Use the labels in the right column to find what you want. Or you can go thru them one by one, there are only 34,367 posts. Searching is done in the search box in upper left corner. I blog on anything to do with stroke. DO NOT DO ANYTHING SUGGESTED HERE AS I AM NOT MEDICALLY TRAINED, YOUR DOCTOR IS, LISTEN TO THEM. BUT I BET THEY DON'T KNOW HOW TO GET YOU 100% RECOVERED. I DON'T EITHER BUT HAVE PLENTY OF QUESTIONS FOR YOUR DOCTOR TO ANSWER.
Changing stroke rehab and research worldwide now.Time is Brain!trillions and trillions of neuronsthatDIEeach day because there areNOeffective hyperacute therapies besides tPA(only 12% effective). I have 523 posts on hyperacute therapy, enough for researchers to spend decades proving them out. These are my personal ideas and blog on stroke rehabilitation and stroke research. Do not attempt any of these without checking with your medical provider. Unless you join me in agitating, when you need these therapies they won't be there.
What this blog is for:
My blog is not to help survivors recover, it is to have the 10 million yearly stroke survivors light fires underneath their doctors, stroke hospitals and stroke researchers to get stroke solved. 100% recovery. The stroke medical world is completely failing at that goal, they don't even have it as a goal. Shortly after getting out of the hospital and getting NO information on the process or protocols of stroke rehabilitation and recovery I started searching on the internet and found that no other survivor received useful information. This is an attempt to cover all stroke rehabilitation information that should be readily available to survivors so they can talk with informed knowledge to their medical staff. It lays out what needs to be done to get stroke survivors closer to 100% recovery. It's quite disgusting that this information is not available from every stroke association and doctors group.
Showing posts with label EXACT PROTOCOL?. Show all posts
Showing posts with label EXACT PROTOCOL?. Show all posts
'Assessments', biomarkers and predictions don't get you recovered, only EXACT PROTOCOLS DO! SURVIVORS WANT RECOVERY! GET THERE!
I'd
fire everyone involved with this crapola! You're predicting based on
the failure of the status quo! Change the status quo, you blithering
idiots!
The only possibility of assessments being useful is if they POINT DIRECTLY TO EXACT REHAB PROTOCOLS! This did nothing towards that so completely fucking useless!
'Assessments' like Fugl-Meyer NEVER GET ANYONE RECOVERED! I'd have you all fired for incompetency in not solving stroke!
We are providing an unedited version of this manuscript to give early access to its findings. Before final publication, the manuscript will undergo further editing. Please note there may be errors present which affect the content, and all legal disclaimers apply.
Abstract
Stroke is a leading cause of long-term disability, often affecting upper-limb motor function and requiring continuous assessment. The Fugl-Meyer Assessment (FMA), though a clinical gold standard, is time-consuming and demands specialized personnel. This study presents an AI-driven, low-cost rehabilitation exergame that simultaneously provides therapy and automatically estimates upper-limb motor performance during gameplay using only a standard camera. Sixteen kinematic and spatiotemporal features were extracted from 2D hand and arm trajectories of twelve post-stroke individuals (24 limbs, 14 affected) using the MediaPipe framework. Features such as hand angle, range of motion, movement area, traveled distance, and shoulder–elbow coordination showed strong correlations with FMA scores and stratified participants by motor severity. A lightweight linear regression model achieved high predictive performance (Spearman ρ = 0.92, R² = 0.89, RMSE = 4.42) and classified severity levels with 86–93% accuracy. This interpretable approach outperformed complex machine learning models, highlighting the clinical relevance of transparent metrics embedded in gameplay. The proposed framework is sensor-free, scalable, and reproducible, offering immediate feedback while reducing clinical workload and enabling accessible digital biomarkers for telerehabilitation and remote monitoring after stroke.
Data availability
The datasets generated and analyzed during the current study are not publicly available at this stage but are available from the corresponding author (J.T.) upon reasonable request. We also intend to make the anonymized dataset publicly accessible through an open research repository following publication. The custom Python scripts used for data preprocessing, feature extraction, and regression analysis are available from the corresponding author upon request.
References
Tsao, C. W. et al. Heart Disease and Stroke Statistics-2022 Update: a report from the american heart association. Circulation145, e153–e639 (2022).
Background:
In this randomized controlled trial, we assessed the
neuroprotective effect of a 12-week resistance training (RT) program on
executive control and cortical thickness of the prefrontal, temporal,
parietal, and central cortex, regions prone to structural decline in
individuals with mild cognitive impairment (MCI).
