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Latest & greatest articles for stroke
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Robot assisted training for the upper limb after stroke (RATULS): a multicentre randomised controlled trial. Loss of arm function is a common problem after stroke. Robot-assisted training might improve arm function and activities of daily living. We compared the clinical effectiveness of robot-assisted training using the MIT-Manus robotic gym with an enhanced upper limb therapy (EULT) programme based on repetitive functional task practice and with usual care.RATULS was a pragmatic, multicentre (...) , randomised controlled trial done at four UK centres. Stroke patients aged at least 18 years with moderate or severe upper limb functional limitation, between 1 week and 5 years after their first stroke, were randomly assigned (1:1:1) to receive robot-assisted training, EULT, or usual care. Robot-assisted training and EULT were provided for 45 min, three times per week for 12 weeks. Randomisation was internet-based using permuted block sequences. Treatment allocation was masked from outcome assessors
2019LancetControlled trial quality: predicted high
Transcranial direct current stimulation (tDCS) for improving aphasia in adults with aphasia after stroke. Stroke is one of the leading causes of disability worldwide and aphasia among survivors is common. Current speech and language therapy (SLT) strategies have only limited effectiveness in improving aphasia. A possible adjunct to SLT for improving SLT outcomes might be non-invasive brain stimulation by transcranial direct current stimulation (tDCS) to modulate cortical excitability and hence (...) to improve aphasia.To assess the effects of tDCS for improving aphasia in people who have had a stroke.We searched the Cochrane Stroke Group Trials Register (June 2018), CENTRAL (Cochrane Library, June 2018), MEDLINE (1948 to June 2018), Embase (1980 to June 2018), CINAHL (1982 to June 2018), AMED (1985 to June 2018), Science Citation Index (1899 to June 2018), and seven additional databases. We also searched trial registers and reference lists, handsearched conference proceedings and contacted authors
Dabigatran for Prevention of Stroke after Embolic Stroke of Undetermined Source. Cryptogenic strokes constitute 20 to 30% of ischemicstrokes, and most cryptogenic strokes are considered to be embolic and of undetermined source. An earlier randomized trial showed that rivaroxaban is no more effective than aspirin in preventing recurrent stroke after a presumed embolic stroke from an undetermined source. Whether dabigatran would be effective in preventing recurrent strokes after this type (...) follow-up of 19 months, recurrent strokes occurred in 177 patients (6.6%) in the dabigatran group (4.1% per year) and in 207 patients (7.7%) in the aspirin group (4.8% per year) (hazard ratio, 0.85; 95% confidence interval [CI], 0.69 to 1.03; P = 0.10). Ischemicstrokes occurred in 172 patients (4.0% per year) and 203 patients (4.7% per year), respectively (hazard ratio, 0.84; 95% CI, 0.68 to 1.03). Major bleeding occurred in 77 patients (1.7% per year) in the dabigatran group and in 64 patients (1.4
Thrombolysis Guided by Perfusion Imaging up to 9 Hours after Onset of Stroke. The time to initiate intravenous thrombolysis for acute ischemicstroke is generally limited to within 4.5 hours after the onset of symptoms. Some trials have suggested that the treatment window may be extended in patients who are shown to have ischemic but not yet infarcted brain tissue on imaging.We conducted a multicenter, randomized, placebo-controlled trial involving patients with ischemicstroke who had (...) ). Symptomatic intracerebral hemorrhage occurred in 7 patients (6.2%) in the alteplase group and in 1 patient (0.9%) in the placebo group (adjusted risk ratio, 7.22; 95% CI, 0.97 to 53.5; P = 0.05). A secondary ordinal analysis of the distribution of scores on the modified Rankin scale did not show a significant between-group difference in functional improvement at 90 days.Among the patients in this trial who had ischemicstroke and salvageable brain tissue, the use of alteplase between 4.5 and 9.0 hours
