Hurdles in stroke thrombolysis: Experience from 100 consecutive ischemic stroke patients

Background:

Acute management of ischemic stroke involves thrombolysis within 4.5 h. For a successful outcome, early recognition of stroke, transportation to the hospital emergency department immediately after stroke, timely imaging, proper diagnosis, and thrombolysis within 4.5 h is of paramount importance.

Aim:

To analyze the obstacles for thrombolysis in acute stroke patients.

Materials and Methods:

The study was conducted in a tertiary care center in South India. A total of hundred consecutive patients of acute ischemic stroke who were not thrombolysed, but otherwise fulfilled the criteria for thrombolysis were evaluated prospectively for various factors that prevented thrombolysis. The constraints to thrombolysis were categorized into: i) Failure of patient to recognize stroke symptoms, ii) patient''s awareness of thrombolysis as a treatment modality for stroke, iii) failure of patient''s relative to recognize stroke, iv) failure of primary care physician to recognize stroke, v) transport delays, vi) lack of neuroimaging and thrombolysis facility, and vii) nonaffordability.

Results:

The biggest hurdle for early hospital presentation is failure of patients to recognize stroke (73%), followed by lack of neuroimaging facility (58%), nonaffordability (56%), failure of patient''s relative to recognize stroke (38%), failure of the primary care physician to recognize stroke (21%), and transport problems (13%). Awareness of thrombolysis as a treatment modality for stroke was seen only in 2%.

Conclusion:

Considering the urgency of therapeutic measures in acute stroke, there is necessity and room for improvement to overcome various hurdles that prevent thrombolysis.     

Chlamydia pneumoniae seropositivity in adults with acute ischemic stroke: A case�Ccontrol study

Background:

Causative role of Chlamydia pneumoniae infection in patients with acute ischemic stroke (AIS) remains unresolved till date.

Aim:

To investigate the role of C. pneumoniae antibodies in AIS.

Materials and Methods:

Patients with AIS and sex- and environment-matched controls were enrolled. Antibodies to C. pneumoniae (IgA, IgG and IgM) were measured using enzyme-linked immunosorbent assay (ELISA).

Results:

A total of 51 patients and 48 controls were enrolled. The IgA seropositivity was significantly associated with AIS (unadjusted odds ratio 3.1; 95% CI 1.38, 6.96; P = 0.005), whereas IgG (unadjusted OR 0.44; 95% CI 0.18, 1.09; P = 0.07) and IgM (unadjusted OR 1.1; 95% CI 0.36, 3.3; P = 0.88) were not. There was no difference in IgA or IgG positivity in different stroke subtypes. On multivariate analysis after adjusting for sex, hypertension, diabetes mellitus, smoking and alcohol, the IgA seropositivity yielded an adjusted OR for stroke (4.72; 95% CI 1.61, 13.83; P = 0.005), while IgG seropositivity did not (OR 0.25; 95% CI 0.08, 0.83; P = 0.23).

Conclusions:

An increased risk of AIS was demonstrated in patients seropositive for C. pneumoniae for IgA antibodies.     

Process Improvement to Enhance Existing Stroke Team Activity Toward More Timely Thrombolytic Treatment

Background and Purpose

Process improvement (PI) is an approach for enhancing the existing quality improvement process by making changes while keeping the existing process. We have shown that implementation of a stroke code program using a computerized physician order entry system is effective in reducing the in-hospital time delay to thrombolysis in acute stroke patients. We investigated whether implementation of this PI could further reduce the time delays by continuous improvement of the existing process.

Methods

After determining a key indicator [time interval from emergency department (ED) arrival to intravenous (IV) thrombolysis] and conducting data analysis, the target time from ED arrival to IV thrombolysis in acute stroke patients was set at 40 min. The key indicator was monitored continuously at a weekly stroke conference. The possible reasons for the delay were determined in cases for which IV thrombolysis was not administered within the target time and, where possible, the problems were corrected. The time intervals from ED arrival to the various evaluation steps and treatment before and after implementation of the PI were compared.

