Unpacking the 2023 American Heart Association Guidelines: The Ascendancy of Neuroendovascular and Neurocritical Care in Aneurysmal Subarachnoid Hemorrhage Management

 When the hell will we get EXACT PROTOCOLS that follow from an EXACT DAMAGE DIAGNOSIS? Until then you better hope your doctor guesses correctly.

Unpacking the 2023 American Heart Association Guidelines: The Ascendancy of Neuroendovascular and Neurocritical Care in Aneurysmal Subarachnoid Hemorrhage Management

Fawaz Al‐Mufti, MD https://orcid.org/0000-0003-4461-7005 fawaz.al-mufti@wmchealth.org, and Stephan Mayer, MDAuthor Info & Affiliations

Stroke: Vascular and Interventional Neurology

Volume 4, Number 4

https://doi.org/10.1161/SVIN.123.001264

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• Nonstandard Abbreviation and Acronym
• Guiding Precision Care and Tailoring Treatment: Neuroendovascular Techniques at the Forefront
• The Rise of Neurocritical Care
• References
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Nonstandard Abbreviation and Acronym

B‐NR evidence

moderate‐quality evidence

The publication of the 2023 American Heart Association (AHA) Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage represents a milestone in the evolving landscape of cerebrovascular medicine.¹ In this commentary, we aim to examine the fundamental shifts brought into focus by these updated guidelines, highlighting the pivotal roles of neuroendovascular management and the neurocritical intensive care unit (neuro‐ICU). While neurointerventionalists have traditionally played a pivotal role in the management of this condition, these guidelines now expand their responsibilities beyond the confines of the operating room.

Traditionally, aneurysmal subarachnoid hemorrhage (aSAH) management has been centered around the timely repair of ruptured cerebral aneurysms. Indeed, the urgency of preventing rebleeding and securing the aneurysm cannot be overstated, as it most significantly impacts patient outcomes. However, the 2023 AHA Guidelines introduce a paradigm shift by recognizing that the battle against aSAH is 2‐fold. While aneurysm repair remains a critical front, there is a more equitable consideration of securement modality. Furthermore, the neuro‐ICU emerges as an equally vital theater where the clinical outcome is determined.

Guiding Precision Care and Tailoring Treatment: Neuroendovascular Techniques at the Forefront

The updated guidelines for managing aSAH emphasize the importance of personalized treatment strategies that consider the unique characteristics of each aneurysm.¹ Extensive research, exemplified by landmark studies such as the ISAT (International Subarachnoid Aneurysm Trial) and the BRAT (Barrow Ruptured Aneurysm Trial), has provided compelling evidence in favor of coiling as the preferred method, particularly for improving patient outcomes in the critical first year following treatment. However, the landscape of aneurysm management is far from 1‐size‐fits‐all, and these guidelines acknowledge the need for a tailored approach(So guessing).

Timing of Treatment

These guidelines stress the significance of prompt intervention for aSAH.¹ Whether through open surgery or endovascular procedures, treating the ruptured aneurysm as early as possible after presentation, preferably within 24 hours, is strongly recommended. This emphasis on timely care reflects the evolving landscape of aneurysm treatment, where precision and expeditiousness are central to achieving the best results for patients. This recommendation is classified as class I, supported by level B‐NR (nonrandomized) evidence. Delaying treatment, particularly beyond a 3‐day window, is discouraged.

Treatment Goal

The primary objective in treating patients with aSAH is the complete obliteration of the ruptured aneurysm whenever feasible(Why not 100% recovery? That's what all survivors want?).¹ This strategy is advocated to reduce the risk of rebleeding and the need for retreatment. In cases for which immediate complete obliteration is not achievable, partial obliteration to secure the rupture site is an acceptable strategy(So failure is acceptable? Good to know!), with retreatment considered for those displaying functional recovery. This recommendation is also classified as class I, with level B‐NR evidence.

Modality of Treatment for Posterior Circulation Aneurysms

These guidelines provide specific guidance for aSAH resulting from ruptured aneurysms in the posterior circulation.¹ In cases in which coiling these aneurysms is feasible, it is recommended over surgical clipping to enhance patient outcomes. This partiality is supported by class I evidence with level B‐R (randomized).

Emergency Clot Evacuation

For patients with aSAH considered salvageable but presenting with a depressed level of consciousness due to a large intraparenchymal hematoma, emergency clot evacuation is recommended.¹ This intervention is pivotal in reducing death and is classified as a class I recommendation with level B‐R evidence.

Specialist Evaluation

The guidelines underline the importance of involving specialists with expertise in both endovascular and surgical treatments for evaluating ruptured aneurysm.¹ This assessment is essential for determining the most suitable treatment approach tailored to individual patient and aneurysm characteristics. Although categorized as class IIb, this recommendation is supported by level B‐R evidence.

Age‐Specific Considerations

Age plays a crucial role in treatment decisions for patients with aSAH.¹ The efficacy of coiling or clipping in improving outcomes for individuals aged >70 years is uncertain, marked as a class IIb recommendation with level C‐LD (limited data) evidence. Conversely, for patients aged <40 years, surgical clipping of the ruptured aneurysm may be considered preferable to enhance treatment durability and overall outcome.

Modality of Treatment for Equally Suitable Aneurysms

In cases of good‐grade aSAH stemming from ruptured aneurysms in the anterior circulation, where primary coiling and clipping are both viable, the 2023 AHA guidelines endorse primary coiling for superior 1‐year functional outcomes.¹ Supported by level A evidence, this recommendation holds a class I designation. However, both treatment options are considered reasonable to achieve favorable long‐term outcomes, constituting a class IIa recommendation with level B‐R evidence.

Endovascular Advancements

These guidelines underscore the growing acceptance of advanced techniques in aneurysm treatment, particularly for wide‐neck aneurysms resistant to traditional methods.¹ Notably, stent‐assisted coiling and flow diversion have gained favor.

Use of Flow Diverters for Fusiform/Blister Aneurysms

In cases of aSAH from ruptured fusiform or blister aneurysms, the use of flow diverters is considered reasonable to reduce death, as indicated by a class IIa recommendation with level C‐LD evidence.¹

Stents or Flow Diverters for Saccular Aneurysms

It is crucial to note, however, that for patients with aSAH with ruptured saccular aneurysms suitable for either primary coiling or clipping, the guidelines advise against using stents or flow diverters due to a higher risk of complications.¹ This recommendation is classified as class III, indicating harm, with level B‐NR evidence. In such instances, where coiling is not deemed suitable or when there is a state of equipoise, the guidelines emphasize the importance of comprehensive multidisciplinary discussions. These discussions should carefully weigh the merits of both neurosurgical and neuroendovascular alternatives, considering each patient's unique circumstances and clinical presentation.

In summary, these guidelines represent a significant step forward in tailoring aSAH treatment to individual patient needs. By emphasizing precision and timeliness in intervention, they aim to achieve the best possible outcomes for patients facing this critical medical condition. The growing acceptance of advanced techniques reflects the dynamic nature of aneurysm management, highlighting the importance of staying abreast of evolving treatment options and engaging in thoughtful, multidisciplinary discussions to optimize patient care.

