Optimal outcomes obtained with body-weight support combined with treadmill training in stroke subjects

OBJECTIVES: To identify stroke patients who are most likely to benefit from locomotor training with body-weight support (BWS), to determine the extent of carryover from treadmill training to overground locomotion, and to determine the variables that are most likely to influence the recovery of locomotion. DESIGN: A randomized clinical trial. SETTING: Inpatient rehabilitation hospital. PARTICIPANTS: Of 100 stroke subjects, 50 were randomized to receive locomotor training with BWS (BWS group), and 50 were randomized to receive locomotor training with full weight bearing (no-BWS group). The subjects were stratified according to their initial overground walking speed and endurance, initial treadmill speed and endurance, functional balance, motor recovery, side of the lesion, and age. INTERVENTION: Fifty subjects were trained to walk on a treadmill with up to 40% of their body weight supported by a BWS system with an overhead harness (BWS group), and 50 subjects were trained to walk while bearing their full weight (no-BWS group). MAIN OUTCOME MEASURES: Clinical outcome measures included overground walking speed and endurance, functional balance, and motor recovery. The effect of confounding variables such as age, comorbidity, and depression on locomotor outcome was also investigated. RESULTS: After 6 weeks of locomotor training, the BWS group scored significantly higher in all clinical outcomes. When the subjects were stratified according to their initial overground walking speed, endurance, balance, and motor recovery, a significant statistical difference in gait and balance dysfunction of all outcomes occurred in the more severely impaired subjects. An important transfer from treadmill speed to overground walking speed was observed in subjects in the BWS group. Finally, a significantly greater effect was observed in older subjects (65-85y) in the BWS group. CONCLUSIONS: Retraining gait in severely impaired stroke subjects with a percentage of their body weight supported resulted in better walking and postural abilities than did gait training in patients bearing their full weight. It appears that subjects with greater gait impairments benefited the most from training with BWS, as did the older patients with stroke. There is evidence of transfer from treadmill training to overground locomotion.     

Prediction of social activity 1 year poststroke

OBJECTIVE: To develop an easy-to-use prediction rule for social activity 1 year poststroke that can identify patients at risk for social inactivity. DESIGN: Inception cohort. SETTING: Rehabilitation center. PARTICIPANTS: Patients with a first-ever supratentorial stroke were selected in 4 Dutch rehabilitation centers. Data of 250 patients were available for analysis. Potential prognostic factors measured at admission were sex, age, marital status, prestroke employment status, educational level, type of stroke, hemisphere, motor impairment, trunk control, communication, and activities of daily living (ADL) dependency. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Social activity measured by the Frenchay Activities Index (FAI) at 1 year poststroke. RESULTS: Multivariate backward linear regression analysis identified sex, age, marital status, motor impairment, communication, and ADL dependency as important predictors of the FAI score 1 year poststroke. An easy-to-use score chart was constructed that could identify patients at risk for social inactivity. The score chart proved to be well able to discriminate poor social functioning from moderate to good social functioning (area under the curve = .85). CONCLUSIONS: Identifying patients at risk enables health care professionals to focus on the social activity of this patient subgroup at an early stage in the care process.     

