Relationship of Barthel Index and its Short Form with the Modified Rankin Scale in acute stroke patients

BackgroundModified Rankin Scale and Barthel Index are the most common scales for assessing stroke outcomes in clinical practice and trials. Concordance between the Barthel Index scores and the modified Rankin Scale grades is important to define favorable outcome in clinical practice and stroke trials consistently. The purpose of this study was to examine the relationship between the scores of Barthel Index and 3-item Barthel Index Short Form with the modified Rankin Scale grades of acute stroke patients.MethodsBarthel Index, Barthel Index Short Form scores and modified Rankin Scale grades of 516 stroke patients were obtained from a follow-up study of the Longshi Scale in China. A study showed that the assignment of modified Rankin Scale grades to stroke patients was prone to misclassification. Therefore, the recorded modified Rankin Scale grades were compared with the Barthel Index scores of each patient to produce the adjusted modified Rankin Scale grades. Receiver operating characteristics curve analyses were performed to determine the optimal cutoff scores, respective sensitivities and specificities of Barthel Index and Barthel Index Short Form with the corresponding adjusted modified Rankin Scale grades ≤1, ≤2 and ≤3.FindingsAbout 44% of the recorded modified Rankin Scale grades of patients required adjustment. The optimal cutoff scores were ≥100 (sensitivity 100%; specificity 95.3%), ≥100 (sensitivity 98.1%; specificity 100%) and ≥75 (sensitivity 93.8%; specificity, 91.9%) for the Barthel Index and ≥40 (sensitivity 100%; specificity 78.9%), ≥40 (sensitivity 98.1%; specificity 82.8%), and ≥35 (sensitivity 99.3%; specificity, 91.6%) for the Barthel Index Short Form corresponding to the adjusted modified Rankin Scale grade ≤1, ≤2, and ≤3 respectively. The areas under the receiver operating characteristic curves were nearly all above 0.9.ConclusionsThe optimal cutoff scores of Barthel Index and Barthel Index Short Form corresponding to the modified Rankin Scale grades ≤1, ≤2 and ≤3 were recommended to be ≥100 and ≥40, ≥100 and ≥40, and ≥75 and ≥35 respectively for determining the favorable and unfavorable outcome of stroke patients within three months of onset in clinical practice and trials.     

Primary stroke unit treatment followed by very early carotid endarterectomy for carotid artery stenosis after acute stroke

BACKGROUND: Although it is recognized that carotid endarterectomy (CEA) is the treatment of choice in symptomatic internal carotid artery (ICA) stenosis, in the past, very early CEA has been shown to carry substantial risks. We assessed an interdisciplinary concept of very early CEA in patients with high-grade (>70%) symptomatic ICA stenosis at a single center. PATIENTS AND METHODS: The course of treatment and outcomes of patients who underwent CEA as early as possible after being referred to the stroke unit for symptoms of transient ischemic attack and stroke were prospectively evaluated, including the following parameters: age, severity of ischemia-related symptoms according to the modified Rankin scale, duration of symptoms until admission, multimodal imaging findings (color-coded duplex, cranial computed tomography, magnetic resonance imaging, positron emission tomography), duration until CEA, perioperative course and complications, as well as duration of in-hospital care. RESULTS: Fifty consecutive patients (median age 68 years, range 44-90) with clinical and imaging signs of transient ischemic attack (n = 19) or stroke (n = 31) were included from January 2000 until December 2004. All except 1 patient showed a preoperative Rankin < 4. There was a median time period of 6 h between the onset of symptoms and admission (range 1 h to 15 days) and a median duration of 4 days after admission until operation (range 1-21 days). Seven patients underwent CEA of the contralateral, severely stenosed ICA after symptomatic ipsilateral ICA occlusion. Four out of 5 patients who primarily underwent systemic thrombolysis recovered almost completely. Three patients (6%) experienced a clinical deterioration before surgery. In the majority of patients (43/50), CEA was performed under local anesthesia with selective shunt use which became necessary in 26%. Three patients (6%) had postoperative worsening due to new infarcts. In 2 cases, an intracerebral hemorrhage occurred, of which 1 remained asymptomatic. In 1 case, surgical revision was necessary because of an ICA thrombosis without permanent neurological decline. Patients were discharged after a median time of 14.5 days (range 4-44). CONCLUSIONS: After careful selection and preparation in a stroke unit, patients with acute stroke due to carotid stenosis can undergo very early CEA under local anesthesia with a perioperative risk comparable with the risk of later endarterectomy, therefore preventing very early stroke recurrences.     

