Medical complications after stroke: a multicenter study

A novel score for early prediction of urinary tract infection risk in patients with acute ischemic stroke: a nomogram-based retrospective cohort study

This study aimed to construct and externally validate a user-friendly nomogram-based scoring model for predicting the risk of urinary tract infections (UTIs) in patients with acute ischemic stroke (AIS). A retrospective real-world cohort study was conducted on 1748 consecutive hospitalized patients with AIS. Out of these patients, a total of 1132 participants were ultimately included in the final analysis, with 817 used for model construction and 315 utilized for external validation. Multivariate regression analysis was applied to develop the model. The discriminative capacity, calibration ability, and clinical effectiveness of the model were evaluated. The overall incidence of UTIs was 8.13% (92/1132), with Escherichia coli being the most prevalent causative pathogen in patients with AIS. After multivariable analysis, advanced age, female gender, National Institute of Health Stroke Scale (NIHSS) score ≥ 5, and use of urinary catheters were identified as independent risk factors for UTIs. A nomogram-based SUNA model was constructed using these four factors (Area under the receiver operating characteristic curve (AUC) = 0.810), which showed good discrimination (AUC = 0.788), calibration, and clinical utility in the external validation cohort. Based on four simple and readily available factors, we derived and externally validated a novel and user-friendly nomogram-based scoring model (SUNA score) to predict the risk of UTIs in patients with AIS. The model has a good predictive value and provides valuable information for timely intervention in patients with AIS to reduce the occurrence of UTIs.

Is there a relationship between somatosensory impairment and the perception of pain in stroke survivors? An exploratory study

Pain and somatosensory impairments are commonly reported following stroke. This study investigated the relationship between somatosensory impairments (touch detection, touch discrimination and proprioceptive discrimination) and the reported presence and perception of any bodily pain in stroke survivors. Stroke survivors with somatosensory impairment (N = 45) completed the Weinstein Enhanced Sensory Test (WEST), Tactile Discrimination Test, and Wrist Position Sense Test for quantification of somatosensation in both hands and the McGill Pain Questionnaire, visual analog scale and the Neuropathic Pain Symptom Inventory (NPSI) for reporting presence and perception of pain. No relationship was observed between somatosensory impairment (affected contralesional hand) of touch detection, discriminative touch or proprioceptive discrimination with the presence or perception of pain. However, a weak to moderate negative relationship between touch detection in the affected hand (WEST) and perception of pain intensity (NPSI) was found, suggesting that stroke survivors with milder somatosensory impairment of touch detection, rather than severe loss, are likely to experience higher pain intensity [rho = -0.35; 95% confidence interval (CI), -0.60 to -0.03; P = 0.03]. Further, a moderate, negative relationship was found specifically with evoked pain (NPSI) and touch detection in the affected hand (rho = -0.43; 95% CI, -0.72 to -0.02; P = 0.03). In summary, our findings indicate a weak to moderate, albeit still uncertain, association, which prevents making a definitive conclusion. Nevertheless, our findings contribute to our understanding of the complexities surrounding the experience of pain in survivors of stroke and provide direction for future studies.

Low Phase Angle and Skeletal Muscle Index Increase Hospital-Acquired Infections During Stroke Rehabilitation

OBJECTIVES

Sarcopenia is common in patients with stroke and may increase the risk of medical complications such as infection. However, assessing sarcopenia in stroke patients with consciousness disturbance, aphasia or severe paralysis is challenging. This study aimed to investigate whether a combined assessment of phase angle (PhA) and skeletal muscle index (SMI), estimated using bioelectrical impedance analysis, was associated with 2 common nosocomial infections, hospital-acquired pneumonia (HAP) and urinary tract infection (UTI), during inpatient stroke rehabilitation.

DESIGN

Single-center retrospective observational study.

SETTINGS AND PARTICIPANTS

A total of 1068 patients with stroke admitted to a rehabilitation hospital between January 2016 and September 2019 were analyzed.

METHODS

The study variables included demographic characteristics, comorbidities, stroke severity, blood chemistry and urine analysis, SMI, and PhA obtained using bioelectrical impedance analysis. Patients were classified as normal, low PhA only, low SMI only, and low PhA + SMI. Multivariate Cox proportional analysis was used to determine the variables associated with HAP and UTI.

RESULTS

A combination of low PhA + SMI was observed in 429 (40.2%) patients. Over a median follow-up duration of 46 days, HAP occurred in 187 patients (17.5%) and UTI occurred in 155 patients (14.5%). The low PhA + SMI group showed a significantly higher incidence of HAP and UTI than the normal group (32.6% vs 4.6%, P < .001, for HAP; 20.7% vs 6.2%, P < .001, for UTI). In multivariate Cox analyses, low PhA and SMI were associated with significantly higher rates of HAP [hazard ratio (HR) 3.36, 95% CI 1.796-6.304, P < .001] and UTI (HR 1.71, 95% CI 1.002-2.947, P < .05) after adjusting for confounding variables.

CONCLUSIONS AND IMPLICATIONS

Combination of low PhA + SMI was independently associated with a higher risk of HAP and UTI in stroke patients who underwent inpatient rehabilitation. Measuring PhA and SMI using bioelectrical impedance analysis might be helpful in establishing care plans in these population.

Validation of the de Morton mobility index (DEMMI) among acute stroke patients aged ≥65 years: a register study

PURPOSE

To validate the de Morton Mobility Index (DEMMI) in older (≥65 years) patients with acute stroke in a hospital setting within the first week after stroke onset.

MATERIALS AND METHODS

In the Danish National Database of Geriatrics, we identified 4,176 patients with acute stroke (≥65 years). Floor and ceiling effects of DEMMI were investigated. Furthermore, convergent validity was investigated by correlations between DEMMI and the Barthel Index using Spearman's rho. Known-groups validity was tested by comparing DEMMI scores for different groups (with/without dementia, depression, comorbidity, and walking aids), and unidimensionality of DEMMI was evaluated by Mokken scale analysis.

RESULTS

A floor effect was identified with 22.1% of the patients scoring 0 on DEMMI on admission. Both convergent and known-groups validity were confirmed for DEMMI. Patients who were bedbound had a lower DEMMI score (median [IQR]: 0 [0;0]) than patients without any walking aid (median [IQR]: 62 [33;74]). Furthermore, Mokken scale analysis identified unidimensionality with overall fit to the model (Loevinger H 0.88 (p < 0.0001)).

CONCLUSION

DEMMI is a valid instrument for use in patients with acute stroke (≥65 years) in a hospital setting within the first week after stroke onset.

Development and validation of a predictive model for stroke associated pneumonia in patients after thrombectomy for acute ischemic stroke

Objective

This study aims to identify the risk factors associated with stroke-associated pneumonia (SAP) in patients who have undergone thrombectomy for acute ischemic stroke and to develop a nomogram chart model for predicting the occurrence of pneumonia.

Methods

Consecutive patients who underwent thrombectomy for acute ischemic stroke were enrolled from three hospitals at Taizhou Enze Medical Center. They were randomly divided into a training group and a validation group in a 7:3 ratio. The training group data was used to screen for effective predictive factors using LASSO regression. Multiple logistic regression was then conducted to determine the predictive factors and construct a nomogram chart. The model was evaluated using the validation group, analyzing its discrimination, calibration, and clinical decision curve. Finally, the newly constructed model was compared with the AIS-APS, A2DS2, ISAN, and PANTHERIS scores for acute ischemic stroke-associated pneumonia.

Results

Out of 913 patients who underwent thrombectomy, 762 were included for analysis, consisting of 473 males and 289 females. The incidence rate of SAP was 45.8%. The new predictive model was constructed based on three main influencing factors: NIHSS ≥16, postoperative LMR, and difficulty swallowing. The model demonstrated good discrimination and calibration. When applying the nomogram chart to threshold probabilities between 7 and 90%, net returns were increased. Furthermore, the AUC was higher compared to other scoring systems.

Conclusion

The constructed nomogram chart in this study outperformed the AIS-APS, A2DS2 score, ISAN score, and PANTHERIS score in predicting the risk of stroke-associated pneumonia in patients with acute ischemic stroke after thrombectomy. It can be utilized for clinical risk prediction of stroke-associated pneumonia in patients after thrombectomy for acute ischemic stroke.

Effects of gait adaptation training on augmented reality treadmill for patients with stroke in community ambulation

Gait adaptability is essential for stroke survivors to achieve efficient and safe community ambulation. However, conventional treadmill rehabilitation is only a repetitive practice of leg movement. This study compared the effects of augmented reality treadmill-based gait adaptation training with regular treadmill programs for patients with stroke. Forty patients with stroke (n = 40) were randomly assigned to the gait adaptation training {n = 20, age: 49.85 [standard deviation (SD) 8.44] years; onset of stroke: 107.80 (SD 48.31) days} and regular training [n = 20, age: 50.75 (SD 8.05) years, onset of stroke: 111.60 (SD 49.62) days] groups. Both groups completed three sessions of training per week for 5 weeks (15 sessions). The primary outcomes were the 10-m walk test and success rate of obstacle avoidance, while secondary outcomes included the Berg balance scale, component timed-up-and-go, and fall rate in a 6-month follow-up period. Assessments were performed before and after the intervention. The paired t-test was applied to compare the differences within groups and independent sample t-test was performed to compare the differences between groups. The 10-m walk test, success rate of obstacle avoidance, Berg balance scale, and component timed-up-and-go all significantly improved in the both groups (P < .001). The success rate of obstacle avoidance [P = .02, 95% confidence interval (CI): -21.07, -1.64], Berg Balance Scale (P = .02, 95% CI: -8.03, -0.67), 'turning around time' (P = .04, 95% CI: 0.08, 2.81), 'stand-to-sit' (P = .03, 95% CI: 0.16, 2.41) and 'total time' (P = .048, 95% CI: 0.04, 10.32) improved significantly in gait adaptation training group after intervention, while the 10-m walk test (P = .09, 95% CI: -0.17, 0.01), timed 'sit-to-stand' (P = .09, 95% CI: -0.14, 2.04), and 'linear walking' (P = .09, 95% CI: -0.27, 3.25) in gait adaptation training group did not show statistical difference compared to the regular training group. Total fall rate during the follow-up period was statistically decreased in the gait adaptation training group (P = .045). Both interventions improved mobility outcomes, with augmented reality treadmill-based gait adaptation indicating greater improvement in obstacle avoidance, balance, turning, and stand-to-sit. Augmented reality treadmill-based gait adaptation training emerges as an effective and promising intervention for patients with stroke in early rehabilitation.