The Rise of Neurocritical Care

The neuro‐ICU has, in recent years, transitioned from a supporting role to taking center stage in aSAH management. This change is not arbitrary; it is substantiated by a growing body of evidence that underscores the importance of specialized critical care for patients with aSAH.² Multidisciplinary teams in neuro‐ICUs have been shown to significantly enhance patient survival and improve overall outcomes. These teams bring together neurointensivists, neurosurgeons, interventionists, nurses, and other specialists, working in concert to provide the highest standard of care.

The rationale behind this shift is also founded on comparative effectiveness research that consistently demonstrates the benefits of specialized neurocritical care.³ High‐volume centers equipped with dedicated neuro‐ICUs have consistently reported lower mortality rates and improved patient outcomes. This is not merely a theoretical concept but a practical reality that demands acknowledgment and implementation.

Ultimately, the 2023 AHA guidelines serve as a call to action for the medical community, urging physicians, hospitals, medical societies, and national organizations to recognize and champion the importance of neuro‐ICUs in aSAH management.¹ With these guidelines, it is recognized that comprehensive care for patients with aSAH encompasses not only surgical prowess but also the intricate and specialized care delivered within the neuro‐ICU.

Refresher on Mechanical Ventilation

The 2023 guidelines sought to reduce the duration of mechanical ventilation and the risk of hospital‐acquired pneumonia, recognizing that optimal outcomes for critically ill ventilated patients are more likely when evidence‐based care bundles are applied.¹ For patients experiencing aSAH who require mechanical ventilation for >24 hours, it is strongly recommended to implement a standardized ICU care bundle. This recommendation underscores the importance of drawing from the extensive research conducted in both medical and surgical ICUs and consistently applying these principles to patients with high‐grade aSAH (HG‐aSAH). The core components of the ventilator bundle, often referred to as “ABCDEF,” encompass the following aspects:

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Assess, prevent, and manage pain

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Both spontaneous awakening trials and spontaneous breathing trials

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Choice of analgesia and sedation

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Delirium: assess, prevent, and manage

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Early mobility and exercise

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Family engagement and empowerment

In practical terms, what this means for patients with HG‐aSAH is 2‐fold. First, there is substantial evidence supporting the reduction in the use of opioid narcotics and a preference for nonsteroidal anti‐inflammatory drugs like acetaminophen, ibuprofen, and ketorolac.⁴ Second, it involves the regular interruption of sedation, at least once daily, to assess the patient's neurological status and prevent excessive sedation.

Effective prevention of delirium, a common challenge after aSAH, is achieved by avoiding benzodiazepine sedation. Instead, dexmedetomidine is recommended for achieving light sedation while also helping to manage the autonomic dysregulation (ie, storming) often seen in these patients.⁵ Finally, systematic early mobilization necessitates a substantial commitment from both physical therapy and nursing teams. For example, every Hunt–Hess grade III patient capable of following commands with an external ventricular drain should be ambulated daily. These initiatives are best organized and led by a dedicated team of neurointensivists.

Advancements in Neuromonitoring

The updated guidelines emphasize the importance of employing advanced monitoring techniques in the management of patients with HG‐aSAH, particularly when their neurological examination is limited.¹ The direction of neurocritical care, especially for severe brain injuries like HG‐aSAH, is undeniably moving toward sophisticated multimodality brain monitoring. The foundation of this approach involves initiating long‐term continuous video electroencephalogram monitoring, a practice that should be maintained for at least 48 hours in all comatose patients, including those with HG‐aSAH.⁶

Studies have indicated that nonconvulsive seizures are more prevalent in this patient population than previously thought, with a frequency ranging from 10% to 30%.⁷ Importantly, there is substantial evidence to suggest that electrographic seizure activity can significantly impact the patient's level of consciousness and exacerbate secondary brain injury. Furthermore, nonconvulsive seizures have been identified as potential mimics of delayed cerebral ischemia (DCI) after aSAH.^{8, 9}

In recent years, there has been a notable surge in interest and research dedicated to neuromonitoring techniques, encompassing both invasive and noninvasive approaches. One particularly intriguing noninvasive method is transcranial Doppler, often likened to a highly sophisticated ultrasound for the brain. It stands out with an impressive sensitivity exceeding 90%, making it a valuable bedside tool for detecting cerebral abnormalities. However, it is equally important to acknowledge the inherent limitations of this technique. While it excels in sensitivity, it exhibits a specificity of 71% and is also limited by a positive predictive value of 57%. These statistics underscore the need for cautious interpretation and consideration of other clinical factors when using transcranial Doppler data.

Quantitative electroencephalogram patterns have emerged as another noninvasive neuromonitoring approach with great potential.¹ These patterns have shown promise in detecting DCI, with supporting evidence from prospective studies suggesting their clinical relevance. The ability to noninvasively identify DCI is a significant step forward in managing patients with complex neurological conditions.

Invasive neuromonitoring tools, such as brain tissue oxygen monitoring, cerebral microdialysis, and electrocorticography, have also found their place in the realm of DCI detection.¹ This assertion is supported by a comprehensive review encompassing 47 studies. These invasive techniques provide valuable insights into cerebral physiology and can be instrumental in tailoring treatment strategies for individual patients.

In summary, it is important to recognize that the optimal indications and best practices for these neuromonitoring methods are still under investigation. The field continues to evolve as researchers refine their understanding of when and how to deploy these techniques most effectively. Moreover, while these tools hold great promise, their ultimate impact on clinical outcomes in the context of subarachnoid hemorrhage and other neurological conditions remains an area of active exploration.

Antiseizure Medication Controversy

One contentious topic within the management of aSAH that the guidelines grapple with is the use of prophylactic antiseizure medications.¹ While the guidelines do recommend against their routine administration, they do so with an understanding that numerous medical centers continue to adopt a universal approach in administering these medications to patients with aSAH. This disparity in practice highlights the ongoing debate surrounding the benefits and risks associated with prophylactic antiseizure medications in this patient population, particularly in relation to cognitive outcomes.

The rationale for administering prophylactic antiseizure medications stems from concerns about the heightened risk of seizures in patients with aSAH due to the brain's exposure to blood and potential irritants from the hemorrhage. Consequently, some medical institutions have chosen to err on the side of caution by providing antiseizure medications to all patients with aSAH, regardless of their individual risk factors. Although antiseizure medications can effectively reduce the risk of seizures, they are not without their own set of adverse effects. These medications may lead to side effects such as sedation, impaired cognition, and even delirium.

There is a growing body of evidence suggesting that long‐term use of certain antiseizure medications, particularly phenytoin, may be associated with negative cognitive outcomes in patients with aSAH.¹ This raises concerns about whether the potential benefits in terms of seizure prevention outweigh the risks, especially when it comes to the patient's overall cognitive function and quality of life. The cumulative risk of convulsive seizures in hospitalized patients with aSAH has been reported to be 4%. Could the risk of delirium or oversedation from routine antiseizure medication use be higher? It has been reported that continued phenytoin use after discharge in patients with aSAH is associated with worse cognitive outcomes that then improve when the medication is stopped. We do not anticipate any change in practice until clinical trials are conducted to address the issue of antiseizure medication use after aSAH.

The guidelines acknowledge this contentious landscape and the need for further clarity.¹ They highlight the importance of conducting additional clinical trials to better understand the impact of prophylactic antiseizure medications on cognitive outcomes in patients with aSAH. This research would aim to provide concrete evidence regarding the risk–benefit balance, potentially informing more precise recommendations in the future.

