild to moderate stroke reported their recovery using the USIS 3.0. The patients were concurrently assessed on the established tools to assess the validity and were re-evaluated to determine the test-retest reliability, precision, minimal detectable change (MDC), and minimal clinically important difference (MCID). The reliability and internal consistency of USIS were satisfactory except for the emotion domain. The correlations of USIS with the established tools were strong. The discriminant validity was also significant across the levels of the modified Rankin scale (MRS). Only hand function and communication domains exhibited significant floor and ceiling effects, respectively. Regarding weighted K, values ranged from 0.53 to 0.88. The USIS 3.0 has satisfactory psychometric properties and can be used in clinical and research settings for stroke survivors.

Medicare Claim-Based National Institutes of Health Stroke Scale to Predict 30-Day Mortality and Hospital Readmission.

The Centers for Medicare and Medicaid Services (CMS) penalizes hospitals for higher than expected 30-day mortality rates using methods without accounting for condition severity risk adjustment. For patients with stroke, CMS claims did not quantify stroke severity until recently, when the National Institutes of Health Stroke Scale (NIHSS) reporting began. Examine the predictive ability of claim-based NIHSS to predict 30-day mortality and 30-day hospital readmission in patients with ischemic stroke. Retrospective cohort study of Medicare claims data. Medicare beneficiaries with ischemic stroke (N=43,241) acute hospitalization between October 2016 and November 2017. All-cause 30-day mortality and 30-day hospital readmission. NIHSS score was derived from ICD-10 codes and stratified into the following: minor to moderate, moderate, moderate to severe, and severe categories. Among 43,241 patients with ischemic stroke with NIHSS from 2,659 US hospitals, 64.6% had minor to moderate stroke, 14.3% had moderate, 12.7% had moderate to severe, and 8.5% had a severe stroke,10.1% died within 30 days, 12.1% were readmitted within 30 days. The NIHSS exhibited stronger discriminant property (C-statistic 0.83, 95% CI: 0.82-0.84) for 30-day mortality compared to Elixhauser (0.74, 95% CI: 0.73-0.75). A monotonic increase in the adjusted 30-day mortality risk occurred relative to minor to moderate stroke category: hazard ratio [HR]=2.92 (95% CI=2.59-3.29) for moderate stroke, HR=5.49 (95% CI=4.90-6.15) for moderate to severe stroke, and HR=7.82 (95% CI=6.95-8.80) for severe stroke. After accounting for competing risk of mortality, there was a significantly higher readmission risk in the moderate stroke (HR=1.11, 95% CI=1.03-1.20), but significantly lower readmission risk in the severe stroke (HR=0.84, 95% CI=0.74-0.95) categories. Timing of NIHSS reporting during hospitalization is unknown. Medicare claim-based NIHSS is significantly associated with 30-day mortality in Medicare patients with ischemic stroke and significantly improves discriminant property relative to the Elixhauser comorbidity index.

Similar admission NIHSS may represent larger tissue-at-risk in patients with right-sided versus left-sided large vessel occlusion

BackgroundWe investigated the effects of the side of large vessel occlusion (LVO) on post-thrombectomy infarct volume and clinical outcome with regard to admission National Institutes of Health Stroke Scale (NIHSS)...

User-Centered Design and Evaluation of an Upper Limb Rehabilitation System with a Virtual Environment

Virtual environments (VEs) and haptic devices increase patients’ motivation. Furthermore, they observe their performance during rehabilitation. However, some of these technologies present disadvantages because they do not consider therapists’ needs and experience. This research presents the development and usability evaluation of an upper limb rehabilitation system based on a user-centered design approach for patients with moderate or mild stroke that can perform active rehabilitation. The system consists of a virtual environment with four virtual scenarios and a developed haptic device with vibrotactile feedback, and it can be visualized using a monitor or a Head-Mounted Display (HMD). Two evaluations were carried out; in the first one, five therapists evaluated the system’s usability using a monitor through the System Usability Scale, the user experience with the AttrakDiff questionnaire, and the functionality with customized items. As a result of these tests, improvements were made to the system. The second evaluation was carried out by ten volunteers who evaluated the usability, user experience, and performance with a monitor and HMD. A comparison of the therapist and volunteer scores has shown an increase in the usability evaluation (from 78 to &gt;85), the hedonic score rose from 0.6 to 2.23, the pragmatic qualities from 1.25 to 2.20, and the attractiveness from 1.3 to 2.95. Additionally, the haptic device and the VE showed no relevant difference between their performance when using a monitor or HMD. The results show that the proposed system has the characteristics to be a helpful tool for therapists and upper limb rehabilitation.