Factors guiding therapist decision making in the rehabilitation of physical function after severely disabling stroke - an ethnographic study

PURPOSE

Whilst strong evidence supports rehabilitation to improve outcomes post-stroke, there is limited evidence to guide rehabilitation in the most severely disabled group. In an era of evidence-based practice, the aim of the study was to understand what factors guide physiotherapists (PTs) and occupational therapists (OTs) to select particular interventions in the rehabilitation of physical function after severely disabling stroke.

MATERIAL AND METHODS

An ethnographic study was undertaken over an 18-month period involving five London, UK stroke services. Seventy-nine primary participants (30 PTs, 22 OTs, and 27 stroke survivors) were recruited to the study. Over 400 h of observation, 52 semi-structured interviews were conducted. Study data were analysed through thematic analysis.

RESULTS

Key factors guiding therapist decision making were clinical expertise, professional role, stroke survivors' clinical presentation, therapist perspectives about stroke recovery, and clinical guidelines. Research evidence, stroke survivors' treatment preferences, organisational type, and pathway design were less influential factors. Therapy practice did not always address the physical needs of severely disabled stroke survivors.

CONCLUSIONS

Multiple factors guided therapist decision making after severely disabling stroke. Alternative ways of therapist working should be considered to address the physical needs of severely disabled stroke survivors more fully.Implications for rehabilitationMultiple factors guide therapist decision making after severely disabling stroke, some of which result in the use of interventions that do not fully address stroke survivors' clinical needs.Therapists should critically reflect upon their personal beliefs and attitudes about severely disabling stroke to reduce potential sources of bias on decision making.Therapists should consider the timing and intensity of therapy delivery as well as their treatment approach to optimise outcomes after severely disabling stroke.

High-intensity locomotor training during inpatient rehabilitation improves the discharge ambulation function of patients with stroke. A systematic review with meta-analysis

OBJECTIVE

To evaluate the evidence of high-intensity locomotor training on outcomes related to gait and balance for patients with stroke in inpatient rehabilitation.

METHODS

Four databases were searched (PubMed, CINAHL, Web of Science, and MedLINE) for articles published prior to 13 June 2023. Studies of adults (>18 years old) with a diagnosis of stroke who received a high-intensity locomotor intervention while admitted to an inpatient rehabilitation facility were included. A functional outcome in the domain of gait speed, gait endurance, or balance must have been reported. Following the screening of 1052 studies, 43 were selected for full-text review. Studies were assessed for risk of bias using the tool appropriate to the study type. Gait speed, gait endurance, and balance outcome data were extracted for further analysis.

RESULTS

Eight studies were selected with risk of bias ratings as moderate (4), high (2), and low (2). Six studies were analyzed in the meta-analysis (N = 635). A random-effects model analyzed between-group differences. Standard mean differences demonstrated that high-intensity locomotor training produces a moderate effect on gait endurance (0.50) and gait speed (0.41) and a negligible effect on balance (0.08) compared with usual care.

CONCLUSIONS

The meta-analysis supports the use of high-intensity locomotor training over usual care for improving gait speed and gait endurance during inpatient post-stroke. Future studies should investigate dose-response relationships of high-intensity locomotor training in this setting.

PROSPERO REGISTRATION

#CRD42022341329.

Functional outcome improvement from 3 to 12 months after intracerebral hemorrhage

INTRODUCTION

Most intracerebral hemorrhage (ICH) trials assessed outcome at 3 months but the recovery trajectory of ICH survivors may continue up to 1 year after the index event. We aimed to describe the predictors of functional outcome improvement from 3 to 12 months after ICH.

MATERIALS AND METHODS

Retrospective analysis of patients admitted to six European Stroke Centers for supratentorial ICH. Functional outcome was measured with the modified Rankin Scale (mRS) at 3 and 12 months. Predictors of functional outcome improvement were explored with binary logistic regression.

RESULTS

We included 703 patients, of whom 245 (34.9%) died within 3 months. Among survivors, 131 (28.6%) had an mRS improvement, 78 (17.0%) had a worse mRS and 249 (54.4%) had a stable functional status at 12 months. Older age and the presence of baseline disability (defined as pre-stroke mRS > 1), were associated with lower odds of functional outcome improvement (Odds Ratio (OR) 0.98 per year increase, 95% Confidence Interval (CI) 0.96-1.00, p = 0.017 and OR 0.45, 95% CI 0.25-0.81, p = 0.008 respectively). Conversely, deep ICH location increased the probability of long term mRS improvement (OR 1.67, 95% CI, 1.07-2.61, p = 0.023). Patients with mild-moderate disability at 3 months (mRS 2-3) had the highest odds of improvement at 12 months (OR 8.76, 95% CI 3.68-20.86, p < 0.001).

DISCUSSION AND CONCLUSION

Long term recovery is common after ICH and associated with age, baseline functional status, mRS at 3 months and hematoma location. Our findings might inform future trials and improve long-term prognostication in clinical practice.

Canadian Stroke Best Practice Recommendations: Acute Stroke Management, 7th Edition Practice Guidelines Update, 2022

The 2022 update of the Canadian Stroke Best Practice Recommendations (CSBPR) for Acute Stroke Management, 7th edition, is a comprehensive summary of current evidence-based recommendations, appropriate for use by an interdisciplinary team of healthcare providers and system planners caring for persons with an acute stroke or transient ischemic attack. These recommendations are a timely opportunity to reassess current processes to ensure efficient access to acute stroke diagnostics, treatments, and management strategies, proven to reduce mortality and morbidity. The topics covered include prehospital care, emergency department care, intravenous thrombolysis and endovascular thrombectomy (EVT), prevention and management of inhospital complications, vascular risk factor reduction, early rehabilitation, and end-of-life care. These recommendations pertain primarily to an acute ischemic vascular event. Notable changes in the 7th edition include recommendations pertaining the use of tenecteplase, thrombolysis as a bridging therapy prior to mechanical thrombectomy, dual antiplatelet therapy for stroke prevention, the management of symptomatic intracerebral hemorrhage following thrombolysis, acute stroke imaging, care of patients undergoing EVT, medical assistance in dying, and virtual stroke care. An explicit effort was made to address sex and gender differences wherever possible. The theme of the 7th edition of the CSBPR is building connections to optimize individual outcomes, recognizing that many people who present with acute stroke often also have multiple comorbid conditions, are medically more complex, and require a coordinated interdisciplinary approach for optimal recovery. Additional materials to support timely implementation and quality monitoring of these recommendations are available at www.strokebestpractices.ca.

Prevalence of Stroke-Associated Pneumonia and Its Predictors Among Hyperglycaemia Patients During Acute Ischemic Stroke

BACKGROUND

Hyperglycaemia (HG) during an acute ischemic stroke (AIS) is not only associated with unfavourable functional outcomes but also associated with stroke-associated pneumonia (SAP). This study aimed to determine the prevalence of SAP among Malaysian patients with AIS and the predictors of SAP among patients with HG during AIS.

METHODS

This is a retrospective cross-sectional study that included patients with AIS admitted to Hospital Sultanah Nur Zahirah, Malaysia from 2017 to 2020. SAP was defined as infection with pneumonia during the first seven days after IS. HG was defined as a blood glucose level > 7.8 mmol/L within 72 h after admission. Patients with SAP were divided into two groups according to HG status. Multivariate logistic regression analysis was performed using SPSS software, version 22 (IBM Corp., Armonk, NY) to identify SAP predictors among patients with HG. Kaplan-Meier log-rank test was used to compare the survival rate from unfavourable functional outcomes between hyperglycaemic patients with and without SAP.

RESULTS

Among 412 patients with AIS, 69 (16.74%) had SAP. The prevalence of SAP among patients with HG and normoglycemia during AIS was 20.98%, and 10.65%, respectively. Age above 60 years, leucocytosis, and National Institute of Health Stroke Scale (NIHSS) > 14 on admission were independent predictors of SAP with aOR of 2.08 (95% CI;1.01-4.30), 2.83 (95% CI; 1.41-5.67), and 3.67 (95% CI; 1.53-8.80), respectively. No significant difference in unfavourable functional outcomes survival was found among patients with and without SAP (p = 0.653).

CONCLUSION

This study demonstrated the prevalence of SAP was higher among patients with HG compared to normoglycemia during AIS. The patient being old, leucocytosis and severe stroke upon admission predict the occurrence of SAP among patients with HG during AIS.

Blind Spots in Hospital Fall Prevention: Falls in Stroke Patients Occurred Not Only in Those at a High Risk of Falling

OBJECTIVES

Although the standard falls prevention strategy is to identify and respond to patients with high-risk conditions, it remains unclear whether falls in patients with high fall risk account for most observed falls. In this study, fall risk and number of falls were calculated based on patients' motor and cognitive abilities, and the relationship between the two was examined.

DESIGN

We conducted a retrospective cohort study.

SETTING AND PARTICIPANTS

We included 2518 consecutive patients with stroke who were admitted to a rehabilitation hospital.

METHODS

Data on falls during hospitalization and biweekly assessed Functional Independence Measure scores were retrieved from the medical records. The average Functional Independence Measure scores for the motor and cognitive items were obtained and categorized as complete dependence, modified dependence, and independence. The fall rate (falls/1000 person-days) and number of observed falls in each combined condition were investigated.

RESULTS

Modified dependence on motor ability and complete dependence on cognitive ability had the highest risk of falls, with a fall rate of 10.8/1000 person-days and 51 fall observations, which accounted for 4.3% of all falls. Independent motor and cognitive ability had the lowest risk of falls, a fall rate of 2.6/1000 person-days and 146 observed falls, accounting for 12.4% of all falls, which was 2.8 times higher than the number of falls observed in the highest risk of falls condition.

