Challenges and Opportunities in Stroke
Giulia Ciccarese1, Francesco Drago2, Bianco Drago1, Aurora Parodi2
1 Dermatology Clinic, Ospedale Policlinico San Martino, Largo Rosanna Benzi, 10 16132, Genoa, Italy
2 Dermatology Clinic, Ospedale Policlinico San Martino, Largo Rosanna Benzi, 10 16132, Genoa, Italy; DI.S.Sal., Section of Dermatology, University of Genoa, Via Pastore, 1, 16132, Genoa, Italy
Jessica P McCabe1, Janis J Daly2, Michelle Monkiewicz1, Marianne Montana1, Kristi Butler1, Jean Rogers3, David Aron4
1 Cognitive and Motor Learning Research Program, Cleveland VA Medical Center, Cleveland, USA
2 Cognitive and Motor Learning Research Program, Cleveland VA Medical Center, Cleveland, USA; Department of Neurology, College of Medicine, University of Florida, Gainesville, Florida, USA; Brain Rehabilitation Research Center of Excellence, North Florida/South Georgia Department of Veterans Affairs Medical Center, Gainesville, Florida
3 Cognitive and Motor Learning Research Program, Cleveland VA Medical Center, Cleveland, USA; HSR&D Center for Implementation Practice and Research Support, Cleveland VA Medical Center, Cleveland, USA
4 HSR&D Center for Implementation Practice and Research Support, Cleveland VA Medical Center, Cleveland, USA; Medicine and Epidemiology and Biostatistics, School of Medicine; and Weatherhead School of Management, Case Western Reserve University, Cleveland, USA
Background: New models of care delivery are necessary to meet workforce needs while delivering expert care in neurorehabilitation. Therefore, we sought to develop and assess the implementation of a new model of care for neurorehabilitation using a 5-member team of therapists (5-Team Model) for the treatment of individuals with chronic stroke, rather than a conventional single-therapist model.
Methods: A mixed methods approach was employed; continuous quality improvement methods and quasi-experimental pre-test/post-test methods were used to assess the effectiveness of the new model.
Six chronic stroke patients participated in an upper limb neurorehabilitation motor learning protocol 5 days/week, 5 hours/day (60 sessions; 300 hours); treatment was administered using the 5-Team Model approach to treatment.
Results: Mean improvement on the Fugl Meyer (FM) was 11.5 points. All six participants demonstrated improvement on Fugl Meyer that was within or beyond the minimal clinically important difference (MCID) range of 4.25-7.25 points for chronic stroke. Results indicated that the 5-Team Model was effective in implementing care.
Conclusions: The 5-Team Model for neurorehabilitation was successfully implemented, with patient hand-off every day to a different therapist; it produced clinically significant improvement on a measure of coordination (FM) which is comparable to or better than prior reports from a standard care model. This new model of care met the needs of the research team workforce for flexibility, while maintaining the level of quality of care. Successful implementation required addressing a series of hindering factors in an iterative manner and enhancing promoting factors. These elements included the context within which the change was implemented, the methods used in implementing the change, the evidence that the change was successful, and communication that the change was successful. The context requirements included existing framework and participating model members who were willing to exert the required effort for success, model champions. This high level of enthusiastic participation along with strong leadership contributed to long-term success, sustainability.
C (Linda) M.C. van Campen1, Frans C. Visser1
1 Stichting CardioZorg, Planetenweg 5, 2132 HN Hoofddorp, Netherlands
Introduction: In patients with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) a higher-than-normal resting heart rate has been reported in a number of studies. As heart rate is linked to stroke volume, the present study explored the relationship between the supine heart rate and stroke volume index in healthy controls and in ME/CFS patients. Moreover, as patients with a postural orthostatic tachycardia syndrome (POTS) during tilt testing, have a higher supine heart rate than patients with a normal heart rate and blood pressure response during tilting, these two patient groups were also compared.
Methods and results: From a database of individuals who had undergone tilt-testing, including supine Doppler measurements for stroke volume index calculation, we selected ME/CFS patients and healthy controls without evidence of hypotension or syncope. 474 ME/CFS patients were analyzed, 314 with a normal heart rate and blood pressure response and 160 with POTS during tilt-testing, and 56 healthy controls. Resting stroke volume indices were similar between the 3 groups. All 3 groups had an inverse relation between the resting stroke volume index and resting heart rate (all p<0.0001). The slope of the relation was not significantly different between the 3 groups. Using the upper limit of the 95% prediction interval for the heart rate of healthy controls, 46 (15%) of patients with a normal heart rate and blood pressure response had a resting heart rate above the upper limit, 248 (85%) a heart rate between the upper and lower limit. In 47 (29%) patients developing POTS the resting heart rate was above the upper limit, and in 113 (71%) patients within the upper limit and lower limit. This distribution was significantly different between the two patient groups (p=0.0001).
