Standard Stroke Unit Research Articles

Effect of Reperfusion Therapies on Incidence of Early Post-Stroke Seizures.

Objective: This study aimed to determine the effect of reperfusion therapies on the occurrence of early post-stroke seizures (PSS) in patients with acute ischemic stroke (AIS).Background: Reperfusion therapies are paramount to the treatment of stroke in the acute phase. However, their effect on the incidence of early seizures after an AIS remains unclear.Design and Methods: The stroke database at Hamad Medical Corporation was used to identify all patients who received reperfusion therapies for AIS from 2016 to 2019. They were matched with patients of similar diagnosis, gender, age, and stroke severity as measured by National Institutes of Health Stroke Scale (NIHSS) who did not receive such treatment. The rates of early PSS were calculated for each group.Results: The results showed that 508 patients received reperfusion therapies (342 had IV thrombolysis only, 70 had thrombectomies only, and 96 had received both), compared with 501 matched patients receiving standard stroke unit care. Patients who received reperfusion therapies were similar to their matched controls for mean admission NIHSS score (9.87 vs. 9.79; p = 0.831), mean age (53.3 vs. 53.2 years; p = 0.849), and gender distribution (85 vs. 86% men; p = 0.655). The group receiving reperfusion therapies was found to have increased stroke cortical involvement (62 vs. 49.3%, p < 0.001) and hemorrhagic transformation rates (33.5 vs. 18.6%, p < 0.001) compared with the control group. The rate of early PSS was significantly lower in patients who received reperfusion therapies compared with those who did not (3.1 vs. 5.8%, respectively; p = 0.042). When we excluded seizures occurring at stroke onset prior to any potential treatment implementation, the difference in early PSS rates between the two groups was no longer significant (2.6 vs. 3.9%, respectively; p = 0.251). There was no significant difference in early PSS rate based on the type of reperfusion therapy either (3.2% with thrombolysis, 2.9% with thrombectomy, and 3.1% for the combined treatment, p = 0.309).Conclusions: Treatment of AIS with either thrombectomy, thrombolysis, or both does not increase the risk of early PSS.

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.

Stroke Care During the COVID-19 Pandemic: Asian Stroke Advisory Panel Consensus Statement

The COVID-19 pandemic has impacted the health system worldwide. Stroke is one of the leading causes of death and disability in the world. Asia has a diverse health system and more than two-thirds of strokes occur in this region. The Asian Stroke Advisory Panel (ASAP) conducted a survey among the member countries to explore the impact of COVID-19 on stroke care. The stroke admission numbers have fallen, as have the number of patients who received thrombolysis and mechanical thrombectomy. The stroke unit and rehabilitation beds have been reallocated for COVID-19 care. ASAP recommends emergency department screening of stroke patients for COVID-19 and protected stroke code to be activated for COVID-19 suspect stroke patients. Noncontrast computed tomography (CT), CT angiography, and CT chest are the imaging modalities of choice. All health care professionals involved in triaging, imaging, and stroke care should wear appropriate personal protective equipment. All eligible stroke patients (COVID suspect/positive/non-COVID) should receive intravenous thrombolysis/mechanical thrombectomy. Mobile stroke units and robots can be used wherever available for evaluation and triaging. All stroke patients should receive standard stroke unit care. Limited rehabilitation should be offered to patients and training of caregivers if needed. Telemedicine/telestroke should be used for rehabilitation and follow-up. The ASAP consensus statement can be adapted to suit local and national health care systems.

The use of hypnotherapy as treatment for functional stroke: A case series from a single center in the UK.