Caution Against Hemodynamic Prophylaxis and Hypervolemia

The cautionary approach to hemodynamic augmentation and hypervolemia in the 2023 AHA Guidelines for aSAH management signifies another notable departure from previous strategies.¹ This shift aligns with a broader principle in critical care medicine: the recognition that sometimes less intervention can yield better outcomes. It reflects the acknowledgment that excessive medical interventions, even with the best intentions, can lead to unintended complications that may worsen the patient's condition.

One of the critical aspects of this cautionary approach is the recognition of potential complications associated with aggressive hemodynamic management.¹⁰ By attempting to artificially increase blood pressure or volume in patients with aSAH, health care providers may inadvertently trigger an adverse event. In certain circumstances, we may develop a strong fixation on pursuing active interventions, making it quite tempting to deviate from established protocols. For instance, one might consider, “I know that per the guidelines we're only supposed to induce hypertension in the face of symptomatic vasospasm, but I'm concerned about this particular patient.” In addition to potentially fatal complications such as myocardial infarction and pulmonary edema, the guidelines highlight the risk of exacerbating intracranial pressure, which can be detrimental in patients with aSAH, who are already at risk of elevated pressure within the skull. Additionally, there is the practice of prophylactically inducing hypertension to arbitrary blood pressure targets in every patient. This is a common occurrence.

Another noteworthy concern is the possibility of inducing posterior reversible encephalopathy syndrome, a neurological condition characterized by symptoms such as headache, altered mental status, seizures, and visual disturbances. Posterior reversible encephalopathy syndrome can occur when there is a sudden increase in blood pressure, which can result from aggressive attempts to elevate it in patients aSAH. Recognizing the potential harm of such interventions is crucial in avoiding these complications.

As a final deterrent from aggressive hemodynamic management, the guidelines draw attention to the concept of pressor dependence.¹ This phenomenon is thought to occur when patients are subjected to aggressive blood pressure management, resulting in their bodies becoming reliant on medications to sustain blood pressure within a reasonable target range. This can make it challenging to wean patients off these medications without their blood pressure dropping below the desired threshold. Even if only occurring in the thoughts and concerns of the neuro‐ICU team, this phenomenon can lead to prolonged hospital stays and increased health care resource usage.

More Oral Nimodipine?

With a continuance of the 2012 recommendations, the updated guidelines stamp the significance of early enteral nimodipine initiation in preventing DCI and enhancing functional outcomes in cases of aSAH.¹

In clinical practice, the administration of oral nimodipine occurs along a schedule of 60 mg every 4 hours, following the precedent set by the British Nimodipine Trial in 1989.¹¹ Unfortunately, this regimen often gets discontinued as soon as patients with aSAH exhibit symptomatic vasospasm due to its tendency to cause systemic hypotension. As a result, health care providers often resort to halving the dosage or, more commonly, suspending nimodipine altogether.

The question that has persisted over time is whether there might be superior agents or administration protocols for arterial vasodilators that could provide more effective alternatives.¹ Examples include continuous intravenous infusion of nimodipine, a practice prevalent in Europe, or the use of fasudil and clazosentan, which are favored in Japan. However, it is crucial to note that the current body of evidence does not support an immediate shift in US clinical practice. This underscores the dynamic nature of medical practice, with a recognition that as science advances, treatment strategies may evolve to provide better outcomes for patients with aSAH.

Taking the Guidelines Into Practice

In managing cases of aSAH, it is crucial to recognize that there is not a definitive volume threshold that guides treatment decisions. Each patient's condition must be carefully evaluated, highlighting the importance of individualized care. Timely transfer of patients presenting with acute severe headaches or new neurological deficits is paramount to ensure they undergo appropriate diagnostic assessments and receive specialized care as needed. Patients presenting >6 hours after the onset of severe headaches or those with new neurological deficits should undergo a noncontrast head computed tomography. If this initial scan is negative for aSAH, lumbar puncture becomes essential to confirm or exclude the presence of subarachnoid blood. Similarly, for individuals with spontaneous aSAH and a strong suspicion of aneurysmal involvement but inconclusive results from computed tomography angiography, digital subtraction angiography is the recommended diagnostic tool to identify or rule out cerebral aneurysms promptly.

Prompt identification of aneurysmal sources remains a paramount concern for clinical management.¹ Comprehensive use of advanced imaging methods, such as CT angiography, can significantly aid in this regard. Furthermore, using established grading scales can aid in outcome prediction and guide discussions with patients, families, and surrogates regarding treatment choices. Decisions regarding the treatment of ruptured aneurysms should be made by specialists well versed in both endovascular and surgical approaches. Ultimately, the determination to use clipping, coil embolization, or even flow diversion should be tailored to the patient's distinctive characteristics and the aneurysm's unique features. As highlighted by the current guidelines, there is a growing preference for coil embolization for good‐grade aSAH cases originating from anterior circulation ruptured aneurysms.¹

Neuro‐ICU management should encompass preventive measures such as deep vein thrombosis prophylaxis, maintaining euvolemia, and thoughtful fluid management.¹ While invasive neuromonitoring techniques are increasingly valuable for detecting DCI in high‐grade aSAH cases, the specific goals for fluid management require further clarification. Although the risk of rerupture in aSAH cases is relatively low, the use of imaging to guide treatment decisions for survivors in the neuro‐ICU is recommended, particularly in individuals with residual aneurysms. Regular monitoring for the development of new aneurysms is also essential, especially in younger patients with multiple aneurysms or a strong family history of aSAH.

Additionally, considerations such as the timing of cerebrospinal fluid diversion, choice of fluids, sodium goals, temperature management, glucose control, and monitoring of intracranial pressure and multimodal monitoring are important aspects of comprehensive aSAH management that deserve further attention and investigation.¹ Finally, early identification of deficits, especially in behavioral and cognitive domains, is crucial. Interventions for mood disorders can significantly improve long‐term outcomes, and providing counseling on the higher risk of long‐term cognitive dysfunction may prove beneficial for patients recovering from aSAH.

References at link.

Hemodynamic Impairment of Blood Pressure and Stroke Mechanisms in Symptomatic Intracranial Atherosclerotic Stenosis

 So we still have NO BLOOD PRESSURE MANAGEMENT PROTOCOL around stroke issues! You better hope your doctors guess correctly.

Hemodynamic Impairment of Blood Pressure and Stroke Mechanisms in Symptomatic Intracranial Atherosclerotic Stenosis

Zimo Chen,

Jia Liu,

Anqi Wang,

Bokai Wu,

Zaiheng Cheng,

Yingyu Jiang,

Hongqiu Gu,

Lingling Ding,

Jinglin Mo,

Yong Jiang,

Liping Liu,

Lina Jing,

Jing Jing,

Yilong Wang,

Xingquan Zhao,

… See all authors

Originally published5 Jun 2024https://doi.org/10.1161/STROKEAHA.123.046051Stroke. 2024;0

Abstract

BACKGROUND:

Hemodynamic impairment of blood pressure may play a crucial role in determining the mechanisms of stroke in symptomatic intracranial atherosclerotic stenosis). We aimed to elucidate this issue and assess the impacts of modifications to blood pressure on hemodynamic impairment.

