The NIH Stroke Scale Has Limited Utility in Accurate Daily Monitoring of Neurologic Status

Predicting Short- and Long-Term Functional Outcomes Based on Serum S100B Protein Levels in Patients with Ischemic Stroke

BACKGROUND

Ischemic stroke is one of the leading causes of mortality and disability. The neuroimaging methods are the gold standard for diagnostics. Biomarkers of cerebral ischemia are considered to be potentially helpful in the determination of the etiology and prognosis of patients with ischemic stroke.

AIM

This study aimed to investigate the usefulness of serum S100B protein levels as a short- and long-term prognostic factor in patients with ischemic stroke.

STUDY DESIGN AND METHODS

The study group comprised 65 patients with ischemic stroke. S100B protein levels were measured by immunoenzymatic assay. Short-term functional outcome was determined by the NIHSS score on day 1 and the difference in the NIHSS scores between day 1 and day 9 (delta NIHSS). Long-term outcome was assessed by the modified Rankin Scale (MRS) at 3 months after the stroke. At the end of the study, patients were divided into groups based on the NIHSS score on day 9 (0-8 "good" and >8 "poor"), the delta NIHSS ("no improvement" ≤0 and >0 "improvement"), and the MRS ("good" 0-2 and >2 "poor"). Differences in S100B levels between groups were analyzed with the ROC curve to establish the optimal cut-off point for S100B. The odds ratio was calculated to determine the strength of association. Correlations between S100B levels at three time points and these variables were evaluated.

RESULTS

We revealed a statistically significant correlation between S100B levels at each measurement point (<24 h, 24-48 H, 48-72 h) and the NIHSS score on day 9 (R Spearman 0.534, 0.631, and 0.517, respectively) and the MRS score after 3 months (R Spearman 0.620, 0.657, and 0.617, respectively). No statistically significant correlation was found between S100B levels and the delta NIHSS. Analysis of the ROC curve confirmed a high sensitivity and specificity for S100B. The calculated AUC for the NIHSS on day 9 were 90.2%, 95.0%, and 82.2%, respectively, and for the MRS, 83.5%, 83.4%, and 84.0%, respectively. After determining the S100B cut-off, the odds ratio for beneficial effect (NIHSS ≤ 8 at day 9 or MRS 0-2 after 3 months) was determined for each sampling point.

CONCLUSION

S100B is a useful marker for predicting short- and long-term functional outcomes in patients with ischemic stroke.

Association of Neighborhood Recreation Centers and Poststroke Outcomes in a Population-Based Cohort

BACKGROUND

Higher neighborhood socioeconomic status has been favorably associated with stroke outcomes. This may be due to these areas having more beneficial resources such as recreational centers. We aimed to determine if neighborhood density of recreation centers is favorably associated with stroke outcomes.

METHODS

We conducted analyses of data from the Brain Attack Surveillance in Corpus Christi project, a cohort of stroke survivors ≥45 years of age residing in Nueces County, TX (2009-2020). We included non-Hispanic White and Mexican American incident stroke survivors, who were not institutionalized prestroke and completed baseline and follow-up assessments (N=1392). We calculated the density of fitness and recreational sports centers within their residential census tract during the year of their stroke. Outcomes included function (self-ratings on activities of daily living and instrumental activities of daily living), cognition (modified mini-mental state exam), depression (Patient Health Questionnaire-8), and quality of life (abbreviated Stroke-Specific Quality of Life Scale). We fit confounder-adjusted gamma-distributed mixed generalized linear models with a log link for each outcome and considered interaction with stroke severity.

RESULTS

On average, participants were 65 years old, 53% male, and 63% Mexican American. Median recreational centers were 1.60 per square mile (interquartile range, 0.41-3.06). Among moderate-severe stroke survivors, greater density of recreation centers (75th versus 25th percentile) was associated with more favorable function and possibly quality of life (activities of daily living/instrumental activities of daily living, 4.8% change [95% CI, -0.11% to -9.27%]; Stroke-Specific Quality of Life Scale, 3.7% change [95% CI, -0.7% to 8.2%]). Minimal nonsignificant differences were observed among the overall stroke population and those with mild stroke.

