Intravenous Thrombolysis With Tenecteplase in Patients With Large Vessel Occlusions

 Bad research, since we never compare interventions to 100% recovery we will NEVER GET THERE!  Just maybe you'll want to talk to survivors about their requirements and don't lead them down your route of the tyranny of low expectations.

Intravenous Thrombolysis With Tenecteplase in Patients With Large Vessel Occlusions

Systematic Review and Meta-Analysis

Aristeidis H. Katsanos

,

Apostolos Safouris

,

Amrou Sarraj

,

Georgios Magoufis

,

Ronen R. Leker

,

Pooja Khatri

,

Charlotte Cordonnier

,

Didier Leys

,

Ashkan Shoamanesh

,

Niaz Ahmed

, … See all authors

Originally published4 Dec 2020https://doi.org/10.1161/STROKEAHA.120.030220Stroke. 2021;52:308–312

Abstract

Background and Purpose:

Accumulating evidence from randomized controlled clinical trials suggests that tenecteplase may represent an effective treatment alternative to alteplase for acute ischemic stroke. In the present systematic review and meta-analysis, we sought to compare the efficacy and safety outcomes of intravenous tenecteplase to intravenous alteplase administration for acute ischemic stroke patients with large vessel occlusions (LVOs).

Methods:

We searched MEDLINE (Medical Literature Analysis and Retrieval System Online) and Scopus for published randomized controlled clinical trials providing outcomes of acute ischemic stroke with confirmed LVO receiving intravenous thrombolysis with either tenecteplase at different doses or alteplase at a standard dose of 0.9 mg/kg. The primary outcome was the odds of modified Rankin Scale score of 0 to 2 at 3 months.

Results:

We included 4 randomized controlled clinical trials including a total of 433 patients. Patients with confirmed LVO receiving tenecteplase had higher odds of modified Rankin Scale scores of 0 to 2 (odds ratio, 2.06 [95% CI, 1.15–3.69]), successful recanalization (odds ratio, 3.05 [95% CI, 1.73–5.40]), and functional improvement defined as 1-point decrease across all modified Rankin Scale grades (common odds ratio, 1.84 [95% CI, 1.18–2.87]) at 3 months compared with patients with confirmed LVO receiving alteplase. There was little or no heterogeneity between the results provided from included studies regarding the aforementioned outcomes (I²≤20%). No difference in the outcomes of early neurological improvement, symptomatic intracranial hemorrhage, any intracranial hemorrhage, and the rates of modified Rankin Scale score 0 to 1 or all-cause mortality at 3 months was detected between patients with LVO receiving intravenous thrombolysis with either tenecteplase or alteplase.

Conclusions:

Acute ischemic stroke patients with LVO receiving intravenous thrombolysis with tenecteplase have significantly better recanalization and clinical outcomes compared with patients receiving intravenous alteplase.

Although alteplase remains to date the only approved intravenous thrombolytic medication for acute ischemic stroke (AIS),¹ accumulating evidence from clinical trials suggests that tenecteplase may represent an effective treatment(My definition of effective is 100% recovery, WHY THE HELL ISN'T THAT YOUR DEFINITION?) agent compared with alteplase for AIS.^2,3 In a recently published randomized controlled clinical trial (RCT), tenecteplase administration was associated with a 2-fold increase in the odds of successful recanalization(NOT GOOD ENOUGH!) of AIS patients with large vessel occlusion (LVO) before the initiation of endovascular treatment compared with patients receiving pretreatment with intravenous alteplase. Patients randomized to intravenous tenecteplase before endovascular treatment also had better functional outcomes at 3 months compared with patients receiving intravenous alteplase.⁴

 

Achievements and New Initiatives for Stroke in 2021

 Oh God; what ABSOLUTE FUCKING LAZINESS. Nothing on survivors or rehab or 100% recovery. WHY THE HELL IS STROKE IN YOUR NAME ANYWAY?

What is your impact factor in getting survivors recovered?

And Dr. Sacco was former president of the American Heart Association.

Achievements and New Initiatives for Stroke in 2021

Ralph L. Sacco

Originally published22 Dec 2020https://doi.org/10.1161/STROKEAHA.120.033123Stroke. 2021;52:5–7

Although we started the year celebrating the 50th anniversary of Stroke, coronavirus disease 2019 (COVID-19) brought many new challenges that changed all of our lives. As we start a new year, we are all hoping that 2021 brings better times and a new normal. I am confident that more advanced treatments and vaccines for COVID-19 will become available, and enlightened leadership will help guide us toward better implementation of preventive measures. I also hope for improved initiatives to address racial inequality, improve equity, diversity and inclusion, and enhance health equity. We will also strive to advance the American Heart Association (AHA) mission to be champions for health equity and advance cardiovascular health for all, including identifying and removing barriers to health care access and quality.

See related article, p 8

As 2021 begins, I am happy to report on some notable achievements over the last few months. First, I want to thank the amazing editorial board and the over 1600 reviewers from 66 countries who help us maintain the high-quality of our publications. I am also very proud of the progress we have made in improving equity and diversity on our Stroke editorial masthead. We now include 294 people with 47% women (up from 29% in 2019), 43% international, 21% Asians, 5% Hispanic (up from 3%) and 5% Black participants (up from 1%). Without all of these hard-working and dedicated members of our editorial board, we would not be where we are today.

We have other plans to continue to be more inclusive and call upon more diverse individuals to author, review, and engage in the leadership of the journal. To achieve our goals, we will continue to support our trainee reviewer program to provide clinical and translational science trainees the opportunity to learn how to be a good reviewer, perform peer reviews, and receive some constructive feedback. We also plan to launch a new intensive Editor-in-Training program for a selected group of under-represented people in medicine. Our goal is to build a broader pipeline of future editorial board leaders by providing a mentored editorial experience with our associate editor team.