METHODS:

From the Third China National Stroke Registry III, computed fluid dynamics modeling was performed using the Newton-Krylov-Schwarz method in 339 patients with symptomatic intracranial atherosclerotic stenosis during 2015 to 2018. The major exposures were translesional systolic blood pressure (SBP) drop and poststenotic mean arterial pressure (MAP), and the major study outcomes were cortex-involved infarcts and borderzone-involved infarcts, respectively. Multivariate logistic regression models and the bootstrap resampling method were utilized, adjusting for demographics and medical histories.

RESULTS:

In all, 184 (54.3%) cortex-involved infarcts and 70 (20.6%) borderzone-involved infarcts were identified. In multivariate logistic model, the upper quartile of SBP drop correlated with increased cortex-involved infarcts (odds ratio, 1.92 [95% CI, 1.03–3.57]; bootstrap analysis odds ratio, 2.07 [95% CI, 1.09–3.93]), and the lower quartile of poststenotic MAP may correlate with increased borderzone-involved infarcts (odds ratio, 2.07 [95% CI, 0.95–4.51]; bootstrap analysis odds ratio, 2.38 [95% CI, 1.04–5.45]). Restricted cubic spline analysis revealed a consistent upward trajectory of the relationship between translesional SBP drop and cortex-involved infarcts, while a downward trajectory between poststenotic MAP and borderzone-involved infarcts. SBP drop correlated with poststenotic MAP negatively (r_s=−0.765; P<0.001). In generating hemodynamic impairment, simulating blood pressure modifications suggested that ensuring adequate blood pressure to maintain sufficient poststenotic MAP appears preferable to the reverse approach, due to the prolonged plateau period in the association between the translesional SBP drop and cortex-involved infarcts and the relatively short plateau period characterizing the correlation between poststenotic MAP and borderzone-involved infarcts.

CONCLUSIONS:

This research elucidates the role of hemodynamic impairment of blood pressure in symptomatic intracranial atherosclerotic stenosis-related stroke mechanisms, underscoring the necessity to conduct hemodynamic assessments when managing blood pressure in symptomatic intracranial atherosclerotic stenosis.

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Dietary deep dive: Unveiling the good, the bad, and the unclear in blood pressure battleground

Proof once again that really nothing is known about blood pressure management, certainly not after your stroke. Hope you like the guesses your doctor makes. 

Dietary deep dive: Unveiling the good, the bad, and the unclear in blood pressure battleground

In a recent study published in the journal Advances in Nutrition, researchers critically assessed the impact of various dietary elements on blood pressure and hypertension risk through an umbrella review of meta-analyses from both interventional and observational studies.

Review: The role of diet in the prevention of hypertension and management of blood pressure: An umbrella review of meta-analyses of interventional and observational studies. Image Credit: udra11 / Shutterstock

Background 

High blood pressure (BP) is a leading contributor to cardiovascular diseases and adult mortality. A global prevalence of hypertension of 34% for men and 32% for women was observed in 2019, but fewer than half of the treated population had their hypertension controlled. The main risk factors include dietary and lifestyle habits, such as sodium intake and physical activity. While organizations like the European Society of Cardiology provide guidelines highlighting diets like the Mediterranean and Dietary Approaches to Stop Hypertension (DASH), recent studies have delved into specific food groups and nutrients' effects on BP. Further research is needed to assimilate emerging dietary insights and refine current hypertension guidelines.

About the study 

The present umbrella review was carried out based on the Joanna Briggs Institute's methodology and was registered on the International Prospective Register of Systematic Reviews (PROSPERO). A precise literature search spanned databases like PubMed, Embase, Web of Science, and Cochrane Central Register of Controlled Trials until October 2021. The aim was to identify meta-analyses of both randomized controlled trials (RCTs) and observational studies concerning diet and blood pressure. Two researchers worked independently on this search, using specific search terms, focusing on human studies. A third researcher resolved any disagreements in selections.

To avoid duplications, a structured method was used to include meta-analyses. If multiple meta-analyses addressed a similar dietary exposure, the most comprehensive one was selected based on the number of primary studies, total sample size, and depth of information provided. Data extracted included author details, publication year, outcome specifics, intervention type, exposure, study design, number of participants, result types, heterogeneity analysis, effect estimates, and potential conflicts of interest. Effect sizes were visually represented using Forest plots, and dietary effects were further grouped by their impact on blood pressure, classified based on the NutriGrade system.

The quality of the included publications was gauged using the Assessment of Multiple Systematic Reviews 2 (AMSTAR 2) tool, examining various critical domains pertinent to the systematic review process. The NutriGrade system, designed to grade evidence in nutrition research, was used to assess the quality of evidence for each meta-analysis. This system evaluated multiple quality aspects of the meta-analyses, with two reviewers independently making assessments and a third resolving any disagreements. The evidence was then rated based on its quality, from high to very low, providing a comprehensive understanding of the collective research on the relationship between diet and blood pressure.

Study results 

A comprehensive review, employing the PRISMA flowchart, scrutinized 17,099 records, finalizing 175 publications. These encompassed a broad spectrum of dietary factors, from meat and vegetables to beverages and macronutrients. The main contributions hailed from Europe, Asia, and North America.

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The methodological robustness of the publications displayed variation. In RCTs, high-quality studies constituted 7.5%, with a descending quality observed in 43.2% moderate, 27.4% low, and 21.9% critically low. The observational studies did not reach a high-quality rating; 65.5% were deemed moderate, with 27.6% low and 6.9% critically low. Many low-quality studies were critiqued for overlooking grey literature and exhibiting biases.

The NutriGrade system identified limited high-quality RCT meta-analyses. Concerning between-study heterogeneity in RCTs, 6.5% did not acknowledge it, while 35.4% reported significant variations. Only 29.6% of RCTs bore a low risk of publication bias, whereas observational studies exhibited diverse risk profiles.

The review explored dietary regimes and their implications on blood pressure. High-quality RCT data suggested diets like DASH and ketogenic contributed positively to blood pressure control. While observational studies proffered weaker evidence for diets such as vegan and Mediterranean. Within the meat, eggs, and fish category, RCTs offered moderate evidence about fish and egg consumption, contrasting with observational studies that presented a lower quality testament for egg and meat intake.

Diving deeper, the NutriGrade system shed light on the relationship between specific foods and blood pressure. Fruits and vegetables emerged with a moderate quality endorsement, signifying potential blood pressure reduction from foods like blueberries and beetroot. Starch-rich foods garnered mostly low-quality evidence, whereas legumes presented a mixed bag, with pulses being an exception with their moderate evidence. Nuts and seeds, with a special mention of flaxseed, stood out with high-quality proof for their blood pressure-lowering capacities. Cocoa, too, had moderate supportive evidence.

 In the herb domain, cinnamon reduced while licorice escalated diastolic blood pressure. Teas received moderate validation for reducing blood pressure, with coffee's influence remaining ambiguous. Discussions around macronutrients highlighted proteins like L-carnitine and soy protein with favorable evidence. In contrast, the majority of fats and oils, barring a few like Eicosapentaenoic Acid (EPA), exhibited inconsistent results. Minerals also showcased variability; potassium was strongly advocated for blood pressure diminution, whereas calcium and zinc remained inconclusive.

