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Latest & greatest articles for stroke
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Intensive blood pressure reduction with intravenous thrombolysis therapy for acute ischaemicstroke (ENCHANTED): an international, randomised, open-label, blinded-endpoint, phase 3 trial. Systolic blood pressure of more than 185 mm Hg is a contraindication to thrombolytic treatment with intravenous alteplase in patients with acute ischaemicstroke, but the target systolic blood pressure for optimal outcome is uncertain. We assessed intensive blood pressure lowering compared with guideline (...) -recommended blood pressure lowering in patients treated with alteplase for acute ischaemic stroke.We did an international, partial-factorial, open-label, blinded-endpoint trial of thrombolysis-eligible patients (age ≥18 years) with acute ischaemicstroke and systolic blood pressure 150 mm Hg or more, who were screened at 110 sites in 15 countries. Eligible patients were randomly assigned (1:1, by means of a central, web-based program) within 6 h of stroke onset to receive intensive (target systolic blood
2019LancetControlled trial quality: predicted high
dressing (the sham group) in UK-based ambulances by paramedics, with treatment continued in hospital. Paramedics were unmasked to treatment, whereas participants were masked. The primary outcome was the 7-level modified Rankin Scale (mRS; a measure of functional outcome) at 90 days, assessed by central telephone follow-up with masking to treatment. Analysis was hierarchical, first in participants with a confirmed stroke or transientischaemicattack (cohort 1), and then in all participants who were (...) randomly assigned (intention to treat, cohort 2) according to the statistical analysis plan. This trial is registered with ISRCTN, number ISRCTN26986053.Between Oct 22, 2015, and May 23, 2018, 516 paramedics from eight UK ambulance services recruited 1149 participants (n=568 in the GTN group, n=581 in the sham group). The median time to randomisation was 71 min (IQR 45-116). 597 (52%) patients had ischaemicstroke, 145 (13%) had intracerebral haemorrhage, 109 (9%) had transientischaemicattack
2019LancetControlled trial quality: predicted high
% and hemiparesis in 36% to 75% and are clinically covert in 14% to 40%. Braun et al found that cardioembolic stroke may present with abrupt onset compared with a stuttering or fluctuating presentation in children with stroke caused by arteriopathy. Diagnosis of cerebralinfarction is often made when imaging is obtained for other reasons (cardiac arrest, extracorporeal membrane oxygenation cannulation). Children with moyamoya-type arteriopathies are distinguished by a high prevalence of transientischemic (...) in a delayed manner, that are presumed to have occurred in the perinatal period. These infants typically present with pathological early handedness or seizures, leading to brain imaging and the diagnosis of a remote infarction. As in adults, pediatric stroke can also be classified according to whether the underlying cause is ischemic or hemorrhagic, as detailed in the NIH Common Data Elements. Ischemicstroke includes arterial ischemicstroke (AIS) and venous infarction caused by cerebral sinovenous
Risk of IschemicStroke and Total Cerebrovascular Disease in Familial Hypercholesterolemia Background and Purpose- Familial hypercholesterolemia (FH) is a common autosomal dominant disease leading to increased level of serum LDL (low-density lipoprotein) cholesterol and risk of coronary heart disease. Whether FH increases the risk of cerebrovascular disease, including ischemicstroke, is debated. Accordingly, we studied the incidence of cerebrovascular disease in a cohort of people (...) with genetically verified FH compared with the entire Norwegian population and examined whether people in this cohort with previous cohort had increased risk of cerebrovascular disease. Methods- Incidence rates of hospitalization for cerebrovascular disease (among 3144 people with FH) and ischemicstroke (among 3166 people with FH) were estimated by linkage of FH people to Cardiovascular Disease in Norway-a nationwide database of cardiovascular disease hospitalizations (2001-2009). We calculated standardized
Decreasing Fear of Falling in Chronic Stroke Survivors Through Cognitive Behavior Therapy and Task-Oriented Training Background and Purpose- Research has shown that balance training is effective for reducing the fear of falling in individuals with a history of stroke. In this study, we evaluated (1) whether cognitive behavior therapy could augment the beneficial effects of task-oriented balance training (TOBT) in reducing the fear of falling in chronic stroke survivors and (2) whether it could (...) in balance and independent daily living than the general health education + TOBT participants. Conclusions- Cognitive behavior therapy should be considered as an adjuvant therapy to standard physiotherapy for cognitively intact individuals with a history of stroke. Clinical Trial Registration- URL: http://clinicaltrials.gov . Unique identifier: NCT02937532.