Emergency Carotid Artery Stent Insertion for Acute ICA Occlusion

Objective

An effective intervention has not yet been established for patients with acute occlusion of the internal carotid artery (ICA). The aim of our study was to investigate the feasibility, safety, and efficacy of emergent stent placement of carotid artery to improve neurologic symptoms and clinical outcome.

Methods

Of 84 consecutive patients with severe ICA stenosis who were admitted to our institution from March 2006 to May 2009, 10 patients with acute ICA occlusion (11.9%) underwent emergency carotid artery stent placement. We reviewed their records for neurologic outcome using the National Institutes of Health Stroke Scale (NIHSS) score, before and at 7 days after stent placement; clinical outcome using the modified Rankin Scale score (mRS) and Glasgow Outcome Scale (GOS); frequency of procedure-related complications; and recurrence rate of ipsilateral ischemic stroke within 90 days.

Results

Carotid lesions were dilated completely in all patients. Median NIHSS scores before emergency stent placement and at 7 days were 16.6 and 6, respectively, showing significant improvement. Eight patients (80%) had favorable outcomes (mRS score 0-2 and GOS 4-5). Complications occurred in two patients (20%): stent insertion failed in one and an intracerebral hemorrhage occurred in the other. Ipsilateral ischemic stroke did not recur within 3 months.

Conclusion

Emergency carotid artery stent placement can improve the 7-day neurologic outcome and the 90-day clinical outcome in selected patients with acute cerebral infarction.     

Stroke recovery profile and the Modified Rankin assessment

BACKGROUND AND PURPOSE: The purpose of this study was to examine the relationship between the Modified Rankin Scale (MRS) and poststroke recovery in neurological deficits, activities of daily living (ADL), higher level of physical and social functioning and the patients' preference for health state. METHODS: Four hundred and fifty-nine participants in the Kansas City Stroke Study were prospectively assessed for measures of MRS, NIH Stroke Scale (NIHSS), Barthel ADL, SF-36 physical functioning, SF-36 social functioning, and Time Trade-Off (TTO). ANOVA and Bonferroni multiple comparisons were used to examine any differences in 3-month scores of NIHSS, Barthel ADL, SF-36 physical functioning, SF-36 social functioning and TTO between levels of the MRS. In addition, SF-36 physical functioning, SF-36 social functioning and TTO were characterized in patients who demonstrated improvement in global MRS outcome and also achieved a Barthel Index (BI) > or = 95 at 3 months after stroke. RESULTS: Two hundred and eighty patients (62%) shifted at least one grade in MRS from baseline to 3 months after stroke. Only 67 or 194 patients were considered to have a favorable outcome using MRS 0/1 or MRS 0/1/2, respectively, as criteria. Mean 3-month NIHSS and Barthel ADL scores were not significantly different between Rankin 0/1 and 2, but they were significantly different among Rankin 3, 4 and 5 (all p < 0.05). Mean 3-month scores of physical functioning and SF-36 social functioning were significantly different among Rankin 0/1, 2, 3 and 4 (all pairwise p < 0.05). Proportions of patients who achieved NIHSS < or = 1 or BI > or = 95 decreased as MRS grades worsened. In patients who showed improvement in MRS global outcome and also achieved BI > or = 95, mean scores on TTO were similar. CONCLUSIONS: Definition of favorable outcomes should include transition in the Modified Rankin score rather than MRS dichotomized as 0/1 or 0/1/2 because patients with transition in MRS scores have improvement in ADL, increased higher level of functioning and higher utility for health state.     