CONCLUSIONS

The availability of recreation centers may be beneficial for poststroke function and quality of life among those with moderate-severe stroke. If further research confirms recreation centers to be beneficial, this could inform rehabilitation following stroke.

Clinical characteristic of a Haitian stroke cohort and a scoping review of the literature of stroke among the Haitian population

Background and Aim

There are significant disparities in stroke care and outcomes between low- and middle-income countries compared to high-income countries. Haiti, a lower-middle-income country, suffers from a lack of resources for acute stroke management. This study is the first to report the epidemiological profile of the Haitian population presenting with stroke symptoms at the largest academic hospital in the nation.

Methods

This is an observational study conducted over a period of 5 months from April 2021 to August 2021 in the Internal Medicine Department of the State University Hospital of Haiti. There were 51 included patients who were suspected to have had an acute stroke. A descriptive statistical analysis was conducted. A scoping review of the literature was also conducted.

Results

Over 50% of included patients were between 19 and 65 years old. The mean age at presentation was 61 years, and patients were predominantly female (64.7%). The prevalence of severe motor deficits was over 96%. The mean National Institutes of Health Stroke Scale was 12. Only 15.7% of patients (8/51) had a computed tomography (CT) scan during their hospitalization. The median time to CT scan was 84 h after symptom onset. About 80% of those with complications took more than 24 h to arrive at the hospital after the onset of symptoms. Eleven percent of patients had complications, and the mortality rate was 3.9%. There was a significant association between the Modified Rankin Scale and the occurrence of complications (p = 0.016). National Institutes of Health Stroke Scale (NIHSS) score had a significant association with the Glasgow score (F = 6.3; p < 0.001) where an inversely proportional correlation was observed between them (r = -0.7; p < 0.001) and a proportional correlation with the Rankin prediction score and the NIHSS (r = 0.3, p = 0.04). Little is known about the epidemiology of stroke patients in Haiti, and this limits the ability to develop targeted interventions to improve outcomes. In our scoping review, only three pertinent studies were identified over a 25-year period, this leads to a lack of data in regard to stroke care in Haiti mainly due to the absence of trained personnel.

Conclusion

In our cohort, stroke is mainly affecting female patients. The majority of stroke patients have moderate to severe motor deficits and took more than 24 h to arrive at the hospital. Urgent assistance is needed to strengthen personnel and infrastructure dedicated to stroke. Neurological assessment based on NIHSS and Rankin score should be systematic in stroke evaluation in Haiti.

Relevance for Patients

This study is relevant for patients because it emphasizes the challenges of stroke management in Haiti due to the non-availability of reference drugs, the time to arrive at the hospital to start treatment, as well as the means of diagnosis which are limited, like the CT scan. While stroke prevalence is on the rise in the country, it is the highest in the Caribbean and Latin America region.

Neurodata Tracker: Software for computational assessment of hand motor skills based on optical motion capture in a virtual environment

Objectives

Deficits affecting hand motor skills negatively impact the quality of life of patients. The NeuroData Tracker platform has been developed for the objective and precise evaluation of hand motor deficits. We describe the design and development of the platform and analyse the technological feasibility and usability in a relevant clinical setting.

Methods

A software application was developed in Unity (C#) to obtain kinematic data from hand movement tracking by a portable device with two cameras and three infrared sensors (leap motion®). Four exercises were implemented: (a) wrist flexion-extension (b) finger-grip opening-closing (c) finger spread (d) fist opening-closing. The most representative kinematic parameters were selected for each exercise. A script in Python was integrated in the platform to transform real-time kinematic data into relevant information for the clinician. The application was tested in a pilot study comparing the data provided by the tool from ten healthy subjects without any motor impairment and ten patients diagnosed with a stroke with mild to moderate hand motor deficit.