Diffusion weight magnetic resonance imaging analisys with rapid software appication in symptomatic carotid stenosis revascularization

Abstract Objectives The aim of this study was to evaluate whether the extension of preoperative neuroradiological lesions assessed by magnetic resonance imaging (MRI) with Diffusion Weighted sequences (DWI) and Rapid processing of Perfusion and Diffusion software are potentially related to post-operative neurological outcome in patients with symptomatic carotid stenosis (SCS) treated by carotid endarterectomy (CEA). Methods From January 2010 to June 2020, data from 134 consecutive patients affected by SCS, presenting with transient ischemic attack (TIA), and minor or moderate stroke, and submitted to urgent CEA in a single academic center, were prospectively collected and reviewed. All SCS patients underwent independent neurological evaluation, duplex ultrasound scan, computed tomographic angiography, and DW-MRI with RAPID evaluation. RAPID evaluation was performed to assess the volume of acute ischemic brain lesion (IBL); through this method it is possible to obtain the identification of the ischemic core milliliters (mL). According with clinical presentation, and imaging studies analysis CEA endarterectomies were performed within 48 hours, within 14 days or after 14 days from symptoms onset. Outcomes for presented analysis were the post-operative new neurological event, and deathat follow-up. Timing of CEA and IBL volume at RAPID evaluation were considered as risk factor potentially influencing outcomes. Results Among all the 134 enrolled patients, 68 patients (50.7%) presented with TIA, 49 (36.6%) with a minor Stroke, and 17 (12.7%) with a moderate Stroke. No intraoperative death occurred in any group. Overall, 6 (4.4%) new neurological events were noted in this series, 1 minor stroke (0.7%), and 5 TIAs (3.7%). One-hundred-fifteen (86%) underwent surgery within 14 days from neurological symptoms onset (Urgent patients – U), and 19 (14%) after 14 days (Delayed patients – D); U patients were also divided in two subgroups U1 47/115 patients (35%) submitted to CEA within 48 hours from symptoms onset, and U2 68/115 patients (51%) after 48 hours. No neurological complications were noted in group D, while 5 new adverse events occurred in U1, and 1 in U2 (p=0.01). Results from MRI with DWI sequences performed in 100/134 patients (74.6%) showed positive preoperative diffusion in 62 patients. The RAPID processing ascribed a 0 value, for punctiform lesions, and a value from 2 to 77 ml for single acute lesions; average volume lesion volume was 8.6 mL. Patients were then divided into two groups according to IBL volume: 84 &amp;lt;10 ml, and 16≥10 mL. Incidence of new neurological events was significantly higher in &amp;gt;10ml group (18.7% vs 3.6%; p=0.02). Conclusion Our experience seems to suggest that the optimal time for SCS revascularization is between 48 hours and 14 days. Moreover, IBL volume &amp;gt;10ml might greatly increase risk of postoperative adverse events occurrence. Funding Acknowledgement Type of funding sources: None.

Interaction between stroke severity and quality indicators of acute stroke care: a single-center retrospective analysis.