Other approaches to address inequity in our editorial process include the following: (1) collecting better demographic data in eJournal Press, our article submission system; (2) utilizing this information to enhance reviewer selection and increase use of under-represented racial and ethnic groups in peer review; (3) requesting that section editors include women and diverse authors when nominations are made soliciting invited content; and (4) encouraging all board members and senior editors to act as ambassadors at meetings to identify and recruit diverse individuals to the journal.

I also wanted to share some other good news. In July 2020, we were notified about a rise in our 2-year impact factor to 7.190 (from 6.046) and 5-year impact factor of 7.113 (from 6.572). We remain ranked No. 1 among stroke journals, No. 6 out of 65 for peripheral vascular disease journals, No. 16 out of 1204 clinical neurology journals, and No. 4 out the 12 AHA journals. Our new team cannot really claim any of the credit. The hard work of the many editorial members over the last few years need to be recognized and congratulated.

We also have ended the year with a record number of submissions to the journal on track to have over 4100 articles submitted to Stroke with a 18% increase in original article submissions and 33% increase in other types of articles over the last year. We received many reports about COVID-19 that we expedited in the early months of the pandemic and were collated by the AHA coronavirus resource site. Unfortunately, with the increased number of submissions, we are only able to publish 12% of original articles.

As many of you have heard by now, a new open-access journal, Stroke: Vascular and Interventional Neurology will be launched in July 2021. This will be a first in many ways since it is a joint collaboration and ownership between the AHA and the Society of Vascular and Interventional Neurology. While Stroke will continue to evaluate and publish interventional articles, we will also be able to refer many high-quality articles to this journal just as we currently do with other AHA journals such as Journal of the American Heart Association.

I am also happy to announce that for the first time one of our own, Hooman Kamel, a vascular neurologist at Cornell Weill Medical Center, has been named as one of the 2020 Joseph A. Vita award recipients for his contributions to cardiovascular health and to the AHA journals. Selections for this prestigious award are made by the AHA Scientific Publishing committee based on nominations from all journal editors.

With this January 2021 issue, we also are launching a few new initiatives. The Advances in Stroke articles will provide brief summaries of some hot topics and breaking news in specific disciplines authored by our section editors each month. Rather than try to cram these all into one issue, we are planning to provide specific Advances each month and summarize the prior calendar year. This month you can find Advances in Stroke for Treatments–Recovery and a new section on Digital Health.

Page limits are a limiting factor for the number of articles we can publish in-print or online each year. We have expanded our brief article type labeled Research Letters and encourage authors to use this opportunity to update others about advances in the field. These brief 750-word articles with only 1 figure and no abstract are very focused and meant to make an important innovative point in any topic areas covered by Stroke.

We are also making a major change in how we handle Letters to the Editor. As it turns out, our Letters take up a sizable number of pages and accounted for 182 ePages in 2020. The AHA journals have a new online process for remarks on published articles that has been working for Circulation and other journals that has now launched for Stroke. This system allows our readers to write letters about published articles, have them reviewed by our editorial board, and have our authors provide a response. All letters to the editor will track with the online contents of the article and allow us to print other articles with the saved pages. We still have a backlog of letters to the editor that will be appearing the old way, but I hope our readers will find this new system more efficient for following important scientific discussions about our published articles.

We live in a much more enlightened digital age and they say a picture paints a thousand words. We have had graphic abstracts for some time for our translational science articles and started encouraging them for our clinical and population science submissions. Starting in January, we are now asking all authors of our original research articles to create a visual abstract that we will feature online as a way to succinctly summarize the key points of the article. We promise to disseminate these more widely through social media to more effectively spread science to our readers. We also are enhancing our social media presence on Twitter, Facebook, Instagram and Reddit and have continued to expand our blogging editors. We are also planning to initiate Stroke Podcasts very soon.

We have increased the word limits for our review articles and engaged our increased number of section editors to solicit state of the art reviews across our many topic areas. We will continue to collect some multi-article reviews in our Focused Updates in Cerebrovascular Disease. In November, we were able to publish our Focused Update in Health Equity, and we have other great topics planned in 2021.

We have also increased the number of solicited editorials to comment on our publications and place them in perspective. Moreover, we are changing the format of our Table of Contents in-print and online to mirror that of Circulation and some other AHA journals. You will now find the editorial will be placed just after the published article to allow the reader to quickly evaluate the source article and the perspectives of the editorial authors.

Other strategic goals include an increase in the number of timely simultaneous publications with our scientific meetings, attracting more publications of clinical trial results, and continuing to be dedicated to training early career professionals. To advance the next generation of editorial board members, we are maintaining our trainee assistant reviewer program. We also have expanded the number of our trainees and fellows engaged as bloggers to help spread the word about articles and trending topics in our field. We will continue to solicit special articles for our International Stroke Early Career and Training section.

All in all, we continue to do everything we can to advance the Stroke mission and achieve our vision. Our mission is to drive innovative interdisciplinary research, transform patient care, and enhance our understanding of disorders of the cerebral circulation and our vision is to be an indispensable, inspiring, and trusted source of high-quality scientific knowledge for all stroke disciplines. Thanks for all of your help throughout a challenging 2020, and we look forward to success and progress in 2021.

Disclosures

Dr Sacco receives compensation from the AHA as Editor-in-Chief of Stroke.

Footnotes

The opinions expressed in this article are not necessarily those of the American Heart Association.