Conclusion: Patients and healthy controls showed a significant and inverse relation between the SVI and heart rate at rest. Already at rest heart rate in patients developing POTS during tilt-testing were higher compared to the patients with a normal heart rate and blood pressure response per unit of SVI, but the heart rate of the majority of all patients fell within the limits of normal of healthy controls. The difference of patients with heart rate above the upper limit versus between the upper limit and lower limit deserves further investigation and may have therapeutic implications.
Sanjeev Nayak1, Vijay Jeganath2, Qian Zhao3
1 Consultant Interventional Neuroradiologist, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
2 Consultant Anaesthetist, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK (Presently, working as Associate Director, Department of Medical Education, Hamad Medical Corporation, Qatar)
3 Data Scientist, DataRobot Inc, London, UK
Aim: To develop an Artificial Intelligence (AI) based Automated Machine Learning (AutoML) toolkit to aid decision-making for mechanical thrombectomy (MT) based on readily available patient variables that could predict functional outcome following MT.
Methods: Datasets of 1097 patients from Systematic Evaluation of Patients Treated With Stroke Devices for Acute Ischemic Stroke (STRATIS) Registry and SWIFT PRIME Trial were retrospectively evaluated. Linear and non-linear models were built using an automated ML platform, DataRobot. We developed two stage models for predicting the outcome of the patient:
Model 1 predicted survival, defined as an mRS score of 0-5 (alive) or 6 (dead).
Model 2 predicted good/bad survivor, defined as an mRS score of 0-2 (good) or 3-5 (poor).
Results: The primary outcome was the modified Rankin Scale (mRS) score at 90 days after stroke. Prediction of survival was 83% accurate (area under the curve [AUC] 0.7780). Prediction of good/poor survivor was 61% accurate (AUC 0.7061). A two-stage machine learning model has an improved 80% overall accuracy of prediction.
Conclusion: The proposed AI-based AutoML toolkit evaluates various baseline clinical and radiological characteristics and predicts significant variations in treatment benefit between patients. With its improved prediction accuracy, the toolkit is clinically useful as it helps in distinguishing between individual patients who may experience benefit from Mechanical Thrombectomy treatment for acute ischaemic stroke from those who may not.
Background: In the management of patients with ischemic stroke and transient ischemic attack, determining the source of the embolic event is critical. In 15–30 percent of all strokes, cardiogenic embolism is suspected to be the cause. In these patients, echocardiography is a frequently utilized and adaptable method that can provide full information on thromboembolic risk. The relevance of transthoracic-echocardiography(TTE) and transesophageal-cardiography(TEE) in clinical practice is discussed in this article, which analyses probable cardiac origins of stroke. Aim of this study is to determine the clinicoradiological association between ischemic stroke in young and find out the relevance of Transthoracic and Transesophageal Echocardiography in evaluation of cardiac source in ischemic stroke.
Methods: This cross- sectional observational study was done between July 2020 and April 2022. A total of 31 patients of ischemic stroke were included. The mean Glasgow coma scale(GCS) and National Institutes of Health Stroke Scale(NIHSS) score of these patients They underwent transthoracic-echocardiography followed by transesophageal-cardiography, their clinical profile has been recorded and analyzed using Statistical Package for the Social Sciences (SPSS), V21 software.
Results: The mean age of the subjects was 34.74± 6.38 years, the group was consisting of 28 males and 3 females. The most common complaint was one sided weakness and speech difficulty. transesophageal-cardiography detected bicuspid aortic valve in one patient, right atrial thrombus in one patient and patent foramen ovale in one patient over and above transthoracic-echocardiography findings in this study.
Conclusion: This study reinforces the importance of transesophageal-cardiography in stroke in young patients. transesophageal-cardiography is not only an effective tool in picking up the clots inside the cardiac chambers but also it was found to be significantly effective in detecting valvular lesions and small septal defects like patent foramen ovale. It is recommended that all strokes in young patients need to undergo transthoracic-echocardiography as well as transesophageal-cardiography to find the source and etiology of cardio embolic stroke.
