Deans' stroke musings

Changing stroke rehab and research worldwide now.Time is Brain!Just think of all the trillions and trillions of neurons that DIE each day because there are NO effective hyperacute therapies besides tPA(only 12% effective). I have 493 posts on hyperacute therapy, enough for researchers to spend decades proving them out. These are my personal ideas and blog on stroke rehabilitation and stroke research. Do not attempt any of these without checking with your medical provider. Unless you join me in agitating, when you need these therapies they won't be there.

What this blog is for:

Shortly after getting out of the hospital and getting NO information on the process or protocols of stroke rehabilitation and recovery I started searching on the internet and found that no other survivor received useful information. This is an attempt to cover all stroke rehabilitation information that should be readily available to survivors so they can talk with informed knowledge to their medical staff. It's quite disgusting that this information is not available from every stroke association and doctors group.
My back ground story is here:

Thursday, April 27, 2017

Bungee cord-induced corneal lacerations correcting for myopic astigmatism

I have myopic astigmatism but would never even consider bungee jumping, I worry too much about tearing some arterial plaque loose. Same reason I don't do roller coasters anymore.

Video Game Helping Patients Rehab from Stroke

Minor help, too expensive and not enough repetitions available in the time periods therapists are allowed with patients.  52 posts on video games here so your stroke hospital can compare them to see which has the best efficacy.
CHARLOTTESVILLE, Va. (WVIR) - A type of video game could be the new way patients rehab from strokes.
Albemarle County based Barron Associates developed the Saebo V-R, it'll be distributed starting this summer to clinics nationwide. The starting cost is nearly $10,000.
Occupational therapists think it could be the key to getting patients back to normal, and to having a little fun while they do it.
"There's a lot of new technology coming out influencing the way we do rehabilitation," said Allison Ellington, an occupational therapist.
This could be the new way to come back from a difficult diagnosis, and now with FDA approval experts are rolling out Saebo V-R.
The virtual reality system was designed in central Virginia, and has patients moving their arms.
"We developed our own algorithms to do the motion tracking," said Eileen Krepkovich, a research scientist with Barrons Associates. "I think it's a great tool for the clients because it uses real life activities, it lets them practice things that they're inherently motivated to get back to doing."
Those activities might include laundry or gardening.
Ellington has her occupational therapy students at Mary Baldwin University's Murphy Deming School studying the system as a tool for working with patients.
And with her own patients at UVA-Healthsouth Rehabilitation Hospital she's seeing success.
"We have measured patient satisfaction with this system, which has been really high, but most exciting, we were able to show a significant improvement in upper-extremity function after just eight weeks of using the system three times a week," said Ellington.

Aging Research: Plasma Protein Revitalizes the Brain

If they can get it down to a manufactured protein you won't have to get blood transfusions from your grandchildren.
Elixir of youth?For centuries, people have yearned for an elixir capable of restoring youth to their aging bodies and minds. It sounds like pure fantasy, but, in recent years, researchers have shown that the blood of young mice can exert a regenerative effect when transfused into older animals. Now, one of the NIH-funded teams that brought us those exciting findings has taken an early step toward extending them to humans.
In their latest work published in Nature, the researchers showed that blood plasma collected from the umbilical cords of newborn infants possesses some impressive rejuvenating effects [1]. When the human plasma was infused into the bloodstream of old mice, it produced marked improvements in learning and memory. Additional experiments traced many of those cognitive benefits to a specific protein called TIMP2—an unexpected discovery that could pave the way for the development of brain-boosting drugs to slow the effects of aging.
When babies are born, a teaspoon or so of blood plasma remains in their umbilical cords that often gets discarded as medical waste. For the team led by Joseph Castellano and Tony Wyss-Coray of Stanford University, Palo Alto, CA, that youthful plasma seemed an obvious place to look for human proteins that might rejuvenate the aging brain.
At four-day intervals over the next two weeks, the team infused the human cord plasma into older mice. They wanted to see if it could revitalize the hippocampus, a part of the brain involved in learning and memory, in much the same way that blood from young mice had done in previous experiments [2]. (By the way, the strain of mice used in these studies had compromised immune systems that prevented their bodies from rejecting the human material.)
To help them gauge the effects of the cord plasma, the researchers also infused similar older mice with human plasma from either young adults (aged 19-24) or elderly donors (aged 61-82). The mice that received plasma from the elderly donors showed little change in gene expression. But those given cord and young adult plasma had a boost in the activity of genes that encourage neurons to grow and form new connections for learning.
Where things got real intriguing was that the cord plasma alone specifically increased the activity of genes playing important roles in memory formation. Most notable was an increase in a gene called c-Fos, which is linked to long-term memory storage and declines with age.
But did this interesting genetic profile translate to improved memories and learning? Sure enough, it did.  Mice given the cord plasma outperformed the other mice in a battery of learning and memory tests, and impressively so.
The researchers compiled a long list of human plasma proteins that vary with age and might explain the cord plasma’s rejuvenating power. To narrow it down further, they searched for proteins on the list that shift in mice with age and also when older mice are infused with young mouse blood. That yielded about 30 proteins. At the top of the list was a total surprise called TIMP2. While the protein has been studied in other contexts, next to nothing was known about its role in the aging brain.
Further study confirmed a decline in TIMP2 with age in the hippocampus. The researchers also found that injections of TIMP2 into mice led to improvements in learning and memory similar to those seen with the cord plasma. And when the researchers treated aged mice with cord plasma that had the TIMP2 protein removed, the treatment lost its brain-rejuvenating effects.
These findings help to confirm that proteins naturally present early in life could help to revitalize aged tissue. Based on these latest findings, TIMP2 holds promise for further study and perhaps even therapeutic development. Such a treatment might ultimately benefit people experiencing normal aging, as well as those with neurodegenerative conditions such as Alzheimer’s disease. We need not get too far ahead of ourselves here. But might the elusive elixir of youth that people have long pined for been inside us all along?
[1] Human umbilical cord plasma proteins revitalize hippocampal function in aged mice. Castellano JM, Mosher KI, Abbey RJ, McBride AA, James ML, Berdnik D, Shen JC, Zou B, Xie XS, Tingle M, Hinkson IV, Angst MS, Wyss-Coray T. Nature. 2017 April 19. [Epub ahead of print]
[2] Young blood reverses age-related impairments in cognitive function and synaptic plasticity in mice. Villeda SA, Plambeck KE, Middeldorp J, Castellano JM, Mosher KI, Luo J, Smith LK, Bieri G, Lin K, Berdnik D, Wabl R, Udeochu J, Wheatley EG, Zou B, Simmons DA, Xie XS, Longo FM, Wyss-Coray T. Nat Med. 2014 May 4.
Cognitive Health and Older Adults (NIA/NIH)
Understanding Memory Loss (National Institute on Aging/NIH)
Wyss-Coray Lab (Stanford University, Palo Alto, CA)
NIH Support: National Institute on Aging

