Neurotechnology-aided interventions for upper limb motor rehabilitation in severe chronic stroke

May provide and may improve give stroke survivors NOTHING to get them recovered. I'd fire the mentors and senior researchers for not setting the proper objectives for this research. A lot of dead wood needs to be removed in stroke and with survivors in charge we would easily get stroke on the path to 100% recovery.

 Neurotechnology-aided interventions for upper limb motor rehabilitation in severe chronic stroke

Jacob Brackenridge

Sheila Lennon

David Hobbs

593 Views

18 Pages

1 File ▾

Medical Device Design,

Stroke rehabilitation,

Activities of Daily Living,

Stroke,

Medical devices

 ...more ▾

Background: Stroke is a major contributor to the reduced ability to carry out activities of daily living (ADL) post cerebral infarct. There has been a major focus on understanding and improving rehabilitation interventions in order to target cortical neural ...read more

 

Neuroscience and Biomedical Engineering   2213-3860/16 $58.00+.00 ©2016 Bentham Science Publishers Jacob Brackenridge 1 , Lynley V. Bradnam 2,3 , Sheila Lennon 2 , John J. Costi 1 and David A. Hobbs 1, * 1 Medical Device Research Institute, School of Computer Science, Engineer- ing and Mathematics, Flinders University, Adelaide, South Australia, Australia; 2 Discipline of Physiotherapy, School of Health Sciences, Flinders University, Adelaide, South Australia, Australia; 3 Discipline of Physiotherapy, Graduate School of Health, University of Technology, Sydney, NSW, Australia  

 

Abstract:  

 

Background:  

 

Stroke is a major contributor to the reduced ability to carry out activities of daily living (ADL) post cerebral infarct. There has been a major focus on understanding and improving rehabilitation interventions in order to target cortical neural plasticity to support recovery of upper limb function. Conventional therapies delivered by therapists have been combined with the application of mechanical and robotic devices to provide controlled and assisted movement of the paretic upper limb. The ability to provide greater levels of intensity and reproducible repetitive task practice through the application of intervention devices are key mechanisms to support rehabilitation efficacy.  

 

Results:  

 

This review of literature published in the last decade identified 141 robotic or mechanical devices. These devices have been characterised and assessed by their individual characteristics to provide a review of current trends in rehabilitation device interventions. Correlation of factors identified to promote positive targeted neural plasticity has raised questions over the benefits of expensive robotic devices over simple mechanical ones. 

 

Conclusion:  

 

A mechanical device with appropriate functionality to support the promotion of neural plasticity after stroke may provide an effective solution for both patient recovery and to stimulate further research into the use of medical devices in stroke rehabilitation. These findings indicate that a focus on simple, cost effective and efficacious intervention solutions may improve rehabilitation outcomes. Keywords: Activities of daily living, exercise therapy, paresis, recovery of function, robotics, stroke, upper extremity, me- chanical devices, neural plasticity.

Glial Cells Reprogrammed to Neurons for Brain Repair

 Ask your competent? doctor if anything here will get you recovered from your stroke. If your doctor doesn't even know about this research; YOU DON'T HAVE A FUNCTIONING STROKE DOCTOR!

Glial Cells Reprogrammed to Neurons for Brain Repair

Summary: Researchers have discovered how glial cells can be reprogrammed into neurons through epigenetic modifications, offering hope for treating neurological disorders. This reprogramming involves complex molecular mechanisms, including the transcription factor Neurogenin2 and the newly identified protein YingYang1, which opens chromatin for reprogramming.

The study reveals how coordinated epigenome changes drive this process, potentially leading to new therapies for brain injury and neurodegenerative diseases.

Key Facts:

1. Neuronal Reprogramming: Glial cells can be transformed into neurons via epigenetic modifications.
2. Key Players: Neurogenin2 and YingYang1 are crucial for the reprogramming process.
3. Therapeutic Potential: This discovery could lead to new treatments for brain disorders and injuries.

Source: LUM

Researchers at LMU and Helmholtz Munich have shown how glial cells are reprogrammed into neurons via epigenetic modifications.

Neurological disorders, such as trauma, stroke, epilepsy, and various neurodegenerative diseases, often lead to the permanent loss of neurons, causing significant impairments in brain function.

Current treatment options are limited, primarily due to the challenge of replacing lost neurons. Direct neuronal reprogramming, a complex procedure that involves changing the function of one type of cell into another, offers a promising strategy.

For the first time, the teams have now shown how coordinated the epigenome rewiring is, elicited by a single transcription factor. Credit: Neuroscience News

In cell culture and in living organisms, glial cells – the non-neuronal cells in the central nervous system – have been successfully transformed into functional neurons. However, the processes involved in this reprogramming are complex and require further understanding.

This complexity presents a challenge, but also a motivation, for researchers in the field of neuroscience and regenerative medicine.

Modifications in the epigenome

Two teams, one led by Magdalena Götz, Chair of Physiological Genomics at LMU, Head of the Stem Cell Center Department at Helmholtz Munich, and researcher in the SyNergy Cluster of Excellence, and the other led by Boyan Bonev at the Helmholtz Pioneer Campus, explored the molecular mechanisms at play when glial cells are converted to neurons by a single transcription factor. Specifically, the researchers focused on small chemical modifications in the epigenome.

The epigenome helps control which genes are active in different cells at different times. For the first time, the teams have now shown how coordinated the epigenome rewiring is, elicited by a single transcription factor.

