Experiences with carotid endarterectomy at Sree Chitra Tirunal Institute

Background:

Atherosclerotic carotid artery disease poses a grave threat to cerebral circulation, leading to a stroke with its devastating sequelae, if left untreated. Carotid endarterectomy has a proven track record with compelling evidence in stroke prevention.

Objectives:

a) To confirm that carotid endarterectomy (CEA) is safe and effective in preventing stroke at both short and long term. b) to demonstrate long term patency of internal carotid artery when arteriotomy repair is performed using autologous saphenous vein patch.

Materials and Methods:

During ten years, from September 1997 to February 2008, thirty nine patients who underwent consecutive carotid endarterectomy at our institute, form the basis of this report. Their age ranged from thirty to seventy eight years, with a mean age of 56. There were four women in this cohort. Thirty seven patients were symptomatic with >70% stenosis and two were asymptomatic with >80% stenosis, incidentally detected. Imaging included Duplex scan and MRA for carotid territory and brain, and non-invasive cardiac assessment. Co-morbidities included smoking, hypertension, diabetes, and coronary artery disease. Carotid Endarterectomy was performed under general anaesthesia, using carotid shunt and vein patch arteriotomy repair.

Results:

All the patients made satisfactory recovery, without major adverse cerebral events in this series. Morbidities included Transient Ischemic Attack (TIA) in two, needing only medications in one, and carotid stenting in the other. Minor morbidities included neck hematoma in two and transient hypoglossal paresis in three patients. Yearly follow-up included duplex scan assessment for all the patients. Two patients died of contralateral stroke, two of myocardial events and two were lost to follow up. Thirty three patients are well and free of the disease during the follow up of three to 120 months.

Conclusion:

Carotid endarterectomy provided near total freedom from adverse cerebral events and its catastrophic sequelae, leading to excellent outcome, both short as well as long term.     

Correlation of intracranial atherosclerosis with carotid stenosis in ischemic stroke patients

Introduction:

Carotid stenosis is a major risk factor for ischemic stroke. However, the effect of carotid stenosis on the site of stroke is still under investigation.

Aims:

This study aimed to elucidate how the presence of carotid stenosis influenced the pattern of stroke and also how it interacted with other risk factors for stroke.

Materials and Methods:

Thirty-eight patients with ischemic stroke were included in this study and were investigated with carotid artery Doppler and magnetic resonance angiography for carotid stenosis and intracranial stenosis in the circle of Willis, respectively. Other known risk factors of stroke were also studied in and compared between the subgroups with and without carotid stenosis.

Results:

In patients without carotid stenosis, anterior cerebral artery was the commonest site of stenosis. In patients with carotid stenosis, middle cerebral artery was the commonest site of stenosis. Overall, middle cerebral artery was the commonest territory of stroke. Patients with hypertension, diabetes and history of smoking had preferential stenosis of the anterior cerebral artery.     

Urgent Recanalization with Stenting for Severe Intracranial Atherosclerosis after Transient Ischemic Attack or Minor Stroke

Objective

Stenting of symptomatic intracranial stenosis has recently become an alternative treatment modality. However, urgent intracranial stenting in patients with intracranial stenosis following a transient ischemic attack (TIA) or minor stroke is open to dispute. We sought to assess the feasibility, safety, and effectiveness of urgent intracranial stenting for severe stenosis (>70%) in TIA or minor stroke patients.

Methods

Between June 2009 and October 2010, stent-assisted angioplasty by using a balloon-expandable coronary stent for intracranial severe stenosis (>70%) was performed in 7 patients after TIA and 5 patients after minor stroke (14 stenotic lesions). Technical success rates, complications, angiographic findings, and clinical outcomes were retrospectively analyzed.