Ischemic stroke leads to substantial mortality and morbidity worldwide. Door-to-CT time, door-to-needle time (DNT), and door-to-groin time (DGT) are important quality indicators of stroke care. However, patient characteristics remain important determinants of outcome as well. In this single-center study, we investigated the interaction between these quality indicators and stroke severity regarding long-term functional outcome. All consecutive stroke patients treated at the ZOL stroke center, Genk, Belgium, between 2017 and 2020 were included in this retrospective observational study. Stroke severity was graded as "mild" if National Institutes of Health Stroke Scale (NIHSS) was equal to or lower than 8, "moderate" if NIHSS was between 9 and 15, and "severe" if NIHSS was higher than 16. Modified Rankin Scale (mRS) scores were collected before and 3months after stroke. Ordinal regression analysis with correction for patient characteristics of functional outcome was done. A total of 1255 patients were included, of which 84% suffered an ischemic CVA (n = 1052) and 16% a TIA (n = 203). The proportion of patients treated conservatively or with thrombolysis, thrombectomy, or the combination of both differed according to stroke severity (p < 0.0001). Door-to-CT time was longer in mild and moderate stroke (p < 0.0001). Median DNT also differed between stroke categories: 46 (IQR 31-70) min for mild vs. 36 (25-56) min for moderate vs. 30 (21-45) min for severe stroke (p = 0.0002). Median DGT did not differ between stroke severity categories (p = 0.15). NIHSS on admission and pre-stroke mRS were independently associated with mRS at 90days. Operational performance, reflected in door-to-CT time and DNT, was worse in patients with mild and moderate stroke severity. DNT was also associated with functional outcome in our center, along with pre-stroke mRS, NIHSS on admission and age.

The Relation Between Subjective and Objective Assessment of Cognitive and Physical Functioning in Community-Dwelling Stroke Survivors

<h3>Research Objectives</h3> To investigate the relation between subjectively and objectively assessed cognitive and physical functioning among community-dwelling stroke survivors, and to examine the association of stroke severity with subjectively and objectively assessed cognitive and physical impairments. <h3>Design</h3> Secondary data analysis of a cross-sectional, multi-site study. <h3>Setting</h3> Community. <h3>Participants</h3> One hundred twenty-seven community-dwelling stroke survivors (mean age 57.4; 48.8% female) who were at least one year after discharge from rehabilitation. <h3>Interventions</h3> Not applicable. <h3>Main Outcome Measures</h3> Objective cognitive functioning measured by the NIH Toolbox Cognition Battery and the Executive Function Performance Test (EFPT). Subjective cognitive functioning measured by the Quality of Life in Neurological Disorders (Neuro-QoL) Applied Cognition. Objective and subjective physical functioning measured by the NIH Toolbox 2-Minute Walk Test and the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function, respectively. <h3>Results</h3> A strong positive correlation was found between subjective and objective physical functioning (r = 0.52; P < 0.001), whereas the association between subjective and objective cognitive functioning was nonsignificant. Compared to moderate stroke survivors, mild stroke survivors had lower odds for objective cognitive impairment (total cognition: odds ratio [OR] = 0.28, 95% confidence interval [CI] = 0.12 to 0.64; fluid cognition: OR = 0.34, 95% CI = 0.14 to 0.81; functional cognition: OR = 0.22, 95% CI = 0.08 to 0.61), objective physical impairment (OR = 0.27, 95% CI = 0.08 to 0.86), and subjective physical impairment (OR = 0.37, 95% CI = 0.15 to 0.93). However, no significant association was found between stroke severity and subjective cognitive impairment. <h3>Conclusions</h3> The discordance between objective and subjective cognitive functioning contradicts the conventional assumption that perceived functioning reflects actual performance. Our findings suggest that unique information may be captured in each approach and that they are not interchangeable. As such, incorporating both objective and subjective measures into routine assessment is recommended for clinicians to comprehensively characterize and early identify post-stroke cognitive and physical impairments, enhancing the recognition and management of functional consequences of stroke by clinicians as well as stroke survivors and caregivers. <h3>Author(s) Disclosures</h3> None disclosed.

The Effect of Bright Light Therapy on Sleep and Quality of Life in Patients With Poststroke Insomnia.