DARPA Wants to Hack Your Brain to Make You Learn Faster

A great stroke association would take the results from here and create a stroke protocol to get survivors 100% recovered. But since we have fucking failures of stroke associations instead this won't be occurring. You are on your own.
If the brain is just a bunch of wires and circuits, it stands to reason that those components can simply be re-wired in order to create a better, smarter us. At least, that’s the theory behind a new project from the military’s secretive DARPA research branch announced on Wednesday, which aims to enhance human cognitive ability by activating what’s known as “synaptic plasticity.”
Recent research has suggested that stimulating certain peripheral nerves—those that relay signals between the brain, the spinal cord and the rest of the body—can enhance a person’s ability to learn, by triggering the release of neurochemicals that reorganize connections in the brain. Through its new Targeted Neuroplasticity Training program, DARPA is is funding eight different research efforts that seek to enhance learning by targeting those nerves with electrical stimulation. The end goal is to translate those findings into real-world applications that boost military training regimens—allowing a soldier, to say, soak up a new language in months instead of years. Should DARPA figure out a way to do that, its efforts will likely go on to impact all of us.
“TNT aims to deliver new knowledge of the neural processes that regulate cognitive functions associated with learning,” Doug Weber, the program’s manager, told Gizmodo. In other words, DARPA wants to study the basic biology at work here, and eventually, design neurostimulation devices that exploit our biological wiring to enhance learning.
One DARPA-funded team, at Johns Hopkins University, will focus on speech and hearing. These researchers will be experimenting with vagal nerve stimulation, exploring whether this can accelerate learning a new language. Another team at the University of Florida will study how vagal nerve stimulation impacts perception, executive function, decision-making, and spatial navigation in rodents. Yet another at Arizona State University will stimulate the trigeminal nerve, and study how that impacts visual, sensory and motor functions of military volunteers studying intelligence, surveillance, reconnaissance, marksmanship and decision-making.
Already, there are plenty of products on the market that claim to offer cognitive, psychological, and physical performance enhancement. (Basketball’s Golden State Warrior’s, for one, are known to rely on brain-zapping for a purported edge in their game.) But there is little understanding of how these devices work—and many scientists suspect they don’t. The aim of the DARPA program is to settle this debate, testing the efficacy of both implanted and non-invasive devices to understand not only whether they actually work, but if so, how.
“We are starting with a bit of knowledge about how the peripheral nerves are wired, but relatively little knowledge about the effects of neurostimulation on their function,” Weber said.
If, it turns out, there is a sufficient link between neurostimulation and improvements in learning, the second phase of the program will work to design devices that enhance training in foreign language learning, image analysis, and spatial navigation tasks.
“Most computer analogies for the brain idea are bad,” said Michael Kilgard, the lead researcher on the University of Texas at Dallas project. “But there really are wires from point A to point B. When you cut those wires you lose function. But after they’re cut they can make new connections. We have technologies now that allow us to see those connections.”
Kilgard’s work has, until recently, focused on repairing damaged circuits. Areas of research like deep brain stimulation (which involves implanting a chip deep in the brain) and transcranial direct stimulation (which changes brain chemistry using non-invasive electrical stimulation) have seen some success in using electricity to correct faulty wiring to, say, help treat mental health conditions. Kilgard has had success using targeted plasticity therapy to treat PTSD.
“Our idea was, after brain injury how do you get better? What you really need is to rewire circuits,” he said. “This is the next logical step. If you can help recover function you’ve lost, can you increase the rate at which you learn new things?”
Eventually, he envisions a device that, for a few hundred bucks, will non-invasively allow anyone to pick up a language at an accelerated pace. Under the current grant, he hopes to in five years have a (likely much more expensive) version of that device ready for FDA approval.
But there are plenty of hurdles. For one, that any of this will even work is still little more than an educated guess.
“We are leveraging state-of-art tools for probing the molecular and cellular processes underlying these functions, but even the most advanced instrumentation is limited,” said Weber.
What’s more, the very premise of the research is likely to stoke fears that DARPA is creating a race of cognitively enhanced super soldiers. The agency has several other brain projects in the works, which seek to use implanted chips to treat mental illness as well as to restore memories and movement to battle-wounded soldiers. For now, the aim of the program is to just give our brain’s a little boost—allowing us to learn a new skill maybe, say, 30% faster than we would naturally. But even the use of brain stimulants like Ritalin or Modafinil readily available on today’s college campuses is controversial.
Critics argue that such enhancement defies human nature. Supporters say that seeking out enhancement is human nature. The new research makes this debate, on how far we as a society are willing to take human cognitive enhancement, all the more urgent.
“Issues related to safety, equal access to the technology, and freedom of choice are often the earliest topics considered when new, breakthrough technologies are created,” Weber said. “It’s important that we carefully consider the broader impact of this work.”

Clinical Outcome Measures for Contraversive Lateropulsion Post-Stroke: An Updated Systematic Review

So rather than use a layperson term like pusher behavior, they tried for obsfucation in order to sound more intelligent.  The purpose should have been to create a stroke protocol to address the problems this causes.
The following article has just been accepted for publication in Journal of Neurologic Physical Therapy:
“Clinical Outcome Measures for Contraversive Lateropulsion Post-Stroke: An Updated Systematic Review”
Ryan Zachary Koter, DPT; Sara Regan, DPT; Caitlin Clark, DPT; Vicki Huang, DPT; Melissa Mosley, DPT; Erin Wyant, DPT; Chad Cook, PT, PhD, MBA, FAAOMPT; Jeffrey Hoder, PT, DPT, NCS
Provisional Abstract:
Background and Purpose: Pusher behavior (PB) can lead to increased hospital length of stay, increased healthcare costs, and delayed outcomes in stroke patients. The purpose of this updated systematic review was to identify scales used to classify PB, investigate literature that addresses their clinimetric properties, and create a resource for clinicians recommending use in clinical practice.
Methods: Three databases were searched for articles from inception to March 2017. The search strategy followed Cochrane Collaboration guidelines. The Consensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist was applied to evaluate methodological quality.
Results: 403 records were screened. Seven studies met inclusion criteria. Four scales were identified: the Scale for Contraversive Pushing (SCP), the Modified Scale for Contraversive Pushing (M-SCP), the Burke Lateropulsion Scale (BLS), and the Swedish Scale for Contraversive Pushing (S-SCP). Psychometric property investigation was most robust for the SCP and BLS. Cross-cultural validity has not been fully investigated in scales used outside of their country of origin.
Discussion and Conclusions The BLS is recommended for identifying PB. The scale assesses the presence of PB across several functional tasks, from rolling to walking, and is the only scale originally written in English. The BLS is the only tool to receive ratings greater than poor for reliability and responsiveness. The BLS should be implemented as soon as PB is suspected to guide frontline clinicians’ initial plan of care, allow objective identification of change over time, and facilitate easier investigation of interventional efficacy.
Video Abstract available for further insight (see Supplemental Digital Content 1)
Want to read the published article?
To be alerted when this article is published, please sign up for the Journal of Neurologic Physical Therapy eTOC.