Results

Stenting was successful in all 12 patients. The mean time from symptom onset to stenting was 2.1 days (1-8 days). Post-procedural angiography showed restoration to a normal luminal diameter in all patients. In-stent thrombosis occurred in one patient (n=1, 8.3%), and was lysed with abciximab. No device-related complications, such as perforations or dissections at the target arteries or intracranial hemorrhaging, occurred in any patient. The mortality rate was 0%. No patient had an ischemic event over the mean follow-up period of 12.5 months (range, 7-21 months), and follow-up angiography (n=7) revealed no significant in-stent restenosis (>50%).

Conclusion

Urgent recanalization with stenting is feasible, safe, and effective in patients with TIA or acute minor stroke with intracranial stenosis of ≥70%.     

Early outcomes after carotid angioplasty with stenting performed by neurologists

Aims:

To evaluate the results of carotid artery angioplasty and stenting (CAS) in treating extracranial carotid artery stenosis performed by neurologists in our center and compare the results with other large published series.

Materials and Methods:

Data for all patients who underwent CAS from January 2003 through November 2007, was retrieved from the Nanjing Stroke Registry. Perioperative and post-procedural complications within 30 days following stenting were analyzed and compared with that from other series. A total number of 75 patients were enrolled, with a mean age of 65.9 ± 8.8 years, and 64 (85.3%) of them were male.

Results:

Procedural success was achieved in 74 patients (98.7%). Pre-treatment stenosis was 73.8 ± 14.9 and post-treatment residual stenosis was less than 10%. Thirty-four patients (45.3%) had bilateral carotid artery disease and seven (9.3%) had tandem stenosis. The neurological complication rate was 3.9% (one major and two minor strokes). Bradycardia in four (5.3%) and hypotension in 13 (17.3%) were observed during procedures. Using the Fischer’s exact t test, the complication rate compared with the large published series did not reveal any statistically significant difference (P > 0.05).

Conclusions:

We conclude that neurologists, with adequate training, can develop and add this technical skill to the existing cognitive skill of vascular neurology and safely perform stenting.     

The Clinical Outcomes of 75 Consecutive Patients with Cervical Carotid Artery Stenosis Treated by Carotid Artery Stenting

Objective

The purpose of this study was to analyze the clinical outcome of 75 consecutive patients with cervical carotid artery stenosis and who were treated by carotid artery stenting (CAS) only.

Methods

From February 2003 to June 2008, there were 78 stents placed in 75 symptomatic patients (mean age : 67.3 years); 69 patients had carotid stenosis ≥70%, and 6 patients had asymptomatic stenosis ≥80%. No carotid endarterectomy (CEA) was performed during the same period. The patients were clinically followed-up for a mean of 20.1 months.

Results

The procedures were technically successful in all cases. Three (3.8%) patients had procedure-related complications. During the 30-day postprocedural period, there were no restenosis or major stroke. Minor stroke was noticed in 3 (3.8%) patients and 1 (1.3%) of the 75 patients suddenly expired 2 days after discharge. There were no new neurological symptoms that developed during the clinical follow-up period. The results of our series were not inferior to those the previously published in CAS studies, and in fact they were better.

Conclusion

Our results suggest that CAS may be safe and useful for the treatment of cervical carotid artery stenosis when it is used as the first line treatment in those institutions that lack enough experience with CEA.     

Asymptomatic Carotid Stenosis: Intervention or Best Medical Therapy?

Purpose of Review

Provide a current overview regarding the optimal strategy for managing patients with asymptomatic carotid artery stenosis.

Recent Findings

Carotid endarterectomy (CEA) and carotid artery stenting (CAS) reduce long-term stroke risk in asymptomatic patients. However, CAS is associated with a higher risk of peri-procedural stroke. Improvements in best medical therapy (BMT) have renewed uncertainty regarding the extent to which results from older randomised controlled trials (RCTs) comparing outcomes following carotid intervention can be generalised to modern medical practise.

Summary

‘Average surgical risk’ patients with an asymptomatic carotid artery stenosis of 60–99% and increased risk of late stroke should be considered for either CEA or CAS. In patients deemed ‘high risk’ for surgery, CAS is indicated. Use of an anti-platelet, anti-hypertensive and statin, with strict glycaemic control, is recommended. Results from ongoing large, multicentre RCTs comparing CEA, CAS and BMT will provide clarity regarding the optimal management of patients with asymptomatic carotid artery stenosis.