Poststroke insomnia is common and negatively affects stroke recovery. The objective of this study was to determine the effectiveness of bright light therapy for mild-to-moderate stroke patients with insomnia. This study was randomized, double blind, and placebo controlled. A 2-week trial was conducted on patients with mild-to-moderate stroke who had poststroke insomnia. Only patients who had experienced a first episode of stroke were enrolled in this study. Sleep parameters were measured using the Actiwatch Spectrum Pro for 7 days before and after light therapy. The instrument specifically collected data concerning sleep, mood state, fatigue, and subjective quality of life. Participants with poststroke insomnia received bright light therapy (10,000 lux) or placebo therapy for 30 minutes in the early morning. A total of 112 eligible participants entered the study, but only 56 patients were randomized to treatment (27 to bright light therapy and 29 to placebo therapy). Results from analysis of variance showed that the mean change of sleep latency (F(1,55) =4.793, p = .033) and sleep efficiency (F(1,55) = 5.625, p = .022) were significantly superior in bright light therapy over placebo. Bright light therapy resulted in significant improvements in daytime sleepiness, fatigue, mood, and quality of life in study participants (p < .05). Bright light therapy is a nonpharmacological treatment of early, poststroke insomnia in patients who had a mild to moderate stroke. In addition, bright light therapy is effective for the treatment of daytime sleepiness, fatigue, and depression and for improving quality of life in patients with poststroke insomnia. ClinicalTrials.gov Identifier: NCT04721574.

Dual-Antiplatelet Therapy May Not Be Associated With an Increased Risk of In-hospital Bleeding in Patients With Moderate or Severe Ischemic Stroke.

Background and Purpose: Dual antiplatelet therapy (DAPT), compared to single antiplatelet therapy (SAPT), lowers the risk of stroke or death early after TIA and minor ischemic stroke. Prior trials excluded moderate to severe strokes, due to a potential increased risk of bleeding. We aimed to compare in-hospital bleeding rates in SAPT and DAPT patients with moderate or severe stroke (defined by NIHSS ≥4).Methods: We performed a retrospective cohort study of ischemic stroke over a 2-year period with admission NIHSS ≥4. The primary outcome was symptomatic intracranial hemorrhage (ICH) with any change in NIHSS. Secondary outcomes included systemic bleeding and major bleeding, a composite of serious systemic bleeding and symptomatic ICH. We performed analyses stratified by stroke severity (NIHSS 4–7 vs. 8+) and by preceding use of tPA and/or thrombectomy. Univariate followed by multivariate logistic regression evaluated whether DAPT was independently associated with bleeding.Results: Of 377 patients who met our inclusion criteria, 148 received DAPT (39%). Symptomatic ICH was less common with DAPT compared to SAPT (0.7 vs. 6.4%, p < 0.01), as was the composite of major bleeding (2.1 vs. 7.6%, p = 0.03). Symptomatic ICH was numerically less frequent in the DAPT group, but not statistically significant, when stratified by stroke severity (NIHSS 4–7: 0 vs. 5.9%, p = 0.06; NIHSS 8+: 1.5 vs. 6.6%, p = 0.18) and by treatment with tPA and/or thrombectomy (Yes: 2.6 vs. 9.1%, p = 0.30; No: 0 vs. 2.9%, p = 0.25). DAPT was not associated with major bleeding in either the univariate or the multivariate regression.Conclusions: In this single center cohort, symptomatic ICH and the composite of serious systemic bleeding and symptomatic ICH was rare in patients on DAPT. Relative to single antiplatelet therapy DAPT was not associated with an increased risk of in-hospital bleeding in patients with moderate and severe ischemic stroke.

Association between HBA1C and NIHSS score in stroke

Diabetes Mellitus is a very common metabolic disorder and it is an independent risk factor for stroke and is associated with 2 to 6 fold increased risk compared with non-diabetic subjects and worsens survival of patients with acute stroke. Glucose intolerance or even fasting hyperglycemia may follow an acute vascular event, and ensuing physical inactivity and poor food intake may lead to continued glucose intolerance. Glucose intolerance in a stroke patient may or may not reflect glycemia prior to the event. Measurement of HbA1C rather than glucose as an indicator of prior glycemia offers a new perspective. Hence this study is to find out association between HbA1c levels with NIHSS score in stroke. To find out association between HbA1c levels with NIHSS score in stroke. This a cross sectional descriptive study. In this study well controlled Diabetes has moderate stroke severity, fairly controlled Diabetes has moderate to severe stroke severity and poorly controlled Diabetes has severe stroke. It is observed that severity of the presenting complaints worsened from well controlled Diabetes to poorly controlled Diabetes. The NIHSS score correlates with the HbA1C, with increase in severity of the stroke from well controlled Diabetes to poorly controlled Diabetes. Severity of the score increases as the infarct size increases. Poorly controlled Diabetes has more severe stroke as per NIHSS score with large sized infarcts. Stroke is a medical emergency and can cause permanent neurological damage, complications and death. National Institutes of Health Stroke Scale (NIHSS) is a well-validated, reliable scoring system for use specifically with stroke patients. The National Institutes of Health Stroke Scale (NIHSS) can be used as a standard measurement instrument by physicians to evaluate the severity of a patient and outcome.