Results

The median time interval from ED arrival to IV thrombolysis in acute stroke patients was significantly reduced after implementation of the PI (from 63.5 to 45 min, p=0.001). The variation in the time interval was also reduced. A reduction in the evaluation time intervals was achieved after the PI [from 23 to 17 min for computed tomography scanning (p=0.003) and from 35 to 29 min for complete blood counts (p=0.006)].

Conclusions

PI is effective for continuous improvement of the existing process by reducing the time delays between ED arrival and IV thrombolysis in acute stroke patients.     

N-terminal pro-brain natriuretic peptide levels and short term prognosis in acute ischemic stroke

Background:

Sparse published data are available regarding the prognostic importance of plasma N-terminal pro-brain natriuretic peptide (NT-proBNP) in patients with acute ischemic stroke.

Materials and Methods:

We prospectively studied 74 consecutive patients presenting with acute ischemic stroke within 24 hours of onset. All of them underwent laboratory and imaging evaluation and were treated as per guidelines. In all subjects, plasma NT-proBNP levels were measured at initial admission and again on day 7.

Results:

Their mean age was 54 ± 13.5years; there were 49 males; 18 (24%) patients died during the hospital stay. A statistically significant negative correlation between log NT-proBNP and Glasgow coma scale (GCS) score (P < 0.001); and a significant positive correlation between log NT-proBNP and National Institutes of Health Stroke Scale (NIHSS) score (P < 0.001) were observed. Baseline log NT-proBNP levels were higher among non-survivors compared with survivors (6.7 ± 0.47 vs. 5.37 ± 0.62; P = 0.06); day 7 log NT-proBNP levels were significantly higher in non-survivors compared with survivors (7.3 ± 0.26 vs. 4.5 ± 0.4; P = 0.000). In survivors, there was a statistically significant decline in log NT-proBNP levels from baseline to day 7 (5.3710 ± 0.620 vs. 4.5320 ± 0.451; P < 0.001). In contrast, among non-survivors, log NT-proBNP levels showed a statistically significant increase from baseline to day 7 (4.5322 ± 0.451 vs. 7.2992 ± 0.263; P < 0.001). On receiver operator characteristic curve (ROC) analysis, at a cut-off value of ≥ 6.0661, log NT-proBNP had a sensitivity and specificity of 98.2 and 88.9, respectively, in predicting death.

Conclusions:

Plasma log NT-pro-BNP level appears to be a useful biological marker for predicting in-hospital mortality inpatients presenting with acute ischemic stroke.     

Non-cardioembolic Mechanisms in Cryptogenic Stroke: Clinical and Diffusion-weighted Imaging Features

Background

The role of several cardiogenic risk factors, including patent foramen ovale, in patients with cryptogenic stroke has been extensively studied. However, little attention has been paid to the role of non-cardioembolic causes of cryptogenic stroke. We therefore sought to identify the characteristics of cryptogenic stroke.

Methods

We studied 832 patients with acute infarction in the middle cerebral arterial territory. We divided the patients into four subtypes: 402 with large artery atherosclerosis (LAA), 133 with cardioembolism, 182 with small arterial occlusion (SAO), and 115 with cryptogenic stroke. We compared risk factors and lesion patterns observed by diffusion-weighted imaging (DWI) between patients with cryptogenic stroke and those with stroke of other subtypes.

Results

Both risk factors and DWI lesion patterns differed between the cryptogenic and cardioembolic groups (P<0.05). Risk factors for cryptogenic stroke were similar to those for the LAA and SAO groups. Similarly, DWI lesion patterns for cryptogenic stroke were similar to LAA patients. Large cortical infarcts on DWI were more common in the cardioembolic group than in the LAA or cryptogenic groups (P<0.001). In contrast, deep, non-lacunar (OR 5.02; 95% CI 2.68~9.40; P<0.001) and superficial perforator infarcts (OR 2.23; 95% CI 1.08~4.59; P=0.029) were independently associated with the cryptogenic group.

Conclusions

Our results indicate that non-cardioembolic causes, such as macro- and microangiopathy, are important mechanisms in the pathogenesis of cryptogenic stroke.     