Initial Glasgow Coma Scale score predicts outcome following thrombolysis for posterior circulation stroke

BACKGROUND: Randomized trials of thrombolytic stroke treatment have either excluded patients with posterior circulation ischemia or used inclusion criteria making enrollment of these patients less likely. Consequently, there is less published information on thrombolytic therapy for posterior circulation stroke. OBJECTIVE: To determine effective thrombolytic treatment times for posterior circulation stroke and factors that might help predict clinical outcome. DESIGN: We describe our experience treating 21 consecutive patients with either intravenous or intra-arterial thrombolytic therapy for posterior circulation ischemic stroke between October 9, 1993, and February 19, 2001. MAIN OUTCOME MEASURES: National Institutes of Health Stroke Scale, Glasgow Coma Scale, and modified Rankin Scale scores were evaluated at baseline, and the modified Rankin Scale was measured 3 months after stroke, with a good outcome being a modified Rankin Scale score of 2 or less. RESULTS: Nine patients received intravenous therapy; 12 patients received intra-arterial therapy. The median National Institutes of Health Stroke Scale score at onset was 20 (range, 2-39), and the median Glasgow Coma Scale score was 9 (range, 3-15). Twelve patients were treated within 8 hours of symptom onset (range, 1 1/2 hours to 16 days). Nine patients (43%) had a modified Rankin Scale score of 2 or less at 3 months. The initial Glasgow Coma Scale score and treatment within 8 hours of symptom onset were each associated with good outcome, but the initial National Institutes of Health Stroke Scale score was not predictive. CONCLUSIONS: Thrombolytic therapy for posterior circulation stroke may be beneficial even when initiated 8 hours after symptom onset. Level of consciousness, as measured by Glasgow Coma Scale score, seems to be a more important predictor of outcome than the initial National Institutes of Health Stroke Scale score.     

11例颈动脉盗血综合征临床分析

目的分析11例颈动脉盗血综合征(CSS)的临床表现和影像学特点,评估其侧支循环建立与代偿方式及不同治疗方式的预后,为CSS的诊治提供依据。方法纳入2016年1月~2016年5月住院治疗的CSS患者11例。所有患者均进行颈部血管彩超、头颅CT血管造影(CTA)或磁共振血管成像(MRA)、数字剪影血管造影(DSA)等检查明确CSS诊断,进行侧支循环代偿评估。11例CSS患者中,4例患者行颈动脉内膜剥除术(CEA),5例行颈动脉内支架植入术(CAS),2例颈动脉闭塞患者药物保守治疗。对11例患者在治疗3个月、6个月和1年后进行随访,并评估缺血性脑血管事件及改良RANKIN量表评分(mRs)。结果 11例CSS患者中,单侧颈内动脉病变7例,双侧颈内动脉病变4例。临床表现为短暂性脑缺血发作7例,分水岭梗死3例,腔隙性脑梗死1例;其中后循环缺血7例,前循环缺血4例。DSA评估侧支循环建立单以一级侧支循环(11例)和二级侧支循环(4例)开放为主。ASITN评分大部分为3~4级。治疗后随访,有2例行CAS的患者出院后出现不同时期卒中样症状,4例行CEA的患者随访期内均未发生卒中。CAS和CEA术后3个月、6个月和1年的mRs评分均有不同程度改善。结论 CSS患者多发生于颈动脉狭窄严重患者,其侧支循环开放良好,以一、二级侧支循环开放为主,临床表现以后循环缺血症状多见。CAS及CEA能改善颈动脉狭窄,可能成为CSS的治疗手段。     

Performance of the ABCD and ABCD2 scores in TIA patients with carotid stenosis and atrial fibrillation

BACKGROUND: It has been suggested that scores for risk stratification of TIA patients might not identify patients with carotid stenosis or atrial fibrillation (AF) and that this might undermine the usefulness of such scores. METHODS: In patients with TIA in the Oxford Vascular Study, we studied the associations between ABCD and ABCD2 scores, the presence of > or =50% ipsilateral carotid stenosis or AF, and the risk of stroke at 7 days. RESULTS: Among 285 TIA patients (from 559 referrals of possible TIA), 69 (24.2%) had either > or =50% carotid stenosis (n = 29) or AF (n = 42), or both (n = 2). Although the ABCD and ABCD2 scores were highly predictive of stroke at 7 days (p < 0.0001), there was no clear relationship between either score and the prevalence of > or =50% carotid stenosis or AF. However, the scores did predict the 7-day stroke risk in patients with these pathologies: ABCD score (trend-p = 0.05); ABCD2 (trend-p = 0.03). Five of the 6 patients with AF or symptomatic stenosis who had a stroke within 7 days of their TIA had an ABCD score of > or =5 and all 6 had an ABCD2 score of > or =4. CONCLUSIONS: The ABCD and ABCD2 risk scores appear to identify patients with > or =50% carotid stenosis or AF who are at high risk of stroke. However, these findings should be interpreted with caution due to the small number of outcomes among these subgroups, and further validations are necessary.     

