Who goes home? Predictive factors in stroke recovery

The Impact of Level of Physical Therapist Assistant Involvement on Patient Outcomes Following Stroke

OBJECTIVE

This study investigates if higher utilization of physical therapist assistants adversely affects patient outcomes in the acute rehabilitation setting for patients following a cerebrovascular accident (CVA).

METHODS

Participants were admitted to 1 of 5 inpatient rehabilitation facilities following a CVA from 2008 to 2010. High physical therapist assistant use was defined as ≥20% of the physical therapist visits being provided by the physical therapist assistant for an episode of care. Multivariable regression techniques examined differences in functional outcome, discharge location, and length of stay between high and low physical therapist assistant use groups. Propensity scoring methods supplemented findings of the regression analyses.

RESULTS

Of the 1561 participants, 496 (32%) had high physical therapist assistant involvement. Baseline participant characteristics such as age, sex, baseline motor function, and comorbidities did not differ between high and low physical therapist assistant use groups. After adjusting for patient characteristics, rehabilitation facility, and year, higher physical therapist assistant use did not adversely affect functional outcome or length of stay. Fewer conclusions can be drawn regarding discharge location, although there was no significant difference in discharge location between groups with high and low physical therapist assistant utilization. Propensity scoring methods supported the findings of the regression analyses.

CONCLUSIONS

Higher physical therapist assistant involvement in the rehabilitation of patients following CVA did not adversely affect functional outcome, increase length of stay, or reduce the likelihood of discharge to home from an inpatient rehabilitation facility.

IMPACT

The results demonstrate the value of the physical therapist assistant in the provision of physical therapy for patients with stroke in the inpatient rehabilitation setting. Higher involvement of the physical therapist assistant may provide cost savings while maintaining patient outcomes for this setting and population.

Effect of Care Capacity on Stroke Patients' Recovery in Activities of Daily Living: A Multi-Hospital Study

BACKGROUND

This study aimed to investigate whether care capacity for patients following stroke contributes to improved activities of daily living (ADL) at discharge from hospital based on the degree of stroke severity.

DESIGN

Retrospective, observational, longitudinal study.

SETTING

Acute phase hospitals.

PARTICIPANTS

From 2005 to 2011, 5006 patients with stroke at acute phase hospitals were registered in a database. There were 2501 individuals from 11 hospitals who met the following four criteria: (1) a pre-stroke modified Rankin Scale (mRS) score of 0-3; (2) admission to hospital within 7 days of suffering a stroke; (3) ischemic or hemorrhagic stroke; and (4) staying in hospital for 8-60 days.

MAIN OUTCOME MEASURES

The main outcome measure was the Functional Independence Measure (FIM, version 3.0) score at discharge. The FIM is an internationally used scale, which is used as an ADL outcome assessment scale for after rehabilitation.

RESULTS

Among patients with stroke, those with care capacity had higher FIM scores at hospital discharge than did those without care capacity (unstandardized coefficient = 2.3, P = 0.015). Examination of this relationship by stroke severity showed that the FIM score at discharge was only significantly higher in patients who suffered from a moderate to severe stroke (unstandardized coefficient = 7.0, P = 0.040). No associations were observed in patients who suffered from minor, moderate, or severe stroke.

CONCLUSIONS

These results suggest that care capacity facilitates total recovery of the FIM, especially among patients who suffer from a moderate to severe stroke.

Clinical characteristics affecting motor recovery and ambulation in stroke patients

[Purpose] To describe the clinical characteristics affecting motor recovery and ambulation in stroke patients. [Subjects and Methods] Demographic and clinical characteristics of 53 stroke patients (31 M, 22 F), such as age, gender, etiology, hemiplegic side, Brunnstrom stage, functional ambulation scale scores, history of rehabilitation, and presence of shoulder pain and complex regional pain syndrome were evaluated. [Results] The etiology was ischemic in 79.2% of patients and hemorrhagic in 20.8%. Brunnstrom hand and upper extremity values in females were lower than in males. Complex regional pain syndrome was observed at a level of 18.9% in all patients (more common in females). Brunnstrom hand stage was lower in complex regional pain syndrome patients than in those without the syndrome. Shoulder pain was present in 44.4% of patients. Brunnstrom lower extremity values and functional ambulation scale scores were higher in rehabilitated than in non-rehabilitated cases. [Conclusion] Brunnstrom stages of hand and upper extremity were lower and complex regional pain syndrome was more common in female stroke patients. Shoulder pain and lower Brunnstrom hand stages were related to the presence of complex regional pain syndrome.