BackgroundFunctional neurological disorder is defined by symptoms not explained by the current model of disease and its pathophysiology. It is found in 8.4% of patients presenting as acute stroke. Treatment is difficult and recurrence rates are high. We introduced hypnotherapy as a therapeutic option in addition to standard stroke unit care.MethodsThis is an observational study of successive patients with functional neurological disorder presenting as acute stroke treated with hypnotherapy between 1 April 2014 and 1 February 2018. The diagnosis of functional neurological disorder was confirmed by clinical examination and computed tomography/magnetic resonance imaging. Hypnosis was delivered by a hypnotherapy trained stroke physician using imagery for induction. A positive response was defined as a National Institutes of Health Stroke score reduction to 0 or by ≥4 points posthypnotherapy. Costs were calculated as therapist time and benefits as reduction in disability/bed days.ResultsSixty-eight patients (mean age 36.4 years, 52 (76%) females, mean baseline National Institutes of Health Stroke 5.0 (range 1–9)) were included. Two patients (3%) could not be hypnotized. Fifty-eight 58 (85%) responded, 47 (81%) required one treatment session, while 19% needed up to three sessions for symptomatic improvement. No adverse events were observed. Disability (modified Rankin Scale) reduced from a mean of 2.3 to 0.5 resulting in an average cost saving of £1,658 per patient. Most (n = 50, 86%) remained well without recurrence at six-month follow-up.ConclusionsIn this case series, hypnotherapy was associated with rapid and sustained recovery of symptoms. A prospective randomized controlled study is required to confirm the findings and establish generalizability of the results.

Abstract WP377: Heart Rate Variability Biofeedback Improves Cardiac Autonomic Function in Patients With Acute Ischaemic Stroke: A Randomized Controlled Study

Introduction: In patients with acute ischaemic stroke (AIS) dysregulation of cardiac function with decreased heart rate variability (HRV) due to impaired integrity of the autonomic nervous system is a frequent complication which is associated with increased mortality and worsening of clinical outcome. HRV biofeedback has previously been suggested to improve cardiac autonomic function by increasing parasympathetic tone. Hypothesis: We hypothesized that HRV biofeedback can be used to complement stroke unit care and alleviate autonomic cardiac dysfunction following AIS. Methods: We randomly allocated patients with AIS to either receive 9 sessions of HRV (n=24) or sham (n=24) biofeedback in addition to standard stroke unit care. These patients underwent detailed assessment of autonomic cardiac function including analysis of HRV via standard deviation of NN intervals (SDNN) and spectral analysis. Furthermore, we assessed vasomotor and sudomotor autonomic function, severity of autonomic symptoms and neurological and functional outcomes. Results: We included 48 patients (19 females, ages 65±14 years, baseline NIHSS 2.2 ± 2.2, mean ± standard deviation). Patients who had undergone HRV biofeedback displayed improved cardiac function compared to baseline (SDNN 72.6 ± 52.4 ms vs. 45.5 ± 34.7 ms, p&lt;0.01) which was not seen in those who received sham biofeedback (p=ns). Similar changes were seen on spectral analysis measures of parasympathetic function (p&lt;0.01). Improvement of autonomic cardiac function following HRV biofeedback was paralleled by decreased severity of autonomic symptoms (p&lt;0.05). Contrasting our observation of an increase in predominantly parasympathetic parameters such as CVNN, sympathetic measures of sudomotor and vasomotor function remained unchanged in both groups (p=ns). Neurological and functional outcomes were unchanged immediately post intervention, however 3-month follow up is yet to be completed. Discussion: HRV biofeedback can modulate autonomic cardiac function post AIS to increase HRV and alleviate autonomic symptoms which might be beneficial in facilitating recovery from functional impairment. This seems to be mediated by a predominantly parasympathetic mechanism of action.

Abstract TP285: Ongoing Clinical Trial: Treatment With Exenatide in Acute Ischaemic Stroke (TEXAIS) Trial: Prospective, Randomised, Open Label, Blinded End-point Study of Exenatide vs. Standard Care in Post Stroke Hyperglycaemia

Background and Aims: Post-stroke hyperglycaemia (PSH) occurs in up to 50% of patients presenting with acute ischaemic stroke (AIS). It reduces the efficacy of thrombolysis, increases infarct size, and worsens clinical outcomes. Insulin-based therapies have generally not been beneficial in treating PSH as they are difficult to implement, may cause hypoglycaemia, possibly increase mortality and worse clinical outcomes. Exenatide may be a safer, simple, and more effective alternative to insulin in AIS. Methods: TEXAIS is a 3-year, Phase 2, multi-centre, prospective, randomised, open label, blinded end-point (PROBE) trial comparing Exenatide to Standard of Care. It aims to recruit 528 patients with a primary end point of major neurological improvement1 at 7 days defined as a ≥8-point improvement in NIHSS score, or NIHSS 0-1. Secondary outcomes of hyper- and hypoglycaemia at 5 days and NIHSS and mRS at 90 days will be measured. The treatment arm will receive Exenatide 5μg subcutaneously twice daily. The control arm will receive standard stroke unit care. Continuous glucose monitors will track the dynamic variability of glucose. Results: Recruitment in TEXAIS is continuing with over 40 patients enrolled to date. Conclusion: TEXAIS aims to show that Exenatide is safe and effective in the treatment of PSH. It has been designed to be highly generalisable with an ability to enroll a large percentage of patients with AIS, regardless of admission blood glucose level, diabetes status, or stroke severity, with very low risk of hypoglycaemia.