CONCLUSIONS AND IMPLICATIONS

The combined motor-cognitive ability with the highest risk of falls in stroke inpatients did not have the highest number of observed falls. Rather, the combined motor-cognitive ability with the lowest risk of falls tended to have a high number of observed falls. A different strategy is needed to reduce the total number of falls.

Impact of rehabilitation dose on body mass index change in older acute patients with stroke: a retrospective observational study

Background

It is established that a low body mass index (BMI) correlates with a diminished home discharge rate and a decline in activities of daily living (ADL) capacity among elderly stroke patients. Nevertheless, there exists a paucity of knowledge regarding strategies to mitigate BMI reduction during the acute phase. This investigation seeks to elucidate the impact of rehabilitation dose, as determined by both physical and occupational therapy, on BMI alterations, positing that a heightened rehabilitation dose could thwart BMI decline.

Methods

This retrospective, observational study was conducted in the stroke unit of a university hospital. Enrollees comprised individuals aged ≥65 years, hospitalized for stroke, and subsequently relocated to rehabilitation facilities between January 2019 and November 2020. The percentage change in BMI (%ΔBMI) was calculated based on BMI values at admission and discharge. Multivariate multiple regression analysis was employed to ascertain the influence of rehabilitation dose on %ΔBMI.

Results

A total of 187 patients were included in the analysis, of whom 94% experienced a reduction in BMI during acute hospitalization. Following adjustment for sociodemographic and clinical factors, multivariable analyzes revealed a positive association between rehabilitation dose and %ΔBMI (β = 0.338, p < 0.001).

Conclusion

The findings of this study suggest that, in the context of acute stroke treatment, an augmented rehabilitation dose is associated with a diminished decrease in BMI.

Prevalence, Trajectory, and Predictors of Poststroke Pain: Retrospective Analysis of Pooled Clinical Trial Data Set

BACKGROUND

Poststroke pain remains underdiagnosed and inadequately managed. To inform the optimum time to initiate interventions, we examined prevalence, trajectory, and participant factors associated with poststroke pain.

METHODS

Eligible studies from the VISTA (Virtual International Stroke Trials Archives) included an assessment of pain. Analyses of individual participant data examined demography, pain, mobility, independence, language, anxiety/depression, and vitality. Pain assessments were standardized to the European Quality of Life Scale (European Quality of Life 5 Dimensions 3 Level) pain domain, describing no, moderate, or extreme pain. We described pain prevalence, associations between participant characteristics, and pain using multivariable models.

RESULTS

From 94 studies (n>48 000 individual participant data) in VISTA, 10 (n=10 002 individual participant data) included a pain assessment. Median age was 70.0 years (interquartile range [59.0-77.1]), 5560 (55.6%) were male, baseline stroke severity was National Institutes of Health Stroke Scale score 10 (interquartile range [7-15]). Reports of extreme pain ranged between 3% and 9.5% and were highest beyond 2 years poststroke (31/328 [9.5%]); pain trajectory varied by study. Poorer independence was significantly associated with presence of moderate or extreme pain (5 weeks-3 months odds ratio [OR], 1.5 [95% CI, 1.4-1.6]; 4-6 months OR, 1.7 [95% CI, 1.3-2.1]; >6 months OR, 1.5 [95% CI, 1.2-2.0]), and increased severity of pain (5 weeks-3 months: OR, 1.2 [95% CI, 1.1-1.2]; 4-6 months OR, 1.1 [95% CI, 1.1-1.2]; >6 months, OR, 1.2 [95% CI, 1.1-1.2]), after adjusting for covariates. Anxiety/depression and lower vitality were each associated with pain severity.

CONCLUSIONS

Between 3% and 9.5% of participants reported extreme poststroke pain; the presence and severity of pain were independently associated with dependence at each time point. Future studies could determine whether and when interventions may reduce the prevalence and severity of poststroke pain.

Inhibition of insulin-regulated aminopeptidase confers neuroprotection in a conscious model of ischemic stroke

Stroke is a leading cause of mortality and morbidity with a paucity of effective pharmacological treatments. We have previously identified insulin-regulated aminopeptidase (IRAP) as a potential target for the development of a new class of drugs for the treatment of stroke, as global deletion of this gene in mice significantly protected against ischemic damage. In the current study, we demonstrate that small molecular weight IRAP inhibitors reduce infarct volume and improve neurological outcome in a hypertensive animal model of ischemic stroke. The effects of two structurally distinct IRAP inhibitors (HFI419 or SJM164) were investigated in a model of stroke where the middle cerebral artery was transiently occluded with endothelin-1 in the conscious spontaneously hypertensive rat. IRAP inhibitor was administered into the lateral ventricle at 2 or 6 h after stroke, with subsequent doses delivered at 24, 48 and 70 h post-stroke. Functional outcomes were assessed prior to drug treatment, and on day 1 and 3 post-stroke. Histological analyses and neuroinflammatory cytokine profiling were conducted at 72 and 24 h post-stroke respectively. IRAP inhibitor treatment following stroke significantly reduced infarct volume and improved neurological and motor deficits. These protective effects were maintained even when the therapeutic window was extended to 6 h. Examination of the cellular architecture at 72 h post-stroke demonstrated that IRAP expression was upregulated in CD11b positive cells and activated astrocytes. Furthermore, IRAP inhibitor treatment significantly increased gene expression for interleukin 6 and C-C motif chemokine ligand 2 in the ischemic core. This study provides proof-of-principle that selective inhibition of IRAP activity with two structurally distinct IRAP inhibitors reduces infarct volume and improves functional outcome even when the first dose is administered 6 h post-stroke. This is the first direct evidence that IRAP inhibitors are a class of drug with potential use in the treatment of ischemic stroke.

Insufficiencies in sensory systems reweighting is associated with walking impairment severity in chronic stroke: an observational cohort study

Background

Walking and balance impairment are common sequelae of stroke and significantly impact functional independence, morbidity, and mortality. Adequate postural stability is needed for walking, which requires sufficient integration of sensory information between the visual, somatosensory, and vestibular centers. "Sensory reweighting" describes the normal physiologic response needed to maintain postural stability in the absence of sufficient visual or somatosensory information and is believed to play a critical role in preserving postural stability after stroke. However, the extent to which sensory reweighting successfully maintains postural stability in the chronic stages of stroke and its potential impact on walking function remains understudied.

Methods

In this cross-sectional study, fifty-eight community-dwelling ambulatory chronic stroke survivors underwent baseline postural stability testing during quiet stance using the modified Clinical test of Sensory Interaction in Balance (mCTSIB) and assessment of spatiotemporal gait parameters.

Results

Seventy-six percent (45/58) of participants showed sufficient sensory reweighting with visual and somatosensory deprivation for maintaining postural stability, albeit with greater postural sway velocity indices than normative data. In contrast, survivors with insufficient reweighting demonstrated markedly slower overground walking speeds, greater spatiotemporal asymmetry, and limited acceleration potential.

Conclusion

Adequate sensory system reweighting is essential for chronic stroke survivors' postural stability and walking independence. Greater emphasis should be placed on rehabilitation strategies incorporating multisensory system integration testing and strengthening as part of walking rehabilitation protocols. Given its potential impact on outcomes, walking rehabilitation trials may benefit from incorporating formal postural stability testing in design and group stratification.

Microbiota, diet, and the gut-brain axis in multiple sclerosis and stroke

Intestinal microbiota can influence the phenotype and function of immune cell responses through the dissemination of bacterial antigens or metabolites. Diet is one of the major forces shaping the microbiota composition and metabolism, contributing to host homeostasis and disease susceptibility. Currently, nutrition is a complementary and alternative approach to the management of metabolic and neurological diseases and cancer. However, the knowledge of the exact mechanism of action of diet and microbiota on the gut-brain communication is only developing in recent years. Here, we reviewed the current knowledge on the effect of diet and microbiota on the gut-brain axis in patients with two different central nervous system diseases, multiple sclerosis and stroke. We have also highlighted the open questions in the field that we believe are important to address to gain a deeper understanding of the mechanisms by which diet can directly or indirectly affect the host via the microbiota. We think this will open up new approaches to the treatment, diagnosis, and monitoring of various diseases.

Health Care-Associated Infection in Elderly Patients With Cerebrovascular Disease in Intensive Care Units: A Retrospective Cohort Study in Taizhou, China

BACKGROUND

Cerebrovascular diseases are associated with high incidence of health care-associated infections (HAIs) and poor prognosis in elderly patients. This study aimed to investigate the incidence and clinical characteristics of HAIs in elderly patients with cerebrovascular disease in the intensive care unit (ICU).

METHODS

Patients admitted with cerebrovascular disease, aged ≥65 years, were included. The clinical data of the patients were retrospectively analyzed to determine the risk factors, infection type, distribution, and pathogenic characteristics of HAIs in the context of cerebrovascular diseases.

RESULTS

Out of 381 ICU inpatients monitored, 79 (20.73%) developed HAIs. Risk analysis revealed number of ventilator days as significant risk factors for HAIs in elderly patients with cerebrovascular diseases in the comprehensive ICU. In the HAI group, 56 patients (70.89%) had respiratory tract infection (RTI). Sixty-five patients (82.28%) were infected with Gram-negative bacteria (GNB), and 42 (53.16%) with multi-drug-resistant organism (MDRO). The length of hospitalization days, ventilator days, and overall hospitalization costs were higher in the HAI group than in the non-HAI group (P < 0.05), but there was no significant difference between groups in the treatment outcome of patients. Patients with MDRO infection had longer duration and higher cost of hospitalization than those infected with non-MDRO (P < 0.05), but there was no significant difference between the groups in the treatment outcome of patients.

CONCLUSIONS

HAIs occurred mostly due to RTI and GNB infection. The hospitalization cost and duration, as well as the length of ventilator days, were higher for cerebrovascular patients with HAIs than for non-HAIs patients.

Comparison of the Predictive Value of Inflammatory Biomarkers for the Risk of Stroke-Associated Pneumonia in Patients with Acute Ischemic Stroke

Purpose

To investigate the predictive value of various inflammatory biomarkers in patients with acute ischemic stroke (AIS) and evaluate the relationship between stroke-associated pneumonia (SAP) and the best predictive index.