Methods:
Seventy older adults (aged 60-85 y old, 38 females and 32 males)
were randomly allocated to a 12-week lower limb RT program or a waiting
list control group. The Montreal Cognitive Assessment (MoCA) was used to
stratify participants screened for high (< 26) or low (≥ 26) MCI
risk. Cognitive measurements consisted of the two-choice reaction time,
Go/No-go, mathematical processing, and memory search tests. Cortical
thickness was estimated from 3D T1-weighted MR images.
Results:
Complete randomized controlled trial data was obtained from 50
individuals (24 with high MCI risk). Significant Group x Time
interactions were found for response on the Go/No-go task and cortical
thickness of the right parahippocampal gyrus [F ≥ 5.3, p ≤ 0.03; η2p
≥ 0.12]. An inspection of these observations revealed an increase in
cortical thickness (+1.18 %) and a decrease in response time (-4.35 %)
in individuals with high MCI risk allocated to the exercise group (both
uncorrected p = 0.08). Decreased response time on the Go/No-go task was
associated with increased cortical thickness in the right entorhinal
gyrus (uncorrected p = 0.01).
Conclusions:
Our study demonstrated that 12 weeks of RT intervention may
effectively improve cognitive performance and slow neuronal loss in the
hippocampal complex of older adults at high MCI risk. Findings support
evidence for the neuroprotective effects of resistance training and its
potential role in cognitive health.
This is a simple test of your doctor's competence.
Music last night at Moriarties. Bass, violin, drums, keyboard, saxophone. All requiring two completely functioning hands. If your doctor has nothing, find a better one!
There should never be an inspirational stroke story, it should be a common occurrence of 100% recovery from EXACT STROKE REHAB PROTOCOLS! But that won't occur until we remove all the dead wood in stroke and put survivors in charge.
It was 10 years ago that Tim Niemann suffered a stroke. He lives now to help others.
Anna Kuschel
Tim Niemann
suffered a stroke in November of 2014. Niemann was so impressed and
grateful for the care he received at Mercy Hospital that he went on to
serve on the board for Mercy Health Foundation St. Louis. | photo by Ursula Ruhl
It was already an unusual day on
Nov. 19, 2014, with tensions high as the public awaited a grand jury
decision on whether to indict a Ferguson police officer in the fatal
shooting of Michael Brown.
Because of this unease,
Kirkwood native Tim Niemann, a general partner at Edward Jones, was at
home that Wednesday morning instead of traveling for work.
His
wife, Debra Niemann, at home as well, and the two had a conversation
before Tim Niemann left the house to return his rental car to the
airport.
As he was leaving the house, Niemann tripped
over the couple’s dog and fell. He instantly lost all feeling on the
left side of his body, and lost his vision. His wife called 911 and
within minutes paramedics arrived and transported Niemann to Mercy
Hospital St. Louis.
“Fear didn’t really kick in until I got to the emergency room and watched him quickly deteriorate,” Debra Niemann said.
Within
30 minutes, doctors determined that Niemann, 44 years old at the time,
had suffered a stroke. His carotid artery had been unknowingly cut
during a recent chiropractic adjustment, causing the stroke(Wrong, a clot from that dissection let go and blocked an artery in the brain. Exactly what happened to me. If our stroke medical personnel can't explain this stuff properly to the media, they shouldn't be there!).
“With
a stroke, every minute matters,” said Niemann, now 54. “The good news
is they knew what caused it. I wasn’t a victim — I was a survivor.”
At
the hospital, Niemann was given tissue plasminogen activator (tPA)
which, when administered within three hours of stroke onset, works by
dissolving blood clots that block blood flow to the brain, limiting the
risk of damage and impairment. Within minutes of receiving tPA,
Niemann’s vision returned and he regained feeling in the left side of
his body.
But the drug isn’t available at all
hospitals. In 2021, 65% of hospitals worldwide were unable to provide
tPA to their patients, according to the World Stroke Organization.
Niemann
was able to walk with assistance just three days after the stroke, and
could walk on his own two days after that. He returned to work three
months later in February of 2015.
Gratitude
Nearly
10 years later, Niemann has fully recovered from the stroke and works
to give back to the community following the life-saving care he
received.
Rather than feel angry or upset, Niemann
said he feels lucky to be alive and uses this positive attitude to
inspire and better the lives of others.