Results

The NeuroData Tracker allowed the parameterization of kinematics of hand movement and the issuance of a report with the results. The comparison of the data obtained suggests the feasibility of the tool for detecting differences between patients and healthy subjects.

Conclusions

This new platform based on optical motion capturing provides objective measurement of hand movement allowing quantification of motor deficits. These findings require further validation of the tool in larger trials to verify its usefulness in the clinical setting.

Enhanced Street Crossing Features are Associated with Higher Post-Stroke Physical Quality of Life

BACKGROUND

Features of the physical environment may affect post-stroke recovery, but empirical evidence is limited. This study examines associations between features of the physical environment and post-stroke physical quality of life (PH-QOL).

METHODS

The study sample included stroke survivors enrolled in the Caring for Adults Recovering from the Effects of Stroke project, a prospective cohort. Features of the physical environment surrounding participants' home addresses were audited using Google Earth. Audits captured information about crossings (e.g. curb-cuts; range 0-4), street segments (e.g. sidewalks; range 0-17.5), and a route (e.g. parks; range 0-27) near participants' home. Summary scores were categorized into tertials representing "few," "some," and "many" pedestrian-friendly features. Post-stroke PH-QOL was measured by the SF-12 (range 0-100) around 6 to 12-, 18-, 27-, and 36-months post-stroke. Linear mixed models were used to estimate PH-QOL over time. Chained multiple imputation was used to account for missing data.

RESULTS

Two hundred and seventy-five participants were eligible, among whom 210 had complete data. Most participants lived in areas with "few" features to promote outdoor mobility. Participants living in environments with "some" crossing features had a 4.90 (95% CI: 2.32, 7.48) higher PH-QOL score across the observation period in comparison to participants living in environments with "few" crossing features. Features of the physical environment along street segments and routes were not associated with post-stroke PH-QOL.

CONCLUSION

Crossing features are associated with post-stroke PH-QOL. Modifying features of the physical environment at nearby crossings, such as curb-cuts, may be a promising strategy for increasing PH-QOL.

Assessment of Neurological Status in Patients with Cerebrovascular Diseases through the Nursing Outcome Classification: A Methodological Study

Nurses play an important role in healthcare, and the Nursing Outcomes Classification is a key tool for the standardization of care. This study aims to validate the nursing outcome “Neurological Status” for patients with cerebrovascular diseases. A methodological study was performed in four phases. In Phase 1, the relevance of the indicators was evaluated by seven specialists and the modified kappa coefficient and content validity index were calculated. In Phase 2, conceptual and operational definitions were formulated. In addition, their content was validated with a focus group in Phase 3. In Phase 4, the results were applied in clinical practice and convergence with the National Institute of Health Stroke Scale was verified. The reliability was measured by Cronbach’s alpha. Of the 22 initial indicators, 6 were excluded. The focus group suggested changes in the definitions and the exclusion of two indicators. In Phase 4, only 13 indicators were validated due to the impossibility of measuring intracranial pressure. A strong correlation between the two scales and agreement among all the indicators were observed. Following the specialists’ review, the nursing outcome was reliable and clinically validated with 13 indicators: consciousness, orientation, language, central motor control, cranial sensory and motor function, spinal sensory and motor function, body temperature, blood pressure, heart rate, eye movement pattern, pupil size, pupil reactivity, and breathing pattern.

EEG spectral exponent as a synthetic index for the longitudinal assessment of stroke recovery

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The Spectral Exponent (SE) indexes power-law features of the resting EEG in stroke patients.

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SE is consistently steeper in the affected hemisphere of patients after middle cerebral artery stroke.

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SE is linked to clinical status and seems to be a good predictor of clinical outcome.