Functional outcome and quality of life after angiography and operation for unruptured intracranial aneurysms. On behalf of the MARS Study Group

OBJECTIVES: To assess outcome after elective treatment for unruptured intracranial aneurysms. METHODS: Of 193 consecutive patients with subarachnoid haemorrhage 626 first degree relatives (parents, siblings, children) were screened with magnetic resonance angiography. Subsequently, 18 relatives underwent elective angiography and operation. Outcome was assessed in terms of impairments (neurological examination), disabilities (Barthel index), handicaps (Rankin scale), and quality of life (sickness impact profile (SIP) and short form-36 (SF-36)) 3 months and 1 year after operation; it was compared with baseline measurements. RESULTS: Before angiography all patients had a normal neurological examination, optimal Barthel and Rankin scores, and a quality of life similar to that in a reference population. Three months postoperatively five patients (28%; 95% confidence interval (95% CI) 10-54%) had neurological impairments (one after angiography), two (11%; 95% CI 1-35%) had a decrease in Barthel index, and 15 (83%; 95% CI 59-96%) had suboptimal Rankin scores (none was dependent in daily living). Quality of life (SIP and SF-36) was reduced for most domains. After 1 year, five patients still had neurological impairments, all had an optimal Barthel index, and eight (47%; 95% CI 23-72%) had suboptimal Rankin scores. Quality of life returned to baseline levels for all SIP and most SF-36 domains. CONCLUSIONS: Treatment of unruptured aneurysms has a considerable short term negative impact on functional health and quality of life in most patients, despite the low rate of impairments. Outcome improves markedly but not completely within 1 year after operation.     

Serial study of apparent diffusion coefficient and anisotropy in patients with acute stroke.

BACKGROUND AND PURPOSE: We sought to characterize the evolution of apparent diffusion coefficient (ADC) and apparent diffusion anisotropy (ADA) in acute stroke and to evaluate their roles in predicting stroke evolution and outcome. METHODS: We studied 26 stroke patients acutely (<24 hours), subacutely (3 to 5 days), and at outcome (3 months). Ratios of the ADC and ADA within a region of infarction and the normal contralateral region were evaluated and compared with the Canadian Neurological Scale, Barthel Index, and Rankin Scale. RESULTS: Heterogeneity in ADC and ADA evolution was observed not only between patients but also within individual lesions. Three patterns of ADA evolution were observed: (1) elevated ADA acutely and subacutely; (2) elevated ADA acutely and reduced ADA subacutely; and (3) reduced ADA acutely and subacutely. At outcome, reduced ADA with elevated ADC was observed generally. We identified 3 phases of diffusion abnormalities: (1) reduced ADC and elevated ADA; (2) reduced ADC and reduced ADA; and (3) elevated ADC and reduced ADA. The ADA ratios within 12 hours correlated with the acute Canadian Neurological Scale (r=0.46, P=0.06), subacute Canadian Neurological Scale (r=0.55, P=0.02), outcome Barthel Index (r=0.62, P=0.01), and Rankin Scale (r=-0.77, P<0.0005) scores. CONCLUSIONS: Combined ADC and ADA provide differential patterns of stroke evolution. Early ADA changes reflect cellular alterations in acute ischemia and may provide a potential marker to predict stroke outcome.     

Predictive value of median-SSEP in early phase of stroke: a comparison in supratentorial infarction and hemorrhage