Treatment with exenatide in acute ischemic stroke trial protocol: A prospective, randomized, open label, blinded end-point study of exenatide vs. standard care in post stroke hyperglycemia.

Rationale Post-stroke hyperglycemia occurs in up to 50% of patients presenting with acute ischemic stroke. It reduces the efficacy of thrombolysis, increases infarct size, and worsens clinical outcomes. Insulin-based therapies have generally not been beneficial in treating post-stroke hyperglycemia as they are difficult to implement, may cause hypoglycaemia, possibly increase mortality and worsen clinical outcomes. Exenatide may be a safer, simpler, and more effective alternative to insulin in acute ischemic stroke. Design TEXAIS is a three year, Phase 2, multi-center, prospective, randomized, open label, blinded end-point trial comparing exenatide to standard of care. It aims to recruit 528 patients with a primary end point of major neurological improvement at 7 days defined as a ≥8-point improvement in NIHSS score, or NIHSS 0-1. Secondary outcomes of hyper- and hypoglycaemia at 5 days and NIHSS and mRS at 90 days will be measured. The treatment arm will receive exenatide 5 µg subcutaneously twice daily. The control arm will receive standard stroke unit care. Continuous glucose monitors will track the dynamic variability of glucose. Conclusion TEXAIS aims to show that exenatide is safe and effective in the treatment of post-stroke hyperglycemia. It has been designed to be highly generalizable with an ability to enroll a large percentage of patients with acute ischemic stroke, regardless of admission blood glucose level, diabetes status, or stroke severity, with very low risk of hypoglycemia. Trial registration: ClinicalTrials.gov/ANZCTR NTA1127.

Preventive Antibiotics in Stroke Study (PASS): A cost-effectiveness study.

To evaluate the cost-effectiveness of preventive ceftriaxone vs standard stroke unit care without preventive antimicrobial therapy in acute stroke patients. In this multicenter, randomized, open-label trial with masked endpoint assessment, 2,550 patients with acute stroke were included between 2010 and 2014. Economic evaluation was performed from a societal perspective with a time horizon of 3 months. Volumes and costs of direct, indirect, medical, and nonmedical care were assessed. Primary outcome was cost per unit of the modified Rankin Scale (mRS) and per quality-adjusted life year (QALY) for cost-effectiveness and cost-utility analysis. Incremental cost-effectiveness analyses were performed. A total of 2,538 patients were available for the intention-to-treat analysis. For the cost-effectiveness analysis, 2,538 patients were available for in-hospital resource use and 1,453 for other resource use. Use of institutional care resources, out-of-pocket expenses, and productivity losses was comparable between treatment groups. The mean score on mRS was 2.38 (95% confidence interval [CI] 2.31-2.44) vs 2.44 (95% CI 2.37-2.51) in the ceftriaxone vs control group, the decrease by 0.06 (95% CI -0.04 to 0.16) in favor of ceftriaxone treatment being nonsignificant. However, the number of QALYs was 0.163 (95% CI 0.159-0.166) vs 0.155 (95% CI 0.152-0.158) in the ceftriaxone vs control group, with the difference of 0.008 (95% CI 0.003-0.012) in favor of ceftriaxone (p = 0.006) at 3 months. The probability of ceftriaxone being cost-effective ranged between 0.67 and 0.89. Probability of 0.75 was attained at a willing-to-pay level of €2,290 per unit decrease in the mRS score and of €12,200 per QALY. Preventive ceftriaxone has a probability of 0.7 of being less costly than standard treatment per unit decrease in mRS and per QALY gained.

The Randomized Controlled STRAWINSKI Trial: Procalcitonin-Guided Antibiotic Therapy after Stroke.