Objective

Quantitative Electroencephalography (qEEG) can capture changes in brain activity following stroke. qEEG metrics traditionally focus on oscillatory activity, however recent findings highlight the importance of aperiodic (power-law) structure in characterizing pathological brain states. We assessed neurophysiological alterations and recovery after mono-hemispheric stroke by means of the Spectral Exponent (SE), a metric that reflects EEG slowing and quantifies the power-law decay of the EEG Power Spectral Density (PSD).

Methods

Eighteen patients (n = 18) with mild to moderate mono-hemispheric Middle Cerebral Artery (MCA) ischaemic stroke were retrospectively enrolled for this study. Patients underwent EEG recording in the sub-acute phase (T0) and after 2 months of physical rehabilitation (T1). Sixteen healthy controls (HC; n = 16) matched by age and sex were enrolled as a normative group. SE values and narrow-band PSD were estimated for each recording. We compared SE and band-power between patients and HC, and between the affected (AH) and unaffected hemisphere (UH) at T0 and T1 in patients.

Results

At T0, stroke patients showed significantly more negative SE values than HC (p = 0.003), reflecting broad-band EEG slowing. Most important, in patients SE over the AH was consistently more negative compared to the UH and showed a renormalization at T1. This SE renormalization significantly correlated with National Institute of Health Stroke Scale (NIHSS) improvement (R = 0.63, p = 0.005).

Conclusions

SE is a reliable readout of the neurophysiological and clinical alterations occurring after an ischaemic cortical lesion.

Significance

SE promise to be a robust method to monitor and predict patients’ functional outcome.

Quantitative EEG Correlates with NIHSS and MoCA for Assessing the Initial Stroke Severity in Acute Ischemic Stroke Patients

BACKGROUND: National Institutes of Health Stroke Scale (NIHSS) and Montreal Cognitive Assessment (MoCA) measure stroke severity by assessing the functional and cognitive outcome, respectively. However, they cannot be used to measure subtle evolution in clinical symptoms during the early phase. Quantitative EEG (qEEG) can detect any subtle changes in CBF and brain metabolism thus may also benefit for assessing the severity. AIM: This study aims to identify the correlation between qEEG with NIHSS and MoCA for assessing the initial stroke severity in acute ischemic stroke patients. METHODS: This was a cross-sectional study. We recruited 30 patients with first-ever acute ischemic stroke hospitalized in Dr. Sardjito General Hospital, Yogyakarta, Indonesia. We measured the NIHSS, MoCA score, and qEEG parameter during the acute phase of stroke. Correlation and regression analysis was completed to investigate the relationship between qEEG parameter with NIHSS and MoCA. RESULTS: Four acute qEEG parameter demonstrated moderate-to-high correlations with NIHSS and MoCA. DTABR had positive correlation with NIHSS (r = 0.379, p = 0.04). Meanwhile, delta-absolute power, DTABR, and DAR were negatively correlated with MoCA score (r = −0.654, p = 0.01; r = −0.397, p = 0.03; and r = −0.371, p = 0.04, respectively). After adjusted with the confounding variables, delta-absolute power was independently associated with MoCA score, but not with NIHSS (B = −2.887, 95% CI (−4.304–−1.470), p < 0.001). CONCLUSIONS: Several qEEG parameters had significant correlations with NIHSS and MoCA in acute ischemic stroke patients. The use of qEEG in acute clinical setting may provide a reliable and efficient prediction of initial stroke severity. Further cohort study with larger sample size and wide range of stroke severity is still needed.