Prediction of destination at discharge from a comprehensive rehabilitation hospital using the home care score

[Purpose] This study investigated whether it is possible to predict return to home at discharge from a rehabilitation hospital in Japan using the home care score of patients with cerebrovascular or osteoarticular disease and low activities of daily living at admission. [Subjects and Methods] The home care score and functional independent measurement were determined for 226 patients at admission and at discharge from five hospitals, and receiver operating characteristic analyses were conducted. [Results] The home care score cutoff point for the prediction of return to home at admission and at discharge was 11, and the area under the curve was more than 0.8. The area under the curve of the home care score was 0.77 for patients with low activities of daily living and within this group, the probability of return to home was approximately 50%, as predicted by the functional independent measurement. The home care score increased after receiving intervention at a rehabilitation hospital. [Conclusion] The home care score is useful for the prediction of return to home from a rehabilitation hospital, although prediction using the functional independent measurement is difficult for patients with low activities of daily living. Moreover, comprehensive interventions provided by the rehabilitation hospitals improve the ability to provide home care of the patient’s family, which is assessed by the home care score.

Depression and Lability: The Effects on Occupation following Stroke

Case study methodology was used to explore the effect of emotional changes following a stroke on engagement in occupation. Two people who had had a stroke, and their partners, were interviewed. The participants' medical case notes from acute, rehabilitation and outpatient treatment were also reviewed. As a result of the stroke, one participant experienced depression and the other lability.

The case studies illustrate the impact that emotional changes can have on the performance of occupations. They also illustrate the reverse, that perceived competence in the performance of occupations can affect emotions, either negatively or positively. The results point to a need for occupational therapists to take an occupational perspective, if wellbeing is to be maximised, as they consider and address the effects of emotional changes with people who have had a stroke.

Prediction of Advisability of Returning Home Using the Home Care Score

Purpose. The aim of this study was to assess whether the home care score (HCS), which was developed by the Ministry of Health and Welfare in Japan in 1992, is useful for the prediction of advisability of home care. Methods. Subjects living at home and in assisted-living facilities were analyzed. Binominal logistic regression analyses, using age, sex, the functional independence measure score, and the HCS, along with receiver operating characteristic curve analyses, were conducted. Findings/Conclusions. Only HCS was selected for the regression equation. Receiver operating characteristic curve analysis revealed that the area under the curve (0.9), sensitivity (0.82), specificity (0.83), and positive predictive value (0.84) for HCS were higher than those for the functional independence measure, indicating that the HCS is a powerful predictor for advisability of home care. Clinical Relevance. Comprehensive measurements of the condition of provided care and the activities of daily living of the subjects, which are included in the HCS, are required for the prediction of advisability of home care.

Evaluating Unilateral Spatial Neglect Post Stroke: Working Your Way Through the Maze of Assessment Choices

This study identified, using a comprehensive review of the literature, 62 standardized and nonstandardized assessment tools that exist to evaluate unilateral spatial neglect (USN). Each standardized tool was critically appraised according to its purpose (hemispace assessed), psychometric properties, and client appropriateness. The findings on the 28 standardized tools were compiled into a USN Assessment Summary Guide to facilitate clinical decision-making regarding the standardized USN assessments that are appropriate for specific clients at different phases of their recovery post stroke.

Effect of training with whole body vibration on the sitting balance of stroke patients

[Purpose] The purpose of this study was to determine the effects of task-oriented training with whole body vibration (WBV) on the sitting balance of stroke patients. [Subjects] The subjects were 30 stroke patients who were randomly divided into experimental (n1=15) and control (n2=15) groups. [Methods] Subjects in both groups received general training five times per week. Subjects in the experimental group practiced an additional task-oriented training program with WBV, which was performed for 15 minutes, five times per week, for four weeks. The center of pressure (COP) path length and average velocity were used to assess subjects static sitting balance, and the Modified Functional Reach Test (MFRT) was used to assess their dynamic sitting balance. The paired t-test was performed to test the significance of differences between before and after the intervention. The independent t-test was conducted to test the significance of differences between the groups. [Results] Following the intervention, the experimental group showed a significant change in MFRT. [Conclusion] The results of this study suggest that task-oriented training with WBV is feasible and efficacious for stroke patients.

Prognosis and prognostic factors in ADL-dependent stroke patients during their first in-patient rehabilitation – a prospective multicentre study

PURPOSE

This prospective longitudinal study aimed at a description of ADL-functioning and at an analysis, which clinical instruments predict independency 6 months after discharge from in-patient rehabilitation following disabling first stroke.

METHOD

A total of 147 patients with disabling first stroke were recruited from three neurological rehabilitation centres. They were assessed during their first in-patient rehabilitation with the NIH Stroke Scale, Hemispheric Stroke Scale (HSS), Activity Index, Barthel Index, Neurobehavioural Rating Scale, Cornell Depression Scale, and the prognostic prediction of the rehabilitation neurologist. The 6 months outcome was established with the Nottingham Extended ADL Scale (NEADL) and by the legal dependency status.

RESULTS

The best prediction of 6 months outcome as measured by the NEADL was obtained by the HSS and a multivariate model that also included the physician's prognostic prediction, both early in rehabilitation and at discharge. The dependency status was best predicted by the HSS and patient's sex.

CONCLUSION

Clinical scales performed during rehabilitation such as the HSS are valid for prediction of ADL-dependency 6 months after discharge.