Metrion taps Venomtech’s venom library for ion channel modulator discovery

There is a venom library. What the fuck are our stroke researchers doing with this to help with stroke recovery? There is already this out there:

Snake Venom Helps Hydrogels Stop the Bleeding

Intravenous Ancrod for Treatment of Acute Ischemic Stroke

Biting back - snake venom contains toxic clotting factors


Snake Venom Could Hold Key To Alzheimer’s Breakthrough

Metrion taps Venomtech’s venom library for ion channel modulator discovery

Strokes to be discussed at county board meeting - Sturtevant WI

More awareness crapola rather than discussing all the fucking problems in stroke. Good conscience laundering though.
YORKVILLE — Racine County Board Supervisor Mark Gleason, a stroke survivor, will speak about his experience with strokes during a County Board meeting Tuesday, according to a news release issued by County Executive Jonathan Delagrave’s office.
The presentation will be given at 6:30 p.m. Tuesday at the Ives Grove Complex, 14200 Washington Ave., as part of the regular County Board meeting.
Presenters will include Dr. Tom Wolfe, neurologist and stroke prevention specialist, and another professional from Aurora St. Luke’s Medical Center. They will discuss the physical and neurological effects of stroke, signs of a stroke, and recommended actions in case of a suspected stroke.
Gleason said he wanted to raise public awareness about strokes after surviving one last year.
“You can survive a stroke and have a very normal life. You can recover,” he said. “It’s not like it used to be. And that’s what the medical professionals are going to talk about.”
The National Stroke Association holds Stroke Awareness Month annually in May. The association’s mission is “to reduce the incidence and impact of stroke by developing compelling education and programs focused on prevention, treatment, rehabilitation and support for all impacted by stroke.” According to the association:
Stroke is the fifth-leading cause of death in America and a leading cause of adult disability.
Each year, about 185,000 people die from a stroke.

Up to 80 percent of strokes can be prevented.
There are nearly 7 million stroke survivors in the United States.
“Education and awareness are crucial factors for saving or supporting someone who is experiencing a stroke,” Delagrave stated. “The public is welcome and encouraged to attend the presentation.”
For stroke information and free awareness resources, go to the National Stroke Association online at

Neuroplasticity, Neuroregeneration, and Brain Repair

Your doctor should be able to get some takeaways from this conference to update your stroke recovery protocol to 100% recovery. If 100% recovery is not your doctors goal for you then you have a fucking incompetent asshole for a doctor.
June 13 - 14, 2017
The New York Academy of Sciences
Presented by Eli Lilly and Company and the New York Academy of Sciences
Register Now
  • Early Bird Deadline:
    May 01, 2017
  • Poster Abstract Deadline:
    April 17, 2017
  • Fellowship Deadline:
    April 17, 2017
  • Add to Outlook/Google/iCal
Strategies to stimulate neuroregeneration and neurorestoration hold promise to vastly improve the treatment of a range of neurological diseases and injuries, including Alzheimer's disease, Parkinson's disease, amyotrophic lateral sclerosis (ALS), spinal cord injury, and multiple sclerosis (MS). While progress has been made in understanding the cellular mechanisms of these processes, more research is needed in order to translate this knowledge into more effective treatments that restore function to the central nervous system.
This 2-day convening will bring together leading researchers, clinicians, industry, and governmental stakeholders from around the world to explore neuroregenerative processes and identify strategies for translating knowledge into treatments for neurodegenerative diseases and nervous system injuries. Plenary sessions will be designed to present emerging basic and clinical research in the following areas: neurodegenerative disease-modifying therapies that slow progression; mechanisms of neuroplasticity, including the role of dendritic spines, axonal growth, synaptic plasticity, inflammation, oxidative stress, mitochondrial function, and autophagy; glial function in the central nervous system; cutting-edge strategies to promote and modify neurogenesis; and biomarker and imaging modalities for neuroregeneration. The conference will conclude with an interactive panel discussion exploring future directions, critical open questions, and promising therapies in the field of neuroregeneration and neurorestoration.

Review Finds No Benefit to Aspirin for Preserving Cognitive Function

So what the fuck is the protocol for preserving cognitive function? Or is your doctor so incompetent that no research is read on this and s/he doesn't have the brains to hire an analyst to summarize research results needed to get their stroke patients to 100% recovery?
April 20, 2017
HOBOKEN, NJ -- April 20, 2017 -- An analysis of published studies found no evidence that low- dose aspirin buffers against cognitive decline or dementia or improves cognitive test scores.
The review and meta-analysis, published in the Journal of the American Geriatrics Society, included 8 studies with 36,196 participants (mean age, 65 years) who did not have cognitive impairment at baseline.
Nicola Veronese, MD, Aging Section, Institute of Neurosciences, Italian Research Council, Padova, Italy, and colleagues wanted to investigate whether low-dose aspirin (<300 mg/day) can influence the onset of cognitive impairment or dementia in observational studies and improve cognitive test scores in randomised controlled trials (RCTs) in participants without dementia.
After adjusting for a median of 3 potential confounders over a median follow-up period of 6 years, chronic use of low-dose aspirin was not associated with onset of dementia or cognitive impairment (5 studies, n = 26,159; odds ratio [OR] = 0.82; 95% confidence interval [CI], 0.55-1.22; P = .33; I2 = 67%).
In 3 RCTs (n = 10,037; median follow-up 5 years), the use of low-dose aspirin was not associated with significantly better global cognition (95% CI, 0.04-0.05; P = .84, I2 = 0%) in individuals without dementia.
Adherence was lower in participants taking aspirin than in controls, and the incidence of adverse events was higher.
“Additional studies are needed to test the possibility that low-dose aspirin has beneficial effects when taken over a longer period and at an earlier age,” said Dr. Veronese.

Study Shows Parkinson’s Disease May Start in the Gut

Rather than cutting the vagus nerve we should be figuring out a less invasive way to stop the signals or whatever travels along the vagus nerve. In our case stimulating the vagus nerve seems to help stroke recovery. So ask your doctor on the pros and cons of stroke recovery vs. Parkinsons prevention.

