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, the NIHStrokeScale was found to be enhanced in the group with supplemental proteins (-4.4 +/- 1.5 score versus -3 +/- 1.4 of control group; P<0.01). When expressed as difference (triangle up) between baseline and 21 days, the NIHStrokeScale correlated negatively with change in protein intake (g/day) (r=-0.50, P= 0.001) and positively with change in carbohydrate/protein ratio (r = +0.40, P=0.01)Protein supplementation may enhance neurological recovery in subacute patients with ischaemicstroke. (...) of neurological changes (measured using the National Institute of Health (NIH) StrokeScale).Tertiary care rehabilitation in Italy.Forty-two patients (27 male and 15 female; 66.4 +/- 11 years) 16 +/-2 days after the acute event.Supplementation with a hyperproteic nutritional formula (10% protein).NIHStrokeScale and protein intake.At admission to rehabilitation, both groups of patients were homogeneous for demographic, clinical and functional characteristics. After 21 days from the start of the protocol
at least 4-hourly until 48 hours poststroke. The relationship between baseline factors, such as the NIHStrokeScale, and blood glucose was assessed with mixed-effects models. The behavior of glucose over time was modeled in the whole cohort, and for the cohort partitioned into two around an admission glucose of 6.0 mmol/L.In the cohort of 124 patients the mean glucose was 6.6 mmol/L throughout the period of monitoring, with no change over time. Mixed-effects models identified more severe stroke (...) Natural history of blood glucose within the first 48 hours after ischemicstroke. Despite suggestions that glucose levels rise after stroke before falling within a few hours, the natural history and determinants of this phenomenon remain unclear. We aimed to better characterize the time course of changes in glucose levels after ischemicstroke and to identify factors that affect poststroke glycemia.Patients with ischemicstroke without previously diagnosed diabetes had blood glucose measured
randomized clinical trials, uncontrolled studies, or consensus expert opinion if definitive data were lacking.Recommendations with Level I evidence include the delivery of poststroke care in a multidisciplinary rehabilitation setting or stroke unit, early patient assessment via the NIHStrokeScale, early initiation of rehabilitation therapies, swallow screening testing for dysphagia, an active secondary stroke prevention program, and proactive prevention of venous thrombi. Standardized assessment tools (...) Veterans Affairs/Department of Defense Clinical Practice Guideline for the Management of Adult Stroke Rehabilitation Care: executive summary. A panel of experts developed stroke rehabilitation guidelines for the Veterans Health Administration and Department of Defense Medical Systems.Starting from previously established guidelines, the panel evaluated published literature through 2002, using criteria developed by the US Preventive Services Task Force. Recommendations were based on evidence from
Reversed Robin Hood syndrome in acute ischemicstroke patients. Recurrent hemodynamic and neurological changes with persisting arterial occlusions may be attributable to cerebral blood flow steal from ischemic to nonaffected brain.Transcranial Doppler monitoring with voluntary breath-holding and serial NIHStrokeScale (NIHSS) scores were obtained in patients with acute middle cerebral artery or internal carotid artery occlusions. The steal phenomenon was detected as transient, spontaneous (...) worsening (>2 points increase in NIHSS scores) at stable blood pressure. In 3 of 5 patients receiving noninvasive ventilatory correction for snoring/sleep apnea, no further velocity or NIHSS score changes were noted.Our descriptive study suggests possibility to detect and quantify the cerebral steal phenomenon in real-time. If the steal is confirmed as the cause of neurological worsening, reversed Robin Hood syndrome may identify a target group for testing blood pressure augmentation and noninvasive
NINDS clinical trials in stroke: lessons learned and future directions. Since 1977 the National Institute of Neurological Disorders and Stroke (NINDS) at the National Institutes of Health (NIH) has sponsored 28 phase 3 trials to evaluate treatments of stroke, which when all completed will have randomized a total of 44 862 patients in the United States and other countries. NINDS stroke clinical trials have been successful in finding beneficial and cost-effective treatments for cerebrovascular (...) disease. Future trials are likely to be larger and have simpler designs which allow for the inclusion of more patients and which collect less data for each patient. In addition, measures of cognitive outcomes, particularly timed tests of executive function, disability scales, and quality-of-life outcomes will become more common. The stroke research community can take pride in the solid base of evidence that has been built over the past 2 decades. If we continue to follow the discoveries of science
Minocycline treatment in acute stroke: an open-label, evaluator-blinded study. Ischemic animal model studies have shown a neuroprotective effect of minocycline.To analyze the effect of minocycline treatment in human acute ischemic stroke.We performed an open-label, evaluator-blinded study. Minocycline at a dosage of 200 mg was administered orally for 5 days. The therapeutic window of time was 6 to 24 hours after onset of stroke. Data from NIHStrokeScale (NIHSS), modified Rankin Scale (mRS (...) , recurrent strokes, and hemorrhagic transformations during follow-up did not differ by treatment group.Patients with acute stroke had significantly better outcome with minocycline treatment compared with placebo. The findings suggest a potential benefit of minocycline in acute ischemicstroke.