Analysis of dynamic sitting balance on the independence of gait in hemiparetic patients

The purpose of this study was to investigate the relationship between dynamic sitting balance and walking ability in stroke patients. Patients were evaluated using functional independence measure (FIM), and those with a locomotion score of 5 or below were categorized into the dependent walking and below group (dependent group) and those with a score of 6 or above were categorized into the independent walking group (independent group). They were asked to take a sitting position at the center of an unstable platform (seesaw). The experimenter passively tilted the unstable platform to the paretic side or non-paretic side by 10 degrees in the frontal plane. The unstable platform was released suddenly, with the experimenter supporting the platform with both hands, and the subjects were asked to control their posture so that their body axis came to the vertical position and the platform came to the horizontal position in the frontal plane. As a result, the body axis of left hemiplegic patients significantly tilted to the non-paretic side. On the other hand, in the dependent group in the right as well as left hemiplegic patients, the patients heads were tilted to the side from which tilting was started, though not significantly in both conditions. This study demonstrated that patients with poor walking function have a deviated verticality of the head and the body axis. We surmise that patients whose body axis tilts towards the non-paretic side during a dynamic balance maintenance task like this test would have lower walking independence.

Effects of light deprivation on recovery from neglect and extinction induced by unilateral lesions of the medial agranular cortex and dorsocentral striatum

A number of previous studies have indicated that an environmental manipulation, 48 h of light deprivation (LD), produces virtually complete and permanent behavioral recovery of function from neglect induced by medial agranular cortex (AGm) lesions. LD-induced behavioral recovery from neglect is correlated with physiological changes in the dorsolateral striatum, an area that contains the projection zone of AGm efferents in the dorsocentral striatum (DCS). In this study, the behavioral effects of 48 h of LD on subjects with either unilateral DCS, AGm, or combined AGm/DCS lesions were investigated to examine whether the integrity of the DCS is crucial for behavioral recovery from neglect and whether LD will have a therapeutic effect on extinction deficits. Subjects were tested for extinction to bilateral simultaneous stimulation of the forepaws, and visual, auditory and tactile neglect. Forty-eight hours of LD failed to produce behavioral recovery from neglect in rats with DCS lesions, or a therapeutic affect on extinction deficits in any of the groups. The results of this study further support the crucial role of the DCS in recovery from neglect induced by AGm lesions and suggests that the DCS may be the crucial site for the mechanisms leading to LD-induced recovery. Further, the ineffectiveness of LD on extinction suggests that components of the neglect syndrome are dissociable and may require different therapeutic interventions.

Unilateral destruction of the dorsocentral striatum in rats produces neglect but not extinction to bilateral simultaneous stimulation

A number of previous studies have indicated that lesions of the medial agranular cortex (AGm) in rats induce multimodal neglect and extinction to bilateral simultaneous stimulation (extinction), the two major symptoms of the neglect syndrome in humans. A recent study demonstrated that lesions of dorsocentral striatum (DCS), the site of AGm projections to the striatum, produce multimodal neglect qualitatively similar to that found with AGm lesions. In the present study, the behavioral effects of unilateral DCS lesions were examined in more detail for the major manifestations of neglect: hemineglect, extinction, and allesthesia/allokinesia. Subjects were tested for extinction to bilateral simultaneous stimulation of the forepaws three times a week for 3 weeks. Neglect testing occurred twice weekly and the subjects were tested for the presence of neglect by rating the magnitude of orientation to visual, tactile, and auditory stimulation. The results indicated that DCS operates, while demonstrating severe neglect, failed to demonstrate extinction or allesthesia/allokinesia. These findings suggest that the neural mechanisms that underlie neglect and extinction are dissociable in this system. A better understanding of the neural mechanisms that underlie extinction is particularly important because humans that have recovered from neglect often continue to demonstrate the debilitating symptoms of extinction.

[Hemiplegia and return to domicile]

OBJECTIVE

We have studied the outcome after a stroke on being discharged from a department of physical medicine and rehabilitation in patients with hemiplegia, and the factors influencing the choice of the orientation.

MATERIAL AND METHOD

This prospective study was based on 93 patients. The mode of discharged was patient's domicile, institution, the number of death was also noted. The potentially influential factors studied were age, the side with hemiplegia, the aetiology of the hemiplegia, co-morbidity, the delay in starting rehabilitation, the neurological damage evaluated by the Orgogozo score, the initial functional damage evaluated by Functional Independence Measure (FIM) and by the functional score carried out within the framework PMSI(1) (computerised programme of medical care), the existence of aphasia, the existence of a depressive syndrome, presence of hemineglect, presence of superficial or profound sensory disorders, incontinence at the start of rehabilitation and at one month after the stroke, the existence of cognitive or psychiatric disorders. The tests used were the non-parametric test of Mann and Whitney, the chi(2) test and the correlation test. The threshold of significance used was 0.05.