Sleep-disordered breathing and cerebral small vessel disease-acute and 6months after ischemic stroke.

Sleep-disordered breathing (SDB) occurs frequently after stroke and is associated with poor functional outcome and increased mortality. The purpose of this study was to detect changes in SDB over time after acute ischemic stroke and investigate relationships between SDB and stroke etiologies with focus on cerebral small vessel disease. From May 2015 to August 2016, we conducted an observational study of 99 patients with mild to moderate stroke (median age: 68years, range 36-88; 56% men). Polysomnography was performed within 7days of stroke onset (n = 91) and after 6months (n = 52). The strokes were classified using the etiological TOAST classification. Total small vessel disease (SVD) scores were calculated based on MRIs. SDB, defined as an apnea-hypopnea index (AHI) ≥ 15, was found in 56% of patients in the acute state and in 44% at follow-up. AHI decreased over time (median change 4.7, 95% confidence interval [95% CI] 0.5-8.9; p = 0.03). Patients with AHI ≥ 15 in both the acute state and at follow-up had higher SVD score at follow-up (p = 0.003). AHI was not associated with ischemic stroke subgroups according to the TOAST classification. In conclusion, 6months after stroke, AHI decreased, but 44% stillhad AHI ≥ 15. Persistent SDB in both the acute state and at follow-up was associated with a higher SVD score, but not to the TOAST subgroups. SDB evaluation should be offered to stroke patients, and the effect of SDB on cerebral small vessel disease needs to be further investigated using the well-defined SVD score. clinicaltrials.gov NCT02111408, April 11, 2014.

Hemorrhagic stroke outcomes of KApSR patients with co-morbid diabetes and Alzheimer's disease.

BackgroundVascular risk factors, such as diabetes mellitus (DM), are associated with poorer outcomes following many neurodegenerative diseases, including hemorrhagic stroke and Alzheimer’s disease (AD). Combined AD and DM co-morbidities are associated with an increased risk of hemorrhagic stroke and increased Medicare costs. Therefore, we hypothesized that patients with DM in combination with AD, termed DM/AD, would have increased hemorrhagic stroke severity.MethodsKentucky Appalachian Stroke Registry (KApSR) is a database of demographic and clinical data from patients that live in Appalachia, a distinct region with increased health disparities and stroke severity. Inpatients with a primary indication of hemorrhagic stroke were selected from KApSR for retrospective analysis and were separated into four groups: DM only, AD only, neither, or both.ResultsHemorrhagic stroke patients (2,071 total) presented with either intracerebral hemorrhage (ICH), n=1,448, or subarachnoid hemorrhage (SAH), n=623. When examining all four groups, subjects with AD were significantly older (AD+, 80.9±6.6 yrs) (DM+/AD+, 77.4±10.0 yrs) than non AD subjects (DM-/AD-, 61.3±16.5 yrs) and (DM+, 66.0±12.5 yrs). A higher percentage of females were among the AD+ group and a higher percentage of males among the DM+/AD+ group. Interestingly, after adjusting for multiple comparison, DM+/AD+ subjects were ten times as likely to suffer a moderate to severe stroke based on a National Institute of Health Stroke (NIHSS) upon admission [odds ratio (95% CI)] compared to DM-/AD- [0.1 (0.02–0.55)], DM+ [0.11 (0.02–0.59)], and AD+ [0.09(0.01–0.63)]. The odds of DM+/AD+ subjects having an unfavorable discharge destination (death, hospice, long-term care) was significant (P<0.05) from DM-/AD- [0.26 (0.07–0.96)] when adjusting for sex, age, and comorbidities.ConclusionsIn our retrospective analysis utilizing KApSR, regardless of adjusting for age, sex, and comorbidities, DM+/AD+ patients were significantly more likely to have had a moderate or severe stroke leading to an unfavorable outcome following hemorrhagic stroke.