Journal reference:

• Ghadeer S. Aljuraiban, Rachel Gibson, Doris SM. Chan, et al. The role of diet in the prevention of hypertension and management of blood pressure: An umbrella review of meta-analyses of interventional and observational studies, Advances in Nutrition, 2023, DOI- https://doi.org/10.1016/j.advnut.2023.09.011, https://www.sciencedirect.com/science/article/pii/S2161831323013844
  

Stroke Scale Cutoff Might Not Be Ideal Guide for Ordering CTA and Detecting Large Vessel Occlusions

Aren't you glad your doctor is guessing about what to do when you present to the ER as a stroke patient?

Stroke Scale Cutoff Might Not Be Ideal Guide for Ordering CTA and Detecting Large Vessel Occlusions

BOSTON — In emergency department stroke consultations, the National Institute of Health Stroke Scale (NIHSS) alone does not appear to be a reliable guide for ordering diagnostic tests for a large vessel occlusion (LVO), according to large body of data presented at the 2023 annual meeting of the American Academy of Neurology.

If the goal is not to miss any LVOs, there is no NIHSS score below which these do not occur, according to Theresa Sevilis, DO, regional medical director, TeleSpecialists, Fort Myers, Fla.

For example, her evaluation of a large and nationally representative dataset shows that more than 10% of the LVOs eventually identified and accepted for intervention would be missed with a cutoff of NIHSS score of 6 or higher. Moving the cutoff NIHSS score to 4 or greater, 6% of LVOs among the 23,166 strokes evaluated would have gone undetected.

"The current guidelines do not address low NIHSS score largely due to a paucity of data," according to Dr. Sevilis, who showed data indicating that there is great variation among institutions in regard to ordering computed tomography angiography (CTA). She indicated that CTA is the current imaging standard for detecting LVO.

Large prospective dataset

The data for this study were derived from the TeleCare database, which captures acute stroke consultations in the emergency departments in 227 facilities in 27 states. Stroke consultations over a 6-month period from July through December 2021 were evaluated. The prospectively collected data were subjected to a multivariate analysis to determine the odds ratio for a CTA performed and LVO found at each NIHSS score of 0 to 5. Scores 6 or above served as the reference.

"Only consults performed within 24 hours [of presentation] were included," Dr. Sevilis said.

After excluding cases in which no NIHSS score was captured, which represented less than 1% of cases, more than 10,500 cases underwent CTA, providing a rate of 45.5%. The rate of CTA for the whole dataset was 45.5%. Of the study population, 24.6% had a NIHSS score of 6 or above.

"When you are discussing when to perform CTA in patients with a low NIHSS score, you are discussing the majority of patients," Dr. Sevilis said.

Of those with a NIHSS stroke of 6 or below, 28.2% had a score of 0. Not surprisingly, these were the least likely to have a CTA performed on the basis of an odds ratio of 0.14 and the least likely to have a LVO detected (OR, 0.1). With the exception of a NIHSS stroke score of 1, the likelihood of CTA and LVO climbed incrementally with higher stroke scores. These odds ratios were, respectively, 0.16 and 0.09 for a score of 1; 0.27 and 0.16 for a score of 2; 0.33 and 0.14 for a score of 3; 0.49 and 0.24 for a score of 4; and 0.71 and 0.27 for a score of 5.

In the group with NIHSS score of 6 or above, 24.1% were found to have an LVO. Of these, the proportion accepted for a mechanical thrombectomy was less than half. The intervention acceptance rate for mechanical intervention among LVOs in patients with lower NIHSS scores again fell incrementally by score. The acceptance rate was about 35% among LVO patients with a NIHSS score of 3 or 4 and 25% for those with a score of 0-2.

The interpretation of these data "depends on goals," Dr. Sevilis said. "If the goal is to not miss a single LVO, then it is important to consider the balance between benefits and risks."

No consistent cutoff

In participating facilities, the protocol for considering CTA to detect and treat LVOs ranges from neurologist choice to cutoffs of NIHSS scores of 2, 4, and 6, according to Dr. Sevilis. Where the data suggest that a cutoff of 4 or above might be reasonable, she said that NIHSS scoring is not a useful tool for those "who do not want to miss any LVOs."

These data are based on emergency room stroke consultations and not on confirmed strokes," Dr. Sevilis emphasized. Indeed, she noted that the final discharge diagnosis was not available. Recognizing that the analysis was not performed on a population with confirmed strokes is particularly important for understanding the limited rate of CTAs performed even in those with relatively high NIHSS scores. She noted this could be explained by many different reasons, including suspicion of hemorrhage or clinical features that took the workup in a different direction.

Reconsidering protocols

Based on the large sample size, Dr. Sevilis contended that it is likely that these data are representative, but she considers this study a first step toward considering protocols and developing guidelines for addressing stroke alerts in the emergency department.

A more important step will be ongoing trials designed specifically to generate data to answer this question. Pascal Jabbour, MD, chief of the division of neurovascular and endovascular neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, is participating in one of these trials. He agreed with the premise that better evidence-based criteria are needed when evaluating acute stroke patients with a potential LVO.

The trial in which he is a coinvestigator, called ENDOLOW, is testing the hypothesis that outcomes will be better if acute stroke patients with a LVO and a low baseline NIHSS score (< 5) are treated with immediate thrombectomy rather than medical management. If this hypothesis is confirmed in the randomized ENDOLOW, it will provide an evidence basis for an approach already being practiced at some centers.

"There should be a very low threshold for CTA," said Dr. Jabbour in an interview. This imaging "takes less than 2 minutes and it can provide the basis for a life-saving endovascular thrombectomy if a LVO is found."

It is already well known that LVO is not restricted only to patients with an elevated NIHSS score, he said.

For determining whether to order a CTA, "I do not agree with NIHSS score of 6 or above. There is no absolute number below which risk of missing a LVO is eliminated," Dr. Jabbour said. He also argued against relying on NIHSS score without considering other clinical features, particularly cortical signs, which should raise suspicion of a LVO regardless of NIHSS score.

One problem is that NIHSS scores are not static. Decompensation can be rapid with the NIHSS score quickly climbing. When this happens, the delay in treatment might lead to a preventable adverse outcome.

"There is a change in the paradigm now that we have more evidence of a benefit from aggressive treatment in the right candidates," according to Dr. Jabbour, referring to the recently published SELECT2 trial. In that trial, on which Dr. Jabbour served as a coauthor, patients with LVO and large territory infarct were randomized to thrombectomy or medical care within 24 hours of a stroke. It was stopped early for efficacy because of the increased functional independence (20% vs. 7%) in the surgical intervention group.

If the ongoing trials establish better criteria for ruling in or out the presence of LVO in patients with acute stroke, Dr. Jabbour predicted that guidelines will be written to standardize practice.(What useless crapola! GUIDELINES NOT PROTOCOLS!)

Dr. Sevilis reports no potential conflicts of interest. Dr. Jabbour has financial relationships with Cerenovus, Medtronic, and Microvention.

This article originally appeared on MDedge.com, part of the Medscape Professional Network.