Carotid intima media thickness measurements coupled with stroke severity strongly predict short-term outcome in patients with acute ischemic stroke: a machine learning study

Acute ischemic stroke (IS) is one of the leading causes of morbidity, functional disability and mortality worldwide. The objective was to evaluate IS risk factors and imaging variables as predictors of short-term disability and mortality in IS. Consecutive 106 IS patients were enrolled. We examined the accuracy of IS severity using the National Institutes of Health Stroke Scale (NIHSS), carotid intima-media thickness (cIMT) and carotid stenosis (both assessed using ultrasonography with doppler) predicting IS outcome assessed with the modified Rankin scale (mRS) three months after hospital admission. Poor prognosis (mRS ≥ 3) at three months was predicted by carotid stenosis (≥ 50%), type 2 diabetes mellitus and NIHSS with an accuracy of 85.2% (sensitivity: 90.2%; specificity: 81.8%). The mRS score at three months was strongly predicted by NIHSS (β = 0.709, p < 0.001). Short-term mortality was strongly predicted using a neural network model with cIMT (≥ 1.0 mm versus < 1.0 mm), NIHSS and age, yielding an area under the receiving operator characteristic curve of 0.977 and an accuracy of 94.7% (sensitivity: 100.0%; specificity: 90.9%). High NIHSS (≥ 15) and cIMT (≥ 1.0 mm) increased the probability of dying with hazard ratios of 7.62 and 3.23, respectively. Baseline NIHSS was significantly predicted by the combined effects of age, large artery atherosclerosis stroke, sex, cIMT, body mass index, and smoking. In conclusion, high values of cIMT and NIHSS at admission strongly predict short-term functional impairment as well as mortality three months after IS, underscoring the importance of those measurements to predict clinical IS outcome.

Association of Neighborhood Socioeconomic Status With Outcomes in Patients Surviving Stroke

OBJECTIVE

To examine associations between neighborhood socioeconomic status (nSES) and 90-day poststroke outcomes.

METHODS

The Brain Attack Surveillance in Corpus Christi Project is a population-based surveillance study in Nueces County, Texas. Patients with strokes were identified between 2010 and 2016 via active and passive surveillance and enrolled in the study. nSES index is a standardized composite of 2010 Census tract-level income, wealth, education, and employment (median -4.56, interquartile range -7.48 to -0.46). The 90-day outcomes were ascertained via interview: functional status measured by the average of 22 activities of daily living/instrumental activities of daily living (range 1-4), biopsychosocial health by the Stroke-Specific Quality of Life scale (range 0-5), and depressive symptoms by the 8-item Patient Health Questionnaire (range 0-24). Associations between nSES and outcomes were estimated using confounder-adjusted generalized estimating equations with an nSES × NIH Stroke Scale score interaction term.

RESULTS

Seven hundred seventy-six survivors made up the analytical sample (52.96% male, 62.24% Mexican American, 52.96% ≥64 years old). Higher compared to lower nSES (mean difference comparing 75th to 25th percentile of nSES) was associated with better function (-0.27, 95% confidence interval [CI] -0.49 to -0.05), better biopsychosocial health (0.26, 95% CI 0.06-0.47), and fewer depressive symptoms (-1.77, 95% CI -3.306 to -0.48) among those with moderate to severe strokes. Among those with minor strokes, higher nSES was associated with better function (-0.13, 95% CI -0.24 to -0.02).

CONCLUSIONS

nSES may influence poststroke recovery. Studies should identify neighborhood characteristics that contribute to poststroke outcomes, particularly in moderate to severe stroke survivors.

Accurate prediction of clinical stroke scales and improved biomarkers of motor impairment from robotic measurements

Objective

One of the greatest challenges in clinical trial design is dealing with the subjectivity and variability introduced by human raters when measuring clinical end-points. We hypothesized that robotic measures that capture the kinematics of human movements collected longitudinally in patients after stroke would bear a significant relationship to the ordinal clinical scales and potentially lead to the development of more sensitive motor biomarkers that could improve the efficiency and cost of clinical trials.

Materials and methods

We used clinical scales and a robotic assay to measure arm movement in 208 patients 7, 14, 21, 30 and 90 days after acute ischemic stroke at two separate clinical sites. The robots are low impedance and low friction interactive devices that precisely measure speed, position and force, so that even a hemiparetic patient can generate a complete measurement profile. These profiles were used to develop predictive models of the clinical assessments employing a combination of artificial ant colonies and neural network ensembles.