Role of magnesium sulfate in neuroprotection in acute ischemic stroke

Aims:

To study the effect of intravenous magnesium sulfate infusion on clinical outcome of patients of acute stroke.

Materials and Methods:

Sixty consecutive cases of acute ischemic stroke hospitalised within 24 h of an episode of stroke were taken as subjects. All subjects underwent a computed tomography head, and those found to have evidence of bleed/space-occupying lesions were excluded from the study. The subjects taken up for the study were divided into two groups of 30 subjects each. Both the groups received the standard protocol management for acute ischemic stroke. Subjects of Group 1 additionally received intravenous magnesium sulfate as initial 4 g bolus dose over 15 min followed by 16 g as slow infusion over the next 24 h. In all the subjects of the two study groups, serum magnesium levels were estimated at the time of admission (Day 0), Day 1 and Day 2 of hospitalization using an atomic absorption spectrometer.

Statistical Analysis Used:

Scandinavian stroke scores were calculated on Day 3, day of discharge and Day 28. Paired t-test was employed for comparison of stroke scores on Day 3, day of discharge and Day 28 within the same group and the unpaired t-test was used for the intergroup comparison, i.e. comparison of stroke scores of control group with corresponding stroke scores of magnesium group.

Results:

Comparison of stroke scores on Day 3 and day of discharge, on the day of discharge and Day 28 and on Day 3 and Day 28 in the magnesium group produced a t-value of 5.000 and P <0.001, which was highly significant. However, the comparison of the mean stroke scores between the magnesium and the control groups on Day 3, day of discharge and Day 28 yielded a P-value of >0.05, which was not significant.

Conclusions:

The study failed to document a statistical significant stroke recovery in spite of achieving a significant rise in serum magnesium level, more than that necessary for neuroprotection, with an intravenous magnesium sulfate regime.     

Factors affecting burden on caregivers of stroke survivors: Population-based study in Mumbai (India)

Background:

Caring for stroke patients leads to caregiver (CG) strain. The aims of this study are to identify factors related to increased CG burden in stroke survivors in a census-defined population and to assess the relationship between patient characteristics and CG stress.

Materials and Methods:

In a prospective population-based study, 223 first ever stroke (FES) were identified over a 1-year period. At 28 days, 127 (56.9%) were alive and 79 (35%) died, and 17 were lost to follow-up. One hundred and eleven CGs of 127 FES survivors agreed to participate. The level of stress was assessed by two scales: Oberst Caregiving Burden Scale (OCBS) and the Caregivers Strain Index (CSI) in CGs of survivors with mild stroke Modified Rankin Scale (MRS 1-2) and in those with significant disability (MRS 3-5).

Results:

The mean age of CGs was 45.6 years, approximately 22 years younger than that of the patients (67.5 years). Eighty-nine (80%) of the CGs were females and only 22 (20%) were males. Urinary incontinence (P=0.000008), morbidity at 28 days by MRS (P=0.0051), female gender (P=0.0183) and moderate to severe neurological deficit by National Institute of Health Stroke Scale (NIHSS) on admission (P=0.0254) were factors in FES cases leading to major CGs stress. CG factors responsible for major stress were long caregiving hours (P≤0.000001), anxiety (P≤0.000001), disturbed night sleep (P≤0.000001), financial stress (P=0.0000108), younger age (P=0.0021) and CGs being daughter-in-laws (P=0.012).

Conclusion:

Similar studies using uniform methodologies would help to identify factors responsible for major CG stress. Integrated stroke rehabilitation services should address CG issues to local situations and include practical training in simple nursing skills and counseling sessions to help reduce CG burden.     

Correlation between serum neuron specific enolase and functional neurological outcome in patients of acute ischemic stroke

Context:

The use of biomarkers to predict stroke prognosis is gaining particular attention nowadays. Neuron specific enolase (NSE), which is a dimeric isoenzyme of the glycolytic enzyme enolase and is found mainly in the neurons is one such biomarker.