OBJECTIVE: To compare the prognostic value of median somatosensory evoked potentials (M-SSEP) changes in the early phase of supratentorial infarction and hemorrhage. MATERIAL AND METHODS: This study includes 130 patients (mean age 62+/-11.4 years, 43 women, large middle cerebral artery territory infarction in 36 patients, restricted/lacunar in 55, massive supratentorial hemorrhage in 10, small/medium size hemorrhage in 31). M-SSEP were recorded early (0-7 days in ischemia, 0-21 days in hemorrhage) and patients stratified into groups with absent, abnormal, normal response. Clinical state was determined by the Medical Research Council (MRC) scale, Barthel Index and Rankin score and followed for at least 6 months. RESULTS: Moderate prognostic correlation was established between N20-P25 amplitudes (r=0.34, p<0.05) and N20-P25 amplitude ratio (r=0.45, p<0.01) and Barthel Index at 6 months in patients with ischemic stroke. Moderate relationship (r=-0.34, p<0.05) exists also between N20-P25 ratio and Rankin score at 6 months in patients with small/medium size hemorrhage. In large infarctions and small/medium size cerebral hemorrhages correlations with all clinical indices of outcome are weak. In massive hemorrhage, only a weak correlation (r=-0.19, p<0.05) between amplitude ratio and Rankin score was found. The combination of initial MRC and N20-P25 amplitude ratio has 10% (in hemorrhage) to 15% (in infarction) greater prognostic value (p<0.05) than initial alone. CONCLUSIONS: M-SSEP have independent predictive value regarding functional recovery in ischemic stroke and small/medium size cerebral hemorrhage. Combined assessment of initial MRC and M-SSEP substantially improves prognosis in acute stroke.     

Evaluation of the American Heart Association Stroke Outcome Classification.

BACKGROUND AND PURPOSE: The purpose of this study was to evaluate the concurrent validity of the American Heart Association Stroke Outcome Classification (AHA.SOC) and compare performance of its function classification with that of the Modified Rankin Scale. METHODS: The individuals in this study included the last 105 consecutive subjects who were part of a cohort of 459 stroke patients in the Kansas City Stroke Study. The patients were evaluated with a variety of standardized assessments at enrollment (within 14 days of stroke onset) and followed at 1, 3, and 6 months after stroke. Specifically, we examined validity of AHA.SOC by comparing its 3 domains (ie, Domain, Severe, and Function) with stroke severity. We correlated AHA.SOC-Function with scores of the Barthel Index, Lawton Instrumental Activities of Daily Living (IADL) Scale, and Medical Outcome Study 36-Item Short-Form Health Survey (SF-36) measures of physical function and mental health. Finally, we compared the discriminant ability of AHA.SOC-Function and the Modified Rankin Scale in assessing disability and handicap. These data were analyzed with the use of Spearman rank correlations and Kruskal-Wallis tests. RESULTS: All 3 domains of the AHA.SOC were significantly associated with stroke severity and scores of Barthel Index, Lawton IADL, and SF-36 physical function (all P<0.001). Both AHA.SOC-Function and the Modified Rankin Scale discriminated well the disabilities and handicap measured by Barthel Index, Lawton IADL, and SF-36 physical function (all P<0.001). CONCLUSIONS: The AHA.SOC was able to capture impairments, disabilities, and handicap after stroke. The AHA. SOC-Function performed equally as well as the Modified Rankin Scale in assessing disabilities related to basic activities of daily living but differentiated slightly better than the Modified Rankin Scale in assessing disabilities/handicap related to instrumental activities of daily living. Neither the AHA.SOC-Function nor the Modified Rankin Scale captured differences in mental health after stroke.     

Baseline NIH Stroke Scale score strongly predicts outcome after stroke: A report of the Trial of Org 10172 in Acute Stroke Treatment (TOAST).

OBJECTIVE: To compare the baseline National Institutes of Health Stroke Scale (NIHSS) score and the Trial of Org 10172 in Acute Stroke Treatment (TOAST) stroke subtype as predictors of outcomes at 7 days and 3 months after ischemic stroke. METHODS: Using data collected from 1,281 patients enrolled in a clinical trial, subtype of stroke was categorized using the TOAST classification, and neurologic impairment at baseline was quantified using the NIHSS. Outcomes were assessed at 7 days and 3 months using the Barthel Index (BI) and the Glasgow Outcome Scale (GOS). An outcome was rated as excellent if the GOS score was 1 and the BI was 19 or 20 (scale of 0 to 20). Analyses were adjusted for age, sex, race, and history of previous stroke. RESULTS: The baseline NIHSS score strongly predicted outcome, with one additional point on the NIHSS decreasing the likelihood of excellent outcomes at 7 days by 24% and at 3 months by 17%. At 3 months, excellent outcomes were noted in 46% of patients with NIHSS scores of 7 to 10 and in 23% of patients with scores of 11 to 15. After multivariate adjustment, lacunar stroke had an odds ratio of 3.1 (95% CI, 1.5 to 6.4) for an excellent outcome at 3 months. CONCLUSIONS: The NIHSS score strongly predicts the likelihood of a patient's recovery after stroke. A score of > or =16 forecasts a high probability of death or severe disability whereas a score of < or =6 forecasts a good recovery. Only the TOAST subtype of lacunar stroke predicts outcomes independent of the NIHSS score.     