Pneumonia is among the most common acute complications after stroke and is associated with poor long-term outcome. Biomarkers may help identifying stroke patients at high risk for developing stroke-associated pneumonia (SAP) and to guide early treatment. This trial investigated whether procalcitonin (PCT) ultrasensitive (PCTus)-guided antibiotic treatment of SAP can improve functional outcome after stroke. In this international, multicenter, randomized, controlled clinical trial with blinded assessment of outcomes, patients with severe ischemic stroke in the middle cerebral artery territory were randomly assigned within 40 h after symptom onset to PCTus-based antibiotic therapy guidance in addition to stroke unit care or standard stroke unit care alone. The primary endpoint was functional outcome at 3 months, defined according to the modified Rankin Scale (mRS) and dichotomized as acceptable (≤4) or unacceptable (≥5). Secondary endpoints included usage of antibiotics, infection rates, days of fever, and mortality. The trial was registered with http://ClinicalTrials.gov (Identifier NCT01264549). In the intention-to-treat-analysis based on 227 patients (112 in PCT and 115 in control group), 197 patients completed the 3-month follow-up. Adherence to PCT guidance was 65%. PCT-guided therapy did not improve functional outcome as measured by mRS (odds ratio 0.79; 95% confidence interval 0.45-1.35, p = 0.47). Pneumonia rate and mortality were similar in both groups. Days with fever tended to be lower (p = 0.055), whereas total number of days treated with antibiotics were higher (p = 0.004) in PCT compared to control group. A post hoc analysis including all PCT values in the intention-to-treat population demonstrated a significant increase on the first day of infection in patients with pneumonia and sepsis compared to patients with urinary tract infections or without infections (p < 0.0001). PCTus-guided antibiotic therapy did not improve functional outcome at 3 months after severe ischemic stroke. PCT is a promising biomarker for early detection of pneumonia and sepsis in acute stroke patients.

Pre-Stroke Use of Beta-Blockers Does Not Lower Post-Stroke Infection Rate: An Exploratory Analysis of the Preventive Antibiotics in Stroke Study

Background: Stroke-associated infections occur frequently and are associated with unfavorable outcome. Previous cohort studies suggest a protective effect of beta-blockers (BBs) against infections. A sympathetic drive may increase immune suppression and infections. Aim: This study is aimed at investigating the association between BB treatment at baseline and post-stroke infection in the Preventive Antibiotics in Stroke Study (PASS), a prospective clinical trial. Methods: We performed an exploratory analysis in PASS, 2,538 patients with acute phase of stroke (24 h after onset) were randomized to ceftriaxone (intravenous, 2 g per day for 4 days) in addition to stroke unit care, or standard stroke unit care without preventive antibiotic treatment. All clinical data, including use of BBs, was prospectively collected. Infection was diagnosed by the treating physician, and independently by an expert panel blinded for all other data. Multivariable analysis was performed to investigate the relation between BB treatment and infection rate. Results: Infection, as defined by the physician, occurred in 348 of 2,538 patients (14%). Multivariable analysis showed that the use of BBs at baseline was associated with the development of infection during clinical course (adjusted OR (aOR) 1.61, 95% CI 1.19-2.18; p < 0.01). BB use at baseline was also associated with the development of pneumonia (aOR 1.56, 95% CI 1.05-2.30; p = 0.03). Baseline BB use was not associated with mortality (aOR 1.14, 95% CI 0.84-1.53; p = 0.41) or unfavorable outcome at 3 months (aOR 1.10, 95% CI 0.89-1.35; p = 0.39). Conclusions: Patients treated with BBs prior to stroke have a higher rate of infection and pneumonia.