Aims:

This study was carried out on patients of acute ischemic stroke with the aims to determine the correlation between NSE levels on the day of admission with infarct volume, stroke severity, and functional neurological outcome on day 30.

Materials and Methods:

Seventy five patients of acute ischemic stroke admitted in the Department of Medicine were included in the study. Levels of NSE were determined on day 1 using the human NSE ELISA kit (Alpha Diagnostic International Texas 78244, USA). Volume of infarct was measured by computed tomography (CT) scan using the preinstalled software Syngo (version A40A) of Siemen''s medical solutions (Forchheim, Germany). Stroke severity at admission was assessed using Glasgow coma scale (GCS) and functional neurological outcome was assessed using modified Rankin scale (mRS) on day 30.

Statistical Analysis Used:

Statistical analysis was performed using the SPSS software for windows version 15.0 (SPSS).

Results:

A positive correlation was found between concentration of NSE on day 1 and infarct volume determined by CT scan (r = 0.955, P < 0.001). A strong negative correlation was found between GCS at presentation and concentration of NSE on day 1 (r = −0.806, P < 0.001). There was a positive correlation between NSE levels at day 1 and functional neurological outcome assessed by mRS at day 30 (r = 0.744, P < 0.001).

Conclusions:

Serum levels of NSE in first few days of ischemic stroke can serve as a useful marker to predict stroke severity and early functional outcome. However, larger studies with serial estimation of NSE are needed to establish these observations more firmly.Key Words: Glasgow coma scale, infarct volume, ischemic stroke, modified Rankin scale, neuron specific enolase     

Gender Differences in the Functional Recovery after Acute Stroke

Background and Purpose

PurposezzInterest in gender differences in the effects of acute stroke is growing worldwide. However, gender differences in functional recovery after acute stroke in the Korean population have yet to be evaluated. The aim of this investigation was to compare long-term functional outcomes between male and female after acute stroke.

Methods

Patients with acute stroke were enrolled prospectively between January 2005 and January 2009. Baseline characteristics, risk factors, stroke subtypes, time delay from onset to arrival at a hospital, active treatment, and stroke severity were compared between male and female. Differences in mortality and disability at discharge, and at 3 months and 1 year after stroke onset were also investigated. Functional disabilities were categorized into two groups: good outcome (score on modified Rankin scale ≤2) and poor outcome (score on modified Rankin scale >2).

Results

Among 1,055 patients with acute stroke, 575 were male (aged 64.83±11.98 years, mean±SD) and 480 were female (aged 70.09±13.02 years). There were no gender differences in mortality at 3 months and 1 year after stroke. The frequency of poor outcomes was higher in female patients than in male patients at discharge (39.8% versus 30.9%, respectively; p=0.003), the 3 months follow-up (32.3% versus 20.8%, respectively; p<0.001), and the 1 year follow-up (31.1% versus 18.7%, respectively; p=0.001). After adjusting for multiple confounding factors including age and stroke severity, the female gender persisted as a predictor of poor functional outcome at 3 months and 1 year after stroke.

Conclusions

Female patients have greater difficulty than male patients in recovering from a disabled state after acute stroke. Future studies should investigate the causes of this gender difference.     

Time course of inflammatory cytokines in acute ischemic stroke patients and their relation to inter-alfa trypsin inhibitor heavy chain 4 and outcome

Background:

Biomarker for prognosis of stroke is urgently needed for the management of acute ischemic stroke (AIS) patients.

Objective:

To evaluate the course of inflammatory cytokines in AIS patients and its comparison with inter-alfa trypsin inhibitor heavy chain 4 (ITIH4) and outcome after AIS.

Materials and Methods:

A panel of 12 inflammatory cytokines and ITIH4 were estimated in serial blood samples collected at admission, 24 h, 48 h, 72 h, 144 h and at discharge of AIS patients (n = 5).