The positive:

Nerve 'Zap' Treatment May Speed Stroke Recovery Mar. 2017 

Safety, Feasibility, and Efficacy of Vagus Nerve Stimulation Paired With Upper-Limb Rehabilitation After Ischemic Stroke  Jan. 2016 

Earlier research on this is here July, 2012;

Nerve stimulation plus standard therapy may accelerate stroke recovery

and here Jan. 2013;

UK docs aim to `rewire` brains of stroke patients

and here - Sept. 2013;

Researchers Find Early Success in New Treatment for Stroke Recovery


The negative:

Vagus Nerve Stimulation Falls Short in Stroke Rehabilitation  Mar. 2017 




Study Shows Parkinson’s Disease May Start in the Gut

April 26, 2017
MINNEAPOLIS, Minn -- April 26, 2017 -- Parkinson’s disease may start in the gut and spread to the brain via the vagus nerve, according to a study published in the April 26, 2017, online issue of Neurology.
The preliminary study examined people who had resection surgery, removing the main trunk or branches of the vagus nerve. The researchers used national registers in Sweden to compare 9,430 people who had a vagotomy over a 40-year period with 377,200 people from the general population.
During that time, 101 people who had a vagotomy developed Parkinson’s disease (1.07%), compared with 4,829 people in the control group (1.28%). This difference was not statistically significant.
However, when researchers analysed the results for the 2 different types of vagotomy surgery, they found that people who had a truncal vagotomy at least 5 years earlier were less likely to develop Parkinson’s disease than those who had not had the surgery and had been followed for at least 5 years.
A total of 19 people who had truncal vagotomy at least 5 years earlier developed the disease (0.78%), compared with 932 people who had no surgery and had been followed for at least 5 years (1.15%). By contrast, 60% of patients who had selective vagotomy 5 years earlier developed Parkinson’s disease (1.08%).
After adjusting for factors such as chronic obstructive pulmonary disease, diabetes, arthritis, and other conditions, the researchers found that people who had a truncal vagotomy at least 5 years before were 40% less likely to develop Parkinson’s disease than those who had not had the surgery and had been followed for at least 5 years.
“These results provide preliminary evidence that Parkinson’s disease may start in the gut,” said Bojing Liu, Karolinska Instituet, Stockholm, Sweden. “Other evidence for this hypothesis is that people with Parkinson’s disease often have gastrointestinal problems, such as constipation, that can start decades before they develop the disease. In addition, other studies have shown that people who will later develop Parkinson’s disease have a protein believed to play a key role in Parkinson’s disease in their gut.”
The theory is that these proteins can fold in the wrong way and spread that mistake from cell to cell.
“Much more research is needed to test this theory and to help us understand the role this may play in the development of Parkinson’s,” Liu said.
Additionally, since Parkinson’s is a syndrome, there may be multiple causes and pathways.
Even though the study was large, Liu said one limitation was small numbers in certain subgroups. Also, the researchers could not control for all potential factors that could affect the risk of Parkinson’s disease, such as smoking, coffee drinking or genetics.
SOURCE: American Academy of Neurology

Can coffee consumption lower the risk of Alzheimer's disease and Parkinson's disease? A literature review

Fuck it all. Write up protocols so we don't have to do these completely stupid review articles. Were these earlier research articles not enough to write up a protocol?

Coffee May Lower Your Risk of Dementia 

Drinking Coffee Can Lower Alzheimer's Risk By 20%, All It Takes Is 3 Cups A Day

How coffee protects against Parkinson’s


If not, then expend your intellectual time and energy to writing protocols rather than this lazy crapola of review.
Archives of Medical Science
Wierzejska R – An observational study was carried out to determine whether coffee intakes lowers the risk of Alzheimer's disease and Parkinson's disease. At present, it appears to be safe to advise the general public that coffee drinkers need not fear for their health. Perhaps, later on, experts will suggest drinking coffee not only to satisfy individual taste preferences as well as to reduce age–related mental deterioration.
  • In light of the fact that the number of elderly citizens in society is steadily increasing, the search for dietary variables which might prolong mental agility is growing in significance.
  • Coffee, together with its main ingredient, caffeine, has been the focus of much attention from different analysts, as information on its beneficial effects on human health continues to accumulate.
  • Most reports show that moderate coffee intake may, in fact, lower the risk for common neurodegenerative conditions, i.e. Alzheimer's and Parkinson's diseases.
  • Regardless, because of their complex pathogenesis and also methodology of scientific research, the exact effect of coffee intake remains to be completely explained.

A Neuromuscular Electrical Stimulation (NMES) and robot hybrid system for multi-joint coordinated upper limb rehabilitation after stroke

Two interventions in this research which means you have no clue which one is the main actor.   I have 11 posts on NMES so your doctor can put together a stroke protocol on how to use this to get you 100% recovered.
Journal of NeuroEngineering and Rehabilitation201714:34
DOI: 10.1186/s12984-017-0245-y
Received: 9 June 2016
Accepted: 14 April 2017
Published: 26 April 2017



It is a challenge to reduce the muscular discoordination in the paretic upper limb after stroke in the traditional rehabilitation programs.


In this study, a neuromuscular electrical stimulation (NMES) and robot hybrid system was developed for multi-joint coordinated upper limb physical training. The system could assist the elbow, wrist and fingers to conduct arm reaching out, hand opening/grasping and arm withdrawing by tracking an indicative moving cursor on the screen of a computer, with the support from the joint motors and electrical stimulations on target muscles, under the voluntary intention control by electromyography (EMG). Subjects with chronic stroke (n = 11) were recruited for the investigation on the assistive capability of the NMES-robot and the evaluation of the rehabilitation effectiveness through a 20-session device assisted upper limb training.


In the evaluation, the movement accuracy measured by the root mean squared error (RMSE) during the tracking was significantly improved with the support from both the robot and NMES, in comparison with those without the assistance from the system (P < 0.05). The intra-joint and inter-joint muscular co-contractions measured by EMG were significantly released when the NMES was applied to the agonist muscles in the different phases of the limb motion (P < 0.05). After the physical training, significant improvements (P  < 0.05) were captured by the clinical scores, i.e., Modified Ashworth Score (MAS, the elbow and the wrist), Fugl-Meyer Assessment (FMA), Action Research Arm Test (ARAT), and Wolf Motor Function Test (WMFT).


The EMG-driven NMES-robotic system could improve the muscular coordination at the elbow, wrist and fingers.

Trial registration NCT02117089; date of registration: April 10, 2014

No Bull: Energy Drinks Tied to Cardiac Changes

You'll have to ask your doctor what repolarization is and if it means anything to you. I stick to coffee.

