Subacute Stage Of Stroke Research Articles

Predicting and accelerating motor recovery after stroke.

This review presents recent developments in the prediction of motor recovery after stroke; explores whether rehabilitation interventions delivered during the spontaneous recovery process can improve outcomes; and identifies the first trials to focus on the rate rather than extent of motor recovery (Supplementary Digital Content 1). Two recent studies have attempted to accelerate the rate of motor recovery during the first few weeks after stroke, with neuromodulation techniques designed to facilitate excitability of the ipsilesional motor cortex. One trial using transcranial direct current stimulation was negative, and the other trial using bilateral priming was positive. These contrasting results may be explained by important differences in trial design. This new focus on modifying rate, rather than extent, of motor recovery is in line with accumulating evidence that the motor recovery plateau is largely determined by the extent of damage to descending motor pathways, which is currently untreatable. Interventions that facilitate neural plasticity and reorganization may accelerate recovery of motor function during the spontaneous recovery period, without affecting final outcome. This may represent a useful new approach for future trials conducted during rehabilitation at the subacute stage of stroke.

Melatonin improves neuroplasticity by upregulating the growth‐associated protein‐43 (GAP‐43) andNMDARpostsynaptic density‐95 (PSD‐95) proteins in cultured neurons exposed to glutamate excitotoxicity and in rats subjected to transient focal cerebral ischemia even during a long‐term recovery period

Recent evidence shows that the NMDAR postsynaptic density-95 (PSD-95), growth-associated protein-43 (GAP-43), and matrix metalloproteinase-9 (MMP-9) protein enhance neuroplasticity at the subacute stage of stroke. Here, we evaluated whether melatonin would modulate the PSD-95, GAP-43, and MMP-9 proteins in cultured neurons exposed to glutamate excitotoxicity and in rats subjected to experimental stroke. Adult male Sprague-Dawley rats were treated with melatonin (5 mg/kg) or vehicle at reperfusion onset after transient occlusion of the right middle cerebral artery (tMCAO) for 90 min. Animals were euthanized for Western immunoblot analyses for the PSD-95 and GAP-43 proteins and gelatin zymography for the MMP-9 activity at 7 days postinsult. Another set of animals was sacrificed for histologic and Golgi-Cox-impregnated sections at 28 days postinsult. In cultured neurons exposed to glutamate excitotoxicity, melatonin significantly upregulated the GAP-43 and PSD-95 expressions and improved dendritic aborizations (P<0.05, respectively). Relative to controls, melatonin-treated stroke animals caused a significant improvement in GAP-43 and PSD-95 expressions as well as the MMP-9 activity in the ischemic brain (P<0.05). Consequently, melatonin also significantly promoted the dendritic spine density and reduced infarction in the ischemic brain, and improved neurobehaviors as well at 28 days postinsult (P<0.05, respectively). Together, melatonin upregulates GAP-43, PSD-95, and MMP-9 proteins, which likely accounts for its actions to improve neuroplasticity in cultured neurons exposed to glutamate excitotoxicity and to enhance long-term neuroprotection, neuroplasticity, and brain remodeling in stroke rats.

Evaluation of influence of chronic kidney disease and sodium disturbances on clinical course of acute and sub-acute stage first-ever ischemic stroke.

BackgroundChronic kidney disease (CKD) is an independent risk factor for cardiovascular morbidity and mortality. Hyponatremia is the most common electrolyte disturbance encountered in the neurological and neurosurgical intensive care units, and can exacerbate existing neurological deficits. The objective of this study was to observe the influences of chronic kidney disease and sodium disturbances on the clinical course of acute and sub-acute stages of first-ever ischemic stroke.Material/Methods464 patients with previously diagnosed chronic kidney disease (aged 70.42±11.49 years; 250 women) who had experienced their first-ever ischemic stroke were qualified. The following examinations were performed: serum levels of sodium, creatinine, lipids, estimated glomerular filtration rate (eGFR), neurological state on 1st day of stroke (according to National Institutes of Health Stroke Scale), functional state measured with the Rankin scale, (RS) and mortality rate at 1 month after stroke.ResultsThe neurological state on 1st day of stroke was worse and the median RS (30 days after stroke) was higher in patients with eGFR ≤60 ml/ (min×1.73). Men with eGFR ≤60 ml had greater neurological deficits and increased mortality within 1 month. In patients with eGFR >60 ml/, male sex was more often associated with worse outcomes at 1 month after ischemic stroke. Hyponatremia was associated with a more severe state in both the acute and sub-acute stages of stroke, with higher incidence of death within 1 month after stroke. Men with hyponatremia had greater neurological deficits on the 1st day and increased mortality within 1 month.ConclusionsRenal impairment and hyponatremia are associated with worse neurological outcomes in patients in the acute stage of their first-ever stroke and within 1 month after the event. Males with impaired kidney function and hyponatremia have a more severe course in their first-ever ischemic stroke, as well as having increased mortality.