     

Prevalence and association of lifestyle factors with extracranial carotid atherosclerosis in non-cardioembolic anterior circulation strokes in adult males less than 50 years: One year cross-sectional study

Background:

Data is scarce on prevalence of extracranial carotid atherosclerosis (ECA) in strokes <50 years and its association with lifestyle factors.

Objective:

Study role of (a) ECA in non-cardio-embolic anterior circulation young strokes, and (b) smoking and alcohol in ECA.

Materials and Methods:

Cardiovascular risk factors and evidence of ECA on carotid doppler ultrasound (CDUS) was evaluated in an one-year preliminary cross-sectional study of consecutive strokes between 20 years and 49 years. Females were excluded.

Results:

There were 46 male strokes (mean age 38.26 yrs), 17.39% had hypertension, 2.23% had coronary artery disease; none was diabetic. Tobacco users and alcohol consumers were 24/46 (52.17%) cases each. ECA was found in 14/46 (30.44%) cases. Seven of these 14 (50%) i.e., 7/46 cases (15.21%) had carotid occlusion, four had <50%, three had >70% stenosis. ‘Smoking and smokeless tobacco use’ was found in 71.42% (10/14) symptomatic carotid lesions compared to 43.75% (14/32) strokes without carotid lesions. Prevalence odds ratio for tobacco use and ECA was 3.21 (95% CI: 0.83-12.44) while that of alcohol and ECA was 1.33 (95% CI: 0.38-4.72).

Conclusion:

Prevalence of ECA in strokes <50 years was high due to lifestyle factors which predispose to atherosclerosis at younger age.Key Words: Alcohol, extracranial carotid atherosclerosis, lifestyle factors, smoking, young stroke     

Diagnostic value of somatosensory evoked potential changes during carotid endarterectomy for 30-day perioperative stroke

Objectives

Somatosensory evoked potentials (SSEPs) have proven useful as an intraoperative modality to predict perioperative stroke during carotid endarterectomy (CEA). However, the predictive value of SSEPs for predicting stroke 30?days postoperatively remains unclear. The primary objective is to evaluate the efficacy of intraoperative SSEP change in predicting the risk of stroke in the postoperative period beyond 24?h but within 30?days. Our secondary aim is to evaluate the predictive value of each subcategory of SSEP change.

Effects of cilostazol on the progression and regression of symptomatic intracranial artery stenosis:it reduces the risk of ischemic stroke

OBJECTIVE: To assess the efficacy and safety of cilostazol on the progression and regression of symptomatic intracranial artery stenosis.DATA RETRIVAL: We searched the main databases for eligible trials including Medline(from 1966 to June 2014), Embase(from 1980 to June 2014), Cochrane Library(Issue 6, 2014), Chinese National Knowledge Infrastructure(from 1995 to June 2014), Current Controlled Trials(http://controlled-trials.com), Clinical Trials.gov(http://clinicaltrials.gov), and Chinese Clinical Trial Registry(http://www.chictr.org). All studies regarding prevention and treatment of symptomatic intracranial arterial stenosis by cilostazol were collected. The Mesh or text keywords were the English words: "cilostazol, phosphodiesterase 3 inhibitor, atherosclerosis, and ischemic stroke." No restrictions were put on publications or publication language.SELECTION CRITERIA: Grade A or B randomized controlled trials were selected according to the quality of evaluation criteria from the Cochrane Collaboration, in which cilostazol and aspirin were used to evaluate the effects of cilostazol in the treatment of patients with symptomatic intracranial artery stenosis. The quality of study methodology was evaluated based on criteria described in Cochrane Reviewer's Handbook 5.0.1. Rev Man 5.2 software was used for data analysis.MAIN OUTCOME MEASURES: Clinical efficacy and safety of cilostazol in stopping progression and promoting regression of symptomatic intracranial artery stenosis were measured by magnetic resonance angiography and transcranial Doppler.RESULTS: Two randomized controlled trials with a total of 203 patients were included in this study. The results showed that while cilostazol was associated with a significantly reduced progression of intracranial artery stenosis(OR = 0.21, 95%CI: 0.09–0.47, P 0.01), it had no beneficial effect on symptom regression(OR = 1.42, 95%CI: 0.80–2.51, P = 0.24). During the follow-up period, although some adverse effects developed, including headache, gastrointestinal disturbance, and dizziness, incidences of bleeding were lower than in aspirin-treated patients.CONCLUSION: Cilostazol may prevent the progression of symptomatic intracranial artery stenosis, which could reduce the incidence of ischemic stroke.     