Study's energy drink arm had higher change in corrected QT interval

  • by
    Staff Writer, MedPage Today
Drinking a high-volume energy drink was linked to more heart and blood pressure changes compared with a control drink containing the same amount of caffeine, according to a small crossover study of military personnel.
Those in the energy drink arm had a significantly higher change in corrected QT interval, a measure of cardiac repolarization, compared with those in the caffeine arm at 2 hours after baseline (0.44 ms versus 10.4 ms, P=0.02), reported Emily A. Fletcher, PharmD, of David Grant U.S.A.F. Medical Center at Travis Air Force Base Fairfield, Calif., and colleagues.
"Based on this preliminary evidence in young, healthy adults, people who have high blood pressure, underlying cardiac conditions or other health issues might want to avoid or use caution when consuming energy drinks until more is known about their impact on heart health," wrote the authors in the Journal of the American Heart Association.
John P. Morrow, MD, of Columbia University Medical Center in New York City, told MedPage Today that the study confirms previous findings that caffeine is probably safe in moderate doses.
"The bad news is that energy drinks may have concerning short-term effects on the cardiovascular system, although they are unlikely to cause serious side effects in healthy young people," said Morrow, who was not involved in the study.
Fletcher's group recruited 18 participants (12 men) via email and flyers from 2013 to 2014 on a U.S. Air Force Base installation. All participants were randomized to receive 32 oz of a commercially available energy drink or a control drink, both which contained 320 mg of caffeine. After a 6-day washout period, participants switched drinks.
The researchers collected ECG, peripheral blood pressure, and central blood pressure measurements at baseline and at 1, 2, 4, 6, and 24 hours after drink consumption.
Fletcher and colleagues found that changes in corrected QT intervals were different between the two groups after 2 hours, but not at other time points.
While both groups initially had similar increases in systolic blood pressure, a significant difference was evident after 6 hours in the energy arm but not the caffeine arm (4.72 mm Hg versus 0.83 mm Hg, P=0.01).
Additionally, the researchers reported a significant decrease in baseline-adjusted augmentation index after 6 hours in the energy drink arm compared with the caffeine arm ( 3.72 versus 1.50, P=0.02). No difference was seen with heart rate, diastolic blood pressure, central systolic blood pressure, and central diastolic blood pressure at any time point between the two groups (P>0.07).
The authors concluded that the findings "suggest that ingredients other than caffeine may have some blood pressure altering effects, but this needs further evaluation."
Study limitations included the absence of a true placebo and that the results only appeared to be significant relative to the caffeine group.
Paul Eugenio, MD, of Montefiore Medical Center in New York City, who was not involved in the study, suggested that factors like the small sample size increase the probability that the study results were a "chance" finding.
However, "that being said, the results are of interest and serve as hypothesis generating for larger, more adequately powered studies to assess for a true effect of energy drinks on cardiac repolarization (the QT interval) and peripheral blood pressure," wrote Eugenio in an email.
Morrow agreed, noting that different energy drinks with different herbal or chemical ingredients may have different effects on the cardiovascular system.
"We cannot assume class effects, and we cannot assume that herbal/natural preparations are always safe. More work is needed, and we should not extrapolate these results to middle-age healthy people, or elderly people with heart disease," he told MedPage Today.
The study was funded by the Clinical Investigations Facility at Travis Air Force Base.
Fletcher and co-authors disclosed no relevant relationships with industry.

Wednesday, April 26, 2017

Stroke rates appear to be rising steadily in young adults

Because the objective diagnosis of young adult strokes is so bad you better have the complete classic symptoms(drooping face, slurred speech, one-sided paralysis and lack of sensation). And still hope your doctor doesn't consider you drugged

Pediatric Stroke Often Misdiagnosed, Treatment Delayed


Doctors tell boy, 15, he had a migraine after rugby tackle - but he was actually suffering a paralyzing stroke which nearly killed him


Factors Associated With Misdiagnosis of Acute Stroke in Young Adults


Amy on her 36 hour wait for a diagnosis.
The rate of stroke among young people has apparently been rising steadily since 1995, according to a study published this week. Hospitalization rates for stroke increased for women between the ages of 18 and 44, and nearly doubled for men in that age range from 1995 through 2012.
Using more-detailed data for 2003 through 2012, the researchers found that rates of hospitalizations for acute ischemic stroke increased by nearly 42 percent for men 35 to 44, while rates for women of the same age group increased by 30 percent over the same time, the study published in the JAMA, the Journal of the American Medical Association.
Across all adults, including those in older age ranges, stroke was the fifth leading cause of death in 2013. Overall mortality rates from strokes have significantly decreased over the past 50 years due to multiple factors, including better treatment for hypertension and increased use of aspirin, even as incidence of acute ischemic stroke among young adults has been on the rise.
The study also looked at stroke risk factors and whether there were any changes in their prevalence from 2003 to 2012. The likelihood of having three or more of five common risk factors — diabetes, hypertension, lipid disorders, obesity and tobacco use — doubled in men and women hospitalized for acute ischemic strokes.
“The identification of increasing hospitalization rates for acute ischemic stroke in young adults coexistent with increasing prevalence of traditional stroke risk factors confirms the importance of focusing on prevention in younger adults,” said Mary George, the lead author of the report and deputy associate director for science and senior medical officer in the Division for Heart Disease and Stroke Prevention at the Centers for Disease Control and Prevention.
Researchers used data from the National (Nationwide) Inpatient Sample, a large and nationally representative administrative database of hospital discharge information.
The researchers hypothesize that hospitalization rates kept increasing with time because stroke risk factors such as high blood pressure, diabetes and obesity have been increasing in the general population.
“The high and increasing rates of traditional stroke risk factors among young adults experiencing an acute stroke is quite worrisome,” George said.
The results reinforce the need for physicians to monitor patients for risk factors such as high blood pressure or high cholesterol and treat them early. Young adults and their health-care professional should have discuss engaging in healthy behaviors throughout their lives, such as eating a healthy diet with plenty of fruits and vegetables, being physically active, maintaining a healthy weight, and if they smoke then what steps they should take to quit, George said.
“Most people think that having a stroke is something that only happens to older people, but the impact of stroke is significant — it is uniquely complex in younger adults, in midst of careers, serving as wage earners and caregivers, who may suffer disability that can impact their lives and the lives of family members and loved ones,” George said.
Previous studies have looked at how stroke rates have increased in young adults, but this was a larger study that looked over a longer period of time, said Diana Greene-Chandos, a neurologist and director of neuroscience critical care at the Ohio State University Wexner Medical Center who was not part of the study.
“It showed us that not only was there an increase but also an increase that was associated with common risk factors in stroke,” she said. “It is  an important call to us as stroke neurologists and critical-care neurologists to start to study this more and more because of the way it was done. There are some limitations to it, but I think that it's enough good data that we should start to spend more of our resources in looking at this.”