Results

The resulting models replicated commonly used clinical scales to a cross-validated R² of 0.73, 0.75, 0.63 and 0.60 for the Fugl-Meyer, Motor Power, NIH stroke and modified Rankin scales, respectively. Moreover, when suitably scaled and combined, the robotic measures demonstrated a significant increase in effect size from day 7 to 90 over historical data (1.47 versus 0.67).

Discussion and conclusion

These results suggest that it is possible to derive surrogate biomarkers that can significantly reduce the sample size required to power future stroke clinical trials.

Neutrophil to Lymphocyte Ratio Predicts Outcome of Stroke by Cervicocranial Arterial Dissection

Background and Purpose: Neutrophil to lymphocyte ratio (NLR) is positively associated with poor prognosis in patients with cerebral infarction. The goal of this prospective study is to explore the predictive value of NLR in patients with acute ischemic stroke (AIS) caused by cervicocranial arterial dissection (CCAD).

Methods: Ninety-nine patients with AIS caused by CCAD met criteria for inclusion and exclusion were selected for this study. We collected baseline data on the admission including NLR. The primary poor outcome was major disability (modified Rankin Scale score ≥ 3) or death at 3 months after AIS.

Results: A total of 20 (20.2%) patients had a poor outcome at 3 months after AIS. According to the 3-month outcome, the patients were divided into two groups and univariate and multivariable analyses were conducted. Among the risk factors, elevated NLR levels were independently associated with 3-month poor outcomes. Further, we made the ROC curve to evaluate the predictive value of NLR level on prognosis. The area under the curve was 0.79 and a cut-off value of NLR was 2.97 for differentiating the poor outcome. We divided patients into groups according to the cut-off value. Patients with high NLR have a higher risk of poor outcome than those with low NLR (P < 0.05).

Conclusion: As an inflammatory marker, elevated NLR levels were associated with 3-month poor outcome in AIS caused by CCAD.

Falling stroke rates during COVID-19 pandemic at a comprehensive stroke center

INTRODUCTION

Although there is evidence to suggest a high rate of cerebrovascular complications in patients with SARS-CoV-2 infection, anecdotal reports indicate a falling rate of new ischemic stroke diagnoses. We conducted an exploratory single-center analysis to estimate the change in number of new stroke diagnoses in our region, and evaluate the proximate reasons for this change during the COVID-19 pandemic at a tertiary care center in New Jersey.

PATIENTS AND METHODS

A Comprehensive Stroke Center prospective cohort was retrospectively analyzed for the number of stroke admissions, demographic features, and short-term outcomes 5 months prior to 3/1/2020 (pre-COVID-19), and in the 6 weeks that followed (COVID-19 period). The primary outcome was the number of new acute stroke diagnoses before and during the COVID-19 period, as well as the potential reasons for a decline in the number of new diagnoses.

RESULTS

Of the 328 included patients, 53 (16%) presented in the COVID-19 period. There was a mean fall of 38% in new stroke diagnoses (mean 1.13/day [SD 1.07] from 1.82/day [SD 1.38], p<0.01), which was related to a 59% decline in the number of daily transfers from referral centers (p<0.01), 25% fewer telestroke consultations (p=0.08), and 55% fewer patients presenting directly to our institution by private vehicle (p<0.01) and 29% fewer patients through emergency services (p=0.09). There was no significant change in the monthly number of strokes due to large vessel occlusion (LVO), however the proportion of new LVOs nearly doubled in the COVID-19 period (38% vs. 21%, p=0.01).

CONCLUSIONS

The observations at our tertiary care center corroborate anecdotal reports that the number of new stroke diagnoses is falling, which seems related to a smaller proportion of patients seeking healthcare services for milder symptoms. These preliminary data warrant validation in larger, multi-center studies.