, stroke etiology (Trial of ORG 10172 in Acute Stroke Treatment [TOAST] classification), severity (NIHStrokeScale [NIHSS]), length of stay (LOS), and functional 3-month outcome using modified Rankin Scale, Barthel Index, and a dichotomized outcome status (living at home vs institutionalization or death).Acute infratentorial DWI lesions were detected in 95% (21/22) of the patients. The number (p = 0.01) and the distribution (p < 0.001) of DWI lesions were correlated with stroke etiology. Patients (...) The clinical significance of diffusion-weighted MR imaging in infratentorial strokes. To study the association between diffusion-weighted imaging (DWI) characteristics and stroke etiology, stroke severity, and functional outcome in patients with infratentorial strokes.The authors prospectively studied 22 consecutive patients with acute infratentorial strokes. They used a blinded comparison of DWI features (number, distribution, and volume of lesions) with clinical characteristics, namely
ultrasound. Baseline, 1-week, and 1-month NIHStrokeScale (NIHSS) scores were used to evaluate the short-term clinical course.H. pylori infection was found in 79% of patients; 58% of these tested positive for CagA. IMT was higher among CagA-positive patients than among CagA-negative ones (1.13 +/- 0.26 mm vs 0.97 +/- 0.15 mm; univariate analysis, p = 0.0001; multivariate analysis, odds ratio [OR], 2.36; 95% CI, 1.57 to 3.54; p = 0.0001) or H. pylori-negative ones (1.01 +/- 0.17 mm; univariate analysis (...) CagA-positive Helicobacter pylori strains may influence the natural history of atherosclerotic stroke. To test the hypothesis that infection with virulent cytotoxin-associated gene-A (CagA)-bearing Helicobacter pylori strains influences the atherosclerotic process and the clinical course in atherosclerotic stroke patients.ELISA was used to assess the seroprevalence of infection by H. pylori and CagA-positive strains in 185 patients. Intima-media thickness (IMT) was determined by Doppler
Stroke in patients with cancer: incidence and etiology. To assess the incidence and type of strokes in patients with cancer at Memorial Sloan-Kettering Cancer Center.Retrospective review of all ischemicstrokes diagnosed by a neurologist and confirmed by neuroimaging between February 1997 and April 2001 was conducted. Age, gender, cancer diagnosis and stage, and vascular risk factors were recorded. NIHStrokeScale and modified Rankin Scale scores were calculated retrospectively. Stroke (...) etiology was assigned independently by two neurologists using the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria.Ninety-six patients with a confirmed stroke were identified. The median age was 67, and 61.5% were men. The distribution of vascular risk factors was comparable with that seen in large stroke trials. Lung cancer (30%) was the most common primary tumor followed by brain and prostate cancer (9% each). Strokes were embolic in 52 (54%) and nonembolic in 44 (46%). Eleven of 12
- counts of >8.0% (p = 0.003, Cochran linear test of trend). Higher CD4+CD28- counts were also present in patients with a history of prior stroke (p = 0.03). After adjustment for age, admission NIHStrokeScale score, prior stroke, and atrial fibrillation, CD4+CD28- counts of >8.0% were associated with a cumulative hazard ratio of 5.81 (95% CI: 1.58 to 21.32) for stroke recurrence or death.Rising counts of circulating CD4+CD28- cells are associated with an increasing risk of stroke recurrence and death (...) Elevated pro-inflammatory CD4+CD28- lymphocytes and stroke recurrence and death. To determine if the CD4+CD28- T-cell subset is expanded in patients with recurrent stroke or death after acute ischemicstroke. This subset of the peripheral blood T-cell lymphocyte population has a strong pro-inflammatory and tissue-damaging potential.Consecutive patients within the first 48 hours of ischemicstroke were prospectively studied. Peripheral blood CD4+CD28- cells were quantified by flow cytometry
Prospective reliability of the STRokE DOC wireless/site independent telemedicine system. The authors evaluated a site-independent telemedicine system. Telemedicine may be limited by the need for fixed connectivity. Wireless and site-independent technologies eliminate this limitation. Twenty-five stroke patients underwent evaluations by remote and bedside examiners. Ten of 15 (67%) NIHStrokeScale and 9 of 11 (82%) Modified NIHStrokeScale items showed excellent interrater reliability (...) . Spearman correlations were > or =0.93. This Internet system is reliable and valid. Further studies should assess its use in acute stroke.