Using novel methods in epigenome profiling, the researchers identified that a posttranslational modification of the reprogramming neurogenic transcription factor Neurogenin2 profoundly impacts the epigenetic rewiring and neuronal reprogramming.

However, the transcription factor alone is not enough to reprogram the glial cells. In an important discovery, the researchers identified a novel protein, the transcriptional regulator YingYang1, as a key player in this process. YingYang1 is necessary to open up the chromatin for reprogramming, to which end it interacts with the transcription factor.

“The protein Ying Yang 1 is crucial for achieving the conversion from astrocytes to neurons,” explains Götz.

“These findings are important to understand and improve reprogramming of glial cells to neurons, and thus brings us closer to therapeutic solutions.”

About this neuroscience research news

Author: Constanze Drewlo
Source: LUM
Contact: Constanze Drewlo – LUM
Image: The image is credited to Neuroscience News

Original Research: Open access.
“Direct neuronal reprogramming of mouse astrocytes is associated with multiscale epigenome remodeling and requires Yy1” by Magdalena Götz et al. Nature Neuroscience

Clinician perceptions of a novel wearable robotic hand orthosis for post-stroke hemiparesis

 I happen to think it is vastly more important to have stroke survivors evaluate the efficacy and protocols used with these interventions. Any clinician evaluations using the Rankin scale can't discriminate any useful improvements.

I consider the Rankin scale useless, not objective except for #6, dead?

Clinician perceptions of a novel wearable robotic hand orthosis for post-stroke hemiparesis

Lauren Winterbottom

,

Ava Chen

,

Rochelle Mendonca

,

Dawn M. Nilsen

,

Matei Ciocarlie

&

Joel Stein

Received 19 Oct 2023, Accepted 27 Jun 2024, Published online: 08 Jul 2024

• Cite this article
• https://doi.org/10.1080/09638288.2024.2375056
• CrossMark

 

Abstract

Purpose

Wearable robotic devices are currently being developed to improve upper limb function for individuals with hemiparesis after stroke. Incorporating the views of clinicians during the development of new technologies can help ensure that end products meet clinical needs and can be adopted for patient care.

Methods

In this cross-sectional mixed-methods study, an anonymous online survey was used to gather clinicians’ perceptions of a wearable robotic hand orthosis for post-stroke hemiparesis. Participants were asked about their clinical experience and provided feedback on the prototype device after viewing a video.

Results

154 participants completed the survey. Only 18.8% had previous experience with robotic technology. The majority of participants (64.9%) reported that they would use the device for both rehabilitative and assistive purposes. Participants perceived that the device could be used in supervised clinical settings with all phases of stroke. Participants also indicated a need for insurance coverage and quick setup time.

Conclusions

Engaging clinicians early in the design process can help guide the development of wearable robotic devices. Both rehabilitative and assistive functions are valued by clinicians and should be considered during device development. Future research is needed to understand a broader set of stakeholders’ perspectives on utility and design.

IMPLICATIONS FOR REHABILITATION

• Clinicians valued both assistive and rehabilitative uses of a wearable robotic hand orthosis designed for individuals with hemiparesis after stroke.

• Wearable robotic hand devices should have the capacity to engage in functional, real-world activities for both assistive and rehabilitative purposes.

• Pragmatic factors, such as set-up and training time, must be balanced with device complexity to enable implementation in clinical settings.

• Stakeholders, such as clinicians, play an important role in identifying design priorities for wearable robotic devices to ensure these devices can meet the needs of end-users.

Does Your Body Composition Affect Your Risk of Dementia or Parkinson’s?

You'll have to ask your competent? doctor if you are at risk, since this tells us nothing specific. I gained 30-40 pounds post stroke since my doctor completely failed at getting me 100% recovered and didn't mention slower metabolism after age 50. In my opinion he knew nothing and did nothing as proven by writing 3 prescriptions of (E.T) - Evaluate and Treat.

Does Your Body Composition Affect Your Risk of Dementia or Parkinson’s?

MINNEAPOLIS – People with high levels of body fat stored in their belly or arms may be more likely to develop diseases like Alzheimer’s and Parkinson’s than people with low levels of fat in these areas, according to a study published in the July 24, 2024, online issue of Neurology^®, the medical journal of the American Academy of Neurology. The study also found that people with a high level of muscle strength were less likely to develop these diseases than people with low muscle strength. “These neurodegenerative diseases like Alzheimer’s and Parkinson’s affect over 60 million people worldwide, and that number is expected to grow as the population ages, so it’s crucial that we identify ways to modify risk factors to develop some preventive tools,” said study author Huan Song, MD, PhD, of Sichuan University in Chengdu, China. “This study highlights the potential to lessen people’s risk of developing these diseases by improving their body composition. Targeted interventions to reduce trunk and arm fat while promoting healthy muscle development may be more effective for protection against these diseases than general weight control.” The study involved 412,691 people with an average age of 56 who were followed for an average of nine years. At the beginning of the study, measurements were taken for body composition, such as waist and hip measurements, grip strength, bone density and fat and lean mass. During the study, 8,224 people developed neurodegenerative diseases—mainly Alzheimer’s disease, other forms of dementia, and Parkinson’s disease. Men with high levels of body fat in their bellies developed the neurodegenerative diseases at a rate of 3.38 per 1,000 person-years, compared to 1.82 cases per 1,000 person-years for those with low levels of body fat in their bellies. For women, the rates were 2.55 for high levels and 1.39 for low levels. Person-years represent both the number of people in the study and the amount of time each person spends in the study. After adjusting for other factors that could affect the rate of disease, such as high blood pressure, smoking and drinking status and diabetes, researchers found that overall people with high levels of belly fat were 13% more likely to develop these diseases than people with low levels of belly fat. People with high levels of arm fat were 18% more likely to develop the diseases than those with low levels of arm fat. Those with high muscle strength were 26% less likely to develop the diseases than those with low levels of strength. The relationship between these body compositions and the neurodegenerative diseases was partly explained by the occurrence after the start of the study of cardiovascular diseases such as heart disease and stroke. “This underscores the importance of managing these cardiovascular diseases right away to help prevent or delay the development of Alzheimer’s, Parkinson’s, or other degenerative diseases,” Song said. A limitation of the study is that participants were mainly white people from the United Kingdom of Great Britain and Northern Ireland, so the results may not apply to other populations. The study was supported by Sichuan University, Sichuan Provincial Science and Technology Department and the Swedish Research Council. Learn more about neurologic disorders at BrainandLife.org, home of the American Academy of Neurology’s free patient and caregiver magazine focused on the intersection of neurologic disease and brain health. Follow Brain & Life^® on Facebook, X and Instagram. When posting to social media channels about this research, we encourage you to use the hashtags #Neurology and #AANscience.