Carotid Artery Stenosis: Medical Therapy,Surgery, and Stenting

Purpose of Review

The purpose of the study was to update the recent information pertaining to carotid artery stenosis risk stratification and treatment.

Recent Findings

Current decision-making related to carotid artery stenosis is based on clinical trials that are outdated. Medical therapy has improved considerably in the past two decades, and this has reduced the stroke rate for both symptomatic and asymptomatic carotid stenoses. In recent community-based studies, the stroke risk with asymptomatic stenosis has been < 1% per year. For asymptomatic carotid stenosis, new trials such as CREST 2 and ECST 2 will determine whether revascularization has any benefit beyond aggressive medical management. For symptomatic patients, carotid endarterectomy is associated with a lower periprocedural stroke rate compared to carotid stenting. Age greater than 70 years is also associated with an increased risk for carotid stenting patients.

Summary

Clinicians should consider a variety of clinical and radiologic variables in reaching treatment decisions for patients with carotid stenosis. Both symptomatic and asymptomatic patients should receive optimal medical therapy.

     

Influence of Contralateral Carotid Occlusion on Outcomes After Carotid Endarterectomy: A Meta-Analysis

Background

There is a controversy about whether the contralateral carotid occlusion (CO) in patients undergoing carotid endarterectomy (CEA) is associated with worse early and long-term outcomes. The aim of this systematic review and meta-analysis was to investigate the impact of CO on outcomes after CEA.

Complementarity between 18F-FDG PET/CT and Ultrasonography or Angiography in Carotid Plaque Characterization

Background and Purpose

To estimate clinical roles of 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) versus angiography and ultrasonography in carotid plaque characterization.

Methods

We characterized two groups of patients with recently (<1 month) symptomatic (n=14; age=71.8±8.6 years, mean±SD) or chronic (n=13, age=68.9±9.0 years) carotid stenosis using a battery of imaging tests: diffusion magnetic resonance (MR) imaging, MR or transfemoral angiography, duplex ultrasonography (DUS), and carotid FDG-PET/computed tomography.

Results

The degree of angiographic stenosis was greater in patients with recently symptomatic carotid plaques (67.5±21.5%) than in patients with chronic carotid plaques (32.4±26.8%, p=0.001). Despite the significant difference in the degree of stenosis, lesional maximum standardized uptake values (maxSUVs) on the carotid FDG-PET did not differ between the recently symptomatic (1.56±0.53) and chronic (1.56±0.34, p=0.65) stenosis groups. However, lesional-to-contralesional maxSUV ratios were higher in the recently symptomatic stenosis group (113±17%) than in the chronic stenosis group (98±10%, p=0.017). The grayscale median value of the lesional DUS echodensities was lower in the recently symptomatic stenosis group (28.2±10.0, n=9) than in the chronic stenosis group (53.9±14.0, n=8; p=0.001). Overall, there were no significant correlations between angiographic stenosis, DUS echodensity, and FDG-PET maxSUV. Case/subgroup analyses suggested complementarity between imaging modalities.

Conclusions

There were both correspondences and discrepancies between the carotid FDG-PET images and DUS or angiography data. Further studies are required to determine whether FDG-PET could improve the clinical management of carotid stenosis.     