Patients and Methods

We calculated the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), monocyte-to-lymphocyte ratio (MLR), prognostic nutritional index (PNI), systemic inflammation response index (SIRI), systemic immune inflammation index (SII), Glasgow prognostic score (GPS), modified Glasgow prognostic score (mGPS), and prognostic index (PI). Variables were selectively included in the logistic regression analysis to explore the associations of NLR, PLR, MLR, PNI, SIRI, SII, GPS, mGPS, and PI with SAP. We assessed the predictive performance of biomarkers by analyzing receiver operating characteristic (ROC) curves. We further used restricted cubic splines (RCS) to investigate the association. Next, we conducted subgroup analyses to investigate whether specific populations were more susceptible to NLR.

Results

NLR, PLR, MLR, SIRI, SII, GPS, mGPS, and PI increased significantly in SAP patients, and PNI was significantly decreased. After adjustment for potential confounders, the association of inflammatory biomarkers with SAP persisted. NLR showed the most favorable discriminative performance and was an independent risk factor predicting SAP. The RCS showed an increasing nonlinear trend of SAP risk with increasing NLR. The AUC of the combined indicator of NLR and C-reactive protein (CRP) was significantly higher than those of NLR and CRP alone (DeLong test, P<0.001). Subgroup analyses suggested good generalizability of the predictive effect.

Conclusion

NLR, PLR, MLR, PNI, SIRI, SII, GPS, mGPS, and PI can predict the occurrence of SAP. Among the indices, the NLR was the best predictor of SAP occurrence. It can therefore be used for the early identification of SAP.

Malnutrition and Associated Factors in Acute and Subacute Stroke Patients with Dysphagia

Most patients with stroke suffer from complications and these include dysphagia. Dysphagia can cause malnutrition, and malnutrition affects prognosis and recovery. However, there is a lack of accurate studies on the nutritional status of stroke patients with dysphagia and its associated factors in different phases of stroke. This study retrospectively investigated 620 stroke patients who underwent a videofluoroscopic swallowing study (VFSS) due to dysphagia, from March 2018 to February 2021. The study aimed to evaluate the nutritional state and associated factors of malnutrition in acute and subacute stroke patients with dysphagia. Serum albumin and percentage of current weight to ideal weight were used to determine nutritional status. Malnutrition was observed in 58.9 and 78.9% of acute and subacute stroke patients. Exact logistic regression analysis revealed that old age and high penetration-aspiration scale score were significantly associated factors for malnutrition in patients with acute stroke. Old age, stroke history, bilateral hemiplegia, high modified Rankin score, low Korean Mini-Mental State Examination, pneumonia, and high functional dysphagia score were significantly associated factors for malnutrition in patients with subacute stroke. Patients with these associated factors in each phase of stroke require active nutritional assessment and care to decrease the risk of malnutrition.

Long-term behavioural alterations in mice following transient cerebral ischemia

Ischemic stroke is one of the leading causes of disability and mortality worldwide. Acute and chronic post-stroke changes have variable effects on the functional outcomes of the disease. Therefore, it is imperative to identify what daily activities are altered after stroke and to what extent, keeping in mind that ischemic stroke patients often have long-term post-stroke complications. Translational studies in stroke have also been challenging due to inconsistent study design of animal experiments. The objective of this study was to clarify whether and to what extent mouse behaviour was altered during a 6 months period after cerebral stroke. Experimental stroke was induced in mice by intraluminal filament insertion into the middle cerebral artery (fMCAo). Neurological deficits, recovery rate, motor performance, and circadian activity were evaluated following ischemia. We observed severe neurological deficits, motor impairments, and delay in the recovery rate of mice during the first 14 days after fMCAo. Aberrant circadian activity and distorted space map were seen in fMCAo mice starting one month after ischemia, similarly to altered new and familiar cage activity and sucrose preference using the IntelliCage, and was still evident 60- and 180- days following stroke in the voluntary running wheel using the PhenoMaster system. A preference towards ipsilateral side turns was observed in fMCAo mice both acutely and chronically after the stroke induction. Overall, our study shows the importance of determining time-dependent differences in the long-term post-stroke recovery (over 180 days after fMCAo) using multiple behavioural assessments.

Inpatient Rehabilitation Outcomes after Primary Severe Haemorrhagic Stroke: A Retrospective Study Comparing Surgical versus Non-Surgical Management

BACKGROUND

Haemorrhagic stroke, accounting for 10-20% of all strokes, often requires decompressive surgery as a life-saving measure for cases with massive oedema and raised intracranial pressure. This study was conducted to compare the demographics, characteristics and rehabilitation profiles of patients with severe haemorrhagic stroke who were managed surgically versus those who were managed non-surgically.

METHODS

A single-centre retrospective study of electronic medical records was conducted over a 3-year period from 1 January 2018 to 31 December 2020. The inclusion criteria were first haemorrhagic stroke, age of >18 years and an admission Functional Independence Measure (FIM™) score of 18-40 upon admission to the rehabilitation centre. The primary outcome measure was discharge FIM™. Secondary outcome measures included modified Rankin Scale (mRS), rehabilitation length of stay (RLOS) and complication rates.

RESULTS

A total of 107 patients' records were analysed; 45 (42.1%) received surgical intervention and 62 (57.9%) patients underwent non-surgical management. Surgically managed patients were significantly younger than non-surgical patients, with a mean age of [surgical 53.1 (SD 12) vs. non-surgical 61.6 (SD 12.3), p = 0.001]. Admission FIM was significantly lower in the surgical vs. non-surgical group [23.7 (SD6.7) vs. 26.71 (SD 7.4), p = 0.031). However, discharge FIM was similar between both groups [surgical 53.91 (SD23.0) vs. non-surgical 57.0 (SD23.6), p = 0.625). Similarly, FIM gain (surgical 30.1 (SD 21.1) vs. non-surgical 30.3 (SD 21.1), p = 0.094) and RLOS [surgical 56.2 days (SD 21.5) vs. non-surgical 52.0 days (SD 23.4), p = 0.134) were not significantly different between groups. The majority of patients were discharged home (surgical 73.3% vs. non-surgical 74.2%, p = 0.920) despite a high level of dependency.

CONCLUSIONS

Our findings suggest that patients with surgically managed haemorrhagic stroke, while older and more dependent on admission to rehabilitation, achieved comparable FIM gains, discharge FIM and discharge home rates after ~8 weeks of rehabilitation. This highlights the importance of rehabilitation, especially for surgically managed haemorrhagic stroke patients.

Association of vitamin D deficiency with post-stroke depression: a retrospective cohort study from the TriNetX US collaborative networks

Background

Post-stroke depression (PSD) affects up to one-third of patients who survive stroke. This matched cohort study aimed to investigate the relationship between vitamin D deficiency (VDD) and PSD using a global health research network.

Methods

Adult patients with first-ever stroke were eligible for inclusion if their circulating vitamin D levels were available within 3 months before the onset of stroke. Patients were subdivided into those with VDD [VDD group, 25(OH) D < 20 ng/mL] and those with normal vitamin D levels [control group, 25(OH) D: 30-80 ng/mL]. By using propensity score matching (PSM), potential confounding factors were adjusted. The primary outcomes were the association of VDD with the risk of PSD at the 3-month and 12-month follow-ups, while the secondary outcomes were the relationships between VDD and the risk of pneumonia as well as emergency department visits at the 12-month follow-up.

Results

After PSM, 758 individuals were included in each group, with no significant differences in baseline characteristics. Musculoskeletal diseases, metabolic disorders, and hypertension were the three leading comorbidities in both the groups. The incidence of PSD was not significantly different between the two groups at the 3-month (5.8% vs. 4.7%, p = 0.358) and 12-month (11.6% vs. 10.2%, p = 0.364) follow-up. VDD was not associated with an increased risk of PSD at the 3-month [hazard ratio (HR) = 1.258, p = 0.358] or 12-month follow-up (HR = 1.210, p = 0.364). In addition, VDD was not associated with an increased risk of pneumonia (HR = 1.053, p = 0.823) or emergency visits at the 12-month follow-up (HR = 1.206, p = 0.148).

Conclusion

The results revealed no significant link between VDD and PSD risk during the 3-month and 12-month follow-up periods, suggesting that VDD might not play a substantial role in PSD risk. However, further extensive studies employing a prospective design are necessary to explore the potential protective effects of vitamin D against PSD and validate these findings.

As an inhibitor of norepinephrine release, dexmedetomidine provides no improvement on stroke-associated pneumonia in mice

Background: Dexmedetomidine (DEX) is commonly employed as a sedative agent to attenuate sympathetic tone and reduce norepinephrine (NE) levels. In the context of stroke-associated pneumonia (SAP), which is believed to arise from heightened sympathetic nervous system activity and elevated NE release, the precise influence of DEX remains uncertain. Methods: In this study, we generated an SAP model using middle cerebral artery occlusion (MCAO) and examined NE levels, immunological statuses in the brain and periphery, pneumonia symptoms, and extent of infarction. We aimed to determine the effects of DEX on SAP and explore the underlying. Despite its potential to reduce NE levels, DEX did not alleviate SAP symptoms or decrease the infarct area. Interestingly, DEX led to an increase in spleen size and spleen index. Furthermore, we observed a decrease in the CD3+ T cell population in both the blood and brain, but an increase in the spleen following DEX administration. The precise mechanism linking decreased CD3+ T cells and DEX's role in SAP requires further investigation. Conclusion: The clinical use of DEX in stroke patients should be approached with caution, considering its inability to alleviate SAP symptoms and reduce the infarct area. Further research is necessary to fully understand the relationship between decreased CD3+ T cells and DEX's influence on SAP.