脑血管病急性期的康复与护理

对４７例脑血管病患者采用急性期康复治疗，并与非急性期康复治疗组４４例进行对比观察，Ｐ＜０．０１，差异非常显著。结果提示：脑血管病患者的康复治疗宜早期进行。     

缺血性卒中脑血管反应性与颈动脉狭窄的相关研究

目的 应用经颅彩色多普勒超声（transcranial color Doppler ultrasound,TCD）结合屏气试验分析颈动脉狭窄患者的脑血管反应性（cerebrovascular reactivity,CVR）,为干预缺血性卒中的发生进展及预防时机的选择提供依据。方法 选取2018年1月至2020年1月于延边大学附属医院神经内科就诊者150例,分为脑梗死组110例,对照组（无颅内外血管狭窄及脑梗死者）40例。脑梗死患者根据是否存在颈动脉狭窄、狭窄程度及有无临床症状进行组别比较。采用经颅彩色多普勒超声检测仪检测双侧大脑中动脉屏气试验前后的血流速度,计算平均血流速度变化值（change value of average blood flow velocity,ΔVm）和呼吸抑制指数（breath–holding index,BHI）。结果 脑梗死组ΔVm及BHI值分别低于对照组,差异有统计学意义（P<0.05）。梗死组依据是否合并颈动脉狭窄分为狭窄组和非狭窄组,狭窄组ΔVm及BHI值分别低于对照组,差异有统计学意义（P<0.05）。患侧轻、中度分别与重度狭窄组比较,差异有统计学意义（P<0.05）。狭窄程度与患侧BHI值呈负相关。结论 经颅多普勒超声检测CVR具有可行性,BHI可作为评价CVR指标之一。脑血管的反应性与缺血性卒中的发生有相关性,可作为预测缺血性脑卒中发生风险的指标之一。脑血管反应性与颈动脉狭窄程度呈负相关,随着狭窄程度的增加CVR逐步减低。     

Brain magnetic resonance and cognitive function changes in maintenance hemodialysis patients

Objective To investigate cerebrovascular lesions on maintenance hemodialysis (MHD) patients, including types of cerebrovascular disease, and cognitive function changes. Methods A cross-sectional study was applied. A total of 270 MHD patients at hemodialysis center of Peking Union Medical College Hospital were screened, and finally 117 cases were enrolled. Demographic information, aboratory data, MRI and MRA data were collected and assessed. Cognitive function was evaluated with C - MMSE (Chinese mini mental test examination) and C - MoCA (Chinese montreal cognitive assessment). The related factors were selected by Spearman correlation analysis, multiple linear regression and logistic regression analysis. Results The patients’average age was (56.0± 12.5) years, average hemodialysis age was (73.5±60.8) months. Only 5.1% patients had clinical history of cerebral infarction or hemorrhage. Pre - hemodialysis blood pressure was (142.7/80.3±18.2/12.9) mmHg, Post-hemodialysis blood pressure was (130.2/79.1±23.4/14.9) mmHg. A total of 18.8% patients had intra-hemodialysis hypotension, spKt/V was (1.45±0.25). MR results showed that 12.0% patients had cerebral artery stenosis, 5.1% patients had cortical infarcts, 39.3% patients had lacunar infarcts, 47.0% patients had microbleeds, 7.7% patients had chronic hematoma, 52.1% patients had abnormal brain whiter matter lesions (WMLs). In cognitive function evaluation, 20.9% patients had abnormal C-MMSE scores, but 65.2% patients had abnormal C-MoCA results. Multiple linear regression showed age (b=0.059, P＜0.01), dialysis age (b=0.005, P＜0.05) were associated with WMLs in MHD patients. Intra-hemodialysis hypotension was an independent risk factor of lacunar infarcts (b=2.123, P＜0.01) and microbleeds (b=3.531, P＜0.01). Low serum albumin level was an independent risk factor of cognitive decline (b=0.314, P＜0.05). Logistic regression analysis showed pre - hemodialysis systolic blood pressure was an independent risk factor of cortical infarcts [OR=1.088, 95%CI (1.018-1.152), P＜ 0.05]. Gender, dialysis age and pre - dialysis serum TCO2 level were related with chronic hematoma. Conclusions WMLs is related with dialysis voltage. Lacunar infarcts and mirobleeds are related with intra - hemodialysis hypotension. Lacunar infarcts, WMLs and nutritional status are contributed to decline of cognition in MHD patients.     

Controversias en enfermedad cerebrovascular: rt-PA a dosis bajas vs. dosis estándar en el tratamiento del ictus agudo. Una revisión de la literatura

IntroductionThe use of low doses of recombinant tissue plasminogen activator (rt-PA) was initially proposed in Asian countries in response to racial peculiarities related to the functionality of fibrinogen and coagulation factors that potentially increased the risk of intracerebral haemorrhage, and with a view to saving costs. In view of the controversy over the use of rt-PA below the standard dose, we conducted a literature review of studies promoting the use of low doses or comparing different doses of rt-PA.DevelopmentWe reviewed 198 abstracts related to the search terms and the full texts of 52 studies published in the last 30 years. We finally included 13 randomised clinical trials aiming to determine the efficacy and safety of the use of rt-PA at different doses in acute stroke, 14 observational cohort studies, 5 meta-analyses, and 3 systematic reviews.ConclusionsThere is insufficient evidence to classify low doses of rt-PA as superior or at least not inferior to the standard treatment in the management of acute stroke in western populations. More clinical trials are required to determine whether the use of low doses is beneficial in patients with relative contraindications for thrombolytic therapy or other particular circumstances that may increase the risk of intracerebral haemorrhage.     