Results:

Out of the 12 cytokines, only interleukin (IL)-2, tumor necrosis factor-alfa (TNF-α), IL-10, IL-6, IL-1B and IL-8 were in the measurable range of the kit (10 pg/mL). We found high IL-2 at admission, which decreased (P < 0.05) in the follow-up samples. TNF-α initially increases (P < 0.05) at 24 h followed by gradual decrease (P < 0.05) after 72 h. IL-10 decreases initially (P < 0.05) till 72 h as compared with its level at admission and then increases (P < 0.05) after 144 h. Similarly, ITIH4 was down-regulated in the early 72 h followed by further increase with improvement of the patient. ITIH4 correlates with IL-10 and computed tomography scan infarct volume. Serum IL-6, IL-1B and IL-8 increased in the AIS patients, but did not show any pattern.

Conclusions:

Serial measurement of IL-10, IL-2 and TNF-α and ITIH4 may be useful for the follow-up of clinical outcome after AIS.     

Effectiveness of mirror therapy on lower extremity motor recovery,balance and mobility in patients with acute stroke: A randomized sham-controlled pilot trial

Objective:

To evaluate the effectiveness of mirror therapy on lower extremity motor recovery, balance and mobility in patients with acute stroke.

Design:

A randomized, sham-controlled, assessor blinded, pilot trial.

Setting:

Inpatient stroke rehabilitation unit.

Subjects:

First time onset of stroke with mean post-stroke duration of 6.41 days, able to respond to verbal instructions, and Brunnstrom recovery stage 2 and above were enrolled.

Intervention:

Mirror therapy group performed 30 minutes of functional synergy movements of non-paretic lower extremity, whereas control group underwent sham therapy with similar duration. In addition, both groups were administered with conventional stroke rehabilitation regime. Altogether 90 minutes therapy session per day, six days a week, for two weeks duration was administered to both groups.

Outcome Measures:

Lower extremity motor subscale of Fugl Meyer Assessment (FMA), Brunnel Balance Assessment (BBA) and Functional Ambulation Categories (FAC).

Results:

Amongst the 22 patients included, equal number of patients participated in mirror group (N = 11) and control group (N = 11). Baseline variables were similar in both groups, except for Brunnstrom recovery stage. There was no statistical difference between groups, except for FAC. (FMA: P = 0.894; BBA: P = 0.358; FAC: P = 0.02). Significance was set at P < 0.05.

Conclusion:

Administration of mirror therapy early after stroke is not superior to conventional treatment in improving lower limb motor recovery and balance, except for improvement in mobility.Key Words: Acute stroke, balance, mobility, mirror therapy, motor recovery     

Pattern and risk factors of stroke in the young among stroke patients admitted in medical college hospital,Thiruvananthapuram

Background:

Stroke in the young is particularly tragic because of its potential to create a long-term burden on the victims, their families, and the community. There had been relatively few studies on young stroke in Kerala''s socio-economic setup, that too encapsulating the mentioned apparently relevant dimensions of stroke in the young.

Objective:

To study the prevalence, patterns and risk factors of young stroke.

Settings and Design:

A cross-sectional study with case control comparison at Government Medical College Hospital, Thiruvananthapuram, Kerala, India.

Materials and and Methods:

Total 100 stroke patients were identified over a period of 2 months, and data were collected on the basis of questionnaire developed for the purpose.

Results:

Of 100 stroke patients, 15 had stroke in the young, among which 9 (60%) had ishaemic stroke. Hypertension was the most common risk factor. Smoking, alcohol, atrial fibrillation, and hyperlipidemia were found to be more common in cases (young stroke) when compared with controls. Alcohol use and atrial fibrillation were significantly higher among young stroke patients. Physical inactivity was significantly lesser in those with stroke in the young than elderly. Atrial fibrillation emerged as an independent risk factor of stroke in the young with adjusted odds ratio of 6.18 (1.31-29.21).

Conclusion:

In all, 15% of total stroke occurred in young adults <50 years. The proportion of hemorrhagic stroke in young adults is higher than in elderly. Atrial fibrillation is identified as an independent risk factor of stroke in the young. Compared with stroke in elderly alcohol use, smoking, hyperlipidemia, and cardiac diseases, which are known risk factors, are higher in young stroke.     