Non-paretic leg movements can facilitate cortical drive to the paretic leg in individuals post stroke with severe motor impairment: Implications for motor priming

Cross-education, a phenomenon where unilateral strength (or skill) training enhances strength (or skill) in the contralateral untrained limb, has been well studied in able-bodied individuals. Cross-education effect accompanies bilateral changes of corticomotor activity in the motor cortex (M1). Recent reports demonstrated greater cross-education effect in stroke survivors compared to healthy individuals, however, corticomotor responses to cross-education in stroke remains unclear. This study aimed to determine the effects of non-paretic leg movements on corticomotor excitability (CME) and reaction time of the paretic leg in severely impaired stroke survivors. Seventeen post stroke individuals with severe leg motor impairment (Fugl-Meyer lower extremity score less than 21 and absence of motor evoked potential in the paretic leg) performed three 20-min motor trainings using their non-paretic ankle: skill (targeted dynamic movements), strength (isometric resistance) and sham (sub-threshold electrical nerve stimulation). During training, verbal instructions were given to the participants to limit their movement to the non-paretic leg and this was confirmed with visual observation of the paretic leg. Transcranial magnetic stimulation measured CME of the contralateral pathways from the non-lesioned M1 to the non-paretic tibialis anterior (TA) muscle, ipsilateral pathways to the paretic TA and transcallosal inhibition (TCI) from the non-lesioned to lesioned M1. Paretic ankle reaction time was measured using a reaction time paradigm. All outcomes were measured before, immediately post, 30-min post and 60-min post priming. CME of the non-paretic TA increased after skill (.08 ± .10 mV) and strength (.06 ± .05 mV) training (p < .01). Ipsilateral CME of the paretic TA (.02 ± .01 mV) and TCI (.01 ± .01 s, ipsilateral silent period; more inhibition to the lesioned M1) increased after skill (p < .05) but not strength training. Reaction time of the paretic ankle improved after skill and strength training (-.11 ± .2 and -.13 ± .20 s, respectively; p < .05) and was sustained at 60 min. No changes were observed during the sham condition. Our findings may inform future studies for using non-paretic leg movements as a priming modality, especially for those who are contraindicated to other priming paradigms (e.g., brain stimulation) or unable to perform paretic leg movements. Conclusion: Non-paretic leg movements can be used as a priming modality, especially for those who are contraindicated to other priming paradigms (e.g., brain stimulation) or unable to perform paretic leg movements.

Pregnancy-Associated Stroke and Outcomes Related to Timing and Hypertensive Disorders

OBJECTIVE

To estimate temporal trends of stroke in the peripartum period and to assess the relationship between stroke and maternal adverse outcomes vis-à-vis timing and hypertension.

METHODS

We conducted a retrospective, cross-sectional study using the National Inpatient Sample to identify hospitalizations with pregnancy-associated stroke in the United States (2016-2019). Temporal trends in pregnancy-associated stroke were examined according to timing of stroke (antepartum vs postpartum) and both prepregnancy and pregnancy hypertensive disorders (yes vs no). Multivariable Poisson regression models with robust error variance were used to examine the association among maternal adverse outcomes, timing of stroke, and hypertensive disorders.

RESULTS

Among 15,977,644 pregnancy hospitalizations, 6,100 hospitalizations (38.2/100,000 hospitalizations) were with pregnancy-associated stroke. Of these, 3,635 (59.6%) had antepartum pregnancy-associated stroke and 2,465 (40.4%) had postpartum pregnancy-associated stroke; alternatively, 2,640 (43.3%) had hypertensive disorders, and 3,460 (56.7%) were without hypertensive disorders. From 2016 to 2019, the overall rate of pregnancy-associated stroke (37.5 to 40.8/100,000 pregnancy hospitalizations, P=.028), rate of postpartum pregnancy-associated stroke (14.6 to 17.6/100,000 pregnancy hospitalizations, P=.005), and rate of pregnancy-associated stroke with hypertensive disorders (14.9 to 17.2/100,000 pregnancy hospitalizations, P=.013) increased. Antepartum pregnancy-associated stroke and pregnancy-associated stroke without hypertensive disorders, however, remained stable. Despite higher risk of maternal morbidity in postpartum stroke hospitalizations, including mechanical ventilation and pneumonia, there was no significant difference in in-hospital mortality between antepartum and postpartum stroke. Similarly, between pregnancy-associated stroke with hypertensive disorders and stroke without hypertensive disorders, an increased risk of mechanical ventilation, seizure, and prolonged hospital stay was seen for stroke with hypertensive disorders without an increase in mortality.

CONCLUSION

A nationally representative sample of hospitalizations in the United States indicates an increasing trend in the rate of postpartum stroke. Almost half of hospitalizations with pregnancy-associated stroke have concomitant hypertensive disorders. Risk of adverse outcomes, but not mortality, is elevated in patients with stroke occurring in the postpartum period and stroke associated with hypertensive disorders.

Timing of Initiation of Acute Stroke Rehabilitation and Management Corresponding to Complications at Primary Stroke Centers in Japan: A Nationwide Cross-Sectional Web-Based Questionnaire Survey

INTRODUCTION

Many guidelines now recommend early rehabilitation for acute stroke patients. However, evidence remains lacking regarding the specific timings for initiation of various rehabilitation steps and management when complications are encountered in acute stroke rehabilitation. This survey aimed to investigate actual clinical situations in acute stroke rehabilitation in Japan and to improve the medical systems for rehabilitation and plan further studies.

METHODS

This nationwide, cross-sectional, web-based questionnaire survey was administered between February 7, 2022, and April 21, 2022, targeting all primary stroke centers (PSCs) in Japan. Among several components of the survey, this paper focused on the timing of the initiation of three rehabilitation steps (passive bed exercise; head elevation; and out-of-bed mobilization), along with the management of rehabilitation (continued or suspended) in the event of complications during acute stroke rehabilitation. We also investigated the influence of facility features on these contents.

RESULTS

Responses were obtained from 639 of the 959 PSCs surveyed (response rate: 66.6%). In cases of ischemic stroke and intracerebral hemorrhage, most PSCs initiated passive bed exercise on day 1, head elevation on day 1, and out-of-bed mobilization on day 2 (with day of admission defined as day 1). In cases with subarachnoid hemorrhage, rehabilitation steps were delayed compared to other stroke subtypes or showed wide variation depending on the facility. Passive bed exercise was accelerated by the presence of protocols for rehabilitation and weekend rehabilitation. Out-of-bed mobilization was accelerated by the presence of a stroke care unit. Facilities with board-certified rehabilitation doctors were cautious regarding the initiation of head elevation. Most PSCs suspended rehabilitation training in the event of symptomatic systemic/neurological complications.

CONCLUSION

Our survey revealed the actual situation of acute stroke rehabilitation in Japan and indicated that some facility features appear to influence early increases in physical activity levels and early mobilization. Our survey provides fundamental data to improve the medical systems for acute stroke rehabilitation in the future.

Predicting new-onset post-stroke depression from real-world data using machine learning algorithm

Introduction

Post-stroke depression (PSD) is a serious mental disorder after ischemic stroke. Early detection is important for clinical practice. This research aims to develop machine learning models to predict new-onset PSD using real-world data.

Methods

We collected data for ischemic stroke patients from multiple medical institutions in Taiwan between 2001 and 2019. We developed models from 61,460 patients and used 15,366 independent patients to test the models' performance by evaluating their specificities and sensitivities. The predicted targets were whether PSD occurred at 30, 90, 180, and 365 days post-stroke. We ranked the important clinical features in these models.

Results

In the study's database sample, 1.3% of patients were diagnosed with PSD. The average specificity and sensitivity of these four models were 0.83-0.91 and 0.30-0.48, respectively. Ten features were listed as important features related to PSD at different time points, namely old age, high height, low weight post-stroke, higher diastolic blood pressure after stroke, no pre-stroke hypertension but post-stroke hypertension (new-onset hypertension), post-stroke sleep-wake disorders, post-stroke anxiety disorders, post-stroke hemiplegia, and lower blood urea nitrogen during stroke.

Discussion

Machine learning models can provide as potential predictive tools for PSD and important factors are identified to alert clinicians for early detection of depression in high-risk stroke patients.

Discrepancies in perception of fall risk between patients with subacute stroke and physical therapists in a rehabilitation hospital: a retrospective cohort study

Objective: Falls are one of the most common complications of a stroke. This study aimed to clarify the discrepancy between the perceived fall risk of hospitalized patients with stroke and the clinical judgment of physical therapists and to examine the changes in discrepancy during hospitalization. Design: Retrospective cohort study. Patients: This study included 426 patients with stroke admitted to a Japanese convalescent rehabilitation hospital between January 2019 and December 2020. Methods: The Falls Efficacy Scale-International was used to assess both patients' and physical therapists' perception of fall risk. The difference in Falls Efficacy Scale-International scores assessed by patients and physical therapists was defined as the discrepancy in fall risk, and its association with the incidence of falls during hospitalization was investigated. Results: Patients had a lower perception of fall risk than physical therapists at admission (p < 0.001), and this trend continued at discharge (p < 0.001). The discrepancy in fall risk perception was reduced at discharge for non-fallers and single fallers (p < 0.001), whereas the difference remained in multiple fallers. Conclusion: Unlike physical therapists, patients underestimated their fall risk, especially patients who experienced multiple falls. These results may be useful for planning measures to prevent falls during hospitalization.

The role of circulating cell-free DNA as an inflammatory mediator after stroke

Stroke is the second leading cause of death worldwide and a leading cause of disability. Clinical and experimental studies highlighted the complex role of the immune system in the pathophysiology of stroke. Ischemic brain injury leads to the release of cell-free DNA, a damage-associated molecular pattern, which binds to pattern recognition receptors on immune cells such as toll-like receptors and cytosolic inflammasome sensors. The downstream signaling cascade then induces a rapid inflammatory response. In this review, we are highlighting the characteristics of cell-free DNA and how these can affect a local as well as a systemic response after stroke. For this purpose, we screened literature on clinical studies investigating cell-free DNA concentration and properties after brain ischemia. We report the current understanding for mechanisms of DNA uptake and sensing in the context of post-stroke inflammation. Moreover, we compare possible treatment options targeting cell-free DNA, DNA-sensing pathways, and the downstream mediators. Finally, we describe clinical implications of this inflammatory pathway for stroke patients, open questions, and potential future research directions.

Pain tolerance after stroke: The Tromsø study

BACKGROUND

Stroke lesions might alter pain processing and modulation by affecting the widely distributed network of brain regions involved. We aimed to compare pain tolerance in stroke survivors and stroke-free persons in the general population, with and without chronic pain.