Evidence for the effectiveness of walking training on walking and self-care after stroke: a systematic review and meta-analysis of randomized controlled trials.

To examine the effect of randomized controlled trials of walking training on walking and self-care in patients with stroke. MEDLINE, CINAHL, Embase, PEDro, OTSeeker, Central, and manual search to the end of August 2012. English, Finnish, Swedish, or German language walking training randomized controlled trials for patients over 18 years of age with stroke. The meta-analyses included 38 randomized controlled trials from 44 reports. There was high evidence that in the subacute stage of stroke, specific walking training resulted in improved walking speed and distance compared with traditional walking training of the same intensity. In the chronic stage, walking training resulted in increased walking speed and walking distance compared with no/placebo treatment, and increased walking speed compared with overall physio-therapy. On average, 24 training sessions for 7 weeks were needed. Walking training improves walking capacity and, to some extent, self-care in different stages of stroke, but the training frequency should be fairly high.

Change of muscle architecture following body weight support treadmill training for persons after subacute stroke: evidence from ultrasonography.

Although the body weight support treadmill training (BWSTT) in rehabilitation therapy has been appreciated for a long time, the biomechanical effects of this training on muscular system remain unclear. Ultrasonography has been suggested to be a feasible method to measure muscle morphological changes after neurological diseases such as stroke, which may help to enhance the understanding of the mechanism underlying the impaired motor function. This study investigated the muscle architectural changes of tibialis anterior and medial gastrocnemius in patients after subacute stroke by ultrasound. As expected, we found the effect of BWSTT on the muscular system. Specifically, the results showed larger pennation angle and muscle thickness of tibialis anterior and longer fascicle length of medial gastrocnemius after the training. The findings of this study suggest that the early rehabilitation training of BWSTT in subacute stage of stroke provides positive changes of the muscle architecture, leading to the potential improvement of the force generation of the muscle. This may not only help us understand changes of subacute stroke in muscular system but also have clinical implications in the evaluation of rehabilitation training after neurological insults.

Constraint-Induced Movement Therapy to Improve Paretic Upper-Extremity Motor Skills and Function of a Patient in the Subacute Stage of Stroke

Upper-extremity (UE) dysfunction is common after stroke. Four out of five people with stroke initially present with hemiparesis of the affected UE.1 Of those with significant impairment at onset (~30%), over 80% will demonstrate persistent functional deficits at 6 months post-stroke.2 These findings strongly support the notion that more effective therapeutic interventions for the paretic UE are needed. This article examines the potential role of constraint-induced movement therapy (CIMT) as a strategy to improve motor skills and function of the paretic UE of a patient undergoing stroke rehabilitation.

Effects of neuromuscular electrical stimulation on arterial hemodynamic properties and body composition in paretic upper extremities of patients with subacute stroke.

Neuromuscular electric stimulation (NMES) induces repeated muscular contraction, possibly promoting the perfusion/oxygenation of the regional tissues. It remains unclear how NMES influences vascular hemodynamic property and segmental fluid distribution/composition in paretic extremities of hemiplegic patients. Eleven hemiplegic patients aged 62.6 ± 12.5 years in the subacute stage of stroke received NMES for paretic wrist extensor and flexor muscles 30 min daily, 5 days per week for 4 weeks. The non-paretic upper extremities (NPUE) that did not receive NMES served as control. Distribution of fluid to intra/extracellular milieu and arterial hemodynamic properties were determined by using the multi-frequency bioelectrical impedance and pulse wave analysis, respectively. Compared with NPUE without NMES, paretic upper extremity (PUE) with NMES revealed a significantly less decrease in arterial blood flow, impedance quotient, slope quotient, and less increase in crest width and crest time of arterial pulse wave. NMES for 4 weeks increased body cell mass in PUE. Furthermore, NPUE without NMES reduced intracellular water, whereas PUE with NMES retarded loss of intracellular water after stroke. NMES therapy increases body cell mass, attenuates reduction of intracellular water, and alleviates arterial hemodynamic disturbance in PUE in subacute stroke. However, stroke-related physical deconditioning may negatively regulate body composition and impair hemodynamic function in NPUE.