CHA2DS2-VASc Score and Stroke Prediction in Atrial Fibrillation in Whites, Blacks, and Hispanics Background and Purpose- Despite modest predictive ability for ischemicstroke (IS), the CHA2DS2-VASc score is widely used for stroke prediction in atrial fibrillation. Among patients with atrial fibrillation, we aimed to (1) compare the IS or transientischemicattack (TIA) incidence by CHA2DS2-VASc in blacks and Hispanics versus whites; (2) compare predictive ability of CHA2DS2-VASc score (...) for IS or TIA in blacks and Hispanics versus whites; and (3) determine improvement in predictive ability of CHA2DS2-VASc score from addition of race/ethnicity. Methods- Using data from Optum Clinformatics, a large administrative claims database, we analyzed patients with atrial fibrillation enrolled in commercial and Medicare Advantage health plans from 2009 to 2015. We computed IS or TIA incidence rates, improvement in C statistic, continuous and categorical net reclassification improvement, and relative
Dual-Task Exercise Reduces Cognitive-Motor Interference in Walking and Falls After Stroke Background and Purpose- Functional community ambulation requires the ability to perform mobility and cognitive task simultaneously (dual-tasking). This single-blinded randomized controlled study aimed to examine the effects of dual-task exercise in chronic stroke patients. Methods- Eighty-four chronic stroke patients (24 women; age, 61.2±6.4 years; time since stroke onset, 75.3±64.9 months) with mild (...) during serial-3-subtractions and verbal fluency task. Secondary outcomes included the Activities-specific Balance Confidence Scale, Frenchay Activities Index, and Stroke-specific Quality of Life Scale. The above outcomes were measured at baseline, immediately after, and 8 weeks after training. Fall incidence was recorded for a 6-month period posttraining. Results- Only the dual-task group exhibited reduced dual-task interference in walking time posttraining (forward walking combined with verbal
Stride management assist exoskeleton vs functional gait training in stroke: A randomized trial To test the hypothesis that gait training with a hip-assistive robotic exoskeleton improves clinical outcomes and strengthens the descending corticospinal drive to the lower limb muscles in persons with chronic stroke.Fifty participants completed the randomized, single-blind, parallel study. Participants received over-ground gait training with the Honda Stride Management Assist (SMA) exoskeleton (...) had greater improvement in walking endurance (46.0% ± 27.4% vs 35.7% ± 20.8%, p = 0.033), took more steps during therapy days (4,366 ± 2,426 vs 3,028 ± 1,510; p = 0.013), and demonstrated larger changes in CME of the paretic rectus femoris (178% ± 75% vs 33% ± 32%, p = 0.010). Participants with hemorrhagic stroke demonstrated greater improvement in balance when using the SMA (24.7% ± 20% vs 6.8% ± 6.7%, p = 0.029).Gait training with the SMA improved walking speed in persons with chronic stroke
-related ischemic stroke.We included 2229 participants from the ARIC study (Atherosclerosis Risk in Communities) and 700 participants from MESA (Multi-Ethnic Study of Atherosclerosis) with incident AF who were not on anticoagulants within 1 year of AF diagnosis. PWIs were obtained from study visit ECGs before development of AF. AF was ascertained using study visit ECGs and hospital records. Ischemicstroke cases were based on physician adjudication of hospital records. We used Cox proportional hazards (...) models to estimate hazard ratios and 95% CIs of PWIs for ischemicstroke. Improvement in 1-year stroke prediction was assessed by C-statistic, categorical net reclassification improvement, and relative integrated discrimination improvement.Abnormal P-wave axis was the only PWI associated with increased ischemicstroke risk (hazard ratio, 1.84; 95% CI, 1.33-2.55) independent of CHA2DS2-VASc variables, and that resulted in meaningful improvement in stroke prediction. The β estimate was approximately
. Physical Inactivity e99 5. Nutrition e119 6. Overweight and Obesity e138 Health Factors and Other Risk Factors 7. High Blood Cholesterol and Other Lipids e161 8. High Blood Pressure e174 9. Diabetes Mellitus e193 10. Metabolic Syndrome e212 11. Kidney Disease e233 12. Sleep e249 Cardiovascular Conditions/Diseases 13. Total Cardiovascular Diseases e257 14. Stroke (Cerebrovascular Disease) e281 15. Congenital Cardiovascular Defects and Kawasaki Disease e327 16. Disorders of Heart Rhythm e346 17. Sudden (...) (95% CI, 17.3–18.1 million) deaths were attributed to CVD globally, which amounted to an increase of 14.5% (95% CI, 12.1%–17.1%) from 2006. The age-adjusted death rate per 100 000 population was 277.9 (95% CI, 272.1–284.6), which represents a decrease of 14.5% (95% CI, −16.2% to −12.5%) from 2006. Stroke (Cerebrovascular Disease) (Chapter 14) An estimated 7.0 million Americans ≥20 years of age self-report having had a stroke, and the overall stroke prevalence was an estimated 2.5%. In the National