RESULTS

Based on 93 patients (47 women and 46 men, average age 64.8) 81 have gone back to their previous domicile, 11 were oriented toward an institution. One patient died. The predictive factors or those linked to an absence of return to the previous domicile were the age, social situation, the delay in starting rehabilitation, presence of aphasia, the initial and final functional damage, the impossibility to walk, the presence of a depressive syndrome, urinary incontinence.

CONCLUSION

The authors stress the importance of familial environment and of functional independence in establishing a prognosis for return to the domicile.

Is there a relation between neuropsychologic variables and quality of life after stroke?

OBJECTIVES

To describe the quality of life (QOL) of stroke patients and to distill neuropsychologic predictors for poor QOL.

DESIGN

A cohort study in which patients were neuropsychologically assessed at a mean of 72.2 days after stroke, with follow-up at a mean of 9.8 months after stroke.

SETTING

Research department of a rehabilitation center.

PATIENTS

A consecutive sample of 164 stroke patients (mean age, 55.2yr) recruited from a university hospital, a regional hospital, and a rehabilitation center.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Orientation, memory, attention and concentration, visuospatial and visuoconstructive functions, language, and arithmetic skills were assessed with neuropsychologic tests. QOL was assessed with the Sickness Impact Profile (SIP).

RESULTS

An overall mean SIP score +/- standard deviation of 20 +/- 11 showed that stroke has a high impact on everyday functioning. Further analyses indicated that QOL is related in particular to tests measuring spatiotemporal and/or sequential aspects of behavior. Forward/backward stepwise regression analysis (n = 106) showed that poor QOL was more likely if patients had a poor result on the Trailmaking Test (TMT) B and/or were women.

CONCLUSION

The predictive value of the TMT is most effective and very useful because the TMT is a short and economical procedure. However, the gender-related aspects of recovery deserve more attention, as does the possible bias that can be caused by the composition of a measurement. Further research is needed to refine predictive models that are needed to facilitate the development of more adequate, individual rehabilitation programs.

Predicting outcomes of patients in Japan after first acute stroke using a simple model

OBJECTIVE

Prediction of patient outcome can be useful as an aid to clinical decision making. Many studies, including my own, have constructed predictive multivariate models for outcome following stroke rehabilitation therapy, but these have often required several minutes work with a pocket calculator. The aim is to develop a simple, easy-to-use model that has strong predictive power.

METHODS

Four hundred sixty-four consecutive patients with first stroke who were admitted to a rehabilitation hospital during a period of 19 mo were enrolled in the study. Sex, age, the stroke type, Functional Independence Measure total score on admission (X), onset to admission interval (number of days from stroke onset to rehabilitation admission), and length of rehabilitation hospital stay (number of days from hospital admission to discharge) were the independent variables. Functional Independence Measure total score at discharge (Y) was the dependent variable.

RESULTS

Stepwise multiple regression analysis resulted in the model containing age (P < 0.0001), X (P < 0.0001), and onset to admission interval (P < 0.0001). The equation was: Y = 68.6 - 0.32 (age) + 0.80X - 0.13 (onset to admission interval), a multiple correlation coefficient (R) = 0.82, and a multiple correlation coefficient squared (R2) = 0.68. Simple regression analysis revealed the relation between Xand Y: Y = 0.85X + 37.36, and R = 0.80 R2 = 0.64. In fact, plots of X vs. Ywere nonlinear, but seemed to be able to be linearized by some form of equation. It was found that there is a linear relation between logX and Y. The equation is Y = 106.88x - 95.35, where x = logX, R = 0.84, and R2 = 0.70. The correlation is improved by a regression analysis of a natural logarithmic transformation of X (R = 0.84 vs. R = 0.82).

CONCLUSION

The results in this study confirm that the simple regression model using a logarithmic transformation of X (R = 0.84) has predictive power over the simple regression model (R = 0.80). This model is well validated and clinically useful.

Early versus delayed inpatient stroke rehabilitation: a matched comparison conducted in Italy

OBJECTIVE

To assess the specific influence of onset-admission interval (OAI) on rehabilitation results.

DESIGN

A case-control study in consecutive stroke inpatients, enrolled in homogeneous subgroups, matched for age (within 1 year) and Barthel Index (BI) score at admission, and different for OAI to the rehabilitation ward. The short OAI group began rehabilitation treatment within the first 20 days from stroke, medium OAI group between days 21 and 40, and long OAI between days 41 and 60.

SETTING

Rehabilitation hospital.

PATIENTS

One hundred forty-five patients with sequelae of first stroke.

MAIN OUTCOME MEASURES

Efficiency (average increase in BI per day), effectiveness (proportion of potential improvement achieved during rehabilitation) of treatment, and percentage of low- and high-response patients, calculated on BI, were evaluated. Odds ratios (ORs) of dropouts and of poor and excellent therapeutic response were also quantified.