Can drinking in moderation be healthy? Probably not, new study says.

 Ah well, not going to change my mind, I'm using the social connections at jazz and trivia nights to ensure that I won't get dementia.

Not for me, I'm using social connections to prevent dementia and that means going to bars with friends for live music.  

But what if you are using Guinness for blood thinning?

Guinness could really be good for you

A pint of the black stuff a day may work as well as a low dose aspirin to prevent heart clots that raise the risk of heart attacks.

Don't do this on your own, you know how deadly even one glass of alcohol is.

What about this?

Men must drink with male friends twice a week to stay healthy, study finds

 Do not bring this to your doctor's attention, you don't want to be responsible for an exploding head.

 

I like this excuse:

SuperAgers indulge. They also indulged in an occasional glass of alcohol; people who drink moderately were 23% less likely to develop Alzheimer’s disease or signs of memory problems than those who don’t drink alcohol. The key here is moderation.

From one of my earlier posts:

Can drinking in moderation be healthy? Probably not, new study says.

522

Experts say it's untrue that moderate drinking can be good for your health. (Getty Images)

In a perfect world, an occasional glass of wine would not only be enjoyable, but also offer some serious health benefits like a lower risk of heart disease, as some studies have shown. But unfortunately, moderate drinking — which the Centers for Disease Control and Prevention defines as up to one drink a day for women and up to two drinks a day for men — may not be the health tonic it’s purported to be.

New research published on Thursday in the Journal of Studies on Alcohol and Drugs found that many of the studies touting the benefits of moderate drinking suffer from design flaws that undermine the claim that your favorite cocktail can help you live longer.

What does the study say?

Researchers reviewed 107 different studies that had looked at people’s drinking habits over time and how those drinking habits correlated with longevity. Tim Stockwell, co-author of the new study and a psychology professor at the University of Victoria, tells Yahoo Life that typically, if you don't look too closely, the average study shows apparent health benefits for moderate drinkers — meaning people who drink in moderation live longer than those who completely abstain from alcohol.

But once you dig deeper, it becomes clear that that’s not the case. Stockwell and his team found that many lower-quality studies didn’t ask about participants’ previous drinking habits and involved older people in their 60s and 70s. These design flaws, Stockwell says, can distort the data and make it appear as though abstaining from alcohol is less healthy than drinking in moderation. Higher-quality studies that did ask about participants’ previous drinking habits and included younger participants, however, found no health benefits to moderate drinking.

“If you find a 60-year-old person who’s abstaining and you compare them with a drinker, they may be less healthy than the drinker, but that’s not because they’re abstaining. [The nondrinker] may have been drinking heavily in the past but cut down because they were unwell, so you end up comparing an unhealthy abstainer with somebody who’s well enough to continue drinking,” Stockwell explains.

Dr. Anna Lembke, chief of the Stanford Addiction Medicine Clinic, who was not involved in the new study, tells Yahoo Life that many of the nondrinkers in studies looking at alcohol habits include a group of so-called sick quitters, or people who used to drink heavily and then quit drinking because they had damaged their liver or pancreas, or suffered some other severe health consequence attributed to drinking. These “sick quitters” then skew the data and give the false impression that drinking in moderation is better than not drinking at all.

“There’s long been this myth that alcohol has health benefits, and the consensus is that that’s a misinterpretation of the data,” Lembke says.

Is any amount of drinking safe?

While the World Health Organization says that no amount of alcohol is safe, the CDC says that any decrease can improve your health; the less alcohol you drink, the lower your risk for adverse health effects related to alcohol, such as high blood pressure, heart disease, liver disease and certain cancers.

Lembke says that drinking in “extreme moderation” — meaning one to two alcoholic beverages per week — probably won’t reap dire health consequences, but that it’s time to put to rest the notion that you can benefit from it.

And Stockwell says it’s a good idea to be dubious of those who claim otherwise.

“I think perhaps the main conclusion that’s relevant to people out there who are interested in their health and whether alcohol is a good or a bad thing is just to be skeptical about claims that it is go

od for you,” he says. “Mainstream opinion now in my field is that alcohol has no health benefits, and this study contributes to providing reasons for being skeptical that there are any health benefits.”