Effects of Electromechanical Exoskeleton-Assisted Gait Training on Walking Ability of Stroke Patients: A Randomized Controlled Trial To assess the efficacy of electromechanical exoskeleton-assisted gait training on walking ability of stroke patients based on ambulatory function, muscle strength, balance, gait speed, and capacity.Randomized controlled trial.University rehabilitation hospital.Individuals (N=40) with stroke who could stand alone.Patients were randomly assigned to control (...) significant in the experimental group alone. Most secondary outcomes in both groups also showed improvement after gait training. However, the differential outcomes were not varied between the 2 groups after adjusting the data for age and stroke duration. We did not exclude patients based on time since stroke onset. The average stroke duration was 530.11±389.21 days in the experimental group. The changes in FAC of the experimental group were negatively correlated with stroke duration. No adverse events
neurology center.Adult patients with acute middle cerebral artery territory ischemicstroke.60 patients were randomized into three groups of 20 each: TBS+PT; FES+PT; and PT alone. TBS group received intermittent TBS of ipsilesional hemisphere and continuous TBS of contralesional hemisphere while FES group received FES of paretic limb, both for four weeks. All groups received supervised physical therapy for four weeks followed by home physiotherapy for one year.Fugl Meyer Assessment upper limb score (FMA (...) The comparative efficacy of theta burst stimulation or functional electrical stimulation when combined with physical therapy after stroke: a randomized controlled trial To study the long-term effectiveness of Theta Burst Stimulation (TBS) or Functional Electrical Stimulation (FES) combined with Physical therapy (PT) as compared to PT alone for improving arm functions in patients with acute stroke.Single blind randomized controlled trial.Outpatient clinics and inpatient wards at tertiary care
Canagliflozin and Stroke in Type 2 Diabetes Mellitus Background and Purpose- This study reports the detailed effects of canagliflozin on stroke, stroke subtypes, and vascular outcomes in participants with and without cerebrovascular disease (stroke or transientischemicattack) at baseline from the CANVAS (Canagliflozin Cardiovascular Assessment Study) Program. Methods- The CANVAS Program, comprising 2 similarly designed and conducted clinical trials, randomly assigned 10 142 participants (...) with type 2 diabetes mellitus and high cardiovascular risk to canagliflozin or placebo. Its primary outcome was a composite of major adverse cardiovascular events. The main outcome of interest for this report was fatal or nonfatal stroke. Additional exploratory outcomes were stroke subtypes and other vascular outcomes defined according to standard criteria. Results- There were 1 958 (19%) participants with prior stroke or transientischemicattack at baseline. These individuals were older, more
Impact and sustainability of centralising acute stroke services in English metropolitan areas: retrospective analysis of hospital episode statistics and stroke national audit data. To investigate whether further centralisation of acute stroke services in Greater Manchester in 2015 was associated with changes in outcomes and whether the effects of centralisation of acute stroke services in London in 2010 were sustained.Retrospective analyses of patient level data from the Hospital Episode (...) Statistics (HES) database linked to mortality data from the Office for National Statistics, and the Sentinel Stroke National Audit Programme (SSNAP).Acute stroke services in Greater Manchester and London, England.509 182 stroke patients in HES living in urban areas admitted between January 2008 and March 2016; 218 120 stroke patients in SSNAP between April 2013 and March 2016.Hub and spoke models for acute stroke care.Mortality at 90 days after hospital admission; length of acute hospital stay; treatment