METHODS

We included all participants of the sixth and seventh wave of the population-based Tromsø Study who had been tested with the cold pressor test (hand in cold water bath, 3°C, maximum time 106 s in the sixth wave and 120 s in the seventh) and who had information on previous stroke status and covariates. Data on stroke status were obtained from the Tromsø Study Cardiovascular Disease Register and the Norwegian Stroke Register. Cox regression models were fitted using stroke prior to study attendance as the independent variable, cold pressor endurance time as time variable and hand withdrawal from cold water as event. Statistical adjustments were made for age, sex, diabetes, hypertension, hyperlipidaemia, body mass index and smoking.

RESULTS

In total 21,837 participants were included, 311 of them with previous stroke. Stroke was associated with decreased cold pain tolerance time, with 28% increased hazard of hand withdrawal (hazard ratio [HR] 1.28, 95% CI 1.10-1.50). The effect was similar in participants with (HR 1.28, 95% CI 0.99-1.66) and without chronic pain (HR 1.29, 95% CI 1.04-1.59).

CONCLUSIONS

Stroke survivors, with and without chronic pain, had lower cold pressor pain tolerance, with possible clinical implications for pain in this group.

SIGNIFICANCE

We found lower pain tolerance in participants with previous stroke compared to stroke-free participants of a large, population-based study. The association was present both in those with and without chronic pain. The results may warrant increased awareness by health professionals towards pain experienced by stroke patients in response to injuries, diseases and procedures.

Risk factors for in-hospital complications in patients with acute ischemic stroke: Retrospective cohort in a national reference hospital in Peru

Objective

To describe the clinical and demographic characteristics of patients with acute cerebral infarction treated at a national reference hospital in Peru and determine the risk factors for in-hospital complications.

Methods

We conducted a retrospective cohort study including 192 patients with acute ischemic stroke in a national reference hospital in Peru from January to September 2021. Clinical, demographic and paraclinical information was recorded from medical records. We estimated risk ratios and 95% confidence intervals using regression models with Poisson family and robust variance for the bivariate and multivariate model, adjusting for age, sex and risk factors for stroke.

Results

At least one in-hospital complication occurred in 32.3% of the patients. The most frequent complications were infectious in 22.4%, followed by 17.7% of neurological complications, with other complications, such as thromboembolism, immobility and miscellaneous, being much less frequent. Regression analysis showed that stroke severity (RR = 1.76; 95%CI:1.09-2.86) and albumin greater than 3.5 mg/dL (RR = 0.53; 95%CI: 0.36-0.79) were independent risk factors for the presence of in-hospital complications.

Conclusions

A high rate of in-hospital complications were observed, among which infectious and neurological complications were the most frequent. Stroke severity was a risk factor and albumin greater than 3.5 mg/dL was a protective factor for the incidence of in-hospital complications. These results can serve as a starting point for establishing stroke care systems that consider differentiated flows for the prevention of in-hospital complications.

Early mobilisation is associated with lower subacute blood pressure and variability in ICH: A retrospective cohort study✰

BACKGROUND

Very early rehabilitation after stroke appears to worsen outcome, particularly in intracerebral haemorrhage (ICH). Plausible mechanisms include increased mean blood pressure (BP) and BP variability.

AIMS

To test associations between early mobilisation, subacute BP and survival, in observational data of ICH patients during routine clinical care.

METHODS

We collected demographic, clinical and imaging data from 1372 consecutive spontaneous ICH patients admitted between 2 June 2013 and 28 September 2018. Time to first mobilisation (defined as walking, standing, or sitting out-of-bed) was extracted from electronic records. We evaluated associations between early mobilisation (within 24 h of onset) and both subacute BP and death by 30 days using multifactorial linear and logistic regression analyses respectively.

RESULTS

Mobilisation at 24 h was not associated with increased odds of death by 30 days when adjusting for key prognostic factors (OR 0.4, 95% CI 0.2 to 1.1, p = 0.07). Mobilisation at 24 h was independently associated with both lower mean systolic BP (-4.5 mmHg, 95% CI -7.5 to -1.5 mmHg, p = 0.003) and lower diastolic BP variability (-1.3 mmHg, 95% CI -2.4 to -0.2 mg, p = 0.02) during the first 72 h after admission.

CONCLUSIONS

Adjusted analysis in this observational dataset did not find an association between early mobilisation and death by 30 days. We found early mobilisation at 24 h to be independently associated with lower mean systolic BP and lower diastolic BP variability over 72 h. Further work is needed to establish mechanisms for the possible detrimental effect of early mobilisation in ICH.

Cortical reactivity to transcranial magnetic stimulation predicts risk of post-stroke delirium

OBJECTIVE

Post-stroke delirium (PSD) is a frequent and with regard to outcome unfavorable complication in acute stroke. The neurobiological mechanisms predisposing to PSD remain poorly understood, and biomarkers predicting its risk have not been established. We tested the hypothesis that hypoexcitable or disconnected brain networks predispose to PSD by measuring brain reactivity to transcranial magnetic stimulation with electroencephalography (TMS-EEG).

METHODS

We conducted a cross-sectional study in 33 acute stroke patients within 48 hours of stroke onset. Brain reactivity to single-pulse TMS of dorsolateral prefrontal cortex, primary motor cortex and superior parietal lobule of the right hemisphere was quantified by response intensity, effective connectivity, perturbational complexity index (PCI^ST), and natural frequency of the TMS-EEG response. PSD development was clinically tracked every 8 hours before and for 7 days following TMS-EEG.

RESULTS

Fourteen patients developed PSD while 19 patients did not. The PSD group showed lower excitability, effective connectivity, PCI^ST and natural frequency compared to the non-PSD group. The maximum PCI^ST over all three TMS sites demonstrated largest classification accuracy with a ROC-AUC of 0.943. This effect was independent of lesion size, affected hemisphere and stroke severity. Maximum PCI^ST and maximum natural frequency correlated inversely with delirium duration.

CONCLUSIONS

Brain reactivity to TMS-EEG can unravel brain network states of reduced excitability, effective connectivity, perturbational complexity and natural frequency that identify acute stroke patients at high risk for development of delirium.

SIGNIFICANCE

Findings provide novel insight into the pathophysiology of pre-delirium brain states and may promote effective delirium prevention strategies in those patients at high risk.

Age- and Sex-Specific Trends in Medical Complications After Acute Ischemic Stroke in the United States

BACKGROUND AND OBJECTIVES

To test the hypothesis that the age and sex-specific prevalence of infectious (pneumonia, sepsis, and urinary tract infection [UTI]) and noninfectious (deep venous thrombosis [DVT], pulmonary embolism [PE], acute renal failure [ARF], acute myocardial infarction [AMI], and gastrointestinal bleeding [GIB]) complications increased after acute ischemic stroke (AIS) hospitalization in the United States from 2007 to 2019.

METHODS

We conducted a serial cross-sectional study using the 2007-2019 National Inpatient Sample. Primary AIS admissions in adults (aged 18 years or older) with and without complications were identified using International Classification of Diseases codes. We quantified the age/sex-specific prevalence of complications and used negative binomial regression models to evaluate trends over time.

RESULTS

Of 5,751,601 weighted admissions, 51.4% were women. 25.1% had at least 1 complication. UTI (11.8%), ARF (10.1%), pneumonia (3.2%), and AMI (2.5%) were the most common complications, while sepsis (1.7%), GIB (1.1%), DVT (1.2%), and PE (0.5%) were the least prevalent. Marked disparity in complication risk existed by age/sex (UTI: men 18-39 years 2.1%; women 80 years or older 22.5%). Prevalence of UTI (12.9%-9.7%) and pneumonia (3.8%-2.7%) declined, but that of ARF increased by ≈3-fold (4.8%-14%) over the period 2007-2019 (all p < 0.001). AMI (1.9%-3.1%), DVT (1.0%-1.4%), and PE (0.3%-0.8%) prevalence also increased (p < 0.001), but that of sepsis and GIB remained unchanged over time. After multivariable adjustment, risk of all complications increased with increasing NIH Stroke Scale (pneumonia: prevalence rate ratio [PRR] 1.03, 95% CI 1.03-1.04, for each unit increase), but IV thrombolysis was associated with a reduced risk of all complications (pneumonia: PRR 0.80, 85% CI 0.73-0.88; AMI: PRR 0.85, 95% CI 0.78-0.92; and DVT PRR 0.87, 95% CI 0.78-0.98). Mechanical thrombectomy was associated with a reduced risk of UTI, sepsis, and ARF, but DVT and PE were more prevalent in MT hospitalizations compared with those without. All complications except UTI were associated with an increased risk of in-hospital mortality (sepsis: PRR 1.97, 95% CI 1.78-2.19).

DISCUSSION

Infectious complications declined, but noninfectious complications increased after AIS admissions in the United States in the last decade. Utilization of IV thrombolysis is associated with a reduced risk of all complications.

Development of acute lung injury or acute respiratory distress syndrome after subarachnoid hemorrhage, predictive factors, and impact on prognosis

Acute lung injury or acute respiratory distress syndrome (ALI/ARDS) is a common complication after aneurysmal subarachnoid hemorrhage (aSAH), and is associated with worse neurologic outcomes and longer hospitalization. However, the effect of ALI/ARDS in SAH has not been well elucidated. The purpose of this study was to determine the incidence of ALI/ARDS in a cohort of patients with SAH and to determine the risk factors for ALI/ARDS and their impact on patient prognosis. We performed a retrospective analysis of 167 consecutive patients with aSAH enrolled. ALI/ARDS patients were rigorously adjudicated using North American-European Consensus Conference definition. Regression analyses were used to test the risk factors for ALI/ARDS in patients with SAH. A total of 167 patients fulfilled the inclusion criteria, and 27% patients (45 of 167) developed ALI. Among all 45 ALI patients, 33 (20%, 33 of 167) patients met criteria for ARDS. On multivariate analysis, elderly patients, lower glasgow coma scale (GCS), higher Hunt-Hess grade, higher simplified acute physiology score (SAPS) II score, pre-existing pneumonia, gastric aspiration, hypoxemia, and tachypnea were the strongest risk factor for ALI/ARDS. Patients with ALI/ARDS showed worse clinical outcomes measured at 30 days. Development of ALI/ARDS was associated with a statistically significant increasing the odds of tracheostomy and hospital complications, and increasing duration of mechanical ventilation, intensive care unit (ICU) length and hospitalization stay. Development of ALI/ARDS is a severe complication of SAH and is associated with a poor clinical outcome, and further studies should focus on both prevention and management strategies specific to SAH-associated ALI/ARDS.