For Disclosures, see page 7.

Correspondence to: Ralph L. Sacco, MD, Departments of Neurology and Public Health Sciences, Miami Clinical Translational Science Institute, Evelyn McKnight Brain Institute, Miller School of Medicine, University of Miami, 1120 NW 14th St, Suite 1352, Miami, FL 33136. Email rsacco@med.miami.edu

 

Comparison of Robotics, FES, and Motor Learning Methods for Treatment of Persistent Upper Extremity Dysfunction after Stroke: a Randomized Controlled Trial

Gains are NOT GOOD ENOUGH, survivors still expect 100% recovery. 

WHY THE HELL AREN'T YOU PROVIDING THAT?

Comparison of Robotics, FES, and Motor Learning Methods for Treatment of Persistent Upper Extremity Dysfunction after Stroke: a Randomized Controlled Trial

2014, Archives of Physical Medicine and Rehabilitation
Authors:
Jessica McCabe, M.P.T.
1
; Michelle Monkiewicz, D.P.T.
1
; John Holcomb, Ph.D. 2
 ,
Svetlana Pundik, M.D., M.S.
1
; Janis J. Daly, Ph.D., M.S.
1
*
Author affiliations:
1. Stroke Motor Control/Motor Learning Laboratory of the Louis Stokes Cleveland
Department of Veterans Affairs Medical Center, Cleveland, OH 44106
2. Department of Mathematics and Statistics, Cleveland State University, Cleveland OH
44016 *Dr. Daly currently holds the position of Director, Brain Rehabilitation Research Center
of Excellence, Malcom Randall Gainesville DVA Medical Center. Research Career
Scientist, DVA.; Professor, Department of Neurology, College of Medicine, University
of Florida.; Director, Brain Rehabilitation Research Program, McKnight Brain Institute, University
of Florida

Abstract

Objective: To compare response to upper limb treatment using robotics (ROB) + motor
learning (ML) vs. functional electrical stimulation (FES) + ML vs. ML alone, according to a
measure of complex functional everyday tasks for chronic, severely impaired stroke survivors.
Design: single-blind, randomized trial.
Setting: Clinical research lab, Medical Center.
Participants: 39 enrolled subjects, >1 year post single stroke (attrition rate=10%; 35 completed
the study). No adverse effects.
Interventions: All groups received treatment 5 days/week, 5hrs/day (60 sessions), with unique
treatment as follows: ML alone (n=11), 5hrs/day partial and whole task practice of complex
functional tasks; ROB+ML (n=12), 3.5hrs/day ML and 1.5hrs/day shoulder/elbow robotics;
FES+ML (n=12), 3.5hrs/day ML and 1.5hrs/day FES wrist/hand coordination training.
Main Outcome Measures: Primary measure: Arm Motor Ability Test (AMAT), 13 complex
functional tasks; secondary measure: upper limb Fugl-Meyer coordination (FM).
Results: No significant difference found in treatment response across groups (AMAT (p≥.584)
and FM (p≥.590)). All three treatment groups demonstrated clinically and statistically significant
improvement in response to treatment (AMAT and FM,p≤.009). A group treatment paradigm of
1:3 (therapist:patient) ratio proved feasible for provision of the intensive treatment.
Conclusions: Severely impaired stroke survivors with persistent (>1yr) upper extremity
dysfunction can make clinically and statistically significant gains in coordination and functional
task performance, in response to ROB+ML, FES+ML, and ML alone, in an intensive and long25 duration intervention, and no group difference was found. Additional study is warranted to
determine the effectiveness of these methods in the clinical setting.

Only 1 in 10 medical treatments is backed by high-quality evidence, study finds

 If your doctor doesn't know if your treatments are backed by high quality research, WHY THE HELL ARE YOU SEEING THEM?

Only 1 in 10 medical treatments is backed by high-quality evidence, study finds

When you visit your doctor, you might assume that the treatment they prescribe has solid evidence to back it up. But you'd be wrong. Only one in ten medical treatments are supported by high-quality evidence, our latest research shows.

The analysis, which is published in the Journal of Clinical Epidemiology, included 154 Cochrane systematic reviews published between 2015 and 2019. Only 15 (9.9 percent) had high-quality evidence according to the gold-standard method for determining whether they provide high or low-quality evidence, called GRADE (grading of recommendations, assessment, development and evaluation).

Among these, only two had statistically significant results – meaning that the results were unlikely to have arisen due to random error – and were believed by the review authors to be useful in clinical practice.

Using the same system, 37 percent had moderate, 31 percent had low, and 22 percent had very low-quality evidence.

The GRADE system looks at things like risk of bias. For example, studies that are "blinded" – in which patients don't know whether they are getting the actual treatment or a placebo – offer higher-quality evidence than "unblinded" studies.

Blinding is important because people who know what treatment they are getting can experience greater placebo effects than those who do not know what treatment they are getting.

Among other things, GRADE also considers whether the studies were imprecise because of differences in the way the treatment was used.

In the 2016 review, researchers found that 13.5 percent – about one in seven – reported that treatments were supported by high-quality evidence. Lack of high-quality evidence, according to GRADE, means that future studies might overturn the results.

The 154 studies were chosen because they were updates of a previous review of 608 systematic reviews, conducted in 2016. This allows us to check whether reviews that had been updated with new evidence had higher-quality evidence.

They didn't. In the 2016 study, 13.5 percent reported that treatments were supported by high-quality evidence, so there was a trend towards lower quality as more evidence was gathered.

There were a few limitations to the study. First, the sample size in the study may not have been representative, and other studies have found that over 40 percent of medical treatments are likely to be effective.