with masked assessment of stroke outcomes. (ClinicalTrials.gov: NCT01216423).4 French hospital centers.361 consecutive patients with symptomatic acute PE from 13 November 2009 through 21 December 2015.Systematic contrast transthoracic echocardiography (TTE) and cerebral magnetic resonance imaging (MRI) within 7 days after enrollment.Recent symptomatic or silent ischemicstroke was diagnosed on the basis of clinical examination and cerebral MRI showing a hypersignal on the trace diffusion-weighted image (...) with reduction or pseudonormalization of apparent diffusion coefficient.Contrast TTE was conclusive in 324 of 361 patients and showed PFO in 43 patients (13%). The median age was 66 years (interquartile range, 54 to 77 years). In total, 51% of patients (145/284) had associated deep venous thrombosis, 91% (279/306) had cardiovascular risk factors, and 10% (16/151) presented with arrhythmia (no difference between PFO and non-PFO groups). Cerebral MRI was conclusive in 315 patients. Recent ischemicstroke
Stem cell transplantation for ischemicstroke. Stroke is a leading cause of morbidity and mortality worldwide, with very large healthcare and social costs, and a strong demand for alternative therapeutic approaches. Preclinical studies have shown that stem cells transplanted into the brain can lead to functional improvement. However, to date, evidence for the benefits of stem cell transplantation in people with ischemicstroke is lacking. This is the first update of the Cochrane review (...) published in 2010.To assess the efficacy and safety of stem cell transplantation compared with control in people with ischemic stroke.We searched the Cochrane Stroke Group Trials Register (last searched August 2018), CENTRAL (last searched August 2018), MEDLINE (1966 to August 2018), Embase (1980 to August 2018), and BIOSIS (1926 to August 2018). We handsearched potentially relevant conference proceedings, screened reference lists, and searched ongoing trials and research registers (last searched August
Caregivers' effects of augmented cognitive-behavioural therapy for post-stroke depressive symptoms in patients: secondary analyses to a randomized controlled trial To investigate the concomitant effects of two patient-directed interventions for post-stroke depressive symptoms on caregivers' well-being.Secondary analyses of the results of a randomized controlled trial.Fifty caregivers of stroke patients receiving outpatient rehabilitation.Stroke patients and their caregivers were randomly
the accuracy of stroke recognition scales used in a prehospital or ER setting to identify stroke and transientIschemicattack (TIA) in people suspected of stroke. The scales had to be applied to actual people and the results compared to a final diagnosis of stroke or TIA. We excluded studies that applied scales to patient records; enrolled only screen-positive participants and without complete 2 × 2 data.Two review authors independently conducted a two-stage screening of all publications identified (...) Prehospital stroke scales as screening tools for early identification of stroke and transientischemicattack. Rapid and accurate detection of stroke by paramedics or other emergency clinicians at the time of first contact is crucial for timely initiation of appropriate treatment. Several stroke recognition scales have been developed to support the initial triage. However, their accuracy remains uncertain and there is no agreement which of the scales perform better.To systematically identify
A novel biomarker-based prognostic score in acute ischemicstroke: The CoRisk score To derive and externally validate a copeptin-based parsimonious score to predict unfavorable outcome 3 months after an acute ischemicstroke (AIS).The derivation cohort consisted of patients with AIS enrolled prospectively at the University Hospital Basel, Switzerland. The validation cohort was prospectively enrolled after the derivation cohort at the University Hospital of Bern and University Hospital Basel (...) , Switzerland, as well as Frankfurt a.M., Germany. The score components were copeptin levels, age, NIH Stroke Scale, and recanalization therapy (CoRisk score). Copeptin levels were measured in plasma drawn within 24 hours of AIS and before any recanalization therapy. The primary outcome of disability and death at 3 months was defined as modified Rankin Scale score of 3 to 6.Overall, 1,102 patients were included in the analysis; the derivation cohort contributed 319 patients, and the validation cohort