Absent median somatosensory evoked potential is a predictor of type I complex regional pain syndrome after stroke

Purpose: The objective was to determine whether the abnormal finding of somatosensory evoked potentials (SEPs) associated with the development of type I complex regional pain syndrome (CRPS) after stroke. Methods: This was a retrospective study conducted from January, 2003, to December, 2007. Seventy patients were confirmed as CRPS type I, and one hundred and eighty-two patients were assigned to the control group. The initial clinical data were reviewed including age, gender, main type of stroke, lateralization and location of the lesion, presence of glenohumeral subluxation, and the development of CRPS. Somatosensory evoked potentials tests (SEP) in median nerve (N20) and posterior tibial nerve (P37) were performed. Results: CRPS groups revealed significantly higher incidence of the absent and abnormal hemiplegic median SEP, hemorrhagic stroke, and glenohumeral subluxation (GHS). Binary logistic regression analysis indicated that GHS (exp.(B) = 4.083, p < 0.01) with the absent median SEP (exp.(B) = 3.246, p < 0.01) were significant independent predictors of CRPS onset. Conclusions: In conclusion, GHS and the absent median SEP at sub-acute phase of stroke were primary predictors of the onset of post-stoke CRPS.Implications for RehabilitationRecent investigations have suggested that autonomic, motor and somatosensory abnormalities of CRPS are impairments involving the central nervous system (CNS) as well as the peripheral neurogenic inflammatory process. However, the understanding of the pathophysiology of CRPS is still far from complete.The absence of SEP at the sub-acute stage of stroke correlated with the onset of post-stroke CRPS type I.The SEP evaluation at the sub-acute period after stroke might be generally used for predicting the concomitant development of post-stroke CRPS type I as well as functional recovery after stroke.

THE IMPACT OF COMORBIDITY ON COGNITIVE PARAMETERS AFTER ISCHEMIC STROKE

SUMMARY Objective: The aim of our study is to examine the impact of comorbidity on cognitive parameters after the first ever ischemic stroke. Material and methods: We examined 112 patients (aged 46 to 84 (66.67± 5.96), 69 males and 43 females) with first ever ischemic stroke. For cognitive assessment we used Mini Mental State Examination (MMSE), 10 word test (for short term memory and delayed recall), Isaack’s test for verbal fluency (VF), Geriatric depression scale (GDS), Hamilton depression scale (HDS), Blessed dementia information memory concentration test (revised, BDIMCT), Benton Visual Retention test (A,E; BVRT) – number of corrects and number of errors and Wiskonsin Card Sorting Test (number of errors, WCST). The patients were examined on two step model. At acute stage, after collecting medical history, somatic and neurological examinations, MMSE, 10 words test and HDS were applied. At subacute stroke stage (90±5 days after first stroke symptoms), all cognitive tests were used. „STATGRAPHICS Plus 5.0 (free version)”was used for statistical analysis. Results: Chronic ischemic heart disease and chronic obstructive pulmonary disease are the most important additional risk factors for cognitive decline. Thyroid pathology, renal failure and anemia are independently associated with poststroke depression. Conclusions: On the basis of these data we can conclude that vascular risk factors are independently associated with cognitive and emotional changes after stroke and their effects should be assessed and taken into account for subsequent treatment of stroke survivors.

Effect of blood pressure on 3-month functional outcome in the subacute stage of ischemic stroke

We aimed to study various measures of blood pressure (BP) in the subacute phase of ischemic stroke to determine whether any of them predicted clinical outcome. In this retrospective observational study, a consecutive series of patients hospitalized for ischemic stroke within 48 hours of onset were enrolled. The subacute stage of stroke was defined as the time period from 72 hours of symptom onset to discharge or transfer. During this period, mean, maximum, maximum - minimum, SD, and coefficient of variation of systolic BP (SBP) and diastolic BP (DBP) were determined. A baseline severity-adjusted analysis was performed using each patient's 3-month modified Rankin Scale score as the primary outcome. Among a total of 2,271 patients, the median number of BP measurements was 34 per person and the median interval from onset to discharge was 8.7 days. Measures of variability of BP were associated with poor outcome. One SD increase of maximum - minimum (odds ratio [OR], 1.26; 95% confidence interval [CI], 1.12-1.42), SD (OR, 1.20; 95% CI, 1.07-1.34), or coefficient of variation (OR, 1.21; 95% CI, 1.09-1.35) for SBP, but not mean level of SBP (OR, 0.92; 95% CI, 0.79-1.07), was independently associated with poor outcome. Results were similar for DBP. This study shows that variability of BP, but not average BP in the subacute stage of ischemic stroke, is associated with functional outcome at 3 months after stroke onset.