Also, the sample in the study was not large enough to check whether there were certain types of medical treatments (pharmacological, surgical, psychological) that were better than others. It is also possible that the "gold standard" for ranking evidence (GRADE) is too strict.

Too many low-quality studies

Many poor-quality trials are being published, and our study merely reflected this. Because of the pressure to "publish or perish" to survive in academia, more and more studies are being done.

In PubMed alone – a database of published medical papers – more than 12,000 new clinical trials are published every year. That's 30 trials published every day.

Systematic reviews were designed to synthesise these, but now there are too many of those, too: over 2,000 per year published in PubMed alone.

The evidence-based medicine movement has been banging a drum about the need to improve the quality of research for more than 30 years, but, paradoxically, there is no evidence that things have improved despite a proliferation of guidelines and guidance.

In 1994, Doug Altman, a professor of statistics in medicine at Oxford University, pleaded for less, but better, research. This would have been good, but the opposite has happened.

Inevitably, the tsunami of trials published every year, combined with the need to publish in order to survive in academia, has led to a great deal of rubbish being published, and this has not changed over time.

Poor-quality evidence is serious: without good evidence, we simply can't be sure that the treatments we use work.

GRADE system too harsh

A carpenter should only blame their tools as a last resort, so the excuse that GRADE doesn't work should be only be used cautiously.

Yet it's probably true that the GRADE system is too harsh for some contexts. For example, it is near impossible for any trial evaluating a particular exercise regime to be of high quality.

An exercise trial cannot be "blinded": anyone doing exercise will know they are in the exercise group, while those in the control group will know they are not doing exercise. Also, it is hard to make large groups of people do exactly the same exercise, whereas it is easier to make everyone take the same pill.

These inherent problems condemn exercise trials to being judged to be of lower quality, no matter how useful safe exercise is.

Also, our method was strict. Whereas the systematic reviews had many outcomes (each of which could be high quality), we focused on the primary outcomes. For example, the primary outcome in a review of painkillers would be a reduction in pain. Then they might also measure a range of secondary outcomes, ranging from anxiety reduction to patient satisfaction.

Focusing on the primary outcomes prevents spurious findings. If we look at many outcomes, there is a danger that one of them will be high quality just by chance. To mitigate this, we looked at whether any outcome – even if it wasn't the primary outcome. We found that one in five treatments had high-quality evidence for any outcome.

On average, most of the medical treatments whose effectiveness has been tested in systematic reviews are not supported by high-quality evidence. We need less, but better, research to address uncertainties so that we can become more confident that the treatments we take work.

—Jeremy Howick, Director of the Oxford Empathy Programme, University of Oxford

This article is republished from The Conversation under a Creative Commons license.

To read more, click here

 

 

Gait rehabilitation machines based on programmable footplates

My conclusion is that NOTHING SPECIFIC is known about getting you walking properly again.  You will have to figure this out yourself. Why the hell are you paying your doctors and therapists? 

Gait rehabilitation machines based on programmable footplates

 HenningSchmidt*
1,2
, CordulaWerner
2
, RolfBernhardt
1
, StefanHesse
2
 and JörgKrüger
1
 Address:
1
Department of Automation and Robotics, Fraunhofer IPK, Pascalstrasse 8-9, 10587 Berlin, Germany and
2
Department of Neurological Rehabilitation, Charité University Hospital, Kladower Damm 223, 14089 Berlin, Germany Email: HenningSchmidt*-henning.schmidt@ieee.org; CordulaWerner-cowerner@zedat.fu-berlin.de; RolfBernhardt-rolf.bernhardt@ipk.fraunhofer.de ; StefanHesse-bhesse@zedat.fu-berlin.de; JörgKrüger-joerg.krueger@ipk.fraunhofer.de* Corresponding author

Abstract

Background:

Gait restoration is an integral part of rehabilitation of brain lesioned patients. Modern concepts favour a task-specific repetitive approach, i.e. who wants to regain walking has to walk, while tone-inhibiting and gait preparatory manoeuvres had dominated therapy before. Following the first mobilization out of the bed, the wheelchair-bound patient should have the possibility to practise complex gait cycles as soon as possible. Steps in this direction were treadmill training with partial body weight support and most recently gait machines enabling the repetitive training of even surface gait and even of stair climbing.
Results:
With treadmill training harness-secured and partially relieved wheelchair-mobilized patients could practise up to 1000 steps per session for the first time. Controlled trials in stroke and SCI patients, however, failed to show a superior result when compared to walking exercise on the floor. Most likely explanation was the effort for the therapists, e.g. manually setting the paretic limbs during the swing phase resulting in a too little gait intensity. The next steps were gait machines, either consisting of a powered exoskeleton and a treadmill (Lokomat, AutoAmbulator)or an electromechanical solution with the harness secured patient placed on movable foot plates(Gait Trainer GT I). For the latter, a large multi-centre trial with 155 non-ambulatory stroke patients (DEGAS) revealed a superior gait ability and competence in basic activities of living in the experimental group. The Haptic Walker continued the end effector concept of movable foot plates, now fully programmable and equipped with 6 DOF force sensors. This device for the first time enables training of arbitrary walking situations, hence not only the simulation of floor walking but also for example of stair climbing and perturbations.
Conclusion:
Locomotor therapy is a fascinating new tool in rehabilitation, which is in line with modern principles of motor relearning promoting a task-specific repetitive approach. Sophisticated technical developments and positive randomized controlled trials form the basis of a growing acceptance worldwide to the benefits or our patients

Addressing post – stroke sexual rehabilitation

All these reasons for sex post stroke and still no protocol written up and available. 