Clinicoanatomical correlation in stroke related aphasia

Context:

With advances in neuroimaging, traditional views regarding the clinicoanatomic correlation in stroke patients with aphasia are being challenged and it has been observed that lesions at a given cortical or subcortical site may manifest with different aphasia profiles.

Aims:

To study as to whether there is a strict clinicoanatomical correlation between the type of aphasia and lesion site in patients with first ever stroke.

Settings and Design:

Observational study, based in a tertiary care center.

Materials and Methods:

Stroke patient''s ≥18 years of age were screened and those with first ever stroke and aphasia were subjected to a detailed stroke workup and language assessment using the Hindi version of Western Aphasia Battery (WAB). Statistical analysis was done with χ² test with Yates correction and Kruskal-Wallis test. The level of significance was set at P < 0.05.

Results:

Overall aphasia was detected in 27.9% of the 260 screened cases with stroke. Amongst 60 cases with first ever stroke and aphasia, the aphasia type was: Global (33.33%), Broca''s (28.3%), transcortical motor (13.33%), transcortical sensory (10%), Wernicke''s (8.33%), anomic (5%), and conduction (1.67%) aphasia. A definite correlation between the lesion site and the type of aphasia as per the traditional classification was observed in 35% cases only.

Conclusions:

No absolute correlation exists between the lesion site and the type of clinical aphasia syndrome in majority of the patients with cortical and subcortical stroke.     

Awareness of neurocysticercosis: A study from northwest India

Background:

Neurocysticercosis (NCC) is a common cause of epilepsy in developing countries. In order to plan and implement prevention programs, it is essential to study the awareness of NCC.

Objective:

To study the awareness of NCC among patients with NCC and compare with age- and gender-matched controls without NCC.

Setting and Design:

Hospital based case–control study.

Materials and Methods:

Two hundred and fourteen subjects were studied (109 NCC patients, and 105 age- and gender-matched controls without NCC). The participants were selected from neurology and medical wards of a tertiary referral hospital in northwest India. They were interviewed by trained medical interns using a questionnaire.

Results:

64.2% of the NCC patients and 19% of control group had heard about NCC (P < 0.001). Knowledge regarding organ affected by NCC in the NCC group was 61.4% and in the control group was 80% (P = 0.09). Only 12.9% of the NCC group and none in the control group identified tape worm as a causative agent for NCC (P = 0.092). Negative effects of NCC on marriage and social life were more often cited by the NCC group but in the control group it was towards education (P = 0.004).

Conclusions:

The awareness of NCC was poor in both the groups. Educational programs are needed to improve the awareness about NCC among the patients and the public.     

Association of intercellular adhesion molecular-1 gene polymorphism in ischemic stroke patients

Background:

Ischemic stroke (IS) is a prevalent disease causing a body disability, the third leading cause of death in Taiwan. It shows that the level of intercellular adhesion molecular-1 (ICAM-1) in IS patients is higher than control subjects.

Objective:

This study is to investigate the possible association of ICAM-1 (G1548A) polymorphism in IS patients.

Materials and Methods:

A total of 646 subjects were enrolled in this study, including 312 IS patients, and 334 controls without a history of symptomatic IS. The ICAM-1 (G1548A) polymorphism was analyzed by polymerase chain reaction and restriction fragment length polymorphism. Clinical factors were also determined.

Results:

The frequencies of the ICAM-1 (G1548A) polymorphism for G/G, G/A, and A/A were 74.8%, 23.9%, and 0.3%, respectively, in healthy controls, and 62.8%, 32.1%, and 5.1%, respectively, in patients. The frequency of the ICAM-1 (G1548A) A allele (21.2% versus 13.2%, respectively; P = 0.007) and the carriers of the ICAM-1 (G1548A) A allele (37.2% versus 25.2%; P = 0.019, OR 1.76, 95% CI 1.1-2.83) are great in IS patients compared with healthy controls. There is a higher risk of IS associated with homozygosity for the ICAM-1 (G1548A) A allele (AA genotype) compared with the control population (5.1% vs. 0.3%, respectively, P = 0.04; OR 5.1, 95% CI 1.19-21.66). We also observed both hypertension and diabetes has shown a positive association with IS.