 

CATIS-2: Delayed Antihypertension Tx for Acute Ischemic Stroke Still an Option

 

So you acknowledge that there are no blood pressure management protocols but DO NOTHING to solve them. Hope you don't mind dying because your doctor guessed wrong on your blood pressure management.

CATIS-2: Delayed Antihypertension Tx for Acute Ischemic Stroke Still an Option

Early therapy not a better bet for cutting death and disability risks at 3 months

by Elizabeth Short, Staff Writer, MedPage Today February 11, 2023

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DALLAS -- Antihypertensive treatment could wait for 7 days following an acute ischemic stroke (AIS), so long as the patient has no comorbidities that warrant the emergency reduction of their blood pressure (BP).

In the CATIS-2opens in a new tab or window trial, there was no significant difference in the composite of major disability and death between patients with AIS who received either early or delayed antihypertensive treatment after 3 months (OR 1.17, 95% CI 0.98-1.40, P=0.092) reported Liping Liu, MD, PhD, of Capital Medical University and the National Clinical Research Center for Neurological Diseases in Beijing.

There also was no significant difference between the time at which antihypertensive treatment was administered (early or delayed) and major vascular events (OR 1.14, 95% CI 0.89-1.46, P=0.3) and recurrent stroke (OR 1.08, 95% CI 0.85-1.38, P=0.53) at 90 days, according to findings from the multicenter, randomized trial.

"Increased blood pressure is really common in the acute stage and is strongly associated with poor neurological functions and the recurrence of ischemic stroke. So we have lots of concerns and problems facing either in clinical practice and clinical research," Liu said in a presentation at the American Stroke Association International Stroke Conferenceopens in a new tab or window.

Subgroup analysis showed that there were differences observed in systolic BP between the two groups following randomization, with a "moderate reduction" in BP for both.

After the first 24 hours, those who got delayed antihypertensive treatment had an average systolic BP 8.6 mmHg (4.9%), while those who got early antihypertensive treatment had an average systolic BP of 16.4 mmHg (9.7%) for a -7.8 mmHg difference (95% CI -6.7 to -8.9, P<0.0001). After a week, the average systolic BPs were 150.9 mmHg and 139.1 mmHg, respectively, for a -11.9 mmHg difference (95% CI -12.9 to -10.9, P<0.0001).

Results from the first CATIS trial came out in 2014 in JAMAopens in a new tab or window, and showed that among patients with AIS, BP reduction with antihypertensive meds versus no hypertensive meds did not cut the likelihood of death and major disability at 14 days or hospital discharge. Subgroup analysis revealed a reduction in BP levels for patients who had received antihypertensive medications either 24 hours or longer following stoke onset, which was tied to a lowering of risk for major disability or death.

In a 2014 JAMAopens in a new tab or window editorial, Jeffrey L. Saver, MD, of the University of California Los Angeles, stated that "CATIS provides evidence to support the view that how blood pressure is managed in the subacute period from 12 hours to 2 weeks after ischemic stroke does not matter much. When blood pressure remained untreated during the first 2 weeks, the frequency of composite recurrent vascular events (vascular death, nonfatal stroke, nonfatal myocardial infarction, rehospitalization for angina, congestive heart failure, or peripheral arterial disease) was low, approximately 3.0%, affording little opportunity for active blood pressure lowering to improve outcome."

However, Saver warned that "the CATIS trial reflects the population and clinical practice of China and may not be fully generalizable to other populations," while Liu's group noted that the "optimal BP management strategy in these patients remains uncertain and should be the focus of future research."

CATIS-2opens in a new tab or window trial patients had a mean age of 63.7 and the majority were men with an elevated BP following MRI- or CT-confirmed AIS, with systolic BP between 140 and 200 mmHg and diastolic BP between 80 and 120 mmHg.

Analysis was done with 4,783 patients from June 13, 2018 to Oct. 15, 2022 at 106 sites. Patients were more or less evenly split between the two study arms. Median systolic and diastolic BPs were 162.8 and 91.8 mmHg, respectively. Over three-fourths had hypertension. The median time from stroke onset to intervention was 1.9 days. Those with an NIH Stroke Scale score of ≥21 were excluded; median score in the study population was 3.

Study limitations included the fact that the BP reduction seen within the first 7 days in the early-treatment group was moderate, according to the authors. Also, because patients treated with baseline IV thrombolysis or endovascular thrombectomy were excluded, the results cannot be generalized to those patients, they cautioned.

• 

  Elizabeth Short is a staff writer for MedPage Today. She often covers pulmonology and allergy & immunology. Follow

Disclosures

The study was funded by the Ministry of Science and Technology of the People's Republic of China and the National Natural Science Foundation of China.

Liu disclosed no relationships with industry.

Saver disclosed serving as a JAMA associate editor.

Primary Source

International Stroke Conference

Source Reference: opens in a new tab or windowLui L, et al "Early antihypertensive treatment with delayed antihypertensive treatment for acute ischemic stroke (catis-2): a multicenter randomized, open-label, blinded-endpoint, phase 3 trial" ISC 2023.

Lowering blood pressure after clot removal may not be safe; should be individualized

This makes perfect sense, less blood pressure means less oxygen being delivered to the brain probably hastening the death of those neurons in the penumbra.  So we still have no blood pressure management protocol and it seems likely it will stay that way for a long time with NO STROKE LEADERSHIP. Hope your doctor guesses right on blood pressure post stroke. Will your doctor guarantee no bad effects from their guesses on blood pressure management?

 

Lowering blood pressure after clot removal may not be safe; should be individualized

American Stroke Association International Stroke Conference – Late-Breaking Science Presentation LB 18

Research Highlights:

• Using blood pressure medications to lower systolic blood pressure immediately after mechanical clot removal (endovascular treatment) for acute ischemic stroke may not be safe or effective and should be considered with caution and individualized to each patient, according to a preliminary study.
• At 36 hours, stroke volumes showed no conclusive evidence of harm, and after 90 days, the disability outcome showed only a slight indication of harm. The researchers concluded that individualized blood pressure control may be the way forward.

Embargoed until 11:37 a.m. CT/12:37 p.m. ET Friday, Feb. 10, 2023

DALLAS, Feb. 10, 2023 — Using blood pressure medications to lower the top number of blood pressure reading (systolic blood pressure) may not be safe or effective among people who have an acute ischemic stroke and undergo a successful mechanical clot removal — endovascular therapy, according to a phase-2 late-breaking clinical trial presented today at the American Stroke Association’s International Stroke Conference 2023. The meeting, to be held in person in Dallas and virtually, Feb. 8-10, 2023, is a world premier meeting for researchers and clinicians dedicated to the science of stroke and brain health.

“Health care professionals should be cautious when lowering blood pressure after endovascular treatment, as there are some signs that blood pressure that’s too low may be harmful,” explained lead study author Eva Mistry, M.B.B.S., a stroke neurologist and assistant professor in the department of neurology and rehabilitation medicine at the University of Cincinnati in Ohio.

“Individual patients might require lowering of blood pressure due to medical and neurological reasons, however, it should not be done as blanket practice with all patients. It may benefit some patients and needs to be customized,” she said.

“Endovascular therapy has changed the landscape in acute stroke treatment,” she continued. “Patients do drastically better when they receive endovascular treatment, compared to when they don’t. And, despite the enormous effectiveness of endovascular treatment, about 50% of patients remain disabled or die at 90 days, so we are on a quest to understand if there are additional strategies that may further improve outcomes in these patients.”