Does listening to music in acute stroke improve outcomes? A single-blinded quasi-randomized pilot study

Evidence indicates that daily listening to music can improve outcomes in patients recovering from a recent stroke. This study investigated the feasibility and impact of music-listening in addition to standard stroke unit care. It was hypothesized that patients (N = 38) who listened to 70 hours of self-selected music via MP3 players in the first 12 weeks post stroke in addition to standard stroke unit care would experience improved outcomes compared with patients who received standard stroke care alone. Adherence was monitored via weekly diary entries with regular phone contact from researchers. This single-blinded, two armed quasi-randomized pilot study recruited adult participants diagnosed with a recent stroke (≤7 days). The primary outcomes were depression and cognition (memory and attention) at 3 month and the secondary outcomes were anxiety, language, disability and quality of life at 3 or 6 months. Of the 38 participants 11 had a prior history of stroke and 8 died during follow- up. There were no between-group differences in baseline characteristics and no between-group differences in any outcome over time. Adherence to the listening-to-music intervention was low (22.2%). This study demonstrates the feasibility of adding daily listening to music to standard stroke unit care. However, compliance was low. Although those in the intervention group reported that listening to music was a positive experience, it was not associated with any differences in outcomes of interest.

Prophylactic antibiotics after acute stroke for reducing pneumonia in patients with dysphagia (STROKE-INF): a prospective, cluster-randomised, open-label, masked endpoint, controlled clinical trial

Post-stroke pneumonia is associated with increased mortality and poor functional outcomes. This study assessed the effectiveness of antibiotic prophylaxis for reducing pneumonia in patients with dysphagia after acute stroke. We did a prospective, multicentre, cluster-randomised, open-label controlled trial with masked endpoint assessment of patients older than 18 years with dysphagia after new stroke recruited from 48 stroke units in the UK, accredited and included in the UK National Stroke Audit. We excluded patients with contraindications to antibiotics, pre-existing dysphagia, or known infections, or who were not expected to survive beyond 14 days. We randomly assigned the units (1:1) by computer to give either prophylactic antibiotics for 7 days plus standard stroke unit care or standard stroke unit care only to patients clustered in the units within 48 h of stroke onset. We did the randomisation with minimisation to stratify for number of admissions and access to specialist care. Patient and staff who did the assessments and analyses were masked to stroke unit allocation. The primary outcome was post-stroke pneumonia in the first 14 days, assessed with both a criteria-based, hierarchical algorithm and by physician diagnosis in the intention-to-treat population. Safety was also analysed by intention to treat. This trial is closed to new participants and is registered with isrctn.com, number ISRCTN37118456. Between April 21, 2008, and May 17, 2014, we randomly assigned 48 stroke units (and 1224 patients clustered within the units) to the two treatment groups: 24 to antibiotics and 24 to standard care alone (control). 11 units and seven patients withdrew after randomisation before 14 days, leaving 1217 patients in 37 units for the intention-to-treat analysis (615 patients in the antibiotics group, 602 in control). Prophylactic antibiotics did not affect the incidence of algorithm-defined post-stroke pneumonia (71 [13%] of 564 patients in antibiotics group vs 52 [10%] of 524 in control group; marginal adjusted odds ratio [OR] 1·21 [95% CI 0·71-2·08], p=0·489, intraclass correlation coefficient [ICC] 0·06 [95% CI 0·02-0·17]. Algorithm-defined post-stroke pneumonia could not be established in 129 (10%) patients because of missing data. Additionally, we noted no differences in physician-diagnosed post-stroke pneumonia between groups (101 [16%] of 615 patients vs 91 [15%] of 602, adjusted OR 1·01 [95% CI 0·61-1·68], p=0·957, ICC 0·08 [95% CI 0·03-0·21]). The most common adverse events were infections unrelated to post-stroke pneumonia (mainly urinary tract infections), which were less frequent in the antibiotics group (22 [4%] of 615 vs 45 [7%] of 602; OR 0·55 [0·32-0·92], p=0·02). Diarrhoea positive for Clostridium difficile occurred in two patients (<1%) in the antibiotics group and four (<1%) in the control group, and meticillin-resistant Staphylococcus aureus colonisation occurred in 11 patients (2%) in the antibiotics group and 14 (2%) in the control group. Antibiotic prophylaxis cannot be recommended for prevention of post-stroke pneumonia in patients with dysphagia after stroke managed in stroke units. UK National Institute for Health Research.

