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Latest & greatest articles for stroke
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Effect of a Multifaceted Quality Improvement Intervention on Hospital Personnel Adherence to Performance Measures in Patients With Acute IschemicStroke in China: A Randomized Clinical Trial. In China and other parts of the world, hospital personnel adherence to evidence-based stroke care is limited.To determine whether a multifaceted quality improvement intervention can improve hospital personnel adherence to evidence-based performance measures in patients with acute ischemicstroke (AIS (...) in the stroke registry with usual care (control group; 2400 patients).The primary outcome was hospital personnel adherence to 9 AIS performance measures, with co-primary outcomes of a composite of percentage of performance measures adhered to, and as all-or-none. Secondary outcomes included in-hospital mortality and long-term outcomes (a new vascular event, disability [modified Rankin Scale score, 3-5], and all-cause mortality) at 3, 6, and 12 months.Among 4800 patients with AIS enrolled from 40 hospitals
Exercise for stroke prevention We review evidence concerning exercise for stroke prevention. Plausible biological reasons suggest that exercise would be important in preventing stroke. While definitive randomised controlled trials evaluating the impact of physical activity (PA) and exercise on preventing stroke and mortality are lacking, observational studies, small randomised controlled trials and meta-analyses have provided evidence that PA and exercise favourably modify stroke risk factors (...) , including hypertension, dyslipidaemia, diabetes, sedentary lifestyle, obesity, excessive alcohol consumption and tobacco use. It is, therefore, important to understand the factors associated with poststroke PA/exercise and cardiorespiratory fitness. Positively associated factors include self-efficacy, social support and quality of patients' relationships with health professionals. Negatively associated factors include logistical barriers, medical comorbidities, stroke-related deficits, negative exercise
of current evidence, the benefit from PFO closure relies on careful patient selection: those under the age of 60 years with few to no vascular risk factors and embolic-appearing stroke deemed cryptogenic after thorough evaluation. As these data look towards influencing guideline statements and device approvals in the future, patient selection remains the crucial ingredient for clinical decision making and future trials. (...) Patent foramen ovale and cryptogenic stroke: diagnosis and updates in secondary stroke prevention The patent foramen ovale (PFO), given its high prevalence in the general population and especially in patients with cryptogenic stroke, has long generated investigation and debate on its propensity for stroke by paradoxical embolism and its management for stroke prevention. The pendulum has swung for percutaneous PFO closure for secondary stroke prevention in cryptogenic stroke. Based on a review
Stenting for intracranial stenosis: potential future for the prevention of disabling or fatal stroke Intracranial stenosis is a common cause of ischaemicstrokes, in particular, in the Asian, African and Hispanic populations. The randomised multicentre study Stenting and Aggressive Medical Management for the Prevention of Recurrent stroke in Intracranial Stenosis (SAMMPRIS) showed 14.7% risk of stroke or death in the stenting group versus 5.8% in the medical group at 30 days, and 23 (...) % in the stenting group versus 15% in the medical group at a median follow-up of 32.4 months. The results demonstrated superiority of medical management over stenting and have almost put the intracranial stenting to rest in recent years. Of note, 16 patients (7.1%) in the stenting group had disabling or fatal stroke within 30 days mostly due to periprocedural complications as compared with 4 patients (1.8%) in the medical group. In contrast, 5 patients (2.2%) in the stenting group and 14 patients (6.2
B vitamins for stroke prevention Supplementation with B vitamins (vitamin B9(folic acid), vitamin B12 and vitamin B6) lowers blood total homocysteine (tHcy) concentrations by about 25% and reduces the relative risk of stroke overall by about 10% (risk ratio (RR) 0.90, 95% CI 0.82 to 0.99) compared with placebo. Homocysteine-lowering interventions have no significant effect on myocardial infarction, death from any cause or adverse outcomes. Factors that appear to modify the effect of B vitamins (...) on stroke risk include low folic acid status, high tHcy, high cyanocobalamin dose in patients with impaired renal function and concurrent antiplatelet therapy. In regions with increasing levels or established policies of population folate supplementation, evidence from observational genetic epidemiological studies and randomised controlled clinical trials is concordant in suggesting an absence of benefit from lowering of homocysteine with folic acid for prevention of stroke. Clinical trials indicate
Ethics reporting practices in randomized controlled trials of physical therapy interventions after stroke Adequate reporting of ethics-related research methods promotes convergence on best ethics practices. In physical therapy, studies on ethics reporting are limited to few aspects, and none focuses on stroke research. Our objectives were to investigate the reporting of multiple ethics-related features and its variation over time, and the characteristics of the studies associated with ethics (...) reporting in Randomized Controlled Trials (RCTs) of physical therapy interventions after stroke.A random sample of RCTs published in the years 2004, 2009 and 2014, was extracted from the PubMed database, regardless of the publishing journal. For each trial we investigated year of publication, trial registration, sample size, stroke subtype, phase of the disease, setting, interventions and dosing, outcome measures, outcome of the study, PEDro score and 5-year impact factor of the publishing journal