Post-Thrombolysis Recanalization in Stroke Referrals for Thrombectomy: Incidence, Predictors, and Prediction Scores Background and Purpose—Whether all acute stroke patients with large vessel occlusion need to undergo intravenous
thrombolysis before mechanical thrombectomy (MT) is debated as (1) the incidence of post-thrombolysis early
recanalization (ER) is still unclear; (2) thrombolysis may be harmful in patients unlikely to recanalize; and, conversely,
(3) transfer for MT may be unnecessary (...) sign (n=498),
no-ER was independently predicted by long thrombus, proximal occlusion, and mothership paradigm. A 6-point score
derived from these variables showed strong discriminative power for no-ER (C statistic, 0.854) and was replicated in
the validation cohort (n=353; C statistic, 0.888). A second score derived from the whole sample (including negative T2*
or computed tomography–based imaging) also showed good discriminative power and was similarly validated. Highest
grades on both scores
Safety and efficacy of sonothrombolysis for acute ischaemicstroke: a multicentre, double-blind, phase 3, randomised controlled trial Pulsed-wave ultrasound increases the exposure of an intracranial thrombus to alteplase (recombinant tissue plasminogen activator), potentially facilitating early reperfusion. We aimed to ascertain if a novel operator-independent transcranial ultrasound device delivering low-power high-frequency ultrasound could improve functional outcome in patients treated (...) with alteplase after acute ischaemic stroke.We did a multicentre, double-blind, phase 3, randomised controlled trial (CLOTBUST-ER) at 76 medical centres in 14 countries. We included patients with acute ischaemicstroke (National Institutes of Health Stroke Scale score ≥10) who received intravenous thrombolysis (alteplase bolus) within 3 h of symptom onset in North America and within 4·5 h of symptom onset in all other countries. Participants were randomly allocated (1:1) via an interactive web response
outcome evaluations to be completed this year. Dr. Dixon Yang is a 1st year resident at NYU Langone Health Peer reviewed by Matt Sanger, MD, neurology, NYU Langone Health Image courtesy of Wikimedia Commons References Sacco RL, Ellenberg JH, Mohr JP, et al. Infarcts of undetermined cause: the NINCDS Stroke Data Bank. Ann Neurol .1989;25(4):382-90. Ji R, Schwamm LH, Pervez MA, Singhal AB. Ischemicstroke and transientischemicattack in young adults: risk factors, diagnostic yield, neuroimaging (...) with her blood pressure well-controlled by a home medication. Computed tomography (CT) with angiography reveals signs of early acute ischemic changes in the right middle cerebral artery territory but no large vessel occlusion. She has no metabolic disturbances, an unremarkable complete blood count, and normal coagulation profile. She receives intravenous tissue plasminogen activator with improvement in symptoms and is admitted to the stroke unit. Further work up with 24-hour Holter monitor records
Does fluoxetine improve recovery after stroke? The studyFOCUS Trial Collaboration. Effects of fluoxetine on functional outcomes after acute stroke (FOCUS): a pragmatic, double-blind, randomised, controlled trial. Lancet 2019;393:256-74.The study was funded by the UK Stroke Association and the NIHR Health Technology Assessment Programme project number 13/04/30.To read the full NIHR Signal, go to: https://discover.dc.nihr.ac.uk/content/signal-000729/a-commonly-used-antidepressant-doesnt-improve
Effect of Catheter Ablation vs Antiarrhythmic Drug Therapy on Mortality, Stroke, Bleeding, and Cardiac Arrest Among Patients With Atrial Fibrillation: The CABANA Randomized Clinical Trial. Catheter ablation is effective in restoring sinus rhythm in atrial fibrillation (AF), but its effects on long-term mortality and stroke risk are uncertain.To determine whether catheter ablation is more effective than conventional medical therapy for improving outcomes in AF.The Catheter Ablation vs (...) Antiarrhythmic Drug Therapy for Atrial Fibrillation trial is an investigator-initiated, open-label, multicenter, randomized trial involving 126 centers in 10 countries. A total of 2204 symptomatic patients with AF aged 65 years and older or younger than 65 years with 1 or more risk factors for stroke were enrolled from November 2009 to April 2016, with follow-up through December 31, 2017.The catheter ablation group (n = 1108) underwent pulmonary vein isolation, with additional ablative procedures