RESULTS

The short OAI subgroup had significantly higher effectiveness of treatment than did the medium (p < .05) and the long OAI groups (p < .005). Beginning treatment within the first 20 days was associated with a significantly high probability of excellent therapeutic response (OR = 6.11; 95% confidence interval [CI], 2.03-18.36), and beginning later was associated with a similar risk of poor response (OR = 5.18; 95% CI, 1.07-25.00). On the other hand, early intervention was associated with a five times greater risk of dropout than that of patients with delayed start of treatment (OR = 4.99; 95% CI, 1.38-18.03). The three subgroups were significantly (p < .05) different regarding the percentage of low and high responders.

CONCLUSION

Our results showed a strong association between OAI and functional outcome.

Variability not ability: another basis for performance decrements in neglect

OBJECTIVE

To determine reaction time (RT) and its variability, as a function of horizontal spatial position, in subjects with neglect.

BACKGROUND

In neglect, performance is frequently reported a as mean and a decreased ability to perform the task inferred by comparison to control groups. Few studies have examined how consistency and optimal performance relate to spatial neglect.

METHODS

Ten subjects with brain damage, five with and five without spatial neglect, were assessed on a RT task. Subjects responded by pushing a computer key to the onset of a white square appearing on a black screen. The locations of stimuli were randomly varied along the horizontal meridian.

RESULTS

For three of five neglect subjects, optimal RT showed no or little relation to horizontal location. Four of five neglect subjects demonstrated an increased variability in RT that correlated with spatial position and which was not present in our brain damaged subjects without neglect. The relationship was not an artifact of left sided stimuli, in general, being processed differently. For the two neglect subjects with the most trials, a significant correlation between RT variability and spatial position existed for left-sided trials alone. Increased variability was not a consequence of simply looking left proportionately less often, nor could a model of multiple compensatory systems operating in parallel explain the enhanced variability. Neither hemianopsia alone nor brain damage per se could account for the spatial modulation of RT variability.

CONCLUSIONS

That neglect subjects perform the RT task normally on some trials, even in their 'neglected field', challenges the notion that neglect must reflect an irreparably damaged cognitive system. Performance decrements in neglect can reflect an inability to consistently detect and respond. Evaluating optimal performance and variability of performance can indicate if a capacity has been lost absolutely or merely degraded such that normal performance cannot be sustained.

Predicting motor recovery of the upper limb after stroke rehabilitation: value of a clinical examination

BACKGROUND AND PURPOSE

Only a few studies have been conducted to predict motor recovery of the arm after stroke. The aims of this study were to identify which clinical variables, assessed at different points in time, were predictive of motor recovery, and to construct useful regression equations.

METHOD

One hundred consecutive stroke patients who had an obvious motor deficit of the upper limb were evaluated on entry to the study (two to five weeks post-stroke) and at two, six and 12 months after stroke. The Brunnström-Fugl-Meyer test was used as the outcome measure. Predictors included demographic data, overall disability, clinical neurological features, neuropsychological factors and secondary shoulder complications.

RESULTS

In multiple regression analyses, motor performance was invariably retained as the predictive factor with the highest R-square. Other significant predictive variables were overall disability, muscle tone, proprioception and hemi-inattention. Between 53% and 89% of the total amount of variance was accounted for in all selected models. The accuracy of prediction from clinical measurement in the acute phase diminished as the time span of measurement of outcome increased. Similarly, assessment of the variables at two and six months, rather than in the acute stage, resulted in a considerable improvement in the percentage variance explained at 12 months. The highest accuracy was obtained when predictions were made step-by-step in time.

CONCLUSIONS

It is possible to predict motor recovery of the upper limb accurately through the use of a few clinical measures. Predictive equations are proposed, the use of which are practicable in both clinical practice and research.

Geriatric rehabilitation revisited

There is no gold standard for rehabilitation of geriatric patients. Although many studies indicate that a multifaceted team approach, such as seen with specialized stroke units, may enhance outcomes for many patients, how these units achieve this is still unclear. However, the evidence shows that a comprehensive program of both medical and psychosocial support tends to result in patients achieving and maintaining higher levels of function, with less need for readmission, and shorter hospital stays. In addition to interventions aimed at improving function, rehabilitation includes assessment, goal setting, and provision of care to maintain the patient's status. More randomized controlled studies of rehabilitation programs are needed so that we can identify which programs are best for which patients.

On the prognosis of outcome after stroke

OBJECTIVES

The study was aimed at improving the accuracy of prognosis for recovery of function in patients suffering a first stroke.

MATERIALS AND METHODS

Two-hundred and forty-eight patients were enrolled. The mean interval since the stroke was 23 days. Patients entered a rehabilitation program lasting 60 days. The predictive value of 12 factors were analysed, namely motor, cognitive and sphincter subitems of Functional Independence Measure at admission (FIM-a), age, sex, education, body mass index (BMI), depression, neglect, aphasia, ideomotor and constructive apraxia. FIM score at discharge was the dependent variable.

RESULTS

A multiple regression revealed that only age, cognitive and sphincter subitems of FIM-a, neglect and ideomotor apraxia were significantly associated with outcome. Moreover, these factors accounted for only 72% of the variance in outcome scores. A decision of unfavourable prognosis on the basis of a FIM-a value lower than 40 was incorrect in 2.8% of the patients in this study and in 8.2% of those having a FIM score lower than 40.