Carotid Endarterectomy During Index Hospital Admission for Patients With Acute Mild to Moderate Stroke

The timing of carotid endarterectomy (CEA) after acute stroke due to an infarct in the middle cerebral artery territory with ipsilateral internal carotid artery stenosis remains controversial. We evaluated the results of CEA in this group of patients during the index hospital admission.

Revisiting Spasticity After Stroke: Clustering Clinical Characteristics for Identifying At-Risk Individuals.

PurposeTo collectively identify the clinical characteristics determining the risk of developing spasticity after stroke.Patients and MethodsA cross-sectional study was conducted at a single rehabilitation outpatient clinic from June to December 2019. Inclusion criteria were stroke duration of over four weeks, aged 18 years and above. Exclusion criteria were presence of concurrent conditions other than stroke that could also lead to spasticity. Recruited patients were divided into “Spasticity” and “No spasticity” groups. Univariate analysis was deployed to identify significant predictive spasticity factors between the two groups followed by a two-step clustering approach for determining group of characteristics that collectively contributes to the risk of developing spasticity in the “Spasticity” group.ResultsA total of 216 post-stroke participants were recruited. The duration after stroke (p < 0.001) and the absence of hemisensory loss (p = 0.042) were two significant factors in the “Spasticity” group revealed by the univariate analysis. From a total of 98 participants with spasticity, the largest cluster of individuals (40 patients, 40.8%) was those within less than 20 months after stroke with moderate stroke and absence of hemisensory loss, while the smallest cluster was those within less than 20 months after severe stroke and absence of hemisensory loss (21 patients, 21.4%).ConclusionAnalyzing collectively the significant factors of developing spasticity may have the potential to be more clinically relevant in a heterogeneous post-stroke population that may assist in the spasticity management and treatment.

Wake‐up strokes are linked to obstructive sleep apnea and worse early functional outcome

Background and AimsPresence of sleep‐disordered breathing (SDB) and especially obstructive sleep apnea (OSA) is a known risk factor for ischemic stroke. Additionally, SDB effects negatively on recovery after stroke. Up to one fourth of strokes are present on awakening. The link between OSA and wake‐up stroke (WUS) has been suggested. We aim to determine the association between OSA and WUS in a Finnish stroke unit cohort.Material and MethodsAn observational prospective longitudinal study consisted of 95 TIA (transient ischemic attack) and mild to moderate stroke patients referred to a Stroke Unit in Finland. Respiratory polygraphy was performed within 72 h of hospital admission. Patients were classified into WUS and non‐WUS, and functional outcome measures (mRS, rehabilitation, hospitalization time) were collected. Functional outcomes and prevalence of OSA were compared between non‐WUS and WUS.ResultsOSA (AHI > 15/h) was more frequent among WUS than non‐WUS (71% and 36%, respectively, p = 0.009). Functional outcome measured with mRS was worse in patients with WUS than non‐WUS on registration day and at hospital discharge (p = 0.001). Need for rehabilitation in WUS was 43% of cases compared to 23% of non‐WUS (p = 0.067). Hospitalization time was longer (5–15days) in 55% of WUS and 41% of non‐WUS patients (p = 0.261).ConclusionModerate‐to‐severe OSA is related to WUS compared to non‐WUS. In addition, WUS have worse short‐term outcomes measured in mRS. Further studies are needed to determine if OSA is causally linked to WUS.

LncRNA SERPINB9P1 expression and polymorphisms are associated with ischemic stroke in a Chinese Han population.