Conclusions:

The ICAM-1 (G1548A) polymorphism was associated with independent risk factor for the development of IS.     

Intra-rater reliability of the modified Tardieu scale to quantify spasticity in elbow flexors and ankle plantar flexors in adult stroke subjects

Objectives:

The purpose of this study was to investigate Iintra-rater reliability of the Modified Tardieu Scale (MTS) in elbow flexors and ankle plantar flexors in adult subjects with stroke.

Materials and Methods:

A total of 91 subjects with stroke participated in this test-retest study. Intra-rater reliability of the MTS was investigated by a qualified and trained physiotherapist for elbow flexors and ankle plantar flexors in two sessions. A rater was one who performed the procedure and an observer only records the angles so that the rater was blinded to findings. Outcome measures in this study were measurable components of MTS, which are angle of muscle reaction (R1), passive range of motion (R2), dynamic component (R2-R1), and quality of muscle reaction (grade 0 – 4) termed as MTS score.

Results:

Intra-rater reliability of MTS was very good for R1, R2, R2-R1, and MTS score (ICC > 0.85, P<0.0001) across two sessions in elbow flexors and ankle plantar flexors.

Conclusion:

MTS is a reliable clinical tool for measurement of spasticity in the elbow flexors and ankle plantar flexors in adult subjects with stroke.     

Correlation of continuous electroencephalogram with clinical assessment scores in acute stroke patients

Objective To compare electroencephalogram (EEG) symmetry values between stroke patients with different 28-day outcomes, and to assess correlations between clinical characteristics and 28-day outcomes. Methods Twenty-two patients presenting with acute ischemic stroke and persistent neurological deficits at EEG recording were incrementally included. At 28 days after admission, the modified Rankin scale (mRS) was used to evaluate the outcomes, based on which the patients were divided into two a posteriori groups, mRS = 6 and mRS <6. Student’s t-test was used to compare these two groups in terms of brain symmetry index (BSI), National Institutes of Health stroke scale (NIHSS), Glasgow coma scale (GCS) and acute physiology and chronic health evaluation II (APACHE II) assessed at admission. Then EEG parameters, NIHSS, GCS and APACHE II were correlated with the mRS. Results There were significant differences in BSI, NIHSS, GCS, and APACHE II between the two groups. Survivors had lower BSI, NIHSS and APACHE II, and higher GCS values, compared with patients who died within 28 days after admission. Besides, BSI at admission had a positive correlation with mRS at 28 days (r = 0.441, P = 0.040). NIHSS and APACHE II were also correlated with mRS (r = 0.736, P <0.000 1; r = 0.667, P = 0.001, respectively). GCS at admission had a negative correlation with mRS (r = 0.656, P = 0.001). Conclusion A higher BSI predicts a poorer short-term prognosis for stroke patients. Acute EEG monitoring may be of prognostic value for 28-day outcomes. The early prediction of functional outcomes after stroke may enhance clinical management and minimize short-term mortality.     

Study to assess the effectiveness of modified constraint-induced movement therapy in stroke subjects: A randomized controlled trial

Background and Purpose:

The purpose of this study was to assess the effectiveness of modified constraint induced movement therapy (m-CIMT) in stroke subjects.

Materials and Methods:

A total of forty sub-acute stroke subjects were randomly assigned to either a m-CIMT (n = 20) or in a control group (n = 20). The m-CIMT group (14 men, 6 women; mean age = 55.2 years) consisted of structured 2 h therapy sessions emphasizing affected arm use, occurring 5 times/week for 2 weeks. A mitt was used to restrain the unaffected arm for 10 h/day for 2 week. The control group (11 men, 9 women; mean age = 56.4 years) consisted of conventional rehabilitation for time-matched exercise program. The outcome measures were evaluated at pre- and post-intervention by using the Wolf Motor Function Test (WMFT) and Fugl-Meyer assessment (FMA) of motor recovery after stroke.