Elizabeth O’ Connell1, Vicki Livingstone2, Geraldine McCarthy3, Irene Hartigan3
1 Integrated Care Program for Older People, South Lee Hub, St Finbarrs Hospital, Cork.
2 INFANT Research Centre, University College Cork
3 School of Nursing and Midwifery, University College Cork
Background: Timely recognition of stroke symptoms and appropriate emergency response offers those who experience stroke an increased chance of physical and psychosocial recovery. International research suggests there is a lack of knowledge amongst the general population of the signs and symptoms of stroke, this may impact on seeking treatment. Public awareness campaigns are designed to educate the public on how to recognise and respond to symptoms of stroke
Aim: To investigate recognition and response to stroke and associated factors.
Design: A cross-sectional study was designed, a researcher developed questionnaire sought information related to previous experience of stroke, knowledge of risk factors, recognition of stroke symptoms, awareness of treatment available and the ability to identify what the letters of the FAST acronym represent. The Stroke Action Test (STAT)41 was used to investigate how participants would respond to specific symptoms of stroke.
Sample: A convenient sample (n=243) which included older people attending an outpatients’ clinic in a large teaching hospital were included. A mixed method of data collection of online and paper version was used.
Findings: Results identified that 41% of participants recognised all six stroke symptoms as defined by the American Heart and Stroke Association. The symptom most frequently recognised by participants was numbness of the face, arm and leg (97%). The mean STAT score for participants was 9 which indicated that most participants would respond appropriately, by contacting the emerging services, to 9 out of a total of 21 items describing stroke in the STAT. Multivariate analysis identified that having previously had a stroke and knowledge of risk factors for stroke were significantly associated with recognition of stroke symptoms. Participants were most likely to respond to items which described classic stroke symptoms such as limb weakness and difficulty speaking.
Conclusion: Awareness of treatment available for stroke is a predictor of appropriate response to stroke. Future stroke awareness campaigns should include information on the availability, benefits and timelines for treatment of stroke to help individuals who experience stroke overcome delays in their response to the recognition of stroke symptoms.
Halvor Naess1, Nicola Logallo1, Ulrike Waje-Andreassen1, Chrisopher Kvistad1
1 Haukeland University Hospital
Background and aims There seems to be a U-shaped relation between hemoglobin level and ischemic stroke severity. We aimed to explore possible causes of this relation.
Methods All patients with ischemic stroke between 2006 and 2016 admitted within 3 hours of onset were included. Hemoglobin and NIHSS score were obtained on admission. Modified Rankin Scale (mRS) score was obtained day 7. Locally weighted scatterplot smoothing (lowess smoother) curves displaying the frequencies of M1 occlusion and complications according hemoglobin level on admission and lowess smoother curves displaying mRS day 7 in patients with and without middle cerebral artery (M1) occlusion according to hemoglobin level on admission were obtained.
Results This study includes 905 ischemic stroke patients. Low hemoglobin was associated with pneumonia and urinary tract infection. Neurological worsening was not associated with hemoglobin level. Increasing mRS day 7 was strongly associated with increasing high hemoglobin in patients with M1 occlusion (correlation factor=.61, P=.02).
Conclusions Poor outcome in ischemic stroke patients with low hemoglobin is associated with complications during the hospital stay whereas poor outcome in ischemic stroke patients with increasing high hemoglobin levels is associated with occlusion of the middle cerebral artery.
Ludmila Belayev1, Madigan M. Reid1, Nicolas G. Bazan1
1 Neuroscience Center of Excellence, School of Medicine, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA
Despite displaying efficacy in experimental stroke studies, neuroprotection has failed in clinical trials. The translational difficulties include a limited methodological agreement between preclinical and clinical studies and the heterogeneity of stroke in humans compared to standardized strokes in animal models. Promising neuroprotective approaches based on a deeper understanding of the complex pathophysiology of ischemic stroke, such as blocking pro-inflammatory pathways plus pro-survival mediators, are now evaluated in preclinical studies. Combinatorial therapy has become increasingly attractive in recent years as recognizing the complexity of stroke progression becomes evident. The paper aimed to test the hypothesis that blocking pro-inflammatory platelet-activating factor receptor (PAF-R) with LAU-0901 plus administering a selected docosanoid, aspirin-triggered neuroprotectin D1 (AT-NPD1), which activates cell-survival pathways after middle cerebral artery occlusion (MCAo), would lead to neurological recovery. We have demonstrated that LAU-0901 plus AT-NPD1 treatment affords high-grade neuroprotection in MCAo, equaling or exceeding that afforded by LAU-0901 or AT-NPD1 alone at considerably moderate doses, and it has a broad therapeutic window extending to 6 hours after stroke onset.