The Preventive Antibiotics in Stroke Study (PASS): a pragmatic randomised open-label masked endpoint clinical trial

In adults with acute stroke, infections occur commonly and are associated with an unfavourable functional outcome. In the Preventive Antibiotics in Stroke Study (PASS) we aimed to establish whether or not preventive antimicrobial therapy with a third-generation cephalosporin, ceftriaxone, improves functional outcome in patients with acute stroke. In this multicentre, randomised, open-label trial with masked endpoint assessment, patients with acute stroke were randomly assigned to intravenous ceftriaxone at a dose of 2 g, given every 24 h intravenously for 4 days, in addition to stroke unit care, or standard stroke unit care without preventive antimicrobial therapy; assignments were made within 24 h after symptom onset. The primary endpoint was functional outcome at 3 months, defined according to the modified Rankin Scale and analysed by intention to treat. The primary analysis was by ordinal regression of the primary outcome. Secondary outcomes included death, infection rates, antimicrobial use, and length of hospital stay. Participants and caregivers were aware of treatment allocation but assessors of outcome were masked to group assignment. This trial is registered with controlled-trials.com, number ISRCTN66140176. Between July 6, 2010, and March 23, 2014, a total of 2550 patients from 30 sites in the Netherlands, including academic and non-academic medical centres, were randomly assigned to the two treatment groups: 1275 patients to ceftriaxone and 1275 patients to standard treatment (control group). 12 patients (seven in the ceftriaxone group and five in the control group) withdrew consent immediately after randomisation, leaving 2538 patients available for the intention-to-treat-analysis (1268 in the ceftriaxone group and 1270 in the control group). 2514 (99%) of 2538 patients (1257 in each group) completed 3-month follow-up. Preventive ceftriaxone did not affect the distribution of functional outcome scores on the modified Rankin Scale at 3 months (adjusted common odds ratio 0·95 [95% CI 0·82-1·09], p=0·46). Preventive ceftriaxone did not result in an increased occurrence of adverse events. Overgrowth infection with Clostridium difficile occurred in two patients (<1%) in the ceftriaxone group and none in the control group. Preventive ceftriaxone does not improve functional outcome at 3 months in adults with acute stroke. The results of our trial do not support the use of preventive antibiotics in adults with acute stroke. Netherlands Organization for Health Research and Development, Netherlands Heart Foundation, and the European Research Council.

ROLE OF STROKE UNIT CARE WITH PANCHAKARMA IN THE MANAGEMENT OF STROKE: AN OBSERVATIONAL CASE SERIES

The prevalence of stroke in India ranges from 40 - 270 per 100 000 population. Stroke patients who receive stroke unit care are more likely to get better relief than conventional care. S troke unit care doesn’t include Ayurvedic treatment in their protocol but i t is common for stroke patient to seek help of alternative medicine especially A yurvedic panchakarma therapies. The present study is an observational case series on stroke patients who received treatment at stroke unit care. The present study was planned t o assess the role of stroke unit care along with panchakarma in the management o f stroke. Total 1 5 stable stroke patients were observed for 14 days , who received internal mo dern medication, physiotherapy and speech and language therapy along with panchakarma . Total two assessments were carried out. First assessment was taken on the fi rst day of starting panchakarma therapy along with standard stroke unit care . Second assessment was carried out after 14 days of first assessment. A criterion of assessment was based on the scoring of National Institutes of Health Stroke Scale (NIH SS) and Stroke Specific Quality of Life Scale (SS - QOL); Paired‘t’ test was used for statistical evaluation. Stroke unit care with panchakarma has provided 63.49 % relief (P < 0.001) on NIH SS and 77.6 % relief (P < 0.001) on SS QOL. Maximum number of patients (53 .33 % and 40 %) got moderate improvement on NIH SS and SS QOL respectively . Stroke unit care with panchakarma seems to be beneficial and better option in the management of stroke.