Central Carolina recognized for ongoing efforts to improve rural stroke care

I wouldn't go there if all they are offering is 'care'; NOT RECOVERY!

Anytime I see 'care' in any stroke press release I know the stroke medical world is not willing to disclose actual results because they are so fucking bad, it wouldn't look good, so misdirection is used. Don't fall for that misdirection! By touting 'care' they are not telling you about results or recovery which survivors want! Survivors don't care about your 'care'; you FUCKING BLITHERING IDIOTS; they want 100% recovery! Why aren't you providing that?

Big fucking whoopee.

 

 But you tell us NOTHING ABOUT RESULTS. They remind us they 'care' about us multiple times but never tell us how many 100% recovered.  You have to ask yourself why they are hiding their incompetency by not disclosing recovery results.  ARE THEY THAT FUCKING BAD?

Three measurements will tell me if the stroke medical world is possibly not completely incompetent; DO YOU MEASURE ANYTHING?  I would start cleaning the hospitals by firing the board of directors, you can't let incompetency continue for years at a time.

There is no quality here if you don't measure the right things.

1. tPA full recovery? Better than 12%?
2. 30 day deaths? Better than competitors?

3. rehab full recovery? Better than 10%?

 

You'll want to know results so call that hospital president(whomever that is) RESULTS are; tPA efficacy, 30 day deaths, 100% recovery. Because there is no point in going to that hospital if they are not willing to publish results.

In my opinion this partnership allows stroke hospitals to continue with their tyranny of low expectations and justify their complete failure to get survivors 100% recovered. Prove me wrong, I dare you in my stroke addled mind. If your stroke hospital goal is not 100% recovery you don't have a functioning stroke hospital.

 

All you ever get from hospitals are that they are following guidelines; these are way too static to be of any use. With thousands of pieces of stroke research yearly it would take a Ph.D. level research analyst to keep up, create protocols, and train the doctors and therapists in their use. 

If your stroke hospital doesn't have that, you don't have a well functioning stroke hospital, you have a dinosaur. 

Read up on the 'care' guidelines yourself. Survivors want RECOVERY not 'care'

“What's measured, improves.” So said management legend and author Peter F. Drucker 

The latest invalid chest thumping here:

Central Carolina recognized for ongoing efforts to improve rural stroke care

Central Carolina Hospital has received the American Heart Association’s Get With The Guidelines® – Stroke Rural Recognition Silver award for its ongoing efforts to optimize stroke care and eliminate rural healthcare outcome disparities.

This award recognizes the efforts of hospitals nationwide to address the unique health needs of rural communities. People who live in rural areas live an average of three years fewer than their urban counterparts. They have a 40 percent higher likelihood of developing heart disease and face a 30 percent increased risk for stroke mortality — a gap that has grown over the past two decades.

“Rural communities such as ours deserve high quality stroke care,” said Dave Santoemma, Chief Executive Officer of Central Carolina Hospital. “I’m proud of our team for their commitment to stroke care excellence and this achievement.”

Last year, CCH received the American Heart Association’s Get With The Guidelines® – Stroke Rural Recognition Bronze award.

“We are proud to be recognized for the important work we do every day to improve the lives of people in Lee County who are affected by stroke, giving them the best possible chance of recovery and survival,” said Sarah Ricks, RN, MSN, CPHRM, Director of Quality, Patient Safety and Risk Management at CCH. “We work every day to improve the lives of people who are affected by stroke, giving them the best possible chance of recovery and survival.”

The American Heart Association award recognizes hospitals nationwide for their efforts toward acute stroke care excellence as demonstrated by composite score compliance to guideline-directed care for:

Intravenous thrombolytic therapy
Timely hospital inter-facility transfers
Dysphagia screening
Symptom timeline and deficit assessment documentation
Emergency medical services communication
Brain imaging
Stroke expert consultation

As the world’s leading nonprofit organization focused on heart and brain health for all, the American Heart Association recognizes the importance of healthcare services provided to people living in rural areas by rural hospitals that play a vital role in initiation of timely evidence-based care.

“Patients and health care professionals in Lee County face unique healthcare challenges and opportunities,” said Karen E. Joynt Maddox, MD, MPH, volunteer expert for the American Heart Association, co-author on “Call to Action: Rural Health: A Presidential Advisory From the American Heart Association and American Stroke Association” and co-director of the Center for Health Economics and Policy at the Institute for Public Health at Washington University in St. Louis, MO.

“Central Carolina has furthered this important work to improve care for all Americans, regardless of where they live.”

About Central Carolina Hospital

Central Carolina Hospital, a Duke LifePoint Hospital, is a 137-bed acute care hospital that serves the health care needs of Lee County and surrounding communities. With nearly 200 providers, the hospital offers a wide range of specialties, including cardiology, orthopedics, general surgery, obstetrics, gynecology, otolaryngology, emergency medicine, emergency medical services, gastroenterology, pediatrics, hospitalist services, internal medicine, nephrology, neurology, hematology, urology, podiatry, dentistry, pulmonary medicine, and wound care and hyperbaric medicine.

Hospital services include emergency room, physical and occupational therapy, ophthalmology, cardiac rehabilitation, diagnostic imaging and radiology, inpatient and outpatient surgery, dialysis, maternity services, nutritional counseling by clinical dietitians, and diagnostic cardiac catheterization. Central Carolina Hospital was reaccredited by the Joint Commission for a three-year period in 2021.