“I always had
gratitude, but I have a lot more gratitude now,” said Niemann, who lives
with his wife and the couple’s four children in Ladue, less than three
miles from his childhood home on South Woodlawn in Kirkwood.
Debra Niemann shares her husband’s attitude of gratitude.
“Every
day is precious because you never know what’s going to be thrown at
you. Appreciate those boring, quiet days,” she said. “Tim listened to
his doctors and never got depressed over the state he was in. He was
just so happy that he was going to be OK, because it could have been so
much worse.”
Both are grateful for the staff, medication and technology at Mercy Hospital.
“I’m
so blessed that I happened to be at Mercy. The one really cool thing
about the stroke was that I learned how lucky I was,” said Niemann, who
attended De Smet Jesuit High School, then St. Louis University and later
graduated from Boston College.
Service
Niemann’s
positive experience at Mercy inspired him to join the board for Mercy
Health Foundation St. Louis following his stroke. He served on the board
from 2015 to 2021.
Mercy President and CEO Steve Mackin said he appreciates Tim Niemann’s service on the board.
“Tim
was a tremendous leader on our foundation board and helped guide Mercy
through his leadership in many ways,” Mackin said. “He was very willing
to share his personal journey with other board members and prospective
donors.”
John Mozeliak, former board president and current St. Louis Cardinal’s President of Baseball Operations, echoed that sentiment.
“Tim
was inspirational. He focused on something that was personal to him,
and his determination was impressive,” Mozeliak said. “Tim’s connection
with Mercy will have a lasting impact for years to come.”
In
addition to Niemann’s time on the board for Mercy Health Foundation St.
Louis, he and his wife helped Mercy Hospital raise $250,000 for the
Stroke Campaign, which allowed the hospital to hire two more nurses with
specialized training required to quickly help stroke patients.
“We wanted to figure out what we had to do to recreate the experience I had so everybody is as lucky as me,” Niemann said.
Hoping
to inspire others, Niemann has spoken at four Stroke Symposiums, an
annual event where larger hospitals in St. Louis meet to share best
practices.
“I try to make the ordinary feel
extraordinary for people,” he said. “If a person I know has a stroke, I
want to help them be mentally tough and get through it.”
While Niemann has no lingering physical issues from the stroke, it left him with a heightened sense of fear and uncertainty.
“Something will happen and I am not sure if it is due to the stroke, or just getting older,” he said.
Jason
Selk, former director of sport psychology for the St. Louis Cardinals,
has helped Niemann work through his feelings of unease.
“He told me what he tells professional athletes: ‘If the doctor says you’re good, you’re good,’” Selk said.
Giving & Inspiring Others
After
retiring from Edward Jones in 2019 after 31 years with the firm,
Niemann now seeks to make a difference in the community by giving time
and resources to organizations he supports.
One
organization Tim and Debra Niemann are passionate about is the June
Jessee Memorial Foundation, which provides relief and support to help
children with medically complex neurological conditions. The couple
hopes to help open a respite home in St. Louis through the foundation
within the next 15 to 20 years.
Niemann also serves on
the board of the Foster & Adoptive Care Coalition, which strives to
create permanency in the lives of children by finding foster and
adoptive families in the St. Louis area.
“My wife and I don’t go to bed at night without thinking about trying to find forever homes for these kids,” he said.
Since
his stroke, Niemann’s outlook on life has changed to one that is more
focused on helping and listening to others. He views his stroke as the
turning point in which he realized the importance of letting people tell
their stories, and how lucky he is to be able to hear them.
“My mission is to inspire people to give,” said Niemann. “We all have time, talent or treasure to give.”
Anna Kuschel, a student at Concordia University Chicago, is a summer intern with the Webster-Kirkwood Times.
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.
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.
The
publication of the 2023 American Heart Association (AHA) Guidelines for
the Management of Aneurysmal Subarachnoid Hemorrhage represents a
milestone in the evolving landscape of cerebrovascular medicine.1
In this commentary, we aim to examine the fundamental shifts brought
into focus by these updated guidelines, highlighting the pivotal roles
of neuroendovascular management and the neurocritical intensive care
unit (neuro‐ICU). While neurointerventionalists have traditionally
played a pivotal role in the management of this condition, these
guidelines now expand their responsibilities beyond the confines of the
operating room.