Optimal time point for neutrophil-to-lymphocyte ratio to predict stroke-associated pneumonia

PURPOSE

This study aimed at the population receiving thrombolytic therapy and to explore the optimal time point for neutrophil-to-lymphocyte ratio (NLR) in predicting stroke-associated pneumonia (SAP).

METHODS

We assessed patients undergoing intravenous thrombolysis (IVT) for acute ischemic stroke. Blood parameters were sampled before thrombolysis (within 30 min after admission) and within 24-36 h after thrombolysis, respectively. The primary outcome measure was the occurrence of SAP. Multivariate logistic regression analysis was performed to analyze the association between admission blood parameters and the event of SAP. We also used receiver operating characteristic (ROC) curve analysis to assess the discriminative ability of blood parameters measured at different times in predicting SAP.

RESULTS

Among the 388 patients, SAP occurred in 60 (15%) patients. Multivariate logistic regression analysis showed that NLR was significantly associated with SAP (NLR before IVT: aOR = 1.288; 95%CI = 1.123-1.476; p < 0.001; NLR after IVT: (aOR = 1.127, 95%CI = 1.017-1.249; p = 0.023). The ROC curve showed that the predictive ability of NLR after IVT was better than NLR before IVT, not only in predicting the occurrence of SAP but also in predicting short-term and long-term functional outcomes, hemorrhagic transformation, and 1-year mortality.

CONCLUSION

Increased NLR measured within 24-36 h after IVT has a significant predictive effect on the occurrence of SAP and can be used to predict short-term and long-term poor functional outcomes, hemorrhagic transformation, and 1-year mortality.

Frailty and outcomes in lacunar stroke

BACKGROUND

Lacunar strokes (LS) are ischemic strokes of the small perforating arteries of deep gray and white matter of the brain. Frailty has been associated with greater mortality and attenuated response to treatment after stroke. However, the effect of frailty on patients with LS has not been previously described.

OBJECTIVE

To analyze the association between frailty and outcomes in LS.

METHODS

Patients with LS were selected from the National Inpatient Sample (NIS) 2016-2019 using the International Classification of Disease, 10^th edition (ICD-10) diagnosis codes. The 11-point modified frailty scale (mFI-11) was used to group patients into severely frail and non-severely frail cohorts. Demographics, clinical characteristics, and complications were defined. Health care resource utilization (HRU) was evaluated by comparing total hospital charges and length of stay (LOS). Other outcomes studied were discharge disposition and inpatient death.

RESULTS

Of 48,980 patients with LS, 10,830 (22.1%) were severely frail. Severely frail patients were more likely to be older, have comorbidities, and pertain to lower socioeconomic status categories. Severely frail patients with LS had worse clinical stroke severity and increased rates of complications such as urinary tract infection (UTI) and pneumonia (PNA). Additionally, severe frailty was associated with unfavorable outcomes and increased HRU.

CONCLUSION

Severe frailty in LS patients is associated with higher rates of complications and increased HRU. Risk stratification based on frailty may allow for individualized treatments to help mitigate adverse outcomes in the setting of LS.

Rehabilitation assisted by Space technology-A SAHC approach in immobilized patients-A case of stroke

Introduction: The idea behind the presentation of this case relates to utilizing space technology in earth applications with mutual benefit for both patients confined to bed and astronauts. Deconditioning and the progressiveness of skeletal muscle loss in the absence of adequate gravity stimulus have been of physiological concern. A robust countermeasure to muscle disuse is still a challenge for both immobilized patients and astronauts in long duration space missions. Researchers in the space medicine field concluded that artificial gravity (AG) produced by short-radius centrifugation on a passive movement therapy device, combined with exercise, has been a robust multi-system countermeasure as it re-introduces an acceleration field and gravity load. Methods: A short-arm human centrifuge (SAHC) alone or combined with exercise was evaluated as a novel, artificial gravity device for an effective rehabilitation strategy in the case of a stroke patient with disability. The results reveal valuable information on an individualized rehabilitation strategy against physiological deconditioning. A 73-year-old woman was suddenly unable to speak, follow directions or move her left arm and leg. She could not walk, and self-care tasks required maximal assistance. Her condition was getting worse over the years, also she was receiving conventional rehabilitation treatment. Intermittent short-arm human centrifuge individualized protocols were applied for 5 months, three times a week, 60 treatments in total. Results: It resulted in significant improvement in her gait, decreased atrophy with less spasticity on the left body side, and ability to walk at least 100 m with a cane. Balance and muscle strength were improved significantly. Cardiovascular parameters improved responding to adaptations to aerobic exercise. Electroencephalography (EEG) showed brain reorganization/plasticity evidenced through functional connectivity alterations and activation in the cortical regions, especially of the precentral and postcentral gyrus. Stroke immobility-related disability was also improved. Discussion: These alterations were attributed to the short-arm human centrifuge intervention. This case study provides novel evidence supporting the use of the short-arm human centrifuge as a promising therapeutic strategy in patients with restricted mobility, with application to astronauts with long-term muscle disuse in space.

Serum vitamin D levels and peak cough flow in patients with subacute ischemic stroke

Aspiration pneumonia is a major, potentially fatal complication after ischemic stroke. Decreased coughing function is a significant risk factor for aspiration in ischemic stroke survivors. Peak cough flow (PCF) is a useful tool for assessing cough function. Vitamin D deficiency is frequent after ischemic stroke and is linked to a variety of muscle functions and physical activities. There has been no investigation of the correlation between vitamin D levels and PCF in ischemic stroke survivors. This study aimed to examine the relationship between serum vitamin D levels and PCF in patients with ischemic stroke. Patients with ischemic stroke who underwent PCF evaluation and serum vitamin D level measurements within 1 month of onset were retrospectively recruited. The association between PCF parameters and serum vitamin D levels was also analyzed. In total, 142 patients with ischemic stroke were included. PCF parameters and serum vitamin D levels were found to be significantly correlated. Moreover, serum vitamin D levels were shown to be a significant predictor of PCF parameters. Serum vitamin D levels were related to PCF parameters in patients with ischemic stroke. In addition, serum vitamin D level may serve as a predictor of coughing function in patients with ischemic stroke.

Palliative care after stroke survival

Stroke is a leading cause of both death and disability worldwide. While most research has focused on the first hours to days after acute stroke, much less is known about the experience of patients and their families living after a stroke. Stroke survivors have a high burden of physical and psychological symptoms such as pain, fatigue, and depression that are often not addressed in the postacute setting. Similarly, goals-of-care conversations that may have started during the acute hospitalization are often not followed up later. This chapter outlines the prevalence and management of common poststroke symptoms, approaches to postacute goals-of-care conversations, family needs after stroke, and provides an overview of stroke-specific hospice and end-of-life care aspects. We emphasize the need for research in each of these areas.

Transient ischemic attack events and incident cardiovascular and non-cardiovascular complications: Observations from a large diversified multimorbid cohort

Background:

Transient ischemic attack (TIA) is a strong signal prompting the incidence of future cardiovascular and non-cardiovascular complications, in light of recent debate on the so-called “stroke-heart syndrome.” We aimed to investigate the relation of TIAs to incident clinical events.

Methods:

Patients were drawn from three health plans with a wide spectrum of age groups and a wide mix of socio-economic/disability status. Two TIA cohorts in a retrospective design were used to achieve the study specific aims: (i) to investigate the incidence of TIA and associated cardiovascular and non-cardiovascular complications within 30 and 90 days from the onset of incident TIA events; and (ii) to examine the potential risk factors for developing incident TIA events in the general population with/without a history of prior stroke.

Results:

The incident TIA cohort consisted of 53,716 patients with an average age of 64.2 years (SD 15.2) and 46.1% male. Following TIA, the incidence proportions of ischemic stroke within 30 and 90 days were 2.7% and 3.8%, respectively, and for incident acute coronary syndrome being 0.94 and 1.84, respectively. Ventricular arrhythmia had proportions of 1.2 and 2.14, respectively within 30 and 90 days, with acute heart failure having values of 0.49 and 0.923. About 45% or more of the cardiovascular and non-cardiovascular complications occurred in the first 30 days following the incident TIA cases. About one-third of the recurrent TIA cases followed the incident TIA cases within a span of 30 days. Amongst comorbidities with stroke in the comorbid history, prior stroke provided the strongest risk factor in terms of odds ratio (OR = 8.34, 95% CI 7.21–9.66) for incident TIA events. Age was strongly associated with incident TIA events. Without a prior history of stroke (ischemic stroke/transient ischemic attack/thrombo-embolic events), valvular disease was the strongest risk factor from among the comorbidities (OR-1.87, 95% CI 1.51–2.32). Age also provided strong associations with incident TIA events.

Conclusions:

Following a TIA, there was a high risk of stroke, acute coronary syndrome, ventricular arrhythmia, acute heart failure, and non-cardiovascular complications.

Developing and predicting of early mortality after endovascular thrombectomy in patients with acute ischemic stroke

Background

Stroke is one of the leading causes of mortality across the world. However, there is a paucity of information regarding mortality rates and associated risk factors in patients with acute ischemic stroke (AIS) undergoing endovascular thrombectomy (EVT). In this study, we aimed to clarify these issues and analyzed previous publications related to mortality in patients treated with EVT.

Methods

We analyzed the survival of 245 consecutive patients treated with mechanical thrombectomy for AIS for which mortality information was obtained. Early mortality was defined as death occurring during hospitalization after EVT or within 7 days following hospital discharge from the stroke event.