Moon Fai Chan1, Senthilkumar Ravindran2, Hammad Al-Subhi2, Saif Al-Riyami2
1 Department of Family Medicine and Public Health, College of Medicine and Health Sciences, Sultan Qaboos University
2 Department of Physiotherapy & Rehabilitation, Sultan Qaboos University Hospital, Oman
An analysis of scientific literature, photo and video materials showed that plaques in humans are completely different from plaques in animals and the «contemporary official description» of AS. They differ in appearance, lack of inflammation of the walls of the artery, clinical manifestations, complications. It has also been found that «true» plaque has nothing to do with the first four types of atherosclerosis in humans. It was necessary to understand how in the lumen of a healthy artery a strong, elastic, yellow, homogeneous plaque in the form of a hollow cylinder – a «cylindrical plaque» – appears very quickly? As a result, the «Hydrodynamic Theory» was proposed, which answers all the complex questions related to the appearance, aging and destruction of «true» plaques in humans. It describes the etiology, pathogenesis, clinical manifestations, classification, complications, methods of treatment and prevention of «cylindrical» plaques that cause heart attacks and strokes in humans.
Dalton E. Carter1, Tao Peng1, Melanie R. Moody1, Shao-Ling Huang1, David D. McPherson1, Melvin E. Klegerman1
1 Department of Internal Medicine, Division of Cardiovascular Medicine, University of Texas Health Science Center at Houston, Houston, Texas 77030, U.S.A.
Yahia M Lodi1, Adam Bowen2, Aria Soltani2, Irfan Khan2, H Polavarapu2, Anas Hourani3
1CAST Certified in Neuroendovasclar Surgery Professor and Neurosciences Academic Chair Upstate Medical University, Binghamton, NY
2 Upstate Medical University, Binghamton & NYUHS-Hospitals, Binghamton, NY
3 Fort Hays State University, Haya, KS.
Background: Despite the advancement in acute ischemic stroke with large vessel occlusion (LVO), golden time is lost in assessment lengthy neurological examination and redundantly in the Emergency department, often after emergency medical service prehospital stroke scale evaluation indicating possible LVO. A simple acute ischemic stroke scale (AISS) of the cortical representations of the anterior circulation can rapidly predict LVO, saving precious time to initiate early intravenous tissue plasminogen activator and endovascular mechanical thrombectomy. We proposed an ASIS in the emergency department called Gaze Weakness Neglect Speech (GWNS) to evaluate its feasibility and predictability for the detection of LVO in anterior circulation in the emergency department. Additionally, to evaluate if time can be gained that has been lost in obtaining National Institute of Health stroke Scale (NIHSS) and computed tomographic angiography (CTA), avoiding unnecessary radiation.
Methods: This is a prospective observational study. An institutional review board permission was obtained, and patient enrollment started in January 2020 and ended in January 2021. Consecutive patients from January 2020 to September 2021 were selected from the database. The GWNS stroke scale was used by stroke and vascular neurologist during the emergency triage. The GWNS stroke scale scores range from 0 to 4 (1 for positive 0 for negative). The GWNS stroke scale assesses gaze deviation or gaze preference (G), presence of any weakness (W), neglect/disregard (N), and any speech impairment (S). Demographic data, CTA/cerebral angiographic data, and scores from NIHSS were also collected. The collected data was analyzed by a biostatistician to determine the association between the GWNS scale score and LVO.
Results: In our study,109 qualifying patients were selected. Fifty-eight patients had GWNS stroke scale score of 3 or 4, with 57 having confirmed LVO and 1 presenting after a seizure. The GWNS stroke score ≥3 (0.86) correlated with LVO better than NIHSS (0.67), regardless of hemisphere side involvement. The GWNS stroke scale score of ≥3 also was effective in detection of proximal and distal blood vessels occlusion in the anterior circulation (Internal carotid artery, middle cerebral artery and its branches). A GWNS stroke scale score of ≥3 with presence of gaze was the most predictive for LVO (0.9) followed by neglect/disregards (0.8). The time to obtain GWNS stroke scale was 1.5 minutes (range 1-3) and time to obtain/interpretation CTA was 41.3 +/- 7.4 minutes after emergency department arrival (range: 29-51 minutes).