About Get With The Guidelines®

Get With The Guidelines® is the American Heart Association/American Stroke Association’s hospital-based quality improvement program that provides hospitals with the latest research-based guidelines. Developed with the goal of saving lives and hastening recovery, Get With The Guidelines has touched the lives of more than 14 million patients since 2001. For more information, visit heart.org.

CHRISTUS Mother Frances Hospital – Sulphur Springs receives national award for stroke care

 

I wouldn't go there if all they are offering is 'care'; NOT RECOVERY!

Anytime I see 'care' in any stroke press release I know the stroke medical world is not willing to disclose actual results because they are so fucking bad, it wouldn't look good, so misdirection is used. Don't fall for that misdirection! By touting 'care' they are not telling you about results or recovery which survivors want! Survivors don't care about your 'care'; you FUCKING BLITHERING IDIOTS; they want 100% recovery! Why aren't you providing that?

Big fucking whoopee.

 

 But you tell us NOTHING ABOUT RESULTS. They remind us they 'care' about us multiple times but never tell us how many 100% recovered.  You have to ask yourself why they are hiding their incompetency by not disclosing recovery results.  ARE THEY THAT FUCKING BAD?

Three measurements will tell me if the stroke medical world is possibly not completely incompetent; DO YOU MEASURE ANYTHING?  I would start cleaning the hospitals by firing the board of directors, you can't let incompetency continue for years at a time.

There is no quality here if you don't measure the right things.

1. tPA full recovery? Better than 12%?
2. 30 day deaths? Better than competitors?

3. rehab full recovery? Better than 10%?

 

You'll want to know results so call that hospital president(whomever that is) RESULTS are; tPA efficacy, 30 day deaths, 100% recovery. Because there is no point in going to that hospital if they are not willing to publish results.

In my opinion this partnership allows stroke hospitals to continue with their tyranny of low expectations and justify their complete failure to get survivors 100% recovered. Prove me wrong, I dare you in my stroke addled mind. If your stroke hospital goal is not 100% recovery you don't have a functioning stroke hospital.

 

All you ever get from hospitals are that they are following guidelines; these are way too static to be of any use. With thousands of pieces of stroke research yearly it would take a Ph.D. level research analyst to keep up, create protocols, and train the doctors and therapists in their use. 

If your stroke hospital doesn't have that, you don't have a well functioning stroke hospital, you have a dinosaur. 

Read up on the 'care' guidelines yourself. Survivors want RECOVERY not 'care'

“What's measured, improves.” So said management legend and author Peter F. Drucker 

The latest invalid chest thumping here:

CHRISTUS Mother Frances Hospital – Sulphur Springs receives national award for stroke care

(SULPHUR SPRINGS, Texas) – CHRISTUS Mother Frances Hospital – Sulphur Springs is being
recognized for excellence in stroke care by the American Heart Association and American
Stroke Association.

The national award, Get With The Guidelines – Stroke, is given to hospitals who have demonstrated excellence in stroke care. The recognition was created to highlight the health care facilities providing the most up-to-date, research-based guidelines and quick recovery times.

CHRISTUS Mother Frances Hospital – Sulphur Springs earned a gold plus distinction, indicating the hospital has met or exceeded standards for at least 24 months, and elite honor roll recognition, awarded for achieving a door-to-needle time of less than 60 minutes for at least 85% of stroke patients.

“Earning these awards provides confidence in the medical care CHRISTUS Mother Frances Hospital – Sulphur Springs provides for the community we serve,” said Kala Anders, stroke program coordinator. “Receiving these nationally recognized distinctions exemplifies our dedication to having a well-rounded multidisciplinary stroke team and program that serves our community and those surrounding.”

On average, every 40 seconds, someone in the U.S. has a stroke and every 3 minutes and 11 seconds, someone dies of stroke, according to the U.S. Centers for Disease and Prevention.

Stroke is the fifth leading cause of death and a leading cause of adult disability in the U.S.

A stroke occurs when a blood vessel carrying oxygen and nutrients to the brain bursts or is blocked by a clot. When this happens, parts of the brain cannot get the blood and oxygen needed, causing brain cells to die.

Anders said being able to react swiftly to a stroke is key to help minimize the long-term effects of a stroke and even prevent death, emphasizing the access to stroke care for rural communities is vital.

“It’s a common assumption among rural communities in the country that to receive specialty care for things such as stroke, you need to go to large cities,” Anders said. “These recognitions solidify that exemplary clinical stroke care and evidence-based, innovative treatment can be and is being provided to the people in rural communities such as ours in Hopkins County.”

Ascension St. John receives national recognition for stroke program

 Why did they get this honor? It only talks about 'care', NOT RECOVERY! I wouldn't go there.

Ascension St. John receives national recognition for stroke program

TULSA, Okla.— Ascension St. John Medical Center (ASJMC) recently received the American Heart Association's (AHA) Advanced Therapy Distinction as part of the association's Get With The Guidelines Awards.

"This designation by the American Heart Association represents the diligence and dedication of our physicians, surgeons and nursing teams to provide the highest level of care(NOT RECOVERY!) for successful outcomes," said Dr. Rahul Rahangdale, physician and Medical Director of the ASJMC Heyman Stroke Center.

ASJMC is the only program in Oklahoma to earn this distinction.