CONCLUSIONS

The use of statistical methods to examine the outcome after stroke is useful for expressing probability on a group basis but is unsuitable for determining the prognosis of individual patients. Such data should not be used for fiscal management. A significant minority of patients presenting with a FIM lower than 40 can regain a useful measure of independence. The errors in prognosis based upon available methods, although small, have unacceptable effects in human terms if they lead to the clinical decisions which deny patients rehabilitation. All of the patients should therefore be admitted for rehabilitation after their first stroke. Severe comorbidity requires special attention.

Survival and outcome after endotracheal intubation for acute stroke

OBJECTIVE

To assess survival and functional outcome in patients endotracheally intubated after ischemic stroke (IS) or spontaneous intracerebral hemorrhage (ICH).

BACKGROUND

Endotracheal intubation is both a necessary life support intervention and a measure of severity in IS or ICH. Knowledge of associated clinical variables may improve the estimation of early prognosis and guide management in these patients.

METHODS

We reviewed 131 charts of patients with IS or ICH who were admitted to the Neurosciences Intensive Care Unit at Duke University Medical Center between July 1994 and June 1997 and required endotracheal intubation. Stroke risk factors, stroke type (IS or ICH) and location (hemispheric, brainstem, or cerebellum), circumstances surrounding intubation, neurologic assessment (Glasgow Coma Score [GCS] and brainstem reflexes), comorbidities, and disposition at discharge were documented. Survivors were interviewed for Barthel Index (BI) scores.

RESULTS

Survival was 51% at 30 days and 39% overall. Variables that significantly correlated with 30-day survival in multivariate analysis included GCS at intubation (p = 0.03) and absent pupillary light response (p = 0.008). Increase in the GCS also correlated with improved functional outcome measured by the BI (p = 0.0003). In patients with IS, age and GCS at intubation predicted survival, and in patients with ICH, absent pupillary light response predicted survival.

CONCLUSIONS

Predictors for mortality differ between patients with IS and ICH; however, decreased level of consciousness is the most important determinant of increased mortality and poor functional outcome. Absent pupillary light responses also correspond with a poor prognosis for survival, but further validation of this finding is needed.

The accuracy of predicting functional recovery in patients following a stroke, by physiotherapists and patients

BACKGROUND AND PURPOSE

The potential for post-stroke recovery and the range of predictive variables has been studied extensively. Knowledge of these variables alongside other factors, such as performance in therapy and professional experience, enable ongoing predictions to be made by members of the rehabilitation team. Patients' own predictions for their recovery has yet to receive much attention in this area of research. The aim of this study was to compare the predictive accuracy of the physiotherapist and the stroke patient with regard to functional change during a period 6-12 weeks post-stroke.

METHOD

The stroke sample (N = 29) came from two National Health Service Trusts as did the physiotherapists (N = 4). No comparisons were made between the hospitals and data was coded for anonymity. Estimations were made by both physiotherapists and patients regarding items on each of the three sections of The Rivermead Motor Assessment (RMA). Intra-class correlation coefficients (ICCs) were used to describe agreement of each set of predictions with the achieved RMA scores. The results reported here represent the main emphasis of the research; however, other areas were also screened (for example, change in cognition, language and quality of life) by use of basic standardized measures. Recovery was also compared to other known predictive variables, such as age, severity of stroke and urinary incontinence.

RESULTS

At follow-up assessment it was found that both physiotherapists' and patients' predictions demonstrated high and significant agreement with the achieved RMA scores at 12 weeks (ICCs ranging from 0.727 to 0.968). Physiotherapists' predictions demonstrated marginally higher levels of agreement than patients' predictions.

CONCLUSIONS

The degree of accuracy demonstrated by both physiotherapists and patients was considerable. The patient group was perhaps the more notable as no subject had had prior knowledge of a stroke. The implications in respect of lay persons' involvement in decision making and in the rehabilitative process, alongside the health professionals, are perhaps worthy of closer consideration.

Tourette's syndrome: [I-123]beta-CIT SPECT correlates of vocal tic severity

OBJECTIVE

To examine in vivo the density of brain monoaminergic transporters in Tourette's syndrome (TS).

BACKGROUND

TS is a heritable neuropsychiatric disorder characterized by chronic vocal and motor tics and is often associated with obsessive-compulsive symptoms. Hyperstimulation of dopamine receptors and dysfunction of serotonergic transmission have been implicated in its pathogenesis, but direct evidence of involvement of these neurochemical systems has been limited.

METHODS

Symptom severity and the availability of presynaptic monoaminergic transporters in the basal ganglia, midbrain, and thalamus were measured using SPECT and the radioligand [I-123]2beta-carbomethoxy-3beta-(4-iodophenyl)tropane ([I-123]beta-CIT) in 10 patients with TS and in 10 age- and sex-matched normal volunteers.