Falling stroke rates during COVID-19 pandemic at a comprehensive stroke center

INTRODUCTION

Although there is evidence to suggest a high rate of cerebrovascular complications in patients with SARS-CoV-2 infection, anecdotal reports indicate a falling rate of new ischemic stroke diagnoses. We conducted an exploratory single-center analysis to estimate the change in number of new stroke diagnoses in our region, and evaluate the proximate reasons for this change during the COVID-19 pandemic at a tertiary care center in New Jersey.

PATIENTS AND METHODS

A Comprehensive Stroke Center prospective cohort was retrospectively analyzed for the number of stroke admissions, demographic features, and short-term outcomes 5 months prior to 3/1/2020 (pre-COVID-19), and in the 6 weeks that followed (COVID-19 period). The primary outcome was the number of new acute stroke diagnoses before and during the COVID-19 period, as well as the potential reasons for a decline in the number of new diagnoses.

RESULTS

Of the 328 included patients, 53 (16%) presented in the COVID-19 period. There was a mean fall of 38% in new stroke diagnoses (mean 1.13/day [SD 1.07] from 1.82/day [SD 1.38], p<0.01), which was related to a 59% decline in the number of daily transfers from referral centers (p<0.01), 25% fewer telestroke consultations (p=0.08), and 55% fewer patients presenting directly to our institution by private vehicle (p<0.01) and 29% fewer patients through emergency services (p=0.09). There was no significant change in the monthly number of strokes due to large vessel occlusion (LVO), however the proportion of new LVOs nearly doubled in the COVID-19 period (38% vs. 21%, p=0.01).

CONCLUSIONS

The observations at our tertiary care center corroborate anecdotal reports that the number of new stroke diagnoses is falling, which seems related to a smaller proportion of patients seeking healthcare services for milder symptoms. These preliminary data warrant validation in larger, multi-center studies.

Standardizing the Frequency of Neurologic Assessment After Acute Stroke

The National Institutes of Health Stroke Scale (NIHSS) is considered the standard for assessing neurologic status after an acute stroke. Currently, there is no guideline for when this assessment should be completed, nor is there consensus on how frequently or for how long.We initiated a quality improvement project that sought first to determine when and how often nurses at a variety of institutions in our multisite health care system completed the NIHSS assessment and then to identify the minimum frequency at which nurses should complete the assessment. After reviewing the literature and current practices and observing internal and external benchmarks, we set a new standard for all institutions in the system to follow.The new assessment frequency was based on patient condition and level of care, although that frequency would change if a patient showed new or worsening neurologic changes. The new standard was successfully implemented at all the primary and comprehensive certified stroke centers in our network. Ongoing monitoring confirmed that the frequency of NIHSS assessment met the needs of our patients and ensured staff adherence to the new practice.

Longer Time Before Acute Rehabilitation Therapy Worsens Disability After Intracerebral Hemorrhage

OBJECTIVE

Assess the association of time to initiation of acute rehabilitation therapy with disability after intracerebral hemorrhage (ICH) and identify predictors of time to initiation of rehabilitation therapy.

DESIGN

Retrospective data analysis of prospectively collected data from an ongoing observational cohort study.

SETTING

Large comprehensive stroke center in a metropolitan area.

PARTICIPANTS

Adults with ICH consecutively admitted (n=203).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Disability was assessed with the modified Rankin Scale (mRS), with poor outcome defined as mRS 4-6 (dependence or worse). Time to initiation of acute rehabilitation therapy was defined as the number of days between hospital admission and the first consult by any rehabilitation therapy specialist (eg, physical therapy, occupational therapy, speech therapy).

RESULTS

The median number of days from hospital admission to initiation of acute rehabilitation therapy was 3 (range=2-7). Multivariable logistic regression models indicated that each additional day between admission and initiation of acute rehabilitation therapy was associated with increased odds of poor outcome at 30 days (adjusted odds ratio [OR]=1.151; 95% confidence interval [CI]=1.044-1.268; P=.005) and at 90 days (adjusted OR=1.107; 95% CI=1.003-1.222; P=.044) for patients with ICH. A multivariable linear regression model used to identify the predictors of time to initiation of rehabilitation therapy identified heavy drinking (>5 drinks per day), premorbid mRS<4, presence of pulmonary embolism, and longer length of stay in the intensive care unit as independent predictors of later initiation of acute rehabilitation therapy.