Mild Hypothermia After Intravenous Thrombolysis in Patients With Acute Stroke

Hypothermia improves outcome in resuscitated patients and newborns with hypoxic brain injury. We studied the safety and feasibility of mild hypothermia in awake patients with stroke after intravenous thrombolysis. Patients were randomized 1:1 to mild hypothermia (35°C) or to standard stroke unit care within 6 hours of symptom onset. Hypothermia was induced with a surface-cooling device and cold saline infusions. Active cooling was restrained gradually after 12 hours at <35.5°C. The primary outcome measure was the number of patients with <36°C body temperature for >80% of the 12-hour cooling period. We included 36 patients with a median of National Institutes of Health Stroke Scale score of 9 one hour after thrombolysis. Fifteen of 18 (83%) patients achieved the primary end point. Sixteen (89%) patients reached <35.5°C in a median time of 10 hours (range, 7-16 hours) from symptom onset, spent 10.5 hours (1-17 hours) in hypothermia, and were back to normothermia in 23 hours (15-29 hours). Few serious adverse events were more common in the hypothermia group. At 3 months, 7 patients (39%) in both groups had good outcome (modified Ranking Scale, 0-2), whereas poor outcome (modified Ranking Scale, 4-6) was twice as common in the normothermia group (44% versus 22%). Mild hypothermia with a surface-cooling device in an acute stroke unit is safe and feasible in thrombolyzed, spontaneously breathing patients with stroke, despite the adverse events. http://www.clinicaltrials.gov. Unique identifier: NCT00987922.

Laminar infarcts in clinical routine: a prospective analysis in standard stroke unit patients

The present study aimed to investigate prospectively the frequency of laminar infarcts (LI) within a standard stroke unit population. Laminar infarcts follow neuroanatomical borders rather than the vascular architecture. The LI are rarely noticed in clinical routine because they are typically not detected by computed tomography. As there is a lack of systemic studies about this specific infarct pattern, little is known about their frequency, clinical characteristics or pathophysiological mechanisms. Consecutive acute ischemic stroke unit patients were prospectively enrolled during a 12 month period. The LI were defined as ischemic lesions following the gyral anatomy of the cerebral cortex. The clinical assessment included a standardized questionnaire, clinical syndromes and standard diagnostic results. There were 491 consecutive ischemic stroke patients enrolled (243 female, mean age 75 ± 12 years). The MRI revealed no laminar lesion crossing vascular territories and 28 patients with LI non-crossing vascular territories (7 %). According to the TOAST classification, 61 % of LI were classified as stroke of undetermined etiology (TOAST V) including 46 % with completed evaluation (TOAST Vb). In contrast to these findings, only 20 % of the whole study cohort with non-laminar infarcts were classified as TOAST V. The results indicate that LI are rare. In clinical routine, patients with LI require particular attention. Within the TOAST classification, this specific infarct pattern seems to be underrepresented.

STRoke Adverse Outcome is Associated with NoSocomial Infections (STRAWINSKI): Procalcitonin Ultrasensitive-Guided Antibacterial Therapy in Severe Ischaemic Stroke Patients – Rationale and Protocol for a Randomized Controlled Trial

Stroke-associated pneumonia is one of the most common causes of poor outcome in stroke patients. Clinical signs and laboratory parameters of stroke-associated infections are often inconclusive. Biomarkers may help to identify stroke patients at high risk for pneumonia and to guide physicians in an early antibiotic treatment, thereby improving stroke outcome. The aim of the present study is to investigate whether procalcitonin ultrasensitive-guided antibiotic treatment improves functional outcome after severe ischaemic stroke by early treatment of pneumonia. STRAWINSKI is an investigator-initiated, multicentre, randomized, controlled trial with blinded assessment of outcome comparing procalcitonin ultrasensitive-guided antibiotic treatment with standard care. 200 patients with ischaemic stroke in the middle cerebral artery territory and a score >9 on the National Institutes of Health Stroke Scale will be included and randomly assigned to two groups. One group will receive procalcitonin-based antibiotic therapy guidance; the other group will receive standard stroke unit care. The primary endpoint is functional outcome at day 90 after stroke on the modified Rankin Scale, dichotomized as favourable (0-4) or unfavourable outcome (5-6). Secondary endpoints are time to first event of death, rehospitalization, or recurrent stroke; death rate, infection rate, and days with fever up to day 7; length of hospital stay and hospital discharge disposition; shift analysis of the modified Rankin Scale; Barthel Index and days alive and out of hospital at day 90; use of antibiotics until day 90; and modified Rankin Scale, Barthel Index, and infarct volume at day 180.