Augmented visual feedback of movement performance to enhance walking recovery after stroke: study protocol for a pilot randomised controlled trial

BackgroundIncreasing evidence suggests that use of augmented visual feedback could be a useful approach to stroke rehabilitation. In current clinical practice, visual feedback of movement performance is often limited to the use of mirrors or video. However, neither approach is optimal since cognitive and self-image issues can distract or distress patients and their movement can be obscured by clothing or limited viewpoints. Three-dimensional motion capture has the potential to provide accurate kinematic data required for objective assessment and feedback in the clinical environment. However, such data are currently presented in numerical or graphical format, which is often impractical in a clinical setting. Our hypothesis is that presenting this kinematic data using bespoke visualisation software, which is tailored for gait rehabilitation after stroke, will provide a means whereby feedback of movement performance can be communicated in a more meaningful way to patients. This will result in increased patient understanding of their rehabilitation and will enable progress to be tracked in a more accessible way.MethodsThe hypothesis will be assessed using an exploratory (phase II) randomised controlled trial. Stroke survivors eligible for this trial will be in the subacute stage of stroke and have impaired walking ability (Functional Ambulation Classification of 1 or more). Participants (n = 45) will be randomised into three groups to compare the use of the visualisation software during overground physical therapy gait training against an intensity-matched and attention-matched placebo group and a usual care control group. The primary outcome measure will be walking speed. Secondary measures will be Functional Ambulation Category, Timed Up and Go, Rivermead Visual Gait Assessment, Stroke Impact Scale-16 and spatiotemporal parameters associated with walking. Additional qualitative measures will be used to assess the participant’s experience of the visual feedback provided in the study.DiscussionResults from the trial will explore whether the early provision of visual feedback of biomechanical movement performance during gait rehabilitation demonstrates improved mobility outcomes after stroke and increased patient understanding of their rehabilitation.Trial registrationCurrent Controlled Trials ISRCTN79005974

EXAMINATION OF EXECUTIVE DYSFUNCTIONS IN STROKE SURVIVORS VIA 64 – WISCONSIN CARD SORTING TEST

SUMMARY: Objective: The objective of our study was to examine executive dysfunctions in stroke survivors (three months after stroke) via Wisconsin Card Scoring Test (WCST) and to assess the influence of stroke severity and lesion location. Contingent and methods: We examined 20 stroke survivors with the following neuropsychological battery: MMSE, 21 – Hamilton test and WCST. Results: We found executive dysfunctions in 90% of our patients. Stroke severity measured by NIHSS influenced MMSE scoring and some of the WCST results (percent conceptual level, trials to complete first category, failure to maintain set and learning abilities). Patients with left hemispheric lesions had statistically significant higher level of total errors than patients with right hemispheric and brainstem lesions. Conclusion: Sub-acute stroke stage is strongly associated with executive dysfunctions.

Effect of Lokomat trainings on the severity of gait disorders in patients after stroke

Stroke is the one of the major causes of long-term disability. More than 50% of post-stroke patients have motor disorders of various severity. In acute and subacute stage of stroke, in the presence of motor disorders, abnormal synergies, known as Wernicke-Mann posture, are developing rapidly, significantly decreasing the quality of walking. In this article the effect of robotic therapy with the «Lokomat» system on the severity of pathological synergies in 125 post-stroke patients is described. Clinical scales and video analysis motion capture system were used for the assessment of clinical and biomechanical parameters of walking.

The role of stroke units in the subacute stage of stroke

Against the background of the debate about the best models of stroke unit care, Lenzi and Di Piero present their argument that patients with stroke have better outcomes if their stay in a dedicated stroke unit is extended, enabling prolonged and intensive monitoring for stroke complications.

Monitoring After the Acute Stage of Stroke

In the early stage of stroke, the occurrence of neurologic and medical complications is associated with clinical deterioration. Previous studies were focused on the first week after stroke onset. The aim of this study was to evaluate the impact of complications on clinical outcome in patients with stroke in the early subacute stage. We prospectively evaluated the influence on the outcome of complications feasible (MC) and not feasible for monitoring (NMC) in all patients with stroke admitted consecutively in our subacute stroke unit. Patients were divided into three classes according to stroke severity evaluated by the National Institutes of Health Stroke Scale score. A change in the National Institutes of Health Stroke Scale score group from admission to discharge was considered clinically significant. We included 261 patients. Sixty percent of patients had complications (105 MC, 118 NMC). Hyperthermia (OR=14.12; 95% CI: 6.01 to 33.20), urinary infections (OR=4.92; 95% CI: 2.19 to 11.04), hypertension (OR=2.86; 95% CI: 1.21 to 6.76), hypoxia (OR=15.75; 95% CI: 6.73 to 36.84), and neuroradiologic damage progression (OR=58.31; 95% CI, 19.48 to 174.55) were associated with a change to a more severe class at discharge and with a higher risk of mortality. A high percentage of patients can develop both MC and NMC during this subacute stage of stroke. The occurrence of complications influences outcome and raises the question about the need for a prolonged stay in a dedicated ward for patients with stroke.