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.     

Association between Ischemic Stroke and Vascular Shear Stress in the Carotid Artery

Background and Purpose

Vascular shear stress is essential for maintaining the morphology and function of endothelial cells. We hypothesized that shear stress in the internal carotid artery (ICA) may differ between patients with ischemic stroke and healthy control subjects.

Methods

ICA shear stress was calculated in 143 controls and 122 patients with ischemic stroke who had a normal ICA or an ICA with <50% stenosis. The stroke group included patients who presented with a first-ever or recurrent ischemic stroke but excluded cardioembolic stroke and uncertain etiologies. Of the 122 patients, 107 (87.7%) and 15 (12.3%) patients were categorized as first-ever and recurrent stroke, respectively.

Results

Carotid diameters were significantly larger, and both peak-systolic and end-diastolic velocities were significantly lower in patients with ischemic stroke than in controls (all p values <0.05). Mean values of peak-systolic and end-diastolic shear stress in both ICAs were significantly lower in patients with ischemic stroke in models that adjusted for age, sex, and vascular risk factors (p for trend <0.05). The ICA shear stress was lowest in patients with recurrent stroke or the subtype of small-vessel occlusion. Higher peak-systolic and end-diastolic shear stresses in both ICAs were independently and negatively associated with ischemic stroke after adjusting for potential confounders (all p values <0.05).

Conclusions

ICA shear stresses were significantly lower in patients with ischemic stroke than in control subjects. Future studies should attempt to define the causal relationship between carotid arterial shear stress and ischemic stroke.     

Cognitive Dysfunction in 16 Patients with Carotid Stenosis: Detailed Neuropsychological Findings

Background

Impairment of cognitive function is often present in patients with carotid artery stenosis but the details of this dysfunction have rarely been reported. Our purpose was to elucidate the cognitive dysfunction in patients with unilateral severe carotid stenosis using comprehensive neuropsychological testing, and also to identify the specific underlying clinical and radiological factors.

Methods

We analyzed the results of neuropsychological testing, the clinical history, and MR findings in 16 consecutive patients with angiographically proven severe (70-99%) stenosis of the extra cranial internal carotid artery (ICA). Cognitive functions were examined using the Seoul Neuropsychological Screening Battery and the Neglect Battery. We excluded patients with cortical infarction and those with contra lateral ICA occlusion or severe stenosis.

Results

Our comprehensive neuropsychological testing revealed obvious cognitive deficits in all patients with unilateral severe ICA stenosis, the most common being frontal executive impairment. The mean cognitive score on the memory test was also significantly lower in patients with symptomatic ICA stenosis than in asymptomatic patients (29.33±10.98, mean±SD, p < 0.05). The total score on the global cognitive test was significantly lower in patients with an ischemic lesion on MRI than in no lesion patients (113.23±34.78, p < 0.05). The presence of symptoms related to the ICA stenosis was related to cognitive dysfunction even when there were no ischemic lesions on MRI. SPECT revealed ipsilateral cortical hypoperfusion in 9 of 12 patients (75%).

Conclusions

Cognitive deficits are common in patients with unilateral severe ICA stenosis. Our findings suggest that an additional mechanism beyond the structural lesion such as chronic hypoperfusion may affect cognitive function in patients with high-grade ICA stenosis.     

Relation of glycated hemoglobin with carotid atherosclerosis in ischemic stroke patients: An observational study in Indian population

Context:

Glycated hemoglobin A₁c(HbA₁c) indicates long-term uncontrolled hyperglycemia in the body, which in diabetic patients leads to various vascular complications as a part of generalized atherosclerosis culminating ultimately into ischemic stroke.

Aims:

Study aims to show the association between marker of uncontrolled long-term hyperglycemia HbA₁c and marker of atherosclerosis (Carotid intima media thickness [CIMT] and carotid plaque) in ischemic stroke patients.