Drinking Four Cups of Coffee Is Probably Safe

My definition of cup is certainly not 8 oz.  There are too many health benefits of coffee for me to even consider limiting my intake. Read my 129 posts on coffee or 63 posts on caffeine for details. Or you could just ask your knowledgeable doctor for advice. How many references does your doctor point to to back up her recommendation? Is your emergency room doctor applying  this from May, 2014?

Does Coffee and Alcohol (Caffeinol) Prevent and Reduce Severity of Strokes?

 Drinking Four Cups of Coffee Is Probably Safe

Predicting people's 'brain age' could help to spot who is at risk of early death

I can't see any insurance paying for this. Considering my dead area in my brain my volume of brain tissue is considerably reduced.  I will not have cognitive decline and die before 80. I have way too much living to do and much wine to consume.  You just aged/lost 5 years of your brain due to your stroke. What protocols does your doctor have to catch back up?
24 April 2017 Imperial College London
A method for predicting someone’s ‘brain age’ based on MRI scans could help to spot who might be at increased risk of poor health and even dying at a younger age.
By combining MRI scans with machine learning algorithms, a team of neuroscientists led by researchers at Imperial College London, has trained computers to provide a predicted ‘brain age’ for people based on their volume of brain tissue.
When the technique was tested on a study population of older adults in Scotland, they found that the greater the difference between a person’s brain age and their actual age, the higher their risk of poor mental and physical health, and even early death.
The researchers stress that while the technique is a long way from being used in clinical practice, they are hopeful it might one day be used as a screening tool, helping to identify those at risk of cognitive decline and dying before the age of 80, providing an opportunity for early intervention.
Scientists around the world are working to find reliable biomarkers that can be used to measure age, such as from blood and hair samples. In the latest study, published today in the journal Molecular Psychiatry, researchers from Imperial and the University of Edinburgh have added a neuroimaging approach to the growing gerontology toolkit.
“We've come up with a way of predicting someone’s brain age based on an MRI scan of their brain,” explained Dr James Cole, a research associate in the Department of Medicine, who led the study.
“Our approach uses the discrepancy between their chronological age and what we call their brain-predicted age as a marker of age-related atrophy in the brain. If your brain is predicted to be older than your real age than that reflects something negative may be happening.”
At the heart of the approach is a technique first developed in 2010 that measures brain volume and uses machine learning to estimate the overall loss of grey and white matter – a hallmark of the ageing process in the brain.
Dr Cole took this basic technique and refined it by testing it on publicly available datasets of MRI scans of more than 2,000 healthy people’s brains, resulting in normalised maps which accurately predicted the person’s age.
Following this fine-tuning, it was then applied to scans of 669 people from the Lothian Birth Cohort 1936, a well-studied group of adults all born in 1936 who had undergone MRI scans at age 73, giving them a score for predicted brain age.
Analysis revealed that those with a brain age older than their chronological age performed worse on standard physical measures for healthy ageing, including grip strength, lung capacity and walking speed.
Crucially, those with ‘older brains’ were statistically more likely to die before the age of 80, with the average discrepancy between brain age and chronological age being eight years for deceased males and two years for deceased females.
If the initial findings could be applied to a screening programme, the technique could be used to inform health practitioners, showing whether or not a patient had a healthy brain age or was above or below the line, similar to how body mass index (BMI) is used today.
“In the long run it would be great if we could do this accurately enough so that we could do it at an individual level,” said Dr Cole. “Someone could go to their doctor, have a brain scan and the doctor could say 'your brain is 10 years older than it should be’, and potentially advise them to change their diet or lifestyle or to start a course of treatment. However, at the moment, it's not sufficiently accurate to be used at that sort of individual level.”
The team is now looking to refine the technique further, incorporating different types of imaging, such as diffusion MRI scans, to improve accuracy.
Currently, the high cost associated with MRI scans inhibit the technique’s use as a screening tool in the near term, but large scale projects such as the UK Biobank demonstrate the economies of scale that could help reduce the costs in future.
The researchers also stress that while the technique has great potential, there is still a relatively large margin of error, with the absolute error in determining brain age across all of the MRIs found to be five years.
“People use the 'age' of an organ all the time to talk about health,” explained Dr Cole. “Smokers are said to have lungs that are 20 years older than they should be, you can even answer online questionnaires about exercise and diet and get a 'heart age'. This technique could eventually be like that.”
Dr Cole added: “It could be that if your brain looks older than it should do, it could be an indication that something bad has happened or is happening and should put you more at risk of age-related brain disease or cognitive impairment, and the data we have so far seems to back that up, at least at the group level.”

Study finds major health benefits linked to indoor temperature variation

I bet your hospital will never implement these practices.
24 April 2017 Taylor & Francis
Exposure to environments outside a comfortable temperature could help tackle major metabolic diseases, such as diabetes and obesity, and should be reflected in modern building practices, finds a study published today.
This new research reveals how exposure to mildly cold or warm environments, outside the standard comfort zone inside buildings of 21 - 22 oC, increases metabolism and energy expenditure which may help to tackle obesity. For those with type 2 diabetes, exposure to mild coldness influences glucose metabolism and after 10 days of intermittent cold, patients had increased insulin sensitivity by more than 40%. These results for diabetes treatment are comparable with the best pharmaceutical solutions available.
As a result of the positive benefits, the authors advocate that living conditions in modern buildings, such as homes and offices, should be dynamic and incorporate drifting temperatures in order to support healthy human environments. Such measures should go hand in hand with the classical lifestyle factors such diet and physical exercise.
The research, "Healthy Excursions Outside the Thermal Comfort Zone", published in Building Research & Information, [URL live and free to view 26 April 2017] outlines how preventable metabolic syndrome health conditions, such as obesity and type 2 diabetes, may be influenced by exposure to a variable indoor temperature.
The lead author of the study and Professor of Ecological Energetics and Health at Maastricht University Wouter van Marken Lichtenbelt commented, “It has previously been assumed that stable fixed indoor temperatures would satisfy comfort and health in most people. However, this research indicates that mild cold and variable temperatures may have a positive effect on our health and at the same time are acceptable or even may create pleasure.”
Richard Lorch, editor in chief, commented: "This ground-breaking research provides a new approach to how we think about the heating and cooling our of buildings. The health benefits from a short exposure to a more varied temperature range will redefine our expectations on thermal comfort.  In turn, this will change our practices for heating and cooling our buildings."
The research, part of a forthcoming Building Research & Information special issue entitled "Rethinking Thermal Comfort", examines the practices of thermal comfort, and offers solutions providing healthier, comfortable, low-energy solutions in buildings. In developed countries, buildings account for up to 40% of energy demand and constitute a significant proportion of CO2 emissions. A reduction in heating and cooling of buildings will have a positive health effect on the occupants, as well as reduce greenhouse gas emissions.
The full article will be live and free to read on 26th April 2017 here:

Diet sodas, stroke and Alzheimers

In the news lately.

db's Medical Rants has a great takedown on this. 