Very Early Mobilization After Stroke Fast-Tracks Return to Walking

regaining functional independence is an important goal for people who have experienced stroke. We hypothesized that introducing earlier and more intensive out-of-bed activity after stroke would reduce time to unassisted walking and improve independence in activities of daily living. a Very Early Rehabilitation Trial (AVERT) was a phase II randomized controlled trial. Patients with confirmed stroke (infarct or hemorrhage) admitted <24 hours after stroke and who met physiological safety criteria were eligible. Patients randomized to the very early and intensive mobilization group were mobilized within 24 hours of stroke and at regular intervals thereafter. Control patients received standard stroke unit care. The primary outcome for this analysis was the number of days required to return to walking 50 m unassisted. Secondary outcomes were the Barthel Index and Rivermead Motor Assessment at 3 and 12 months after stroke. seventy-one stroke patients with a mean age of 74.7 years were recruited from 2 hospitals. Adjusted Cox regression indicated that very early and intensive mobilization group patients returned to walking significantly faster than did standard stroke unit care controls (P=0.032; median 3.5 vs 7.0 days). Multivariable regression revealed that exposure to very early and intensive mobilization was independently associated with good functional outcome on the Barthel Index at 3 months (P=0.008) and on the Rivermead Motor Assessment at 3 (P=0.050) and 12 (P=0.024) months. earlier and more intensive mobilization after stroke may fast-track return to unassisted walking and improve functional recovery. Clinical Trial Registration- This trial was not registered because enrollment began before July 2005.

P9-13 Prevalence of obstructive sleep apneas in acute stroke patients

Objective: Aim of this study is to investigate the prevalence and clinical correlates of obstructive sleep apnea (OSA) in acute stroke patients. Background: Recent literature demonstrates that OSA is an independent risk factor for acute stroke, yet stroke may also lead to OSA. Moreover, several studies suggest that OSA in acute stroke is associated with a worse clinical outcome by compromising hemodynamics and oxygenation in a phase of critically affected but viable brain tissue (penumbra). Continuous Positive Airways Pressure (CPAP) therapy in acute stroke patients has been proposed as a means of reducing secondary damage to the penumbra, yet the procedure seems hampered by feasibility issues in the acute stroke setting. This study aimed to (1) evaluate the prevalence of OSA in the setting of acute stroke, and (2) investigate which clinical characteristics distinguish acute stroke patients with from those without OSA. Methods: A prospective study was carried out in consecutive patients admitted to the stroke unit with an acute ischemic stroke. In all patients, clinical characteristics and a sleep history was performed and a polygraphic examination was conducted with an Embletta polygraph (Embla, USA) within 48 hours of stroke onset. Results: 20 patients consented to study inclusion (mean age 68 years, mean BMI 29). Stroke severity was mild to moderate (mean National Institute of Health Scale Score 7). OSA, defined as an apnea hypopnea index (AHI) 5, was seen in 55% andAHI 20 in 15% of the stroke patients. There were no clinical stroke characteristics that distinguished patients with from patients without OSA. Conclusions: OSA in acute ischemic stroke patients is a common phenomenon. In order to protect the penumbra, OSA screening and treatment might be considered as part of standard stroke unit care.

Very Early Rehabilitation or Intensive Telemetry after Stroke: A Pilot Randomised Trial

Background: Stroke patients are more likely to make a good recovery if they receive care in a well-organised stroke unit. However, there are uncertainties about how best to provide such care. We studied 2 key aspects of early stroke unit care: early active mobilisation (EM) and automated monitoring (AM) for physiological complications such as hypoxia. Methods: This was an observer-blinded, factorial (2 × 2) pilot randomised controlled trial recruiting stroke patients within 36 h of symptom onset. The patients were randomised to 1 of 4 nurse-led treatment protocols: (a) standard stroke unit care, (b) EM, (c) AM or (d) combined EM and AM. The primary outcome was the Rankin score at 3 months. We also report the data on feasibility and safety. Results: We randomised 32 patients (mean age = 65 years; mean baseline modified NIH score = 6). On unadjusted comparisons, the EM patients were significantly (p < 0.05) more likely to mobilise very early (within 1 h of randomisation) and to achieve walking by day 5 and were less likely to develop complications of immobility. The AM group was significantly (p < 0.05) more likely to have pre-defined physiological complication events detected. All these associations remained, but were less statistically significant, after correcting for age, baseline NIH score and co-interventions. There were no significant safety concerns. Discussion: We have demonstrated the feasibility of implementing EM and AM for physiological complications in a randomised controlled trial. Larger trials are warranted to determine whether these interventions have clinical benefits.