All this is why you need to be doing lots of sex, why the hell can't your doctor get you fucking again?

Sexual Frequency Predicts Greater Well-Being, But More is Not Always Better

 

Sex after stroke

 

Sex linked to better brain power in older age

Sex: The Ultimate Full Body Workout

 

Better Memory From This Extremely Pleasurable Activity - Sex

 

WHY SEX IS BETTER FOR YOUR BRAIN THAN SUDOKU 

 

Sex linked to better brain power in older age

 

Good News About Sex- It Doesn't Cause a Stroke

 

Sex Does Not Increase Heart Attack Risk - What about stroke?

 

Frequent orgasms may protect against heart attacks

 

An orgasm a day keeps the doctor away!

In case you don't have a partner she could prescribe this.

Electrosex

 

Addressing post – stroke sexual rehabilitation

Sandra Lever1,2, Margaret McGrath3, Emma Power4, Annie McCluskey3
1 Sexuality clinic, Graythwaite Rehabilitation Centre, Ryde Hospital, NSLHD 2 Susan Wakil School of Nursing and Midwifery, The University of Sydney 3 Discipline of Occupational Therapy, Faculty of Health Sciences, The University of Sydney 4 Speech Pathology, Graduate School of Health, University of Technology Sydney
 Stroke has a profound impact on the ways in which sexuality is experienced and expressed by stroke survivors (McGrath et al, 2019)
• Stroke Foundation Clinical Guidelines (2010, 2017) recommend that stroke survivors and partners be offered opportunity to discuss sexual intimacy & be provided written information addressing sexuality issues(But not even suggesting that they do the deed as part of rehab in the hospital)
• Research consistently shows that health professionals rarely address sexuality during stroke rehabilitation  (Stein et al, 2013; Park et al, 2015; Rosenbaum  at al, 2014.
• Failure to address sexuality may result in increased anxiety and depression and poorer quality of life outcomes
• Lack of research into sexual rehabilitation hinders health professionals ability to provide evidenced based care  and highlights the need to develop a more comprehensive sexual rehabilitation intervention for stroke survivors & their partners 

Clinical Effects of Early Edaravone Use in Acute Ischemic Stroke Patients Treated by Endovascular Reperfusion Therapy

So instead of coming up with a definitive answer we again need followup research. WHOM is going to do that and when?  

You'll have to ask your doctor why the hell edaravone is approved in Japan since 2001 but not the US.

Clinical Effects of Early Edaravone Use in Acute Ischemic Stroke Patients Treated by Endovascular Reperfusion Therapy

Masaya Enomoto

,

Akira Endo

,

Hiroshi Yatsushige

,

Kiyohide Fushimi

,

Yasuhiro Otomo

Originally published11 Feb 2019https://doi.org/10.1161/STROKEAHA.118.023815Stroke. 2019;0

Abstract

Background and Purpose—

Although several clinical studies suggested the beneficial effects of edaravone in acute ischemic stroke, most were performed under settings that differ from those in the current treatment strategy, which has dramatically changed with progress in reperfusion therapies. This study aimed to evaluate the efficacy of edaravone in patients with acute ischemic stroke treated by emergent endovascular reperfusion therapy.

Methods—

We conducted a retrospective observational study using a national administrative database. Patients with acute ischemic stroke treated by emergent endovascular reperfusion therapy were identified and dichotomized by whether edaravone was used within 2 days of admission. We compared the functional independence at hospital discharge, in-hospital mortality, and intracranial hemorrhage after admission between groups, adjusted by a well-validated case-mix adjustment model, in multivariate mixed-effect regression and propensity score matching analyses.

Results—

Of 11 508 patients eligible for analysis, 10 281 (89.3%) received edaravone therapy. The established risk adjustment model had good predictability for functional independence at hospital discharge, with an area under the receiver operating characteristic curve of 0.74. In the mixed-effect regression analysis, edaravone use was significantly associated with greater functional independence at hospital discharge (32.3% in the edaravone group versus 25.9% in the control group; adjusted odds ratio, 1.21; 95% confidence interval, 1.03–1.41), lower in-hospital mortality (9.9% in the edaravone group versus 17.4% in the control group; adjusted odds ratio, 0.52; 95% confidence interval, 0.43–0.62), and reduced intracranial hemorrhage after admission (1.4% in the edaravone group versus 2.7% in the control group; adjusted odds ratio, 0.55; 95% confidence interval, 0.37–0.82). Results of the propensity score matching analysis corroborated these results.

Conclusions—

This retrospective analysis of a Japanese nationwide administrative database suggested that combination therapy with edaravone and endovascular reperfusion therapy could be a promising therapeutic strategy in acute ischemic stroke. Further randomized control trials are warranted.

Footnotes

The online-only Data Supplement is available with this article at https://www.ahajournals.org/doi/suppl/10.1161/STROKEAHA.118.023815.

Correspondence to Akira Endo, MD, PhD, Trauma and Acute Critical Care Medical Center, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113–8510, Japan. Email eraeaccm@tmd.ac.jp

Impact of Microbleeds on Outcome Following Recanalization in Patients With Acute Ischemic Stroke

Just why the hell are we using the Rankin scale for measuring anything in stroke? It has no discriminatory power and nothing objective except for 6 - death.