Traditionally, aneurysmal
subarachnoid hemorrhage (aSAH) management has been centered around the
timely repair of ruptured cerebral aneurysms. Indeed, the urgency of
preventing rebleeding and securing the aneurysm cannot be overstated, as
it most significantly impacts patient outcomes. However, the 2023 AHA
Guidelines introduce a paradigm shift by recognizing that the battle
against aSAH is 2‐fold. While aneurysm repair remains a critical front,
there is a more equitable consideration of securement modality.
Furthermore, the neuro‐ICU emerges as an equally vital theater where the
clinical outcome is determined.
Guiding Precision Care and Tailoring Treatment: Neuroendovascular Techniques at the Forefront
The
updated guidelines for managing aSAH emphasize the importance of
personalized treatment strategies that consider the unique
characteristics of each aneurysm.1
Extensive research, exemplified by landmark studies such as the ISAT
(International Subarachnoid Aneurysm Trial) and the BRAT (Barrow
Ruptured Aneurysm Trial), has provided compelling evidence in favor of
coiling as the preferred method, particularly for improving patient
outcomes in the critical first year following treatment. However, the
landscape of aneurysm management is far from 1‐size‐fits‐all, and these
guidelines acknowledge the need for a tailored approach(So guessing).
Timing of Treatment
These guidelines stress the significance of prompt intervention for aSAH.1
Whether through open surgery or endovascular procedures, treating the
ruptured aneurysm as early as possible after presentation, preferably
within 24 hours, is strongly recommended. This emphasis on timely care
reflects the evolving landscape of aneurysm treatment, where precision
and expeditiousness are central to achieving the best results for
patients. This recommendation is classified as class I, supported by
level B‐NR (nonrandomized) evidence. Delaying treatment, particularly
beyond a 3‐day window, is discouraged.
Treatment Goal
The primary objective in treating patients with aSAH is the complete obliteration of the ruptured aneurysm whenever feasible(Why not 100% recovery? That's what all survivors want?).1
This strategy is advocated to reduce the risk of rebleeding and the
need for retreatment. In cases for which immediate complete obliteration
is not achievable, partial obliteration to secure the rupture site is
an acceptable strategy(So failure is acceptable? Good to know!), with retreatment considered for those displaying
functional recovery. This recommendation is also classified as class I,
with level B‐NR evidence.
Modality of Treatment for Posterior Circulation Aneurysms
These guidelines provide specific guidance for aSAH resulting from ruptured aneurysms in the posterior circulation.1
In cases in which coiling these aneurysms is feasible, it is
recommended over surgical clipping to enhance patient outcomes. This
partiality is supported by class I evidence with level B‐R (randomized).
Emergency Clot Evacuation
For
patients with aSAH considered salvageable but presenting with a
depressed level of consciousness due to a large intraparenchymal
hematoma, emergency clot evacuation is recommended.1 This intervention is pivotal in reducing death and is classified as a class I recommendation with level B‐R evidence.
Specialist Evaluation
The
guidelines underline the importance of involving specialists with
expertise in both endovascular and surgical treatments for evaluating
ruptured aneurysm.1
This assessment is essential for determining the most suitable
treatment approach tailored to individual patient and aneurysm
characteristics. Although categorized as class IIb, this recommendation
is supported by level B‐R evidence.
Age‐Specific Considerations
Age plays a crucial role in treatment decisions for patients with aSAH.1
The efficacy of coiling or clipping in improving outcomes for
individuals aged >70 years is uncertain, marked as a class IIb
recommendation with level C‐LD (limited data) evidence. Conversely, for
patients aged <40 years, surgical clipping of the ruptured aneurysm
may be considered preferable to enhance treatment durability and overall
outcome.
Modality of Treatment for Equally Suitable Aneurysms
In
cases of good‐grade aSAH stemming from ruptured aneurysms in the
anterior circulation, where primary coiling and clipping are both
viable, the 2023 AHA guidelines endorse primary coiling for superior
1‐year functional outcomes.1
Supported by level A evidence, this recommendation holds a class I
designation. However, both treatment options are considered reasonable
to achieve favorable long‐term outcomes, constituting a class IIa
recommendation with level B‐R evidence.
Endovascular Advancements
These
guidelines underscore the growing acceptance of advanced techniques in
aneurysm treatment, particularly for wide‐neck aneurysms resistant to
traditional methods.1 Notably, stent‐assisted coiling and flow diversion have gained favor.