IQoro for stroke-related dysphagia IQoro for strok IQoro for stroke-related dysphagia e-related dysphagia Medtech innovation briefing Published: 6 March 2019 www.nice.org.uk/guidance/mib175 pathways Summary Summary The technology technology described in this briefing is IQoro. It is a neuromuscular training device used for stimulating the nerves and strengthening the muscles in the face, mouth, throat, oesophagus, and diaphragm. Swallowing therapy is the usual treatment for dysphagia (...) (difficulty starting to swallow) after a stroke. The inno innovativ vative aspect e aspect is that the company claims swallowing exercises can be more accurately and effectively done using IQoro. No similar technologies are currently recommended in care guidelines. The intended place in ther place in therap apy y would be as well as standard speech and language therapy in people with stroke-related dysphagia. The main points from the e main points from the evidence vidence summarised in this briefing
Comparison of prasugrel and clopidogrel in patients with non-cardioembolic ischaemicstroke: a phase 3, randomised, non-inferiority trial (PRASTRO-I) The effect of prasugrel in terms of the prevention of recurrence of ischaemicstroke is unknown. We investigated the non-inferiority of prasugrel to clopidogrel for prevention of ischaemicstroke, myocardial infarction, and death from other vascular causes in Japanese patients with non-cardioembolic stroke.In this phase 3 randomised, double-blind (...) , investigators, and the funder were masked to treatment allocation. The primary endpoint was combined incidence of ischaemicstroke (fatal and non-fatal), myocardial infarction (fatal and non-fatal), and death from other vascular causes in the intention-to-treat population. The safety endpoint was incidence of bleeding events, comprising life-threatening bleeding, major bleeding, and clinically relevant bleeding. The safety analysis was done in the population excluding trial patients with serious Good
Performance of the RACE Score for the Prehospital Identification of Large Vessel OcclusionStroke in a Suburban/Rural EMS Service Introduction: Emergency Medical Services (EMS) providers may identify and preferentially transport patients experiencing large vessel occlusion (LVO) stroke to appropriate treatment centers. The Rapid Arterial oCclusion Evaluation (RACE) scale was created for prehospital LVO detection, yet few studies have evaluated its function in real-world EMS settings. Our (...) objective was to assess the prehospital performance of the RACE scale for detecting LVO stroke following implementation at a large suburban/rural agency in the United States. Methods: In this retrospective analysis, all 9-1-1 patients with an EMS provider primary or secondary impression of stroke treated by the agency between June 1, 2016 and November 1, 2017 were eligible for inclusion. Patient data were abstracted using a standardized form completed by receiving hospitals. Performance for LVO
Mind-Body Interventions, Psychological Stressors, and Quality of Life in Stroke Survivors Background and Purpose- Psychological stressors, including poststroke depression, poststroke anxiety, and posttraumatic stress disorder, are highly prevalent in stroke survivors. These symptoms exact a significant toll on stroke survivors. Clinical and research efforts in stroke recovery focus on motor disability, speech and language deficits, and cognitive dysfunction while largely neglecting (...) psychological stressors. Evidence suggests mind-body interventions in other chronic illness populations decrease symptoms of depression, regulate immune responses, and promote resilience, yet similar studies are lacking in stroke populations. This review aims to synthesize evidence of the effects of mind-body interventions on psychological stressors, quality of life, and biological outcomes for stroke survivors. Methods- A systematic search of PubMed, PsycINFO, and CINAHL was conducted from database