Impact of Microbleeds on Outcome Following Recanalization in Patients With Acute Ischemic Stroke

Kang-Ho Choi

,

Ja-Hae Kim

,

Kyung-Wook Kang

,

Joon-Tae Kim

,

Seong-Min Choi

,

Seung-Han Lee

,

Man-Seok Park

,

Byeong-Chae Kim

,

Myeong-Kyu Kim

,

Ki-Hyun Cho

Originally published7 Dec 2018Stroke. 2018;0:STROKEAHA.118.023084

Abstract

Background and Purpose—

We analyzed the association between cerebral microbleeds (CMBs) and clinical outcome in acute ischemic stroke patients and especially in a subgroup of patients with successful recanalization.(Your definition of success is obviously not what it should be. 100% recovery, not the lazy, 'Hey we got the artery open')

Methods—

A total of 1532 acute ischemic stroke patients treated with intravenous thrombolysis or mechanical thrombectomy were enrolled in this prospective cohort study. The primary outcome was measured using the modified Rankin Scale at 3 months, according to the CMB status based on magnetic resonance imaging at admission. Favorable outcome was defined as functional independence with modified Rankin Scale scores of 0 to 2. Secondary outcomes included the occurrence of symptomatic intracranial hemorrhage.

Results—

There was no statistically significant association between the presence of CMB and favorable outcome at 3 months when considering all patients (44.3% versus 37.6%; P=0.121). In patients with recanalization, the number of patients with favorable outcomes was significantly higher in the CMB-negative than in the CMB-positive group (57.0% versus 36.0%; P<0.001). In the final multivariate analysis, the presence of CMB, and in particular high CMB burden (≥5), and lobar location, were significantly associated with less favorable 3-month outcomes (odds ratio=0.57; 95% CI, 0.33−0.97; P=0.038) and symptomatic intracranial hemorrhage (odds ratio=3.21; 95% CI, 1.37−7.49; P=0.007) in patients with recanalization. In the analysis of subgroups, a statistically significant interaction was found between CMB presence and recanalization in predicting functional outcomes at 3 months.

Conclusions—

These results indicate that the presence of CMBs, and especially high burden and lobar location, are independent predictors of poor 3-month clinical outcomes and may increase symptomatic intracranial hemorrhage risk in acute ischemic stroke patients with recanalization. Our findings suggest that CMBs lead to more unfavorable effects in patients with recanalization after large vessel occlusion than in those without recanalization.

Action Observation in Upper Extremity Rehabilitation for Moderately Impaired Stroke: A Literature Review

Just why in hell was this done? We have all this research back to at least May 2011.  These literature reviews should never be required. Every piece of research should be required to update the protocols that already exist.

• action observation (88 posts)

 

Action Observation in Upper Extremity Rehabilitation for Moderately Impaired Stroke: A Literature Review

Christine Griffin

Ohio State University

Research Poster 793623

DOI: https://doi.org/10.1016/j.apmr.2018.09.007

|

Study examines how people adapt to post stroke visual impairments

Just why the hell are we studying adaptations rather that creating the recovery stroke protocol for this problem? Laziness? Incompetence? Or just don't care? No leadership? No strategy? Not my job?
https://news.liverpool.ac.uk/2018/08/03/study-examines-how-people-adapt-to-post-stroke-visual-impairments/

A new University of Liverpool study, published in Wiley Brain and Behaviour, examines the factors that influence how a person adapts to visual field loss following stroke.

Approximately 65% of acute stroke survivors have visual impairment which typically relates to impaired central or peripheral vision, eye movement abnormalities, or visual perceptual defects.

Symptoms can include blurred or altered vision, double or jumbled vision, loss of visual field, reading difficulty, inability to recognize familiar objects or people and glare. The factors that influence how a person adapts to a Post stroke visual impairment (PSVI) is currently an under researched area.

Compensate and adapt

In order to profile the full range of influencing factors researchers from the University’s Department of Health Services Research, led by Dr Fiona Rowe, systematically reviewed data pertaining to PSVI produced between 1861 and 2016. This data included randomized controlled trials, controlled trials, cohort studies, observational studies, and case controlled studies.

The researchers identified 47 studies which involved a total of 2,900 participants and categorised them into two sections. Section one included seventeen studies where the reviewers were able to identify a factor they considered as likely to be important for the process of adaptation to post stroke visual field loss.

Section two included thirty studies detailing interventions for visual field loss that the reviewers deemed likely to have an influence on the adaptation process.

The study highlighted a substantial amount of evidence showing patients can be supported to compensate and adapt to visual field loss following stroke using a range of strategies and methods.

Valuable starting point

Dr Rowe, said: “This is an area that must be addressed in the interest of equality for those with visual impairment. It is vital that the factors important for adaptation be identified to allow clinicians to recognise which people are likely to have difficulty adapting and target interventions specifically within these areas, as well as to develop methods for assessing adaptation and monitoring change over time.

“Our review also highlights the fact that many unanswered questions remain: what does adaptation to visual field loss mean to the patient, carer, and clinician? How can adaptation be measured over time? Why do some people adapt more effectively and at a quicker rate than others, despite seemingly similar rehabilitation opportunities and experiences? If these questions can be answered through high quality observations and assessments then this would be a valuable starting point for understanding adaptation.”

The study was funded by the National Institute of Health Research.

The full study, entitled ‘Adaptation to post stroke visual field loss: A systematic review’, can be found here.

DOI: 10.1002/brb3.1041

Raising Aphasia Awareness

More fucking laziness from the National Stroke Association. 'AWARENESS' NOT SOLUTIONS! Why the hell is stroke in your name anyway? Is your president afraid to talk to survivors? Like me? 

Raising Aphasia Awareness

Aphasia, which causes communication problems, is not a disease but is most commonly seen in adults who have experienced a stroke. Speech therapy is the most common treatment for aphasia but there are things you can do at home to help you communicate with others.