"I am incredibly proud to be the only hospital recognized for this level of care(NOT RECOVERY!) in Oklahoma and to be part of this team as they continue to set new standards for stroke care(NOT RECOVERY!)," said Dr. Rahangdale

ASJMC's emergency department, stroke, interventional radiology and neurosurgical teams were recognized for their work in improving(NOT RECOVERY!) the lives of patients facing symptoms of acute stroke.

Stroke is the fifth-highest cause of death and a leading cause of disability in the U.S. Early stroke detection and treatment are the keys to improving(NOT RECOVERY!) survival, minimizing disability(NOT RECOVERY!) and accelerating recovery times.

Alongside this recognition, the hospital received three additional awards:

The American Heart Association's Target: StrokeSM Elite Plus award, the American Heart Association's Target: StrokeSM Honor Roll Advanced Therapy award, and the American Heart Association's Target: Type 2 Diabetes™ Honor Roll award.

ASJMC met specific criteria to reduce the time between a stroke patient's arrival at the hospital and treatment with thrombolytic therapy, which includes the use of medications designed to dissolve the blood clot causing the stroke.

For the AHA Target: Type 2 Diabetes award, ASJMC met specific criteria to ensure patients with Type 2 Diabetes, who might be at higher risk for complications, receive the most up-to-date, evidence-based care(NOT RECOVERY!) when hospitalized due to stroke.

ASJMC is home to the only Joint Commission-certified Comprehensive Stroke Center in eastern Oklahoma.

Dr. Yashar Kalani, neurosurgeon and Surgical Director of the ASJMC Heyman Stroke Center, said, "We are proud of the multidisciplinary expertise of our advanced practice providers in the emergency department and across our radiology and neurosurgical teams to improve clinical outcomes after a stroke."

"We are incredibly pleased to recognize Ascension St. John for its commitment to caring(NOT RECOVERY!) for patients with stroke," said Steven Messe, M.D., Volunteer Chairperson of the American Heart Association Stroke System of Care(NOT RECOVERY!) Advisory Group and Professor of Neurology and Director of Fellowships of Neurology at the Hospital of the University of Pennsylvania.

For more information, visit Ascension St. John Heyman Stroke Center or the American Heart Association's website.

Hemodynamic Stroke: Emerging Concepts, Risk Estimation, and Treatment

 Does your hospital have EXACT PROTOCOLS to treat this type of stroke? Or are they just winging it and hope you'll survive? Better ask now before you need this.

Hemodynamic Stroke: Emerging Concepts, Risk Estimation, and Treatment

Susanne Wegener, MD https://orcid.org/0000-0003-4369-7023 susanne.wegener@usz.ch, Jean Claude Baron, MD, ScD https://orcid.org/0000-0002-5264-2588, Colin P. Derdeyn, MD https://orcid.org/0000-0002-5932-2683, Jorn Fierstra, MD, PhD https://orcid.org/0000-0001-6220-0727, Annette Fromm, MD, Catharina J.M. Klijn, MD, PhD https://orcid.org/0000-0002-8495-4578, Christiaan Hendrik Bas van Niftrik, MD, PhD https://orcid.org/0000-0003-0930-8717, and Joanna D. Schaafsma, MD, PhD https://orcid.org/0000-0003-4326-5597Author Info & Affiliations

Stroke

Volume 55, Number 7

https://doi.org/10.1161/STROKEAHA.123.044386

486

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Abstract

Ischemic stroke can arise from the sudden occlusion of a brain-feeding artery by a clot (embolic), or local thrombosis. Hemodynamic stroke occurs when blood flow does not sufficiently meet the metabolic demand of a brain region at a certain time. This discrepancy between demand and supply can occur with cerebropetal arterial occlusion or high-grade stenosis but also arises with systemic conditions reducing blood pressure. Treatment of hemodynamic stroke is targeted toward increasing blood flow to the affected area by either systemically or locally enhancing perfusion. Thus, blood pressure is often maintained above normal values, and extra-intracranial flow augmentation bypass surgery is increasingly considered. Still, current evidence supporting the superiority of pressure or flow increase over conservative measures is limited. However, methods assessing hemodynamic impairment and identifying patients at risk of hemodynamic stroke are rapidly evolving. Sophisticated models incorporating clinical and imaging factors have been suggested to aid patient selection. In this narrative review, we provide current state-of-the-art knowledge about hemodynamic stroke, tools for assessment, and treatment options.

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The anatomy of brainwashing

 How is your doctor making sure this is working correctly to flush out the toxic wastes and prevent dementia? Oh, your doctor doesn't know anything about the problem and has done nothing? Why the fuck are you seeing them?

 

• brain waste removal (4 posts to February 2018)

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The anatomy of brainwashing

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Lymphatic drainage removes metabolic waste and toxins from tissues, which is crucial for maintaining tissue health. In the central nervous system (CNS), lymphatic drainage relies on meningeal lymphatic vessels located in the dura mater and on the glymphatic system, a recently elucidated network that is responsible for cerebrospinal fluid (CSF) circulation and waste clearance. The interaction between glymphatic flow and meningeal lymphatics also ensures vigilant immune monitoring without perturbing the neuronal environment. How CSF travels through complex vascular and perivascular pathways, and the interactions between CSF flow dynamics and brain metabolic demands, are important for understanding brain health and could lead to the development of therapeutic approaches that might transform the treatment of a variety of neurological diseases.