Long noncoding RNAs (lncRNAs) were reported to play important roles in the pathogenesis of ischemic stroke (IS). Our study aimed to investigate the role of lncRNA SERPINB9P1 expression in ischemic stroke and the association between SERPINB9P1 polymorphisms and IS risk, as well as examine the correlation of SERPINB9P1 expression and variants with clinical parameters of IS. The SERPINB9P1 levels in human participants and oxygen-glucose deprivation (OGD)-treated human A172 cells were measured by qRT-PCR. The SERPINB9P1 polymorphisms (rs375556 and rs318429) were genotyped by the MassARRAY platform. We found that the SERPINB9P1 expression was significantly downregulated in patients with IS compared with that in healthy controls. On the 14th day in the hospital, the SERPINB9P1 level in patients with moderate and severe stroke was significantly downregulated compared with the normal group. After stratification by gender, the rs375556 polymorphism was significantly associated with susceptibility to female IS in the recessive model, and the significant association remained after adjusting for age. After adjusting for gender and age, rs318429 was significantly associated with FPG and D-D levels, and rs375556 was significantly associated with INR and PTA levels in IS cases. Besides, the lncRNA SERPINB9P1 expressed downregulated in OGD/reoxygenation-treated human A172 cells. In conclusion, the lncRNA SERPINB9P1 may protect against cerebral ischemia-reperfusion injury and neurological impairment after IS. The SERPINB9P1 rs375556 polymorphism was associated with susceptibility to female IS, and SERPINB9P1 polymorphisms may influence the metabolism of blood glucose and regulation of coagulation function in patients with IS.

Efficacy and Safety of Ticagrelor and Aspirin in Patients With Moderate Ischemic Stroke

Prior trials of dual antiplatelet therapy excluded patients with moderate ischemic stroke. These patients were included in the Acute Stroke or Transient Ischaemic Attack Treated With Ticagrelor and ASA for Prevention of Stroke and Death (THALES) trial, but results have not been reported separately, raising concerns about safety and efficacy in this subgroup. To evaluate the efficacy and safety of ticagrelor plus aspirin in patients with moderate ischemic stroke (National Institutes of Health Stroke Scale [NIHSS] score of 4 to 5). The THALES trial was a randomized trial conducted at 414 hospitals in 28 countries in January 2018 and December 2019. This exploratory analysis compared patients with moderate stroke (baseline NIHSS score of 4 to 5) with patients with less severe stroke (NIHSS score of 0 to 3). A total of 9983 patients with stroke were included in the present analysis, after excluding 2 patients with NIHSS scores greater than 5 and 1031 patients with transient ischemic attack. Data were analyzed from March to April 2021. Ticagrelor (180-mg loading dose on day 1 followed by 90 mg twice daily on days 2 to 30) or placebo within 24 hours after symptom onset. All patients received aspirin, 300 to 325 mg, on day 1 followed by aspirin, 75 to 100 mg, daily on days 2 to 30. Patients were observed for 30 additional days. The primary outcome was time to stroke or death within 30 days. The primary safety outcome was time to severe bleeding. In total, 3312 patients presented with moderate stroke and 6671 presented with less severe stroke. Of those in the moderate stroke group, 1293 (39.0%) were female, and the mean (SD) age was 64.5 (10.8) years; of those in the less severe stroke group, 2518 (37.7%) were female, and the mean (SD) age was 64.8 (11.2) years. The observed primary outcome event rate in patients with moderate stroke was 7.6% (129 of 1671) for those in the ticagrelor group and 9.1% (150 of 1641) for those in the placebo group (hazard ratio, 0.84; 95% CI, 0.66-1.06); the primary outcome event rate in patients with less severe stroke was 4.7% (158 of 3359) for those in the ticagrelor group and 5.7% (190 of 3312) for those in the placebo group (hazard ratio, 0.82; 95% CI, 0.66-1.01) (P for interaction = .88). Severe bleeding occurred in 8 patients (0.5%) in the ticagrelor group and in 4 patients (0.2%) in the placebo group in those with moderate stroke compared with 16 patients (0.5%) and 3 patients (0.1%), respectively, with less severe stroke (P for interaction = .26). In this study, patients with a moderate ischemic stroke had consistent benefit from ticagrelor plus aspirin vs aspirin alone compared with patients with less severe ischemic stroke, with no further increase in the risk of intracranial bleeding or other severe bleeding events. ClinicalTrials.gov Identifier: NCT03354429.