Reflex-mediated dynamic neuromuscular stabilization in stroke patients: EMG processing and ultrasound imaging

Why the hell are we still writing about NDT/Bobath? It has been proven multiple times to not be effective. Because we have no public database of stroke research and protocols we get stuff like this that wastes time and resources.  Meaning that our stroke researchers don't keep up-to-date in their own field. A great stroke association president would be on top of this problem because a strategy would be being followed. But we have NO STRATEGY AND NO LEADERSHIP.

Negative reviews here:

Comparison Of Two Physiotherapy Approaches In Acute Stroke Rehabilitation: Motor Relearning Program Versus Bobath Approach.

 

Motor Relearning Program vs. Bobath:
http://cre.sagepub.com/content/14/4/361.short

 

And here is Peter Levines take on NDT:
http://recoverfromstroke.blogspot.com/2013/01/neuro-developmental-treatment.html

 

The latest crap here:

 

Reflex-mediated dynamic neuromuscular stabilization in stroke patients: EMG processing and ultrasound imaging

Technology and Health Care , Volume 25(Supplement 1) , Pgs. S99-S106.

NARIC Accession Number: J78547.  What's this?
ISSN: 0928-7329.
Author(s): Yoon, Hyun S.; You, Joshua (Sung) H..
Publication Year: 2017.
Number of Pages: 8.
Abstract: Study examined the therapeutic effects of neurodevelopmental treatment (NDT) and dynamic neuromuscular stabilization (DNS) core stabilization exercises on muscular activity, core stability, and core muscle thickness. Ten participants (5 healthy adults and 5 hemiparetic stroke patients) were evaluated. Surface electromyography (EMG) was used to determine core muscle activity of the transversus abdominis/internal oblique (TrA/IO), external oblique, and rectus abdominis muscles. Ultrasound imaging was used to measure transversus abdominals/internal oblique (TrA/IO) thickness, and a pressure biofeedback unit was used to measure core stability during the DNS and NDT core exercise conditions. Data are reported as median and range and were compared using nonparametric Mann–Whitney U test and Wilcoxon signed rank test. Both healthy and stroke groups showed greater median EMG amplitude in the TrA/IO muscles, core stability, and muscle thickness values during the DNS exercise condition than during the NDT core exercise condition. However, the relative changes in the EMG amplitude, core stability, and muscle thickness values were greater during the DNS exercise condition than during the NDT core exercise condition in the stroke patient group. The results provide the first clinical evidence that DNS is more effective than NDT in both healthy and c stroke subjects to provide superior deep core muscle activation, core stabilization, and muscle thickness. Moreover, such advantageous therapeutic benefits of the DNS core stabilization exercise over the NDT exercise were more apparent in the hemiparetic stroke patients than normal controls.
Descriptor Terms: ELECTROPHYSIOLOGY, EQUILIBRIUM, HEMIPLEGIA, IMAGING, NEUROMUSCULAR DISORDERS, POSTURE, STROKE.


Can this document be ordered through NARIC's document delivery service*?: Y.

Citation: Yoon, Hyun S., You, Joshua (Sung) H.. (2017). Reflex-mediated dynamic neuromuscular stabilization in stroke patients: EMG processing and ultrasound imaging.  Technology and Health Care , 25(Supplement 1), Pgs. S99-S106. Retrieved 6/21/2018, from REHABDATA database.

Here's why the 90-day 'golden period' in post-stroke rehabilitation is vital

Crapola like this is just reinforcing the tyranny of low expectations from your stroke medical professionals.  You'll just have to ask them why they have such fucking low expectations. 100% recovery is the standard. Why the hell can't they get you there? Are they that fucking incompetent?
https://www.business-standard.com/article/news-ians/here-s-why-the-90-day-golden-period-in-post-stroke-rehabilitation-is-vital-comment-118061900254_1.html


A stroke can hit anyone at any age. India reports more than 1.8 million cases every year, of which almost 15 per cent affect people in their 30s and 40s.

A stroke or a Cerebro Vascular Accident (CVA) results from a sudden blood loss to the brain or bleeding within the brain resulting in the impairment of neurological function. Obesity, smoking, hypertension, alcohol consumption, diabetes and family history are considered some of the common factors leading to a stroke. While effective treatment for stroke is evolving in the country, a largely neglected area is the 'golden period' of post-stroke rehabilitation.
The first 90 days after recovery of a stroke are referred to as the 'golden period'. This phase is considered extremely important in the complete rehabilitation of a patient since most of the neurological recovery happens during this time.
This is why the 'golden period' is significant:
* In the absence of continued monitoring by a team of skilled nurses and doctors, critical signs in a patient could be overlooked consequently leading to a relapse, disability with profound effects on the quality of life or moving to a vegetative state and death.
Some of the critical signs to watch for after a stroke are:
Symptoms of heart disease - chest pain, fatigue, congestion et al
Deep vein thrombosis - swelling, pain or tenderness in the legs
Pneumonia - fever, shortness of breath
Seizures - tingling sensation, partial loss of consciousness
Depression - feelings of anxiety, irritability, helplessness
* Early rehabilitation in an organised care setting can prevent other common post stroke complications like recurrent stroke, bed sores, aspirations, spasticity and infections.
* A reliable prognosis (the likely course of a medical condition) in all patients is made within 12 weeks from a stroke's onset. The majority of neurological effects of a stroke can be reduced if early, intense and consistent rehabilitation is initiated.
* With the right rehabilitation care provided by a multidisciplinary team of doctors, within the first 90 days itself there will be noticeable signs of improved functional outcomes in the activities of daily living in a stroke patient. These interventions will enhance socialisation and minimize changes of mood issues like depression.
The key objective of stroke rehabilitation is to restore health in an individual through neurological recovery (mainly through neuroplasticity), functional recovery with task-specific training and improving the quality of life by focusing on emotional wellbeing.
The primary steps of rehabilitation care which needs to be initiated within the first 90 days of the Golden Period are:
* Base assessment & risk profiling - The recovery prognosis of a patient should be made as per the severity of the disease, by taking into account any co-morbidities including high blood pressure, diabetes, hypercholesterolemia and preventable risk factors like falls, aspiration, infections et al.
* Goal setting - A multidisciplinary team of care providers including physicians, speech therapists, occupational therapists, nurses, physiotherapists and dieticians should work with the family to set realistic and mutually agreeable goals for enhanced recovery.
* Regular evaluation - Performance indicators should be rigorously monitored to continue/ modify the care plan. Stroke affects differently in individuals and hence each care plan should be customised as per the individual's condition.
* Empowerment - Soon after discharge from a critical care setting, depending on the intensity of the condition a stroke patient should decide to choose the next care setting. He/she should be advised to handle the disease/risk factors and ideally moved to an organised rehabilitation setting for an empowered and accelerated recuperation.
As India battles a rising stroke epidemic compared to other developing nations, it is high time we focused on specialized programmes of stroke rehabilitation to effectively overcome the disability.
(Dr Vijay Janagama is Director - New Initiatives, SuVitas Holistic Healthcare. The views expressed are personal)
--IANS
vijay/vm/tb