Full post here:

Very interesting paragraph copied here:

Aaron Carroll - the Incidental Economist - has a great analysis - They did not prove that diet soda causes Alzheimer’s Disease. THEY DID NOT!
You are on your own here, no help from the medical profession. 

Resetting Body Clock May Help the Brain to Heal

You are going to have to hope that your doctor or your relatives are trained in this if you get locked-in-syndrome. We should have BDNF so if your doctor has any brains at all a bright light protocol should be immediately set up for all stroke survivors.

Circadian temperature rhythms linked to arousal in study

Action Points

  • Note that this small, observational study found that circadian variation in body temperature was associated with arousal among individuals with severe brain injury.
  • Whether manipulating circadian rhythms may aid in restoration of consciousness remains unclear.
Circadian-related variations in body temperatures were found to be linked to arousal in people in vegetative or minimally conscious states in a newly reported study, suggesting a possible role for circadian rhythm manipulation in the treatment of severe brain injury.
Findings from the small, cross-sectional study provide early evidence for an association between circadian body temperature rhythms and arousal as a necessary precondition for consciousness, researcher Christine Blume, PhD, of Austria's University of Saltzburg, and colleagues wrote.
Their study was published online April 19 in the journal Neurology.
The researchers wrote that temporal disorganization of circadian rhythms may impede recovery in critically ill patients, and that studying circadian rhythms in patients with consciousness disorders may be especially important for several reasons.
"First, the presence or absence of circadian rhythms as well as anomalies in them could be informative about the state of the patient as well as the potential for recovery," they wrote. "Second, this could provide information about time points that best capture remaining cognitive functions, e.g., with behavioral scales such as the Coma Recovery Scale-Revised (CRS-R)."
Molecular biologist Helen Hellmich, PhD, of the University of Texas Medical Branch at Galveston, has been studying circadian rhythm disturbances in brain injured rats in her lab for almost two decades.
In an interview with MedPage Today, Hellmich said the newly published human study expands upon her work and those of her colleagues showing that brain injury disrupts circadian gene expression in rat models. They were the first to show this in a study and suggest a mechanism in a study published in the journal PLoS One in 2012.
She said ongoing studies by her colleagues suggest that bright light therapy speeds brain recovery among the brain injured rats, possibly by increasing levels of the protein brain derived neurotrophic factor, or BDNF.
In the newly published study, Blume and colleagues investigated circadian temperature rhythms under a habitual light condition for one week and they also explored the potential of bright light stimulation to enhance circadian rhythmicity.
Lomb-Scargle periodogram analyses revealed circadian rhythms in all 18 patients with period lengths ranging from 23.5 to 26.3 hours (median 23.95 hours). Patients with traumatic brain injury exhibited a marginally significantly longer period length than patients with nontraumatic cause.
Scores on the arousal subscale CRS-R were found to be closely linked to circadian variations in body temperature.
In a light-stimulation substudy, bright light stimulation appeared to boost circadian rhythmicity in two of the eight patients included in the substudy.
The intervention consisted of bright light stimulation three times a day (7 a.m., 1 p.m., and 7 p.m.) for one hour over the course of a week.
While there was some evidence of improvement in arousal in the two patients, the contribution of the light therapy was not clear and the effect was not statistically significant.
The researchers argued that a proof of principal study is needed "before drawing conclusions about the usefulness of bright light stimulation therapy.
In contrast to findings from smaller, similar studies published in 2009 and 2013, the current study showed circadian rhythms in all patients, regardless of disorder of consciousness state, which the researchers attributed to the increased sensitivity of their analysis methods.
"More precisely, our results indicate that the less the patients' circadian temperature rhythm deviated from healthy rhythmicity,the better it was entrained to the 24-hour light-dark cycle and the more pronounced the circadian rhythm (i.e., the higher the normalized power of the circadian peak in the periodogram), the better the behavioral repertoire and the state of the patient (as measured with the CRS-R)," the researchers wrote.
This observation was especially pronounced for the arousal subscale.
Body temperature is believed to be a key player in the regulation of sleep-wake cycles and arousal levels, which are known to fluctuate in patients in vegetative, unresponsive wakefulness and minimally-conscious states, the researchers noted.
"Thus, preserved circadian temperature rhythms may stabilize the integrity of patients' sleep-wake patterns, which in turn would support sustained arousal and eventually attention and (residual) awareness," they wrote. "From a clinical perspective, this renders circadian rhythms promising targets for therapeutic approaches and our findings therefore make a case for treatment aiming at the promotion and stabilization of circadian rhythms."
"There is a whole lot going wrong with the brain in people with severe brain injuries," Hellmich said. "Circadian disruptions is just one thing, but it may be a very important thing."
Funding for this research was provided by the Konrad-Adenauer-Stiftung eV and the Australian Science Fund.
The researchers declared no relevant relationships related to this study.
  • Reviewed by F. Perry Wilson, MD, MSCE Assistant Professor, Section of Nephrology, Yale School of Medicine and Dorothy Caputo, MA, BSN, RN, Nurse Planner

Lifestyle Program May Slow Cognitive Decline

Does your doctor have this protocol available for you? Not just general guidelines. No excuses are allowed even if this is preliminary.