Previous research has indicated that higher systolic blood pressure after endovascular treatment is associated with greater disability in people who have had an acute ischemic stroke (most common type of stroke caused by a blockage). Endovascular treatment is a catheter-based therapy used to remove a blood clot blocking arteries and thereby restoring blood flow. Systolic blood pressure between 140 mm Hg and 160 mm Hg has been associated with better outcomes following the procedure. Normal blood pressure is considered as less than 120 mm Hg systolic (top number in a blood pressure reading) and less than 80 mm Hg diastolic (bottom number in a blood pressure reading). However, whether using blood pressure medications to artificially lower systolic blood pressure to less than 180 mm Hg is safe and effective has not been demonstrated following clot removal.

“There is always the concern if blood pressure is lowered too much in patients who are having an acute ischemic stroke that it could make the size of their stroke worse by reducing already compromised blood flow in that area,” Mistry explained.

In this study, called Blood Pressure After Endovascular Stroke Treatment, or BEST II, researchers hypothesized that patients allocated to lowering systolic blood pressure targets might have a higher volume of stroke size at 36 hours and a higher disability at 90 days.

Researchers enrolled 120 patients (average age of 70 years, 57% female) who had an acute ischemic stroke and successful endovascular treatment at one of three urban comprehensive stroke centers (Vanderbilt University Medical Center in Tennessee; University of Cincinnati in Ohio; and Hartford Health Medical Center in Connecticut) between January 2020 and February 2022. Forty patients were randomly assigned to have their systolic blood pressure lowered to a target of less than or equal to 180 mm Hg; 40 patients were assigned to a systolic blood pressure target of less than 160 mm Hg; and 40 patients were targeted to reach a systolic blood pressure of less than 140 mm Hg. Patients were treated with an anti-hypertensive medication called nicardipine, administered intravenously, started within one hour after endovascular treatment and given for 24 hours if their systolic blood pressure was above the target they were assigned. Researchers wanted to assess whether lowering blood pressure may cause harm to brain tissue, which is particularly vulnerable during the 24 hours after a stroke, and to assess disability 90 days later.

The study found:

• In the less than or equal to 180 mm Hg-target group, average systolic blood pressure reached 129 mm Hg.
• In the below 160 mm Hg-target group, the average systolic blood pressure reached 130 mm Hg.
• In the less than 140 mm Hg-target group, systolic blood pressure was lowered to an average of 123 mm Hg.
• The average 36-hour stroke volumes showed no conclusive evidence of harm.
• In the 90-day disability outcome, there was only a slight indication of harm.

“The main outcomes of the study were the size of stroke at 36 hours and degree of disability at 90-days,” Mistry said. “Although the study did not find significant evidence of an unequivocal harm of lower blood pressure targets in this population in terms of worsening size of stroke or increasing disability, the trends indicated that there may only be marginal benefit on patients’ long-term disability by lowering blood pressure after endovascular treatment. In fact, there was indication that lowering the blood pressure after thrombectomy may worsen patients’ long-term disability.”

“This study provides indication that patients’ blood pressure should be allowed to be auto regulated after endovascular treatment unless about 180 mm Hg, and clinicians might want to be cautious when they reflexively lower the blood pressure since there may be some signal of harm,” Mistry said. “There should be individual patient decision making, such as if there are other medical reasons for lowering the blood pressure or if there are signs of significant bleeding in the brain.”

The study’s limitations include the small number of patients involved in the trial. Additionally, because the trial was conducted at three centers, the results may not apply to stroke patients treated elsewhere.

Study co-authors are Kimberly Hart, Ph.D.; Larry Davis, M.D.; Yue Gao, M.S., M.Ed.; Charles Joseph Prestigiacomo, M.D.; Shilpi Mittal, M.D.; Tapan Mehta, M.D.; Hayden Lafever, Ph.D.; Pablo Harker; Hilary Perez; Kalli Beasley, M.P.H.; Neeharika Krothapalli, M.D.; Emily Lippincott, M.D.; Heather Stefek, M.D.; Michael Froehler, M.D., Ph.D.; Rohan Chitale, M.D.; Matthew Fusco, M.D.; Aaron W. Grossman, M.D., Ph.D.; Peyman Shirani, M.D.; Matthew Smith, M.D.; Matthew N. Jaffa, D.O.; Sharon D. Yeatts, Ph.D.; Gregory W. Albers, M.D.; Jonathan Wanderer, M.D., M.Phil.; Juliana Tolles, M.D.; Christopher Lindsell, Ph.D.; Roger Jay Lewis, M.D., Ph.D.; Gordon R. Bernard, M.D.; and Pooja Khatri, M.D., M.Sc. The list of authors’ disclosures is available in the abstract.

The National Institute of Neurological Disorders and Stroke, a division of the National Institutes of Health, funded the study.

Statements and conclusions of studies that are presented at the American Heart Association’s scientific meetings are solely those of the study authors and do not necessarily reflect the Association’s policy or position. The Association makes no representation or guarantee as to their accuracy or reliability. Abstracts presented at the Association’s scientific meetings are not peer-reviewed, rather, they are curated by independent review panels and are considered based on the potential to add to the diversity of scientific issues and views discussed at the meeting. The findings are considered preliminary until published as a full manuscript in a peer-reviewed scientific journal.

The Association receives funding primarily from individuals; foundations and corporations (including pharmaceutical, device manufacturers and other companies) also make donations and fund specific Association programs and events. The Association has strict policies to prevent these relationships from influencing the science content. Revenues from pharmaceutical and biotech companies, device manufacturers and health insurance providers and the Association’s overall financial information are available here.

Additional Resources:

• Multimedia is available on the right column of release link https://newsroom.heart.org/news/lowering-blood-pressure-after-clot-removal-may-not-be-safe-should-be-individualized?preview=68dcf03750c432a720aeb5150e1801bd
• ·AHA health information: The Facts About High Blood Pressure
• ·AHA health information: Ischemic Stroke Treatment
• AHA news release: Mechanical blood clot removal led to good recovery in half of stroke patients (Feb. 2022)
• For more news at ASA International Stroke Conference 2022, follow us on Twitter @HeartNews #ISC23.

Rehabilitation strategies post-stroke - McMaster University

And yet none of these are protocols, so as guidelines they are just hopeful guesses on what might work rather than what will work. Hope you like paying for guesswork rather than EXACT RECOVERY PROTOCOLS!

Rehabilitation strategies post-stroke

 

Dec 13, 2022 - McMaster University -

Stroke affects up to 10% of older adults in Canada, making it the third leading cause of death nationally and one of the leading causes of disability worldwide. For many people, recovery from the initial event is just the beginning of a longer period of rehabilitation to restore lost function caused by the stroke. 

 

Those who suffer and survive a stroke can face a variety of temporary or permanent disabilities that differ in severity and impact their ability to complete activities of daily living. For instance, approximately 80% of people experience limitations moving their arms or legs following a stroke, while over 30% encounter difficulties communicating. These problems can feel like insurmountable obstacles on the road to recovery. However, research has identified several strategies that can help address these issues and aid with rehabilitation efforts, including mirror therapy, speech and language therapy, and walking training.