Assessment of scales of disability and handicap for stroke patients.

BACKGROUND AND PURPOSE: The purpose of the study is to compare the reliability of the Barthel activities of daily living score, which assesses disability, with the Rankin scale, which assesses handicap, and to determine their mutual agreement. METHODS: Fifty patients with stroke of varying severity were identified by a community-based stroke register and interviewed by two of three research nurses on two occasions that were 2-3 weeks apart. RESULTS: There was no evidence of a systematic difference between the first and second measurements. Repeatability was assessed using a kappa statistic with quadratic disagreement weights (kappa w) to take account of extreme differences. This measure was very good for both Barthel (kappa w = 0.98) and Rankin (kappa w = 0.95) scales. There was also excellent agreement between raters for the Barthel scale (kappa w greater than or equal to 0.88), but some indication of disagreement (kappa w = 0.75) between raters for the Rankin scale. Analysis of variance confirmed these findings. A conversion from the Barthel to the Rankin scale can be derived by assigning the most common Rankin score for the subjects with a given Barthel score, producing a kappa w of 0.91 for agreement. CONCLUSIONS: The Barthel scale is a more reliable and less subjective scale for assessing disability, from which a Rankin handicap score can then be derived to enable those managing stroke patients to assess aspects of handicap as well as disability.     

脑卒中后中枢性面瘫闭目乏力与脑卒中预后的关系

目的探讨脑卒中后中枢性面瘫闭目乏力与脑卒中预后的关系。方法观察1年内所有起病7d内的脑卒中患者,入院当天使用拉力测量器测量双眼闭目力量,按测量结果分为中枢性面瘫伴闭目乏力和不伴闭目乏力两组,比较两组入院当天、发病第7、14、21、30天的美国国立卫生院脑卒中量表评分(National Institute of Health stroke scale,NIHSS)以及发病第30、90、180天的Barthel指数(Barthel index,BI)、修正Rankin量表评分(modified Rankin Scale,mRS)。结果入院当天2组的NIHSS无统计学差异,而伴闭目乏力者在脑卒中发病第21和30天的NIHSS较不伴闭目乏力者高(P<0.05)。在脑卒中发病第30、90、180天,伴闭目乏力者的BI≥85的比例比不伴闭目乏力者低;在脑卒中发病第90、180天,伴闭目乏力者的mRS≤2的比例比不伴闭目乏力者低。结论脑卒中后中枢性面瘫伴闭目乏力提示较差的预后。     

Effect of Early and Intensive Rehabilitation after Ischemic Stroke on Functional Recovery of the Lower Limbs: A Pilot,Randomized Trial

Objective: We aimed to develop an early and intense lower extremity training technique using a recumbent cycle ergometer system in patients with acute ischemic stroke. Methods: This was a pilot, prospective, randomized, controlled study with 2 parallel groups followed for 3 months with blinded assessment of outcomes. Thirty-one eligible patients were randomized to experimental and control groups. To strengthen the motion of the lower extremities within 48 hours after stroke, the control and experimental groups received conventional treatment and additional interventions under a therapist's guidance combined with conventional treatment, respectively. The primary outcome measure was the change in lower extremity motor control from admission to 4 weeks, assessed by the Fugl-Meyer Assessment. Secondary outcomes were the number of days to walking 50 m and the change in the Berg Balance Scale score and Barthel index. The modified Rankin Score was used to assess the overall function and prognosis at 3 months. Results: Fugl-Meyer Assessment and Berg Balance Scale scores and Barthel index increased over time in the experimental group, as did the Berg Balance Scale score and Barthel index in the control group (P < .001). However, Fugl-Meyer Assessment scores in the control group were similar over time (F = 2.303, P = 1.119). Fugl-Meyer Assessment scores in the experimental group were higher than those in the control group after 2 and 4 weeks (P = .084 and .037, respectively). Compared with the control group at 2 weeks or at discharge, the percentage of patients who returned to unassisted walking in the experimental group showed an increasing trend (56.3% versus 26.67%, P = .095), but there was no significant difference between the 2 groups after 3 months (P = .598). The modified Rankin Score at 3 months showed no significant difference between the 2 groups (P > .05). Conclusions: Our early and intense lower extremity training technique involving a leg cycle ergometer system contributes to the recovery of lower extremity function in patients with acute ischemic stroke. This finding will provide a basis for future investigations on the applicability of the intervention in early lower extremity and walking rehabilitation among individuals with neurological disorder.     