Successful Stenting Seven Days After Atherothrombotic Occlusion of the Intracranial Internal Carotid Artery

To report a case of successful stenting after a subacute stroke. A 75-year-old man presented with sudden onset of right-sided weakness and difficulty speaking. Imaging revealed an occlusion of the left petrous to lacerum internal carotid artery (ICA) segment and slightly decreased cerebral blood flow in the left hemisphere; there were stenoses of the ostial and cavernous ICA segments on the right. On the seventh day after the stroke, he underwent protected carotid angioplasty of the left intracranial ICA occlusion to reduce the high risk of ischemic stroke owing to bilateral disease. An external arteriovenous shunt was established with an occluding balloon in the proximal ICA and a filter in the femoral vein. After protected balloon dilation of the ICA occlusion, a 3.5 x 18-mm balloon-expandable coronary stent was deployed across the residual stenotic segment. An intraluminal filling defect of the petrous ICA segment suggested an arterial dissection or intraluminal thrombus, so another 2 coronary stents were deployed. Macroscopically visible materials were captured in the filter. The patient had a good clinical course and was discharged without neurological deficits on the twelfth day after the stroke. Angiography at 3 months confirmed no restenosis of the stented vessel. This experience suggests that short atherothrombotic intracranial ICA occlusions can be opened in the subacute stroke stage without distal migration of thrombi under proximal protection and flow reversal.

High scores on the Western Aphasia Battery correlate with good functional communication skills (as measured with the Communicative Effectiveness Index) in aphasic stroke patients

Objective. To examine the correlation between an impairment-level and a functional-level assessment scale of aphasia.Design. Prospective, longitudinal study.Setting. A stroke rehabilitation unit.Subjects. Sixty-seven aphasic acute stroke patients who were undergoing a multi-disciplinary rehabilitation programme, including conventional speech and language therapy (SLT).Intervention. Patients were assessed on study entry and 4, 8, 12 and 24 weeks after the start of SLT. The language impairment was assessed with the Western Aphasia Battery (WAB) and the communicative functional limitation associated with aphasia was measured with the Communicative Effectiveness Index (CETI).Results. There was a statistically significant correlation between the two scales for all assessment periods (Pearson's r = 0.71; P < 0.01).Conclusion. The study suggests that in the acute and subacute stages of stroke the scores of WAB and CETI can be surmised from one another.

Validation of the aphasic depression rating scale.

The Aphasic Depression Rating Scale (ADRS) was developed to detect and measure depression in aphasic patients during the subacute stage of stroke. Six experts selected an initial sampling of behavioral items from existing depression rating scales. Stroke patients (aphasic and nonaphasic) were assessed with these items by the rehabilitation staff, with the Hamilton Depression Rating Scale (HDRS) for nonaphasic patients only, by a psychiatrist, and by the rehabilitation staff with Visual Analog Scales (VAS). A second item selection was conducted after a regression algorithm was run including VAS as independent variables (criterion validity) and after their factorial structure was analyzed with a principal component analysis (factorial validity). The construct validity was evaluated with respect to the other depression assessments. A threshold for the diagnosis of depression was computed with respect to the psychiatrist's diagnosis. Interrater and test-retest reliability were assessed in 2 additional groups of aphasic patients. Eighty patients participated in the study (59 aphasic). Fifteen behavioral items from existing depression rating scales were selected, and 9 were retained after the validation process. ADRS correlated highly with VAS and HDRS (r=0.60 to 0.78, P=10(-4) to 10(-6)). With respect to the psychiatrist's diagnosis, the sensitivity and specificity of ADRS were 0.83 and 0.71, respectively, when the threshold was set at 9/32. Its factorial structure was comparable to HDRS structure. Interrater and test-retest reliability were high (average kappa coefficient of the 9 items=0.69). ADRS is a valid, reliable, sensitive, and specific tool for the evaluation of depression in aphasic patients during the stroke subacute phase.

Response

Response

The use of a modified Delphi procedure for the determination of 26 prognostic factors in the sub-acute stage of stroke

The use of a modified Delphi procedure for the determination of 26 prognostic factors in the sub-acute stage of stroke