 

We have compiled some of the latest research on these strategies below.

Featured Resources

• Blog Post: Mirror therapy for stroke rehabilitation: Tricking the brain into believing what it sees
• Blog Post: Regaining language skills after a stroke: Will speech therapy help?
• Video Post: Aphasia after stroke: Regaining communication skills with speech-language therapy
• Web Resource Rating: After a stroke: Does fitness training improve health and mobility?
• Web Resource Rating: Stroke rehabilitation: What to expect as you recover

 

10 Best Brain Exercises for Stroke Recovery

What protocols does your doctor have for these? None? Then you just have fairly useless guidelines.  There is nothing specific here so you'll just have to guess on what to do.  Hope you like your recovery based on guesses.

10 Best Brain Exercises for Stroke Recovery

• Board games
• Memory games
• Strategy games
• Art and crafts
• New hobbies
• Sequence finding
• Money counting
• Card matching
• Brain teasers
• Visual processing games
• FAQs  
• Takeaway

Brain exercises can help people regain thinking, reasoning, and memory skills after a stroke. Other brain-strengthening activities include eating a heart-healthy diet, getting regular exercise, and limiting alcohol consumption.

Stroke recovery begins before you leave the hospital. For the greatest chance of recovery, many people will begin various therapies that can help them transition from a hospital to their home.

Among these stroke recovery activities are brain exercises. While physical therapy or occupational therapy can help with body movement and strength, brain exercises can help recover some of the brain’s capabilities.

After a stroke, some people may experience difficulty with thinking, reasoning, awareness, and memory. This isn’t uncommon. Blood flow to the brain is cut off during a stroke, and brain cells can die or experience damage. This can change how a person communicates, moves, thinks, and feels.

But brain exercises, like the 10 reviewed in this article, can help you recover and recapture some of your pre-stroke capabilities.

Can a brain heal itself after a stroke, and can brain exercises help?

It is unclear how well brain exercises and activities help people repair brain function after a stroke. It’s also unclear who can most benefit from these exercises.

But the National Institute on AgingTrusted Source says that lifestyle changes, including keeping your mind active, can positively impact brain health and help restore some capabilities.

1. Board games

A favorite childhood pastime can have a positive impact on your brain after a stroke. Classic board games, such as Connect 4, Qwirkle, Battleship, and Guess Who? call on various brain skills, including concentration, reasoning, organization, and memory.

Better yet, most of these games require a partner or partners, and the extra time spent socializing with friends or loved ones can further benefit a stroke survivor’s recovery.

2. Memory games

Monopoly isn’t the only childhood game that can be of assistance in stroke recovery. Memory games, like Simon and Tap It, call upon focus and memory skills. These games issue a short sequence, instruct people to follow it, and the sequence grows after each successful round.

Some memory games, like Bop It, also call for physical reactions. Bop It in particular requires you to maneuver parts of the hand-held instrument. While this may be difficult for some people with impaired motor skills, it can help others regain some strength and movement post-stroke.

3. Strategy games

Some board games and computer games call on critical thinking skills and strategy skills to play and be successful. Popular options, like Catan and Ticket to Ride, and even classic ones, like mahjongg and yahtzee, require you to think ahead and strategize moves for a successful outcome.

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4. Art and crafts

Healthcare professionals can use art therapy to help people in recovery from various health conditions. Art therapy can help people relieve stress and express emotions that they may have a difficult time sharing.

But beyond the emotional impact of art therapy, drawing, coloring, painting, or crafting requires people to use analytical skills and hand-eye coordination. Furthermore, holding tools or manipulating art supplies for a long period of time can help improve muscle strength and stamina.

5. New hobbies

It may seem the last thing you want to do after a stroke is to enter into a new realm of information, terminology, and skill, but it is precisely that challenge that is so helpful for people recovering from a stroke. Learning a new skill or finding a new hobby calls on memory and communication skills.

You may also need to use your arms, hands, or even legs for these skills. That can further help strengthen muscles and regain some motor skill function.

Consider activities like learning sign language, making scrapbooks, gardening, or even bird watching.

6. Sequence finding

You don’t have to have special board games or computer software to find and make your own strategy games. Give yourself brain teasers by doing things like:

• alphabetizing the words in a sentence
• arranging laundry by size or color
• sorting people in your family by their birthdays
• stacking books by size
• dividing medication or vitamins into a pill organizer

7. Money counting

Grab the loose change from your nightstand or purse, and count totals, arrange by coin type, or return change. These activities call on short-term memory skills and mathematical reasoning.

8. Card matching

Card-matching games have you place various tiles or cards facedown. You flip one card over, then a second card, with the aim of putting matching pairs together. These activities call on memory skills that often need improvement during stroke recovery.

9. Brain teasers

Grab the ink pen and newspapers. Brain teasers, like crossword puzzles and Sudoku, are excellent brain exercises after a stroke. Word searches are good, too. All of these call on and challenge the brain to use analytical skills and reasoning.

You can buy small game books at easy levels, and then gradually move to more advanced options as memory and skills improve.

10. Visual processing games

Side-by-side images with minor differences are great brain-challenging activities for people recovering from a stroke. These activities require you to compare and contrast the images to identify minor changes. This can enhance your spatial processing skills and concentration.

Frequently asked questions about stroke recovery

If you or a loved one is recovering from a stroke, it’s important to understand what is possible in terms of recovery. Here are answers to some common questions about stroke recovery.

How long does it typically take the brain to recover from a stroke?

Stroke recovery can happen rapidly in the weeks and months immediately following the stroke. The biggest gains will likely be in the first 3 to 4 monthsTrusted Source. However, experts often see improvements 1 to 2 years after the stroke, especially if you undertake therapies like brain exercises.

What percentage of people who’ve had strokes make a full recovery?

According to the American Stroke Association, 10% of stroke survivorsTrusted Source will make an almost complete recovery. (This is absolutely appalling! WHOM is changing that to 100% ?)

The organization also says that 25% of stroke survivors will have minor impairments in their capabilities, while another 40% of survivors will experience moderate to severe impairment.

Finally, 10% of stroke survivors will require long-term care after a stroke.

What signs or symptoms indicate a person is recovering from a stroke?

If you or a loved one is recovering from a stroke, it can seem like gains or improvements are slow, but certain signs indicate that stroke recovery is advancing. These signs include:

• gaining a degree of independence in everyday activities, like eating or dressing
• needing less compensatory measures, like walking aides or assisted movement devices
• needing more sleep — a sign the brain is recovering and gaining neuroplasticity (the ability for the brain to make better and faster connections)

Are there other things you can do (aside from brain exercises) to encourage brain healing?

In addition to brain exercises, you can take steps to help your brain heal after a stroke. These measures may also have protective benefits against a future stroke. These include:

• Eating a heart-healthy diet: A diet low in saturated fats and sodium can reduce blood pressure, which is a leading cause of stroke.
• Getting regular exercise: Movement is vital for health, and especially for people recovering from a stroke. Exercise not only helps lower blood pressure, research suggests it can improve coordination and balance. It can also boost emotional health.
• Limiting alcohol: Alcohol can raise blood pressure, which can increase your risk of stroke and impair brain function. Cutting back to a healthy limit (or cutting it out entirely) may boost brain performance after a stroke.