Neuroprotective effect of dapsone in patients with acute ischemic stroke: a pilot study

OBJECTIVES: In a previous study of brain ischemia in rats, dapsone (4,4'-diamino-diphenylsulfone) was associated with a neuroprotective effect. As dapsone is safe and relatively free of adverse reactions, we conducted a pilot clinical trial to assess the possibility of using this drug in patients with a cerebral infarction. METHODS: A double-blind, placebo-controlled, pilot clinical trial of dapsone was conducted from January 1999 to January 2000. Thirty patients with a CT or MRI documented ischemic stroke in the territory of the middle cerebral artery were included. Patients with >4 points of the National Institute of Health Stroke Scale (NIHSS) were randomly allocated to receive either a single dose of 200 mg dapsone or placebo. For follow-up, NIHSS on days 0, 2, 7 and 60, modified Rankin scale and Barthel index at day 60 were applied. Adverse reactions were also recorded. The main cut point was considered when a patient obtained a variation of 2 points for modified Rankin scale and 17 points for Barthel index. RESULTS: Fifteen patients received dapsone and 15 received placebo. Twenty-nine were followed up for 60 days and one patient in the treatment group died during follow-up. Favorable scores were achieved for treated patients by all different measures; NIHSS (p=0.032), Barthel (p=0.049) and Rankin scale (RR=0.182, 95% CI: 0.04 and 0.86). Best results were obtained when treatment started within the first 8-10 hours after stroke. No adverse reactions related to medication were reported. DISCUSSION: Dapsone appears as a useful and safe drug for the treatment of stroke patients. Results of this pilot trial are promising and support further research to define the role of dapsone as a neuroprotective drug.     

Extracranial-intracranial bypass surgery to reduce the risk of haemodynamic stroke in cerebroocclusive atherosclerotic disease of the anterior cerebral circulation - a systematic review

BACKGROUND AND PURPOSE: Selected patients with acute or continual ischaemic symptoms from occlusions or inaccessible stenotic lesions of the internal carotid artery or middle cerebral artery have been considered candidates for an extracranial-intracranial (EC-IC) bypass procedure. Hitherto, no effectiveness of this surgical therapeutic option for various patient subgroups could be found in a large international randomized trial, and therefore various guidelines give negative recommendations for its usefulness. The aim of the present report was to analyze clinical effectiveness of EC-IC bypass for cerebral revascularization in haemodynamic subgroups of patients with advanced occlusive cerebrovascular disease in the anterior cerebral circulation. MATERIAL AND METHODS: A computerized database search from November 1985 to November 2001 was performed. Language restriction was done for English, French and German. Reports dealing with EC-IC bypass surgery for cerebral revascularization in case of advanced cerebrovascular disease in the anterior cerebral circulation were reviewed when appropriate. Studies were included if they contained valuable data on clinical state, pre- and postoperative haemodynamic state, surgical outcome and follow-up. RESULTS: The postoperative outcome related to death or stroke depended mainly on preoperative haemodynamic subgroups (CBF/CBV; OEF). The final functional status was worse the more the CBF/CBV ratio and OEF increased. Perioperative risk for death (0.6%) or stroke (2%) during the first month after surgery was similar to the death or stroke rate during the following 2 to 12 months after surgery. The overall risk profile for subsequent death or stroke of surgically treated patients is significantly better within the first 12 months than that of conservatively treated patients (1.3% vs. 3.6% per year). Neurological function was improved over the preoperative state in 84% of the patients and was unchanged in 6%. Postoperatively, modified Rankin scale score was 0-1 in 90% of patients and 2 in 1% of patients. Long-term patency was excellent, with 1% failure rate per year following the first year after surgery. CONCLUSION: Neurological function and subsequent stroke attributable to haemodynamic insufficiency in patients with symptomatic carotid occlusion or severe stenosis are improved significantly by EC-IC bypass surgery if the brain area corresponding to the impaired neurological function remains viable. The haemodynamic parameters observed for patients who experience improved neurological function or diminished stroke risk profile after EC-IC-bypass surgery contain both significantly elevated OEF and CBF/CBV. Therefore haemodynamic profile represents an important indicator for EC-IC bypass surgery and gives a good rationale for new trials conducted in a subgroup of patients selected on the basis of their haemodynamic profile.     