Combined IV and intra-arterial thrombolysis for acute ischemicstroke. Combined IV and intra-arterial (IA) thrombolysis for acute ischemicstroke may offer advantages over either technique alone. Sixty-two nonrandomized patients with NIHStrokeScale scores of > or =10 who met standard criteria for IV thrombolysis were treated with an IV/IA approach. Three-month modified Rankin Scale scores were 0 to 2 for 50% of patients, mortality was 18%, and symptomatic intracerebral hemorrhage occurred
, the effect of 30, 15, and 0 degrees HOB on middle cerebral artery (MCA) mean flow velocity (MFV) in patients with acute (<24 hours) ischemicstroke was measured with transcranial Doppler using MFV and pulsatility index (PI) of the residual flow signals at the site of persisting acute occlusion.Twenty patients were evaluated (mean age 60 +/- 15 years; median NIHStrokeScale [NIHSS] score 14 points). MCA MFV increased in all patients with lowering head position (maximum absolute MFV value increase 27 cm/s (...) Heads down: flat positioning improves blood flow velocity in acute ischemicstroke. Acute stroke patients are routinely positioned with the head of the bed (HOB) elevated at 30 degrees despite lack of evidence for increased intracranial pressure.To determine the effect of HOB positions in real time on residual blood flow velocity in acutely occluded arteries causing stroke and whether resistance to residual flow increased with lower HOB positions.In a repeated-measures quasi-experiment
StrokeScale (NIHSS) was used to assess the severity of stroke on admission.In univariate analysis, the presence of at least one small apo(a) isoform was associated with ischemicstroke in men (p = 0.02) but not in women (p = 0.33). After allowance for age, gender and traditional vascular risk factors, subjects carrying at least one small apo(a) isoform were at increased risk of atherothrombotic stroke (odds ratio [OR] 7.1, 95% CI 2.8 to 17.5, p = 0.00001) but not of lacunar infarction (OR 1.1, 95 (...) Apo(a) size in ischemicstroke: relation with subtype and severity on hospital admission. To determine the distribution of apolipoprotein (a) (apo[a]) isoforms and their relation to the clinical severity of different ischemicstroke subtypes.Ninety-four hospital cases with a first-ever ischemicstroke and 188 randomly selected control subjects matched for age, gender, and ethnicity were enrolled. Stroke etiology was defined according to Trial of Org 10172 in Acute Stroke Treatment criteria. NIH
incidence and prognosis in a multiethnic, urban population. Northern Manhattan residents age 40 years or older diagnosed with their first ischemicstroke were eligible. Patients or their proxies were interviewed regarding medications being taken at home before stroke onset. The NIHStrokeScale was used to assess stroke severity, categorized as mild (< or =5), moderate (6 to 13), or severe (> or =14), and the Barthel Index at 6 months to assess functional outcome. Clinical worsening in hospital (...) Lipid-lowering agent use at ischemicstroke onset is associated with decreased mortality. 3-Hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors (statins), the most frequently used lipid-lowering agents (LLAs) have neuroprotective effects in rodent models of ischemicstroke. The authors hypothesized that patients with ischemicstroke taking LLAs would have better outcomes than patients not taking LLAs.The Northern Manhattan Study is a population-based study designed to determine stroke
IV thrombolysis in patients with acute stroke due to spontaneous carotid dissection. The authors reviewed the histories of 33 patients (ages 44 to 50 years) treated with IV thrombolysis for acute stroke due to spontaneous cervical carotid artery dissection. Median NIHStrokeScale (NIHSS) score on admission was 15. No new or worsened local signs, subarachnoid hemorrhage, pseudoaneurysm formation, or rupture of the cervical ICA were observed. At 3 months, median NIHSS was 7 and median modified (...) Rankin Scale (mRS) 2.5; mRS < or = 2 was observed in 17 patients.