RESULTS

A significant negative correlation was found between a measure of overall tic severity and beta-CIT binding in the midbrain (r = -0.73, p = 0.02) and the thalamus (r = -0.82, p < 0.01). When examined post hoc, these correlations were determined largely by vocal tic severity. No other significant correlations were found between symptom severity and beta-CIT binding in the striatum or cortex.

CONCLUSIONS

These findings indicate that serotonergic neurotransmission in the midbrain and serotonergic or noradrenergic neurotransmission in the thalamus may be important factors in the expression of TS and may suggest novel targets for treatment.

Effects of intravenous methylprednisolone therapy on leukocyte and soluble adhesion molecule expression in MS

Intravenous methylprednisolone (IVMP) may inhibit inflammatory cell recruitment to active MS lesions by effects on leukocyte or endothelial cell adhesion molecule expression. We investigated 15 MS patients in relapse receiving a 5-day course of IVMP (500 mg/day) and 15 normal subjects. Patients' blood samples were obtained pretreatment, at 6 and 24 hours after the first dose, and 48 hours after completion of therapy. Levels of L-selectin, leukocyte functional antigen 1 (LFA-1), Mac-1, and very late activation antigen 4 (VLA-4) expression were determined on alphabeta and gammadelta T cells and monocytes by dual-color immunofluorescent flow cytometry. Serum levels of soluble (s) L-selectin, sE-selectin, soluble intercellular adhesion molecule 1 (sICAM-1) and soluble vascular cell adhesion molecule 1 (sVCAM-1) were measured by ELISA. There was a marked decrease in the T-cell and monocyte counts at 6 hours after therapy, with recovery to baseline at 24 to 48 hours. Adhesion molecule expression was normal on circulating T cells and monocytes in active MS. IVMP resulted in significant changes in the percent adhesion molecule expression on monocytes: increased L-selectin expression at 24 hours, decreased Mac-1 expression at 6 hours, and decreased VLA-4 expression at 6 hours and 24 hours following treatment. T-cell adhesion molecule expression was unaffected by the therapy. Serum sE-selectin was reduced at 6 hours and 24 hours following treatment. IVMP alters the distribution and kinetics of monocyte adhesion molecule expression and endothelial cell release of E-selectin, which may limit monocyte recruitment to areas of tissue destruction in MS.

Sleep and quantitative EEG in patients with progressive supranuclear palsy

Sleep architecture and quantitative EEG from wakefulness and REM sleep were studied in six patients (mean age, 70.5 years) with progressive supranuclear palsy (PSP) and compared with that of six control subjects (mean age, 69.8 years). Particular attention was given to quantifying REM sleep variables because of the known PSP-associated degeneration of the pedunculopontine tegmentum (PPT)--a critical structure in REM sleep generation. Patients with PSP had a shorter total sleep time, a lower sleep efficiency, a drastic reduction in sleep spindles, an atonic slow-wave sleep, and a lower percentage of REM sleep. The lower percentage of REM sleep was the result of both a reduction in the number of REM periods and a reduction in mean period of duration. REM density was also reduced while REM efficiency, atonia, and phasic EMG were similar to control values. REM sleep findings are consistent with the known role of the PPT in REM sleep induction. A slowing of the awake EEG was found for the six frontal leads and for C4, P4, and T4 in PSP patients. The frontal EEG slowing found in wakefulness is in accord with imaging and neuropsychological studies showing impairment of the frontal lobes in these patients. REM sleep EEG was not significantly slower in any regions. Because all previous studies on PSP have relied on visual inspection of the EEG tracings, the present finding of EEG slowing in the frontal lobes (rather than in the temporal regions or diffusely) suggests that our quantitative EEG approach may be more useful in determining specific regions of impaired cortical activity.

Meta-analysis of the Hachinski Ischemic Score in pathologically verified dementias

Our objectives were to investigate the utility of the Hachinski Ischemic Score (HIS) in differentiating patients with pathologically verified Alzheimer's disease (AD), multi-infarct dementia (MID), and "mixed" (AD plus cerebrovascular disease) dementia, and to identify the specific items of the HIS that best discriminate those dementia subtypes. Investigators from six sites participated in a meta-analysis by contributing original clinical data, HIS, and pathologic diagnoses on 312 patients with dementia (AD, 191; MID, 80; and mixed, 41). Sensitivity and specificity of the HIS were calculated based on varied cutoffs using receiver-operator characteristic curves. Logistic regression analyses were performed to compare each pair of diagnostic groups to obtain the odds ratio (OR) for each HIS item. The mean HIS (+/- SD) was 5.4 +/- 4.5 and differed significantly among the groups (AD, 3.1 +/- 2.5; MID, 10.5 +/- 4.1; mixed, 7.7 +/- 4.3). Receiver-operator characteristic curves showed that the best cutoff was < or = 4 for AD and > or = 7 for MID, as originally proposed, with a sensitivity of 89.0% and a specificity of 89.3%. For the comparison of MID versus mixed the sensitivity was 93.1% and the specificity was 17.2%, whereas for AD versus mixed the sensitivity was 83.8% and the specificity was 29.4%. HIS items distinguishing MID from AD were stepwise deterioration (OR, 6.06), fluctuating course (OR, 7.60), hypertension (OR, 4.30), history of stroke (OR, 4.30), and focal neurologic symptoms (OR, 4.40). Only stepwise deterioration (OR, 3.97) and emotional incontinence (OR, 3.39) distinguished MID from mixed, and only fluctuating course (OR, 0.20) and history of stroke (OR, 0.08) distinguished AD from mixed. Our findings suggest that the HIS performed well in the differentiation between AD and MID, the purpose for which it was originally designed, but that the clinical diagnosis of mixed dementia remains difficult. Further prospective studies of the HIS should include additional clinical and neuroimaging variables to permit objective refinement of the scale and improve its ability to identify patients with mixed dementia.