Results

Early mortality occurred in 22.8% of cases in this cohort. Recanalization status (modified thrombolysis in cerebral infarction, mTICI) (p = 0.002), National Institute of Health Stroke Scale Score (NIHSS) score 24-h after EVT (p < 0.001) and symptomatic intracerebral hemorrhage (sICH) (p < 0.001) were independently associated with early mortality. Age, sex, cardiovascular risk factors, NIHSS score pre-treatment, Alberta Stroke Program Early CT Score (ASPECTS), stroke subtype, site of arterial occlusion and timing form onset to recanalization did not have an independent influence on survival. Non-survivors had a shorter hospitalization (p < 0.001) but higher costs related to their hospitalization and outpatient care.

Conclusion

The recanalization status, NIHSS score 24-h after EVT and sICH were predictors of early mortality in AIS patients treated with EVT.

Chronic Pain Considerations in Patients with Cardiovascular Disease

Cardiovascular disease affects close to half of the United States population and many of these patients will develop chronic pain syndromes as a result of their disease process. This article provides an overview of several pain syndromes that result, directly or indirectly, from cardiovascular disease including peripheral arterial disease, angina, thoracic outlet syndrome, postamputation pain, complex regional pain syndrome, and poststroke pain. Psychological and medical comorbidities that affect the medical decision-making process in the treatment of chronic pain associated with cardiovascular disease are also discussed.

What are the Outcomes After Primary Total Hip and Knee Arthroplasty in Patients With Prior Cerebrovascular Accidents?

BACKGROUND

For patients who have a history of cerebrovascular accident (CVA) with neurological sequelae undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA), we sought to determine mortality rate, implant survivorship, complications, and clinical outcomes.

METHODS

Our total joint registry identified CVA sequelae patients undergoing primary THA (n = 42 with 25 on affected hip) and TKA (n = 56 with 34 on affected knee). Patients were 1:2 matched based upon age, sex, body mass index, and surgical year to a non-CVA cohort. Mortality and implant survivorship were evaluated via Kaplan-Meier methods. Clinical outcomes were assessed via Harris Hip scores or Knee Society scores . Mean follow-up was 5 years (range, 2-12).

RESULTS

For CVA sequelae and non-CVA patients, respectively, the 5-year patient survivorship was 69 versus 89% after THA (HR = 2.5; P = .006) and 56 versus 90% after TKA (HR = 2.4, P = .003). No significant difference was noted between groups in implant survivorship free from any reoperation after THA (P > .2) and TKA (P > .6). Postoperative CVA occurred at an equal rate in CVA sequelae and non-CVA patients after TKA (1.8%); none after THA in either group. The magnitude of change in Harris Hip scores (P = .7) and Knee Society scores (P = .7) were similar for CVA sequelae and non-CVA patients.

CONCLUSION

Complications, including the risk of postoperative CVA, implant survivorship, and outcome score improvement are similar for CVA sequelae and non-CVA patients. A 2.5-fold increased risk of death at a mean of 5 years after primary THA or TKA exist for CVA sequelae patients.

Increased neutrophil-to-lymphocyte ratio is associated with unfavorable functional outcomes in acute pontine infarction

BACKGROUND

The neutrophil-to-lymphocyte ratio (NLR) is positively associated with unfavorable outcomes in patients with cerebral infarction. This study aimed to investigate the relationship between the NLR and the short-term clinical outcome of acute pontine infarction.

METHODS

Patients with acute pontine infarction were consecutively included. Clinical and laboratory data were collected. All patients were followed up at 3 months using modified Rankin Scale (mRS) scores. An unfavorable outcome was defined as an mRS score ≥ 3. Receiver operating characteristic (ROC) curve analysis was used to calculate the optimal cutoff values for patients with acute pontine infarction. risk factors can be predictive factors for an unfavorable outcome after acute pontine infarction.

RESULTS

Two hundred fifty-six patients with acute pontine infarction were included in this study. The NLR was significantly higher in the unfavorable outcome group than in the favorable outcome group (P < 0.05). Additionally, the infarct size was significantly higher in the high NLR tertile group than in the low NLR tertile group (P < 0.05). Multivariate logistic regression analysis revealed that the baseline National Institutes of Health Stroke Scale (NIHSS) score, NLR, platelet count, and fasting blood glucose (FBG) level were significantly associated with unfavorable outcomes 3 months after acute pontine infarction. The optimal cutoff value of the NLR for predicting the 3-month outcome of acute pontine infarction was 3.055. The negative and positive predictive values of NLR were 85.7% and 61.3%, respectively, and the sensitivity and specificity of NLR were 69.2% and 80.9%.

CONCLUSIONS

We found that the NLR may be an independent predictive factor for the outcome of acute pontine infarction.

Pressure pain threshold and somatosensory abnormalities in different ages and functional conditions of post-stroke elderly

Background

Somatosensory deficits and abnormal pain sensitivity are highly prevalent among stroke survivors, which negatively impacts their quality of life and recovery process. However, the factors for pressure pain threshold (PPT) and somatosensory abnormalities in post-stroke elderly remain unknown. The aim of this study was to explore the effects of age, side and other functional conditions, such as spasticity and motor functions, on PPT and sensory abnormalities among elderly after stroke.

Methods

The cross-sectional study finally included 43 post-stroke elderly aged over 60 and assessed the PPT of 14 bilateral muscles widely located in the whole body by using a digital force gage. Meanwhile, spasticity, motor function, joint pain and activity of daily living (ADL) were evaluated by the Modified Ashworth scale, Fugl-Meyer, and Barthel Index, respectively. All participants were divided into higher-aged and lower-aged groups based on the median age of all of them.

Results

Higher age tended to be associated with higher sensitivity but not significant except for one upper limb muscle, and the affected side showed significantly higher PPTs than the unaffected side in three out of seven muscles (p < 0.05). Furthermore, the somatosensory abnormalities in the affected side, particularly hypoalgesia, were more frequent in higher-aged than lower-aged patients in most assessed muscles. Meanwhile, patients with spasticity showed more increment of PPTs in affected muscles around the knee joint than patients without spasticity (p < 0.05). Patients with better motor functions, less joint pain and higher ADL performed less bilateral differences of PPTs than other patients in some muscles (p < 0.05).

Conclusions

The age and side differences of mechanical pain sensitivity were found among post-stroke elderly. Older patients show higher sensitivity in both sides compared with the younger ones, and the affected side of the elder shows more somatosensory abnormalities, particularly hypoalgesia, than that of the younger ones. Post-stroke elderly in good functional conditions, such as normal muscle tone, better physical function and daily activities, and less joint pain, seems to have more equal pain sensitivity between both sides than those in poor conditions.

Pressure Injury on Poststroke Admission Assessment to Skilled Nursing Facilities: Risk Factors, Management, and Impact on Rehabilitation

OBJECTIVE

To describe pressure injury (PrI) prevalence, comorbidities, and rehabilitation utilization among older adults with stroke at skilled nursing facilities' (SNFs') admission assessment.

DESIGN

Retrospective cohort.

SETTING AND PARTICIPANTS

Older Medicare beneficiaries (>65 years old) with stroke admitted to SNFs.

METHODS

We extracted data between 2013 and 2014 using the Master Beneficiary Summary, Medicare Provider Analysis and Review, and Minimum Data Set 3.0. PI data were assessed during admission assessment.

RESULTS

Of the 65,330 older adults poststroke admitted to SNFs, 11% had at least 1 PrI present on admission assessment. Individuals who were non-Hispanic Black, with a longer hospital stay, from lower socioeconomic status, with higher proportions of comorbidities (eg, underweight, urinary and bowel incontinence, diabetes, congestive heart failure, arrhythmias, and infections), and higher functional impairments were likely to present with a PrI at SNF admission assessment. Compared with individuals with superficial PrI, individuals with deep PrI were more likely to be young-old (<75 years), non-Hispanic Black, from lower socioeconomic status, present with a shorter hospital stay, an intensive care unit stay, with higher functional impairments, skin integrity issues, system failure, and infections. Compared to those without PrI or superficial PrI, individuals with any-stage PrI or deep PrI were more likely to be cotreated by physical and occupational therapist and less likely to receive individual therapy. Those with PrI poststroke had low documented turning and repositioning rates than those without PrI.

CONCLUSIONS AND IMPLICATIONS

Identifying modifiable risk factors to prevent PrIs poststroke in SNFs will facilitate targeted preventative interventions and improve wound care efficacy and rehabilitation utilization for optimized patient outcomes. Identifying residents with a higher risk of PrI during acute care discharge and providing early preventive care during post-acute care would possibly decrease costs and improve outcome quality.

A Systematic Review of Fall Risk Factors in Stroke Survivors: Towards Improved Assessment Platforms and Protocols

Background/Purpose: To prevent falling, a common incident with debilitating health consequences among stroke survivors, it is important to identify significant fall risk factors (FRFs) towards developing and implementing predictive and preventive strategies and guidelines. This review provides a systematic approach for identifying the relevant FRFs and shedding light on future directions of research.

Methods: A systematic search was conducted in 5 popular research databases. Studies investigating the FRFs in the stroke community were evaluated to identify the commonality and trend of FRFs in the relevant literature.

Results: twenty-seven relevant articles were reviewed and analyzed spanning the years 1995–2020. The results confirmed that the most common FRFs were age (21/27, i.e., considered in 21 out of 27 studies), gender (21/27), motion-related measures (19/27), motor function/impairment (17/27), balance-related measures (16/27), and cognitive impairment (11/27). Among these factors, motion-related measures had the highest rate of significance (i.e., 84% or 16/19). Due to the high commonality of balance/motion-related measures, we further analyzed these factors. We identified a trend reflecting that subjective tools are increasingly being replaced by simple objective measures (e.g., 10-m walk), and most recently by quantitative measures based on detailed motion analysis.

Conclusion: There remains a gap for a standardized systematic approach for selecting relevant FRFs in stroke fall risk literature. This study provides an evidence-based methodology to identify the relevant risk factors, as well as their commonalities and trends. Three significant areas for future research on post stroke fall risk assessment have been identified: 1) further exploration the efficacy of quantitative detailed motion analysis; 2) implementation of inertial measurement units as a cost-effective and accessible tool in clinics and beyond; and 3) investigation of the capability of cognitive-motor dual-task paradigms and their association with FRFs.