drugs.Consecutive patients presenting within 24 hours of first-ever ischemicstroke over an 18-month period were studied. Subjects were only included if they were on only angiotensin 2 formation increasers, only angiotensin 2 formation suppressors, or no antihypertensive agents. NIHStrokeScale (NIHSS) score at presentation was used as the index of stroke severity. Demographic data, risk factors, admission blood pressures, other medications, and stroke mechanisms were controlled for across the three groups (...) Angiotensin 2 type 2 receptor activity and ischemicstroke severity. Drugs that increase angiotensin 2 formation, including thiazides, calcium channel blockers, and angiotensin 2 type 1 (AT1) receptor blockers, may be more effective in stroke prevention than angiotensin 2 suppressive drugs such as angiotensin-converting enzyme inhibitors and beta-blockers.To assess whether angiotensin 2 formation increasing drugs reduce incident stroke severity compared with angiotensin 2 formation suppressive
Hemostatic markers of recanalization in patients with ischemicstroke treated with rt-PA. To determine whether pretreatment markers of coagulation and fibrinolysis are related to recanalization and functional outcome.The authors included patients treated with IV rt-PA with occlusion on baseline transcranial Doppler (Thrombolysis in Brain Ischemia [TIBI] criteria) in whom recanalization within 6 hours was monitored. At baseline, the authors recorded data about demographics, vascular risk factors (...) , the NIHStrokeScale (NIHSS) score, early CT signs, etiology, blood glucose, and time to rt-PA. The authors also measured plasmatic markers of coagulation (fibrinogen, prothrombin fragments 1 + 2, Factor XIII, Factor VII) and fibrinolysis (alpha2-antiplasmin, Plasminogen Activator Inhibitor, Functional Thrombin Activatable Fibrinolysis Inhibitor [fTAFI]). A favorable outcome was defined as a modified Rankin score < 2 at 3 months.The authors studied 63 patients with a mean age of 67.3 +/- 12.5 years
blindly. Patients who developed PS after stenting were enrolled. Each patient was assessed by an experienced stroke neurologist by neurologic examination and NIHStrokeScale score every day until discharge and at day 30, and by modified Rankin Scale (mRS) score at the end of the first, third, and sixth month, and then at intervals of 6 months.PS frequency was 3.0% (5/169 patients). The patients with preoperative PIAS had a higher frequency of PS and PS exacerbation, resulting from intracranial (...) Perforator stroke after elective stenting of symptomatic intracranial stenosis. To study the frequency, clinical course, and functional outcome of perforator stroke (PS) resulting from elective stenting of symptomatic intracranial stenosis.Between September 2001 and November 2004, 169 consecutive patients with 181 symptomatic intracranial stenoses underwent stenting procedure at our institute. The preoperative perforator infarct adjacent to the stenotic segment (PIAS) on MRI was evaluated
consecutive patients admitted within 4 hours of the onset of acute cerebralischemic symptoms.Underlying reasons for and possible predictors of neurologic worsening.A total of 256 patients (13.0%) had an increased score of 1 point or more on the NIH-SS after 48 to 72 hours. Neurologic worsening was attributed to progressive stroke in 33.6% of patients, increased intracranial pressure in 27.3%, recurrent cerebralischemia in 11.3%, and secondary parenchymal hemorrhage in 10.5%. A multivariate logistic (...) regression analysis identified internal carotid artery occlusion, medial cerebral artery (M1) occlusion, territorial infarction, brainstem infarction, and diabetes mellitus as independent predictors of neurologic worsening on the NIH-SS. Worsening of key neurologic functions (consciousness, gaze, arm or leg motor function, and speech) occurred in 223 patients (11.4%), and worsening of 4 points or more on the NIH-SS total score occurred in 148 patients (7.5%).Besides initial stroke severity and comorbid