Traditionally, the CNS was considered “immune-privileged,” meaning that it was thought to be separated from the immune system, lack proper immune surveillance, and devoid of classical lymphatic drainage. Indeed, healthy brain parenchyma contains no lymphatic vessels. The brain is encapsulated by the meninges, a three-layered membranous cover comprising the dura or dura mater (the outermost layer, closest to the skull), the pia or pia mater (the layer attached to the brain), and the arachnoid that separates them from one another while also forming a subarachnoid space through which CSF flows. About a decade ago, a network of meningeal lymphatic vessels was (re)discovered to be housed in the dura (1); meningeal lymphatic vessels were originally described over 200 years ago but they were ignored by the scientific community. Although meningeal lymphatics are not located within the brain parenchyma, they nevertheless perform the vital function of brain lymphatic drainage (1).

The presence of meningeal lymphatic vessels in the dura perfectly positions this to be the site at which immune surveillance of the brain occurs because antigens from the brain reach the dura before lymphatic drainage. Indeed, the dura mater, especially at the sites surrounding the dural sinuses, is highly populated by various immune cells, including antigen-presenting cells. Dural antigen-presenting cells take up antigens from the CSF for presentation to patrolling T cells, which could enter the dura relatively easily through dural sinuses. Migration of T cells across the dural sinuses is facilitated by the relatively slow flow of blood, the high expression of adhesion molecules on sinus endothelial cells, and the expression of chemokines and retention molecules by dural fibroblasts located in close proximity to the dural sinuses (1). Performing immune surveillance in the dura allows monitoring of the brain for threats and diseases, without the need for direct entry of immune cells into the brain parenchyma, hence avoiding disturbance of the neurons.

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Arguably, the brain “immune code” [i.e., peptides presented on major histocompatibility complex class I (MHCI) and MHCII molecules] represented on dural antigen-presenting cells would change before diseases ensue. Thus, detecting changes in this code could possibly serve as an early diagnostic tool. Dural presentation of brain antigens could also lead to abnormal immune activation due to viral mimicry, for example, and thus result in detrimental inflammatory responses [virus-specific lymphocytes found in the CSF of patients with neurodegenerative and inflammatory diseases (2, 3) support this hypothesis], eventually leading to parenchymal inflammation. Unraveling the immune code of brain tissue and being able to alter it in the dura mater (for example, through the addition of missing peptides, altering antigen-presenting cells, or interfering with protein processing and presentation) could lead to the development of new therapeutic approaches for neuroinflammatory and neurodegenerative disorders such as Alzheimer’s disease in which adaptive immune cells seem to play a role.

Although the advances in understanding meningeal immunity and its relationship to brain immune surveillance have provided important answers, several questions remain. For example, how do antigens from the brain reach the dura? CSF was believed to mainly provide the brain with buoyancy and to assist with the removal of waste products. Beyond these basic functions, however, recent research reveals the physiological complexity and importance of the CSF. After its production in the choroid plexus, clean CSF travels through the ventricular network and the subarachnoid space. At the level of the large cortical arteries entering the brain, the CSF encounters perivascular structures called the Virchow-Robin spaces, which are extensions of the subarachnoid space and accompany vessels entering the brain parenchyma. As the arteries penetrate deeper into the brain, these spaces become narrower, but they continue throughout the brain’s blood vessels (excluding capillaries). Arterial pulsation enables CSF from the perivascular spaces to propel along the arteries and also to enter the brain parenchyma across astrocytic endfeet (4). Aquaporin 4 (AQP4) water channels are expressed by astrocytes and polarized to their endfeet, which in part facilitates the transfer of fluid from perivascular spaces into the parenchyma, and vice versa (5). Once inside the brain, this fluid is thought to create a convective flow through the dense brain parenchyma until it reaches the perivenular spaces . This passage of the CSF along the arteries, through the brain, and then out along the veins constitutes the glymphatic system or glymphatic flow, where “g” stands for the role of glial cells (astrocytes) in the process that resembles “lymphatic” flow.

Glymphatic-lymphatic anatomical connections

The meningeal layers surrounding the brain comprise a rich dural immune environment, meningeal lymphatic vessels, and channels that allow cerebrospinal fluid (CSF) in the dura to access the skull bone marrow. Two anatomical structures–the arachnoid granulation and the arachnoid cuff exit (ACE) point–allow immune monitoring and toxic waste removal from the brain parenchyma through the CSF.

GRAPHIC: A. FISHER/SCIENCE

The glymphatic system and meningeal lymphatic vessels are connected because once the CSF leaves the brain, it drains into the dura, absorbed by the meningeal lymphatic vessels, and from there into the brain-draining cervical lymph nodes. To fully understand the glymphatic-lymphatic connection, some points are to be clarified: for example, how CSF flows along the arteries, what forces facilitate the convective flow within the brain parenchyma, and how CSF reaches the meningeal lymphatics located in the dura .

Cerebral arterial pulsation is the force driving CSF along the arteries in mice and in humans, where magnetic resonance imaging (MRI) demonstrated a strong correlation between CSF flow and arterial pulsatility. Moreover, perivascular and leptomeningeal macrophages (together referred to as parenchymal border macrophages, or PBMs) constantly degrade the extracellular matrix within the perivascular space, allowing CSF passage (6). Elimination or dysfunction of PBMs results in a build-up of extracellular matrix, which physically clogs the perivascular space and interferes with CSF flow.