Conclusions: Our Gaze Weakness Neglect Speech stroke scale can be performed rapidly in the emergency department and is highly predictive of LVO in the internal carotid artery, middle cerebral artery and middle cerebral branches. A GWNS stroke scale score of ≥3 is highly predictive of LVO, especially when gaze or neglect is present. Patients can potentially bypass CTA or advanced imaging in future studies, saving precious time and millions of brain cells for better outcome.
Dolores Cocho1, J J Martínez-Rivas2, Y Monterroso2, M Cuadrado3
1 Department of Neurology, Hospital General de Granollers, Barcelona, Spain; Universitat Internacional de Catalunya, Barcelona, Spain
2 Department of Emergency, Hospital General de Granollers, Barcelona, Spain
3 Department of Radiology, Hospital General de Granollers, Barcelona, Spain
Background: Currently there is no predictive model in acute minor stroke without large vessel occlusion.
Aims: Our objective was to evaluate the independent predictors that correlate with unfavourable outcome and to develop a predictive scale in acute setting.
Methods: Retrospective analysis of consecutive acute minor stroke (NIHSS <5) admitted within 4.5 hours to clinical onset who were previously not disabled and without large vessel occlusion on CT angiography (intracranial or extracranial occlusion or stenosis ≥50%). Unfavourable outcome was defined as modified Rankin Scale 3-6 at 90 days. Independent predictors of disability were included in the model.
Results: A total of 408 patients with acute minor stroke (NIHSS <5) were analyzed. Large vessel occlusion was detected in 83 (20%), who were excluded. The final analysis included 325 patients, with mean age of 68± 14 years, 59% were men and 14.5% had unfavourable outcome. On multivariate analysis, age >70 years, NIHSS >2, recurrent event, posterior circulation ischemia and previous stroke were associated with unfavourable outcome. Recurrent event was excluded to the model because this variable is not available in acute setting. With the variables detected in the logistic regression, a predictive model was made (SPAN2 scale: previous Stroke, Posterior ischemia, Age >70 or NIHSS >2). The model correctly classified 84% of the patients with unfavourable outcome. A score >2 points on the SPAN2 scale showed a sensitivity 95%, specificity 51%, PPV 25% and NPV 99% of unfavourable outcome at 90 days.
Conclusions: SPAN2 scale could be useful to stratify the risk of unfavourable outcome in acute phase of minor stroke without large vessel occlusion. Future studies may validate its usefulness in the selection of patients for thrombolytic therapy.
Robert J Arnold1, Nina Bausek2, Christopher S Gaskill3, Tarek Midani4
1Chief Clinical Officer, Applied Clinical Scientist, Southeastern Biocommunication Associates, LLC., Birmingham, AL, 35216, USA
2Research Collaborator, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, 55905, USA
3Consulting Voice Scientist, Southeastern Biocommunication Associates, LLC., Birmingham, AL, 35216. USA
4Consulting Biomedical Engineer, Southeastern Biocommunication Associates, LLC., Birmingham, AL, 35216. USA
Background: Dysarthria frequently occurs as a result of stroke and adversely impacts speech sound production, making it more difficult for the listener to understand what the person with dysarthria is attempting to communicate. This in turn may lead to social isolation, depression, and increased cost of care. Some studies have underscored the importance of respiratory muscle strengthening as it relates to improvement of speech intelligibility. This retrospective investigation examined the effects of a combined Respiratory Muscle Training (cRMT) protocol upon speech intelligibility in persons post single cerebrovascular accident (CVA).
Methods: The clinical data of 10 patients who requested pro bono speech therapy for the diagnosis and treatment of dysarthria following a single stroke was utilized for this study. The intervention group was treated with three 5-minute sessions with cRMT each day for 28 consecutive days. The control group received no cRMT and no other therapeutic exercise intervention during the time period. Respiratory and speech intelligibility were assessed pre- and post-intervention in terms of peak expiratory flow, subject self-perception of intelligibility, and word level intelligibility.
Results: After 28 days of cRMT, the intervention group (IG) exhibited significant gains compared to the control group (CG) in peak expiratory flow (PEF) (IG: 73.12% vs CG: 4.66%), Self-Perception of Intelligibility (IG: 72.38% vs CG: 0.83%), and the word task of the Assessment of Intelligibility of Dysarthric Speech (AIDS) (IG: 43.92% vs. CG: 0%).
Conclusion: These data suggest cRMT is a feasible and effective treatment for improving breath support and speech intelligibility in persons with dysarthric speech.