Prediction of Outcome in Patients With Acute Ischemic Stroke Based on Initial Severity and Improvement in the First 24 h

Who fucking cares about recovery predictions? Except for researchers needing a subject to study? Survivors care about one thing, 100% recovery. If your research doesn't get closer to that, why the hell are you doing it?

Prediction of Outcome in Patients With Acute Ischemic Stroke Based on Initial Severity and Improvement in the First 24 hours

Anke Wouters^1,2,3†, Céline Nysten^3†, Vincent Thijs^4,5 and Robin Lemmens^1,2,3*

• ¹Department of Neurosciences, Experimental Neurology, KU Leuven – University of Leuven, Leuven, Belgium
• ²Laboratory of Neurobiology, Center for Brain and Disease Research, VIB, Leuven, Belgium
• ³Department of Neurology, University Hospitals Leuven, Leuven, Belgium
• ⁴Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, VIC, Australia
• ⁵Department of Neurology, Austin Health, Heidelberg, VIC, Australia

Introduction: Stroke severity measured by the baseline National Institutes of Health Stroke Scale (NIHSS) is a strong predictor of stroke outcome. Early change of baseline severity may be a better predictor of outcome. Here, we hypothesized that the change in NIHSS in the first 24 h after stroke improved stroke outcome prediction.

Materials and methods: Patients from the Leuven Stroke Genetics Study were included when the baseline NIHSS (B-NIHSS) was determined on admission in the hospital and NIHSS after 24 h could be obtained from patient files. The delta NIHSS, relative reduction NIHSS, and major neurological improvement (NIHSS of 0–1 or ≥8-point improvement at 24 h) were calculated. Good functional outcome (GFO) at 90 days was defined as a modified Rankin Scale of 0–2. Independent predictors of outcome were identified by multivariate logistic regression. We performed a secondary analysis after excluding patients presenting with a minor stroke (NIHSS 0–5) since the assessment of change in NIHSS might be more reliable in patients presenting with a moderate to severe deficit.

Results: We analyzed the outcome in 369 patients. B-NIHSS was associated with GFO (odds ratio: 0.82; 95% CI 0.77–0.86). In a multivariate model with B-NIHSS and age as predictors, the accuracy [area under the curve (AUC): 0.82] improved by including the delta NIHSS (AUC: 0.86; p < 0.01). In 131 patients with moderate to severe stroke, the predictive multivariate model was more accurate when including the RR NIHSS (AUC: 0.83) to the model which included B-NIHSS, age and ischemic heart disease (AUC: 0.77; p = 0.03).

Conclusion: B-NIHSS is a predictor of stroke outcome. In this cohort, the prediction of GFO was improved by adding change in stroke severity after 24 h to the model.

Introduction

Stroke is one of the leading causes of disability and death worldwide (1, 2). Patients who are experiencing deficits as a result of an ischemic stroke are worried about their expected outcome. Identifying predictors of functional outcome may be of assistance to physicians when confronted with these concerns from stroke patients. Stroke severity and evolution of the clinical symptoms during the first days after initial presentation are potential valuable predictors of outcome. Improvement in the estimation of clinical outcomes could result in more specific management of stroke rehabilitation as well as clearer informing of patients and their relatives. Multiple studies have focused on the baseline National Institutes of Health Stroke Scale (B-NIHSS) as a predictor of functional outcome (3–8), but only some data are available on the evolution of the National Institutes of Health Stroke Scale (NIHSS) in the first 24 h after stroke onset (6, 9–11). Different parameters have been described to assess this change in stroke severity: Delta NIHSS (B-NIHSS–24 h NIHSS), relative reduction in NIHSS (RR NIHSS; delta NIHSS/B-NIHSS), and major neurological improvement (MNI; NIHSS of 0–1 or ≥8-point improvement at 24 h).

Other identified, independent predictors of outcome are age, sex, mean arterial pressure, history of diabetes, baseline glucose levels, baseline NIHSS score, CT findings, time to treatment and recanalization, current smoking, atrial fibrillation (AF), and statin intake before stroke (3, 12–14).

The aim of this study was to investigate if the prediction of functional outcome after 3 months could be improved by adding the improvement in the first 24 h into a predictive model.