The impact of apolipoprotein E4 on cause of death in Alzheimer's disease

OBJECTIVE

We tested the hypothesis that the apolipoprotein E epsilon 4 (apoE4) allele is associated with an increased proportion of vascular-related mortality in Alzheimer's disease (AD).

BACKGROUND

ApoE4 is associated with an increased risk of developing AD, with an earlier onset, and may predispose to vascular dementia as well. In the general population, apoE4 has been associated with increased coronary artery disease and shorter lifespan. There is a paucity of data regarding the effect of the apolipoprotein E (apoE) genotype upon the contributing causes of death in AD.

METHODS

Death certificates of 114 AD cases were reviewed blind to apoE genotype. Deaths due to ischemic heart disease (IHD), cerebrovascular disease (CVD), vascular disease (either IHD or CVD), pneumonia, and other causes were analyzed as a function of apoE genotype. Logistic regression analyses were employed to control for age and gender effects.

RESULTS

The likelihood of vascular disease contributing to death increased in association with the epsilon 4 allele (29% in cases without an epsilon 4 allele, 43% in cases with one epsilon 4 allele, 53% in epsilon 4/4 homozygous cases; p = 0.035 after corrections for age and gender). This increase appeared largely due to an increase in ischemic heart disease, which was reported more frequently on death certificates of cases with one or more epsilon 4 allele (adjusted odds ratio [OR] = 1.85 per epsilon 4 allele; p < 0.05). There were nonsignificant trends for apoE4 to be associated with increased mortality related to cerebrovascular disease (OR = 1.45) and decreased mortality related to pneumonia (OR = 0.77) and AD itself (OR = 0.72). The epsilon 4/4 cases had significantly earlier age of onset (mean = 64.5 yr), earlier death, and longer duration of disease (mean = 10.1 yr). Cases with one or more epsilon 4 allele tended to have lower mean MMSE scores prior to death (6.6 versus 9.5) and were more often female (54% versus 45%).

CONCLUSIONS

The apoE4 allele appears to increase the risk of vascular and ischemic heart disease-related death in patients with AD.

Apomorphine produces an acute dose-dependent therapeutic effect on neglect produced by unilateral destruction of the posterior parietal cortex in rats

The neglect syndrome is a complex and devastating neurological disorder typically induced by unilateral destruction of one of three regions of the neocortex: the inferior parietal lobule, the dorsolateral prefrontal cortex or the cingulate cortex. Previous studies of neglect using a rodent model have indicated that disruption of dopaminergic mechanisms may underlie neglect. However, the pharmacological results were obtained using a rodent prefrontal model of the syndrome (medial agranular cortex), whereas the majority of cases of neglect in humans are produced by unilateral destruction of the posterior parietal cortex (inferior parietal lobule). The present study examined the effects of administration of the dopamine receptor agonist apomorphine on neglect induced by unilateral destruction of the posterior parietal cortex (PPC) in rats. The results indicated that administration of apomorphine produced a significant dose-dependent decrease in the severity of neglect. The results support the contention that neglect induced by cortical damage may be produced by a disruption of dopaminergic mechanisms, and that the PPC may be one component of a cortical system for directed attention.

A longitudinal study of multimodal evoked potentials in patients following radiotherapy for nasopharyngeal carcinoma

Radiation rhombencephalopathy and radiation myelopathy may occur in patients months or years after radiotherapy for malignancy of the head and neck. We obtained multimodal evoked potentials longitudinally in 26 patients with proven nasopharyngeal carcinoma. Recordings were made before radiotherapy and at 1 week, 3 months, 9 months, 15 months, and 24 months after radiotherapy. All absolute latencies of evoked response before and after radiation were within normal limits. However, the I-III interpeak latencies of brainstem auditory evoked potentials and the onset latencies of motor evoked potentials in the whole group of patients at 15 months after radiation were significantly longer than those before radiotherapy, whereas the latencies at 24 months were not significantly different. The N20 latencies of somatosensory evoked potentials after radiotherapy were significantly prolonged at 3 months of follow-up; the prolongation then became normal. They indicate that a subclinical reversible radiation-induced dysfunction may occur in the auditory, sensory, and motor systems.