Flunarizine in stroke treatment (FIST): a double-blind, placebo-controlled trial in Scandinavia and the Netherlands

Introduction - An international, multicenter trial was conducted in 331 patients to determine the effect of a large dose of flunarizine (a calcium entry blocker) in the treatment of acute ischemic stroke in the territory of the Middle cerebral artery. Methods - The administration of the trial medication should start within 24 h after the initial symptoms of stroke. According to a random schedule, the patients were assigned to a 4-weeks double-blind treatment with either flunarizine ( n = 166) or placebo ( n = 165): one week intravenous administration (50 mg daily), followed by 3 weeks oral treatment (week 2, 21 mg daily; week 3–4, 7 mg daily). All patients had to be investigated by computerized tomography (CT) within 7 days after stroke onset; 36 patients were secundarily excluded because the CT showed another pathology. During the treatment period, other "stroke therapies" were not allowed. Patients were followed up for 24 weeks. Results - After the 24 weeks trial period, the percentage of patients who were dead or pendent (modified Rankin score 3–5) was similar in both treatment groups (flunarizine 67%, placebo 65%). During the trial, the scores for handicap severity (modified Rankin scale), neurological status (Orgogozo) and activities of daily living (modified Barthel index) strongly improved in both treatment groups, but no differences were found between the treatment groups. In this trial, the administration of trial treatment started relatively late after stroke onset (flunarizine group: mean time interval 13.5 h; placebo 12.3 h). A subgroup of patients received trial medication within 6 h after stroke onset (flunarizine n = 31; placebo n = 29). Also in this subgroup, no differences were found between the flunarizine and placebo group. Conclusion - Flunarizine did not improve neurologic and functional outcome in patients with acute ischemic stroke.     

A controlled prospective study of neuropsychological dysfunction following carotid endarterectomy

BACKGROUND: Although subtle cognitive injury as revealed by neuropsychological testing occurs in a substantial number of patients following carotid endarterectomy (CEA), there is controversy about whether this finding is a result of the surgery or the anesthesia. OBJECTIVES: To examine the changes in neuropsychological test performance in patients following CEA vs a control group of patients older than 60 years following spine surgery, so as to determine whether neuropsychological dysfunction after CEA is a result of surgery or anesthesia. METHODS: Patients undergoing CEA (n = 80) and lumbar spine surgery (n = 25) were assessed with a battery of neuropsychological tests preoperatively and on postoperative days 1 and 30. The neuropsychological performance of patients in the control group was used to normalize performance for patients in the CEA group, by calculating z scores using the mean and SD of the change scores in the control group. Significant cognitive dysfunction was defined as performance that exceeded 2 SDs above the mean performance of patients in the control group. RESULTS: Postoperative days 1 and 30 total deficit scores were significantly worse in the CEA group compared with the controls. When individual test results were examined, the CEA group performed significantly worse than the controls on the Rey Complex Figure test and Halstead-Reitan Trails B on day 1, and on the Rey Complex Figure on day 30. Overall, cognitive dysfunction was seen in 22 patients (28%) in the CEA group on day 1 and in 11 (23%) of 48 patients on day 30. CONCLUSIONS: Subtle cognitive decline following CEA occurs and persists for at least several weeks after surgery. This decline was absent in a control group.     

Intravenous tPA in acute ischemic stroke related to internal carotid artery dissection

The authors describe the outcomes in 11 patients who had acute ischemic stroke related to internal carotid artery (ICA) dissection and were treated with IV tissue plasminogen activator (tPA). One symptomatic intracerebral hemorrhage occurred 36 hours after tPA was given. The mean day 90 modified Rankin Scale (m-RS) score was 2.4 (+/-1.6). No death was observed at 3 months. Four patients of 11 (36.4%) made an excellent recovery (day 90 m-RS score: 0 to 1). This study demonstrates the feasibility of IV thrombolysis with tPA (0.8 mg/kg) in ischemic stroke related to ICA dissection within the first 7 hours.