CONCLUSIONS

Longer time to initiation of acute rehabilitation therapy after ICH may have persistent effects on poststroke disability. Delays in acute rehabilitation therapy consults should be minimized and may improve outcomes after ICH.

Predicting functional outcomes after stroke: an observational study of acute single-channel EEG

Background: Early and objective prediction of functional outcome after stroke is an important issue in rehabilitation. Electroencephalography (EEG) has long been utilized to describe and monitor brain function following neuro-trauma, and technological advances have improved usability in the acute setting. However, skepticism persists whether EEG can provide the same prognostic value as neurological examination.Objective: The current cohort study examined the relationship between acute single-channel EEG and functional outcomes after stroke.Methods: Resting-state EEG recorded at a single left pre-frontal EEG channel (FP1) was obtained from 16 adults within 72 h of first stroke. At 30 and 90 days, measures of disability (modified Rankin Scale; mRS) and involvement in daily activities (modified Barthel Index; mBI) were obtained. Acute EEG measures were correlated with functional outcomes and compared to an early neurological examination of stroke severity using the National Institute of Health Stroke Scale (NIHSS). Classification of good outcomes (mRS ≤1 or mBI ≥95) was also examined using Receiver Operator Curve analyses.Results: One-third to one-half of participants experienced incomplete post-stroke recovery, depending on the time point and measure. Functional outcomes correlated with acute theta values (r_s 0.45-0.60), with the strength of associations equivalent to previously reported values obtained from conventional multi-channel systems. Acute theta values ≥0.25 were associated with good outcomes, with positive (67-83%) and negative predictive values (70-90%) comparable to those obtained using the NIHSS.Conclusions: Acute, single-channel EEG can provide unique, non-overlapping clinical information, which may facilitate objective prediction of functional outcome after stroke.

Associations of Self-Reported History of Depression and Antidepressant Use Before Stroke Onset With Poststroke Post-Acute Rehabilitation Care-An Exploratory Study: The BASIC (Brain Attack Surveillance in Corpus Christi) Project

Background

Prestroke depression status and post–acute rehabilitation care (PARC) are determinants of poststroke depression and function. However, little is known on how prestroke depression status affects PARC placement, a possible pathway for upstream intervention. We examined how prestroke depression status affects PARC in a population‐based study.

Methods and Results

Incident ischemic stroke cases were from the BASIC (Brain Attack Surveillance in Corpus Christi) Project from 2008 to 2012. Prestroke depression status was self‐reported and categorized as (1) never depressed, (2) history of depression without antidepressant use before stroke onset, or (3) antidepressant use before stroke onset. PARC included home, a skilled nursing facility, or an inpatient rehabilitation facility. Confounder‐adjusted multinomial regression models were used to examine the association between prestroke depression status and PARC. Adjustment for stroke severity was deferred in the main analyses because it may lie on the causal pathway. There were 548 stroke survivors (mean age 65.3 years, 48.3% female, 62.6% Mexican‐American). The adjusted odds ratios comparing home discharge to a skilled nursing facility were 1.88 (95% CI: 0.86‐4.11) for those with a history of depression and 2.55 (95% CI: 1.11‐5.83) for those using an antidepressant at stroke onset, relative to those never depressed. The adjusted odds ratios comparing an inpatient rehabilitation facility to a skilled nursing facility were 1.17 (95% CI 0.40‐3.42) and 3.28 (95% CI 1.24‐8.67) for those with a history of depression and those using an antidepressant at stroke onset, respectively, relative to those never depressed.

Conclusions

Antidepressant use before stroke onset may increase odds of home and inpatient rehabilitation facility discharge compared with skilled nursing facility discharge.