Evaluación de la incidencia y tendencia de la enfermedad cerebrovascular en la región sanitaria de Lleida (España) en el periodo 2010-2014

ObjectivesThis study aimed to determine the incidence and trends of cerebrovascular disease (CVD) in the healthcare district of Lleida.Material and methodsWe performed a population-based prospective cohort study including the entire population of the healthcare district of Lleida (440 000 people). Information was gathered from the minimum basic data set from the emergency department and hospital discharges for the period from January 2010 to December 2014. All types of stroke were included. We evaluated crude and age-standardised rates using the world population as a reference. Patients without neuroimaging confirmation of the diagnosis were excluded.ResultsWe identified 4397 patients: 1617 (36.8%) were aged 80 years or over; 3969 (90.3%) presented ischaemic stroke, and 1741 (39.6%) were women. The crude incidence rate ranged from 192 (95% confidence interval [CI], 179-205) to 211 (95% CI, 197-224) cases per 100 000 population, in 2012 and 2013, respectively. Age-standardised rates ranged from 93 (95% CI, 86-100) to 104 (95% CI, 96-111) cases per 100 000 population, in 2012 and 2013, respectively. For all years, incidence rates increased with age, and were significantly higher among men than among women.ConclusionThe impact of CVD in Lleida is comparable to that observed in other European regions. However, population ageing induces a high crude incidence rate, which remained stable over the five-year study period.     

倾向性评分法在脑血管病临床研究中的应用

真实世界研究起源于实用性临床试验,在真实临床实践中评估干预的有效性和安全性,对随机对照试验以外临床疗效评价进行补充。然而,此类研究缺乏随机化,因此对混杂偏倚的控制尤为重要。倾向性评分法对多个混杂因素/协变量进行校正,是真实世界研究控制混杂因素的重要分析方法。本文介绍匹配法、分层法、协变量校正法和逆概率加权法这4种倾向性评分法,并阐述各自的优缺点。随后结合脑血管病临床研究特点,通过研究案例重点介绍倾向性评分法在脑血管病真实世界研究中的应用。     

双源Flash扫描模式CTA结合迭代重建诊断脑血管病变

目的探讨第二代双源Flash扫描模式CTA结合迭代重建诊断脑血管病变的临床应用价值。方法回顾性分析105例接受双源Flash扫描模式结合迭代重建脑血管CTA的疑诊脑血管病变患者的资料。以3D-DSA为金标准,计算Flash扫描模式CTA诊断脑血管病变的敏感度、特异度、阳性预测值、阴性预测值及准确率。比较3D-DSA与Flash扫描模式CTA诊断脑血管病变的差异,计算双源Flash扫描模式CTA的辐射剂量及对比剂用量。结果 105例中,Flash扫描模式CTA诊断60例共73个脑动脉瘤,其中微小动脉瘤24个;诊断13例脉动静脉畸形(AVM);检出颈内动脉海绵窦瘘5例、静脉畸形2例,脑动脉狭窄9例,烟雾病6例。以3D-DSA为金标准,CTA误诊微小动脉瘤2例,漏诊1例位于大脑中动脉远端区域的AVM。Flash扫描模式CTA诊断脑血管病变的敏感度、特异度、阳性预测值、阴性预测值及准确率分别为98.94%(93/94)、81.82%(9/11)、97.89%(93/95)、90.00%(9/10)和97.14%(102/105),辐射剂量为(231.9±13.2)mGy·cm,对比剂用量为(49.32±2.54)ml。结论脑部Flash扫描模式CTA结合迭代重建可快速、准确诊断脑血管病变,同时辐射剂量低、对比剂用量少。