At-risk seniors seem to benefit from nutritional guidance, vigorous exercise

  • by
    Contributing Writer, MedPage Today

Action Points

  • Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.
BOSTON -- A program that provides elderly people at risk for dementia with dietary guidance, exercise, cognitive training, and vascular risk monitoring could prevent cognitive decline, researchers said here.
Prevention has been highlighted "as a key element in managing dementia, said Miia Kivipelto, PhD, of the Center for Alzheimer Research and Aging Research Center, Karolinska Insitutet in Stockholm in a presentation at the American Academy of Neurology annual meeting.
"At the same time it is increasingly clear that it is very difficult to find new drug treatments for Alzheimer's disease and dementia," she noted.
While there has been evidence in observational studies that modifiable vascular and lifestyle-related risk factors are associated with dementia risk, what has been lacking has been evidence from randomized control trials showing that modifying these risk factors can prevent cognitive decline, she noted.
The Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER) study is a proof-of-concept randomized control trial designed to assess a "multidomain" approach to preventing cognitive decline in at-risk elderly persons. The results of the study were originally published in the Lancet.
In this trial conducted from 2009-2011, researchers enrolled individuals between the ages of 60-77, with 631 randomly assigned to the multidomain intervention group, and 629 to the control group. Inclusion criteria include CAIDE (Cardiovascular Risk Factors, Aging, and Incidence of Dementia) Dementia Risk Scores of at least 6 points, and cognition at mean level or slightly lower than expected for age.
Individuals in the intervention group were given nutrition guidance, put on increasingly vigorous exercise regimens, and provided with cognitive training. Their metabolic and vascular risk factors were also monitored and managed. The control group was provided with general health advice.
"As expected, both groups improved over the 2 years, but the intervention group improved much more," Kivipelto said.
The primary outcome was cognitive change as measured through a comprehensive neuropsychological test battery Z score.
The impact of the intervention on global cognition was significantly higher, said Kivipelto, with the intervention group showing a 25% greater improvement over baseline scores compared with the control group.
That pattern also held for outcomes such as executive functioning (83% improvement), processing speed (150%), and complex memory tasks (40%).
"We also saw that the control group had a 30% increased risk of cognitive decline [versus the intervention group] over the 2 years," she said.
Kivipelto added that new data from the trial also indicated that the intervention was beneficial regardless of sociodemographic factors, baseline cognition, or cardiovascular risk factors. "This indicates that the selection of the target group was successful and that this type of intervention may be implemented in a wider population."
The intervention also had positive effects on secondary outcomes such as activities of daily life (ADL) function, mobility, and quality of life. For example, the intervention group had a 30% lower risk of a decline in ADL function versus the control group.
While adverse events occurred in 46 (7%) of the people in the intervention group, compared with six (1%) in the control group, "there were no serious adverse events," Kivipelto said, adding that most adverse events involved slight muscular pain related to exercise.
As for future research in this area, "I think it will be very important in the future to have even larger multidomain, multinational studies, with tailored interventions, and pragmatic prevention programs," Kivipelto said.
Kivipelto disclosed no relevant relationships with industry.

Plaque Protrusion Tied to Stroke in Carotid Stenting

Be careful out there. For you and your stenting doctor to discuss. I still don't understand why you would medically need to stent a carotid artery at all if the Circle of Willis is complete. (Unless the whole point is revenue and profit generation) It would seem to make more sense to just close it up and prevent problems from there.  My right carotid artery has been closed for the past 10 years and I cognitively function quite well with no episodes of fainting.

Nearly 3% of carotid stenting procedures in a decade had plaque protrusion

  • by
    Reporter, MedPage Today/

Action Points

  • Note that this observational study suggests that plaque protrusion during carotid stenting poses a high risk for subsequent stroke.
  • Be aware that only 9 patients in this study had plaque protrusion, limiting the precision of estimates of effect.
Having plaque creep into the lumen of the stent during carotid artery stenting was strongly associated with ischemic strokes, researchers reported.
Over 10 years of carotid artery stenting, Japanese hospitals saw nine cases (a 2.6% rate) of plaque protrusion, wherein plaque is found inside the stent during the procedure. Plaque protrusion involved open-cell stents in all cases. The complication occurred with unstable plaque in 8 out of 9 cases.
Stroke occurred by 30 days in 6 of the 9 patients who had plaque protrusion (1 major stroke, 5 minor strokes). In addition, ischemic lesions were found in 8 of the 9 cases on the treated side at 48 hours on diffusion-weighted imaging, Masashi Kotsugi, MD, of Ishinkai Yao General Hospital in Japan, and colleagues reported in the April 24, 2017 issue of JACC: Cardiovascular Interventions.
Their study included 328 consecutive patients with carotid atherosclerotic stenoses who underwent stenting with IVUS from 2007 to 2016. Operators used embolic protection devices in all cases.
"The present results suggest that the protective effect of an embolic protection device against stroke may be limited in cases of plaque protrusion and may indicate it is not the embolic protection device but rather avoiding plaque protrusion that is necessary to prevent periprocedural ischemic stroke," Kotsugi's group suggested.
And to that end, they urged, "carotid artery stenting should be performed using a stent with as small a free cell area as possible to prevent plaque protrusion."
"Our recent strategy is as follows: if plaque protrusion occurs, we perform IVUS and then check large-volume plaque protrusion to determine if it is convex. In a case of convex plaque protrusion, we perform stent-in-stent placement using closed-cell stents until the plaque protrusion disappears. In a case of nonconvex plaque protrusion, we observe for 5 to 10 min, and, then, if the plaque protrusion is not changed, careful clinical follow-up is considered within 30 days after carotid artery stenting. If the plaque protrusion enlarges, stent-in-stent placement is performed until plaque protrusion disappears."
"When the findings from this study are paired with the emerging data on apparent reductions in both plaque protrusion on optical coherence tomography and new DW-MRI abnormalities with the use of mesh-covered stents, the case begins to grow for such improvements in stent design," commented William Gray, MD, of Lakenau Heart Institute in Wynnewood, Pa.
In an accompanying editorial, he continued: "Toward that end, a U.S. trial [SCAFFOLD] evaluating a mesh-covered open-cell stent in patients at high surgical risk has already completed enrollment ... and two other similar trials using different mesh technologies are imminent. Inherent in these technologies is the hope that the stent can be transformed from a potential offender into a reliable protector during carotid artery stenting. This advance, once proved, along with others such as direct carotid access for flow reversal and double-filtration strategies, will thereby continue to chisel away at the causes of stroke in carotid artery stenting to patients' benefit."
Good options with mesh technologies include the closed-cell Roadsaver (Terumo) and the open-cell C-guard (inspireMD): "Expectations for micromesh stents are high," according to the study authors.
Plaque protrusion was confirmed on both angiography and intravascular ultrasound (IVUS) in their study.
IVUS alone would have detected more cases of plaque protrusion (7.8%), Kotsugi's group found.
"The investigators pre-defined plaque protrusion as having to occur in both modalities, which cut by two-thirds the incidence of IVUS plaque protrusion and which will clearly affect many of the subsequent associations and conclusions," Gray commented.
Other caveats, according to the editorialist: the lack of a core lab, diffusion-weighted MRI not routinely performed before and after stenting, unblinded assessors, stent use not protocol-directed, lack of routine independent neurological assessment, treating plaque prolapse with a second stent, and the difficult distinction between plaque protrusion and actual thrombus.
The retrospective study was further limited by the 30-day follow-up and small sample size.
Kotsugi disclosed no conflicts of interest.
Gray reported consulting for Medtronic, Boston Scientific, Contego, WL Gore, and Silk Road Medical.
  • Reviewed by F. Perry Wilson, MD, MSCE Assistant Professor, Section of Nephrology, Yale School of Medicine and Dorothy Caputo, MA, BSN, RN, Nurse Planner