Subjects and Methods:

Carotid sonography using high resolution 7.5 MHz sonography technique was done in each patient to find the occurrence of increased CIMT and presence of plaque according to Mannheim CIMT Consensus (2004-2006). Levels of HbA₁c measured in blood in both diabetic and non-diabetic patients and a comparison made between them. Finally an association sought between HbA₁c levels with CIMT and plaque.

Results:

The average value of HbA₁c of this cohort was 7.51 ± 1.75% with higher values in diabetic patients (9.29 ± 1.73%). The patients with high CIMT (>0.8 mm) had higher values of HbA₁c then that of normal CIMT patients and this was nearly significantly (P = 0.06). However, HbA₁c levels of blood were significantly associated with stroke patients with presence of carotid arteries plaque (P = 0.008).

Conclusions:

Prediction of future risk and prevention strategies for ischemic stroke could be formulated by utilizing HbA₁c levels in both diabetic and non-diabetic population.     

Preoperative Coronary Stenosis Is a Determinant of Early Vascular Outcome after Carotid Endarterectomy

Background and Purpose

The benefit of carotid endarterectomy (CEA) is directly influenced by the risk of perioperative adverse outcomes. However, patient-level risks and predictors including coronary stenosis are rarely evaluated, especially in Asian patients. The aim of this study was to determine the relationship between the vascular risk factors underlying CEA, including coronary stenosis, and postoperative outcome.

Methods

One hundred and fifty-three consecutive CEAs from our hospital records were included in this analysis. All patients underwent coronary computed tomography angiography before CEA. Data were analyzed to determine the vascular outcomes in patients with mild-to-moderate vs. severe coronary stenosis and high vs. standard operative risk, based on the criteria for high operative risk defined in the Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) trial. The vascular outcome was defined as the occurrence of postoperative (≤30 days) stroke, myocardial infarction (MI), or death.

Results

An adverse vascular outcome occurred in 8 of the 153 CEAs, with 6 strokes, 2 MIs, and 3 deaths. The vascular outcome differed significantly between the groups with mild-to-moderate and severe coronary stenosis (p=0.024), but not between the high- and standard-operative-risk groups (stratified according to operative risk as defined in the SAPPHIRE trial). Multivariable analysis adjusting for potent predictors revealed that severe coronary stenosis (odds ratio, 6.87; 95% confidence interval, 1.20-39.22) was a significant predictor of the early vascular outcome.

Conclusions

Severe coronary stenosis was identified herein as an independent predictor of an adverse early vascular outcome.     

Varied presentations of moyamoya disease in a tertiary care hospital of north-east India

Introduction:

Moyamoya disease is a chronic progressive cerebrovascular disorder, characterized by stenosis or occlusion of bilateral internal carotid arteries (ICAs), anterior cerebral arteries (ACAs) and middle cerebral arteries (MCAs), accompanied by a collateral network of vessels formed at the base of the brain. Ischemia and intracranial hemorrhage are the common typical manifestations. However moyamoya disease has been associated with atypical presentations like headache, seizures and involuntary movements. Although frequently reported from Asian countries like Japan, China and Korea, only few studies reported on clinical manifestations of moyamoya disease from India.

Objectives:

To study the varied presentations of moyamoya disease in a tertiary care hospital of north-east India.

Material and Methods:

Relevant investigations were done to rule out other causes of moyamoya syndrome.

Results:

We report 6 cases of moyamoya disease with varied presentations from a tertiary care referral government hospital. Case 1, 2 and 6 presented with alternating hemiparesis. Case 3 had amaurosis fugax. Case 4 had history suggestive of ischemic stroke and presented with hemichorea. Case 4 had focal seizure as the only manifestation. Cases 4 and 5 notably had stenosis of posterior cerebral artery (PCA) in addition to stenosis of bilateral ICAs, ACAs and MCAs.

Conclusion:

Owing to its low incidence in India, moyamoya disease is easily overlooked as a possible diagnosis. However, because of its progressive nature, it is imperative to diagnose this disease early and offer surgical treatment to the patients.     

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