To identify and understand the forces that drive CSF flow within the brain parenchyma, it is necessary to consider how densely populated the parenchyma is. Because there is very little interstitial space, some force is essential to drive the fluid across the parenchyma. Additionally, diffusion alone is not sufficient to explain the rates of CSF perfusion through the brain tissue. An elegant study demonstrated the coupling of hemodynamics and electrophysiological activity with CSF flow using MRI of the fourth ventricle in humans, suggesting that CSF dynamics become intertwined with neural and hemodynamic rhythmicity (7). Neural activity has also been shown to correlate with CSF flow in mice and humans (8, 9). However, direct evidence (in mouse models) that neural activity drives CSF flow through the brain parenchyma was only recently described (10). Inhibiting neural activity in a specific brain region disrupted fluid flow through that area, whereas enhancing neural activity led to increased perfusion. Although the effects on fluid flow were confined to the areas where neural activity was altered (10), the intriguing possibility remains that there may be a central circuitry that regulates fluid flow throughout the brain.

A conundrum encountered with the above mechanism derives from the empirical finding that during sleep, when arguably fewer neurons are active, fluid flow through the brain tissue is enhanced relative to its flow during wakefulness. One possible explanation is the synchronized neural activity that occurs during sleep (11). Cortical encephalography recordings reveal that different phases of sleep are associated with different wavelengths of neural activity. The slowest waves with high amplitude (delta waves, ranging from 0.5 to 4 Hz) are detected during deep sleep (the most restful phase). The synchronized neural activity that generates delta waves could produce sufficient force and directionality to drive interstitial fluid through the brain tissue (10). This mechanism overcomes discrepancies relating to the production (12) and removal of waste during the sleep?wake cycle. Thus, fewer neurons are active during sleep (and less waste is produced), yet their activity is synchronized, and the waves they produce have enough potential energy to propel the flow of CSF through the parenchyma. Although this hypothesis and its preliminary evidence are promising, further experimental work and new tools that could directly measure movement of water molecules in the tissues are needed to confirm this mechanism.

How does the CSF reach the dura mater? Venous blood from the brain is delivered through bridging veins to the dural sinuses. These veins pierce the arachnoid to reach the dural sinuses. As the bridging veins penetrate the arachnoid, they carry a sleeve of arachnoid with them (13). Upon entering the dura, the arachnoid sleeve along the bridging veins ends in cuff-like structures called “arachnoid cuff exit” (ACE) points. ACE points are complex structures composed of arachnoid and dural fibroblasts, as well as a variety of immune cells. These are critical sites where the phenotype of endothelial cells changes from that of the blood–brain barrier (for example, with specialized tight junctions) to that of peripheral blood vessels as they continue into the dura. Not only fluid and suspended molecules but also immune cells can traffic through ACE points, making the regulation of these sites crucial for brain health. In neuroinflammatory diseases, the initial invasion of brain parenchyma might happen through ACE points (13) and in diseases of debris accumulation, these sites may be clogged, limiting removal of toxic products (such as amyloid-β in Alzheimer’s disease). The identification of ACE points provides a plausible anatomy of how brain-derived molecules can reach the dura mater on their way to meningeal lymphatics, and how dural immune-derived molecules (cytokines) can reach the brain and affect brain function (1).

Because mice, like many other small animals with lissencephalic brains, do not have arachnoid granulations, it could be argued that ACE points simply represent primitive, arachnoid granulation-like structures. However, ACE points also exist in humans, facilitating molecular exchange between the dura and the brain parenchyma (13). This raises questions about the roles of ACE points and arachnoid granulations in CSF drainage. Traditionally, it was believed that CSF exits the brain through arachnoid granulations protruding into the venous sinuses, thereby spilling directly into the blood circulation. However, if granulations protrude directly into the sinus, it is unclear how the area of penetration is sealed to prevent blood leakage. Moreover, such a system would imply that CSF, carrying brain antigens and metabolites, drains directly into the blood rather than into the lymphatic circulation, thereby escaping immune surveillance. Recent studies in mice and humans have demonstrated that CSF is drained into the dura before reaching the blood vasculature (13, 14) and that arachnoid granulations, although closely associated with the sinuses, do not protrude into them (while a minor portion of granulations are found inside the sinus, they are separated from the blood by sinus endothelia) and are densely populated by immune cells (15). This suggests that arachnoid granulations likely function as an interface between the CSF and meningeal immunity. It seems plausible that, as the brain evolved and increased in size, so did the need for efficient surveillance of its immune code, and the evolution of arachnoid granulations might have served this purpose.

The recent discoveries of CSF flow routes, anatomical structures allowing CSF exit, and forces moving CSF through the brain parenchyma provide a new conceptual framework for brain cleansing and immune surveillance (see the figure). Understanding this complex process—comprising numerous functional compartments, each influencing fluid flow—can be expected to facilitate the development of new classes of therapeutic interventions for enhanced brain cleansing. Such interventions—for example, targeting macrophages residing along the vasculature or astrocytic expression and function of AQP4—and inducing synchronized neural activity, could affect neurological disorders in which the accumulation of debris or immune dysfunction is a factor. There is already a precedent for therapeutic intervention using neural stimulation to increase CSF flow to eliminate pathogenic amyloid-β from the brains of people with Alzheimer’s disease (NCT05637801). A better understanding of the anatomy of brainwashing would promote further development of efficient ways not only to enhance brain cleansing but also to improve immune surveillance and effectively engage the immune system in brain diseases, including brain tumors, where immune assistance is likely a powerful solution.

Acknowledgments

Thanks to S. Smith for editing of the manuscript and A. Impagliazzo who generated the figure. J.K. holds patents and provisional applications related to topics discussed here.