Results:

After intervention significant effects were observed in m-CIMT group on WMFT (pre-test and post-test score was 28.04 ± 6.58, 13.59 ± 2.86; P =0.003). Similarly on FMA (pre- and post-test score was 31.15 ± 6.37, 55.7 ± 6.4; P = 0.00).

Conclusion:

There is a significant improvem ent in upper extremity function so it indicates that m-CIMT is effective in improving the motor function of the affected arm in stroke subjects. However, its long-term effect has not proved since there was no follow-up after intervention.     

External validation of the SEDAN score: The real world practice of a single center

Background and Purpose:

Symptomatic intracranial hemorrhage (sICH) is the most serious adverse event in stroke patients who received i.v. rt-PA and is usually associated with poor outcomes. The SEDAN score is built up to predict sICH. We aim to externally validate the SEDAN score in Thai patients from single center in the real world practice.

Materials and Methods:

The SEDAN score of stroke patients treated with intravenous rt-PA at Thammasat University Hospital from January 2010 to June 2012 was calculated. Patients were divided into three groups including symptomatic intracranial hemorrhage (sICH), asymptomatic intracranial hemorrhage (AsICH) and no intracerebral hemorrhage (NoICH). The primary outcome of analyses was sICH. Each parameter of the SEDAN score and correlation between score and sICH were analyzed with univariate and multivariate model.

Results:

295 patients (18.6% of stroke admission) were treated with i.v. rt-PA. 13 patients (4.4%) had sICH and 31 patients (10.4%) had AsICH. Baseline blood sugar >12 mmol/l, early infarction, hyperdense cerebral artery, age >75 years-old and NIHSS ≥10(SEDAN) were associated with sICH by univariate analysis (P value = 0.018, <0.001, <0.001, 0.002 and 0.027 respectively). The rate of sICH occurrence was increased in accordance with the increasing of the SEDAN score. By multivariate analysis, odds ratio of baseline blood sugar >12 mmol/l, early infarction, hyperdense cerebral artery, age >75 years-old and NIHSS ≥10 were 1.248, 2.503, 1.107, 1.532 and 1.263 respectively.

Conclusions:

The SEDAN score was practical to use and predictive in Thai population. Each parameter of the SEDAN score was an independent risk factor for sICH after treatment with i.v. rt-PA.     

Hyperacute thrombolysis with recombinant tissue plasminogen activator of acute ischemic stroke: Feasibility and effectivity from an Indian perspective

Given the constraints of resources, thrombolysis for acute ischemic stroke (AIS) is under evaluation in developing countries like India, especially in areas such as western Utter Pradesh, where it is overly crowded and there is poor affordability.

Aim:

This study was done to evaluate recombinant tissue plasminogen activator r-tpa in acute ischemic stroke in hyper acute phase, in selected patients of western Utter Pradesh, in terms of feasibility and effectivity.

Design:

Open, non randomized study.

Materials and Methods:

Thirty two patients were classified using Trial of ORG 10172 in Acute Stroke treatment (TOAST) criteria (large artery atherosclerotic = 8; cardio embolic = 6; small vessel occlusion = 14; other determined etiology = 2; undetermined etiology = 2). The mean time to reach the hospital was 2 h (1.15-3.0), the mean door to CT scan 20 min (10-40) and door to r-tpa injection was 30 min (24-68). The National Institute of Health Stroke Scale (NIHSS) scores ranged from 11-22 (mean 15.5 +2.7). The dose of r-tpa administered was 0.9 mg/kg.

Results:

Twenty one patients (65.6%) showed significant improvement on the NIHSS score, at 48 h (4 points). (Mean change = 10; range = 4-17). At one month, 25 (78%) recorded improvement on the Barthel index (mean change = 45%). One developed frontal lobe hemorrhage and another developed recurrent stroke; one died of aspiration; and four showed no improvement. Modified Rankin score (m RS) was administered at the end of three months to 28 patients (90%); however, the rest could not be directly observed. The average modified Rankin Score was 1.2 (0-2).

Conclusions:

Hyperacute thrombolysis was found feasible and effective in selected patients with AIS from western Utter Pradesh and who had poor affordability.