Unilateral Strength Training and Mirror Therapy in Patients With Chronic Stroke: A Pilot Randomized Trial. The aim of the study was to investigate the feasibility and potential effectiveness of mirror-aided cross-education compared with cross-education alone in poststroke upper limb recovery.A pilot randomized controlled parallel group study was carried out. Thirty-two patients with chronic stroke followed a 4-wk isometric strength training program performed with the less-affected upper limb (...) Inventory.Compliance was high with no adverse effects. The use of the Biodex Dynamometer must be reviewed. Mirror therapy did not augment the cross-education effect (P > 0.05) in patients with chronic stroke when training isometrically.This pilot trial established the feasibility of a randomized controlled trial comparing mirror-aided cross-education with cross-education alone for poststroke upper limb recovery. Mirror therapy did not augment cross-education when training isometrically. However, results indicate
It is safe to use transdermal glyceryl trinitrate to lower blood pressure in patients with acute ischaemicstroke with carotid stenosis. There is concern that blood pressure (BP) lowering in acute stroke may compromise cerebral perfusion and worsen outcome in the presence of carotid stenosis. We assessed the effect of glyceryl trinitrate (GTN) in patients with carotid stenosis using data from the Efficacy of Nitric Oxide in Stroke (ENOS) Trial.ENOS randomised 4011 patients with acute stroke (...) and raised systolic BP (140-220 mm Hg) to transdermal GTN or no GTN within 48 hours of onset. Those on prestroke antihypertensives were also randomised to stop or continue their medication for 7 days. The primary outcome was the modified Rankin Scale (mRS) at day 90. Ipsilateral carotid stenosis was split: <30%; 30-<50%; 50-<70%; ≥70%. Data are ORs with 95% CIs adjusted for baseline prognostic factors.2023 (60.5%) ischaemicstroke participants had carotid imaging. As compared with <30%, ≥70% ipsilateral
Cryotherapy Reduces Muscle Spasticity But Does Not Affect Proprioception in IschemicStroke: A Randomized Sham-Controlled Crossover Study. The aim of the study was to evaluate the immediate effects of cryotherapy (using an ice pack) on ankle joint position sense and the degree of spasticity after chronic hemiparetic stroke.We used a sham-controlled crossover design. Sixteen chronic hemiparetic patients were randomly assigned to two groups: (1) those who received cryotherapy followed
Comparative Effects of Different Assistance Force During Robot-Assisted Gait Training on Locomotor Functions in Patients With Subacute Stroke: An Assessor-Blind, Randomized Controlled Trial. The aim of the study was to compare the effects of progressive reducing assistance force versus full assistance force controlled robot-assisted gait training combined with conventional physiotherapy on locomotor functions in patients with subacute stroke.Inpatients with subacute stroke (N = 29; 16 men (...) to the full assistance force group, both at postintervention and at follow-up.Progressive reducing assistance force control during robot-assisted gait training combined with conventional physiotherapy may be more beneficial for improving locomotor functions in patients with subacute stroke.
Early CT score. MCA = middle cerebral artery. Thrombectomy provision and population size A recent study developed a decision-tree model based on data from international RCTs and national registries to estimate the number of ischaemicstroke patients eligible for mechanical thrombectomy each year in the UK 40 . Patients were excluded from the eligible population based on criteria such as small artery occlusion rather than large artery occlusion, mild stroke, presentation more than 12 hours after (...) ://www.stroke.org.uk/system/files/sotn_2018.pdf. 2. World Health Organization. Stroke, cerebrovascularaccident. [cited 2018 Oct 11]; Available from: http://www.who.int/topics/cerebrovascular_accident/en/. 3. Scottish Intercollegiate Guidelines Network. Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention. 2008 [cited 2018]; Available from: https://www.sign.ac.uk/assets/sign108.pdf. 4. EUnetHTA. Endovascular therapy using mechanical thrombectomy
Development and validation of a score to detect paroxysmal atrial fibrillation after stroke Prolonged monitoring times (72 hours) are recommended to detect paroxysmal atrial fibrillation (pAF) after ischemicstroke but this is not yet clinical practice; therefore, an individual patient selection for prolonged ECG monitoring might increase the diagnostic yield of pAF in a resource-saving manner.We used individual patient data from 3 prospective studies (ntotal = 1,556) performing prolonged (...) Holter-ECG monitoring (at least 72 hours) and centralized data evaluation after TIA or stroke in patients with sinus rhythm. Based on the TRIPOD (Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis) guideline, a clinical score was developed on one cohort, internally validated by bootstrapping, and externally validated on 2 other studies.pAF was detected in 77 of 1,556 patients (4.9%) during 72 hours of Holter monitoring. After logistic regression analysis