imaging and highly trained multidisciplinary hospital teams rapidly responding to emergency activation. Despite the previous acceptance of intravenous ?brinolysis for acute ischemicstroke and the development of designated stroke centers (1), ischemicstroke remains a leading cause of adult death and disability (2). Many patients are not can- didates for ?brinolysis, and intravenous therapy is relatively ineffective for severe strokes as a result of large cerebral artery occlusions. Moreover (...) in Acute IschemicStroke (THRACE) (8) trials reported 38% and 53% rates of mRS score 0–2 at 90 days, respectively, and, in the per- protocol population of the Pragmatic Ischaemic Thrombectomy Evalua- tion (PISTE) trial (129), 57% of the endovascular group reached an mRS score of 0–2 at 90 days. The major trials focused on stroke patients with large artery occlu- sions, speci?cally internal carotid terminus or proximal middle cerebral (ie, M1) arteries. However, some patients with severe stroke have
Comparison of Neuroplastic Responses to Cathodal Transcranial Direct Current Stimulation and Continuous Theta Burst Stimulation in Subacute Stroke To investigate the effects of cathodal transcranial direct current stimulation (tDCS) and continuous theta burst stimulation (cTBS) on neural network connectivity and motor recovery in individuals with subacute stroke.Double-blinded, randomized, placebo-controlled study.University hospital rehabilitation unit.Inpatients with stroke (N=41; mean age (...) , 65y; range, 28-85y; mean weeks poststroke, 5; range, 2-10) with resultant paresis in the upper extremity (mean Fugl-Meyer score, 14; range, 3-48).Subjects with stroke were randomly assigned to neuronavigated cTBS (n=14), cathodal tDCS (n=14), or sham transcranial magnetic stimulation/sham tDCS (n=13) over the contralesional primary motor cortex (M1). Each subject completed 9 stimulation sessions over 3 weeks, combined with physical therapy.Brain function was assessed with directed and nondirected
Ambulance Clinical Triage for Acute Stroke Treatment: Paramedic Triage Algorithm for Large Vessel Occlusion Clinical triage scales for prehospital recognition of large vessel occlusion (LVO) are limited by low specificity when applied by paramedics. We created the 3-step ambulance clinical triage for acute stroke treatment (ACT-FAST) as the first algorithmic LVO identification tool, designed to improve specificity by recognizing only severe clinical syndromes and optimizing paramedic usability (...) , for the identification of internal carotid or proximal middle cerebral artery occlusion. The diagnostic performance of the full ACT-FAST algorithm was then validated for patients accepted for thrombectomy.In retrospective (n=565) and prospective paramedic (n=104) validation, ACT-FAST displayed higher overall accuracy and specificity, when compared with existing LVO triage scales. Agreement of ACT-FAST between paramedics and doctors was excellent (κ=0.91; 95% confidence interval, 0.79-1.0). The full ACT-FAST
Six hours of task-oriented training optimizes walking competency post stroke: a randomized controlled trial in the public health-care system of South Africa To evaluate a minimal dose intervention of six 1-hour sessions of task-oriented circuit gait training including a caregiver over a 12-week period to persons post stroke in the South African public health sector.Stratified, single blinded, randomized controlled trial with three intervention groups.Persons post stroke ( n = 144, mean age 50 (...) years, 72 women), mean 9.5 weeks post stroke.Task group ( n = 51)-accompanied by a caregiver; task-oriented circuit gait training (to improve strength, balance, and task performance while standing and walking). Strength group ( n = 45); strength training of lower extremities while sitting and lying. Control group ( n = 48); one 90-minute educational session on stroke management.The six-minute walk test (6MinWT) was the primary outcome; the secondary outcomes included comfortable and fast gait speeds
Factors contributing to sex differences in functional outcomes and participation after stroke To examine factors contributing to the sex differences in functional outcomes and participation restriction after stroke.Individual participant data on long-term functional outcome or participation restriction (i.e., handicap) were obtained from 11 stroke incidence studies (1993-2014). Multivariable log-binomial regression was used to estimate the female:male relative risk (RR) of poor functional (...) outcome (modified Rankin Scale score >2 or Barthel Index score <20) at 1 year (10 studies, n = 4,852) and 5 years (7 studies, n = 2,226). Multivariable linear regression was used to compare the mean difference (MD) in participation restriction by use of the London Handicap Scale (range 0-100 with lower scores indicating poorer outcome) for women compared to men at 5 years (2 studies, n = 617). For each outcome, study-specific estimates adjusted for confounding factors (e.g., sociodemographics, stroke
= 0.023]). The events in the medication-only group included ischemicstroke (n = 5), cerebral hemorrhage (n = 1), Thrombolysis In Myocardial Infarction-defined major bleeding (n = 2), and transientischemicattack (n = 1). Nonfatal procedural complications included development of atrial fibrillation (n = 2), pericardial effusion (n = 1), and pseudoaneurysm (n = 1).PFO closure in patients with high-risk PFO characteristics resulted in a lower rate of the primary endpoint as well as stroke recurrence (...) of the PFO, as evaluated by transesophageal echocardiography.Patients with cryptogenic stroke and high-risk PFO were divided between a transcatheter PFO closure and a medication-only group. High-risk PFO included PFO with atrial septal aneurysm, hypermobility (phasic septal excursion into either atrium ≥10 mm), or PFO size (maximum separation of the septum primum from the secundum) ≥2 mm. The primary endpoint was a composite of stroke, vascular death, or Thrombolysis In Myocardial Infarction-defined
: Initial risk stratification and management of nondisabling stroke or TIA The goal of outpatient management of transient ische- mic attack and nondisabling ischemicstroke is to rap- idly identify cardiovascular risk factors, which may have precipitated the initial event, and to initiate treat- ments to reduce the risk of recurrent events. Historically, the 90-day risk of recurrent stroke follow- ing an index transientischemicattack has been esti- mated to be relatively high, between 12% and 20 (...) , and should be seen by a neurologist or stroke specialist for evaluation, ideally within one month of symptom onset [Evidence Level C]. Refer to Section 1.2 for more information on investigations. 1.2 Diagnostic investigations 1.2.1 Initial assessment i. Patients presenting with suspected acute or recent transientischemicattack or non-disabling ischemicstroke should undergo an initial assessment that includes brain imaging, noninvasive vascular imaging (including carotid imaging), 12-lead ECG
Guidelines for evaluation and management of cerebral collateral circulation in ischaemicstroke 2017 Collateral circulation plays a vital role in sustaining blood flow to the ischaemic areas in acute, subacute or chronic phases after an ischaemicstroke or transientischaemicattack. Good collateral circulation has shown protective effects towards a favourable functional outcome and a lower risk of recurrence in stroke attributed to different aetiologies or undergoing medical or endovascular (...) -based recommendations regarding grading methods for collateral circulation, its significance in patients with stroke and methods under investigation to improve collateral flow.
baseline CVD, comprised of incident CVD cases and a subcohort for comparison.Non-fatal and fatal CHD and stroke (including ischaemic and haemorrhagic stroke).There were 9307 non-fatal CHD events, 1699 fatal CHD, 5855 non-fatal stroke, and 733 fatal stroke. Baseline alcohol intake was inversely associated with non-fatal CHD, with a hazard ratio of 0.94 (95% confidence interval 0.92 to 0.96) per 12 g/day higher intake. There was a J shaped association between baseline alcohol intake and risk of fatal CHD (...) . The hazard ratios were 0.83 (0.70 to 0.98), 0.65 (0.53 to 0.81), and 0.82 (0.65 to 1.03) for categories 5.0-14.9 g/day, 15.0-29.9 g/day, and 30.0-59.9 g/day of total alcohol intake, respectively, compared with 0.1-4.9 g/day. In contrast, hazard ratios for non-fatal and fatal stroke risk were 1.04 (1.02 to 1.07), and 1.05 (0.98 to 1.13) per 12 g/day increase in baseline alcohol intake, respectively, including broadly similar findings for ischaemic and haemorrhagic stroke. Associations with cardiovascular
Association of Surgical Left Atrial Appendage Occlusion With Subsequent Stroke and Mortality Among Patients Undergoing Cardiac Surgery. Surgical occlusion of the left atrial appendage (LAAO) may be performed during concurrent cardiac surgery. However, few data exist on the association of LAAO with long-term risk of stroke, and some evidence suggests that this procedure may be associated with subsequent development of atrial fibrillation (AF).To evaluate the association of surgical LAAO (...) those with vs without LAAO, stratified by history of prior AF at the time of surgery.Surgical LAAO vs no surgical LAAO during cardiac surgery.The primary outcomes were stroke (ie, ischemicstroke or systemic embolism) and all-cause mortality. The secondary outcomes were postoperative AF (AF within 30 days after surgery among patients without prior AF) and long-term AF-related health utilization (event rates of outpatient visits and hospitalizations).Among 75 782 patients who underwent cardiac
Practice patterns and outcomes after stroke across countries at different economic levels (INTERSTROKE): an international observational study. Stroke disproportionately affects people in low-income and middle-income countries. Although improvements in stroke care and outcomes have been reported in high-income countries, little is known about practice and outcomes in low and middle-income countries. We aimed to compare patterns of care available and their association with patient outcomes across (...) countries at different economic levels.We studied the patterns and effect of practice variations (ie, treatments used and access to services) among participants in the INTERSTROKE study, an international observational study that enrolled 13 447 stroke patients from 142 clinical sites in 32 countries between Jan 11, 2007, and Aug 8, 2015. We supplemented patient data with a questionnaire about health-care and stroke service facilities at all participating hospitals. Using univariate and multivariate
Edaravone and cyclosporine A as neuroprotective agents for acute ischemicstroke It is well known that acute ischemicstroke (AIS) and subsequent reperfusion produce lethal levels of reactive oxygen species (ROS) in neuronal cells, which are generated in mitochondria. Mitochondrial ROS production is a self-amplifying process, termed "ROS-induced ROS release". Furthermore, the mitochondrial permeability transition pore (MPTP) is deeply involved in this process, and its opening could cause cell