Use of Flow Diverters for Fusiform/Blister Aneurysms
In
cases of aSAH from ruptured fusiform or blister aneurysms, the use of
flow diverters is considered reasonable to reduce death, as indicated by
a class IIa recommendation with level C‐LD evidence.1
Stents or Flow Diverters for Saccular Aneurysms
It
is crucial to note, however, that for patients with aSAH with ruptured
saccular aneurysms suitable for either primary coiling or clipping, the
guidelines advise against using stents or flow diverters due to a higher
risk of complications.1
This recommendation is classified as class III, indicating harm, with
level B‐NR evidence. In such instances, where coiling is not deemed
suitable or when there is a state of equipoise, the guidelines emphasize
the importance of comprehensive multidisciplinary discussions. These
discussions should carefully weigh the merits of both neurosurgical and
neuroendovascular alternatives, considering each patient's unique
circumstances and clinical presentation.
In
summary, these guidelines represent a significant step forward in
tailoring aSAH treatment to individual patient needs. By emphasizing
precision and timeliness in intervention, they aim to achieve the best
possible outcomes for patients facing this critical medical condition.
The growing acceptance of advanced techniques reflects the dynamic
nature of aneurysm management, highlighting the importance of staying
abreast of evolving treatment options and engaging in thoughtful,
multidisciplinary discussions to optimize patient care.
The Rise of Neurocritical Care
The
neuro‐ICU has, in recent years, transitioned from a supporting role to
taking center stage in aSAH management. This change is not arbitrary; it
is substantiated by a growing body of evidence that underscores the
importance of specialized critical care for patients with aSAH.2
Multidisciplinary teams in neuro‐ICUs have been shown to significantly
enhance patient survival and improve overall outcomes. These teams bring
together neurointensivists, neurosurgeons, interventionists, nurses,
and other specialists, working in concert to provide the highest
standard of care.
The rationale behind this
shift is also founded on comparative effectiveness research that
consistently demonstrates the benefits of specialized neurocritical
care.3
High‐volume centers equipped with dedicated neuro‐ICUs have
consistently reported lower mortality rates and improved patient
outcomes. This is not merely a theoretical concept but a practical
reality that demands acknowledgment and implementation.
Ultimately,
the 2023 AHA guidelines serve as a call to action for the medical
community, urging physicians, hospitals, medical societies, and national
organizations to recognize and champion the importance of neuro‐ICUs in
aSAH management.1
With these guidelines, it is recognized that comprehensive care for
patients with aSAH encompasses not only surgical prowess but also the
intricate and specialized care delivered within the neuro‐ICU.
Refresher on Mechanical Ventilation
The
2023 guidelines sought to reduce the duration of mechanical ventilation
and the risk of hospital‐acquired pneumonia, recognizing that optimal
outcomes for critically ill ventilated patients are more likely when
evidence‐based care bundles are applied.1
For patients experiencing aSAH who require mechanical ventilation for
>24 hours, it is strongly recommended to implement a standardized ICU
care bundle. This recommendation underscores the importance of drawing
from the extensive research conducted in both medical and surgical ICUs
and consistently applying these principles to patients with high‐grade
aSAH (HG‐aSAH). The core components of the ventilator bundle, often
referred to as “ABCDEF,” encompass the following aspects:
•
Assess, prevent, and manage pain
•
Both spontaneous awakening trials and spontaneous breathing trials
•
Choice of analgesia and sedation
•
Delirium: assess, prevent, and manage
•
Early mobility and exercise
•
Family engagement and empowerment
In
practical terms, what this means for patients with HG‐aSAH is 2‐fold.
First, there is substantial evidence supporting the reduction in the use
of opioid narcotics and a preference for nonsteroidal anti‐inflammatory
drugs like acetaminophen, ibuprofen, and ketorolac.4
Second, it involves the regular interruption of sedation, at least once
daily, to assess the patient's neurological status and prevent
excessive sedation.
Effective prevention of
delirium, a common challenge after aSAH, is achieved by avoiding
benzodiazepine sedation. Instead, dexmedetomidine is recommended for
achieving light sedation while also helping to manage the autonomic
dysregulation (ie, storming) often seen in these patients.5
Finally, systematic early mobilization necessitates a substantial
commitment from both physical therapy and nursing teams. For example,
every Hunt–Hess grade III patient capable of following commands with an
external ventricular drain should be ambulated daily. These initiatives
are best organized and led by a dedicated team of neurointensivists.
Advancements in Neuromonitoring
The
updated guidelines emphasize the importance of employing advanced
monitoring techniques in the management of patients with HG‐aSAH,
particularly when their neurological examination is limited.1
The direction of neurocritical care, especially for severe brain
injuries like HG‐aSAH, is undeniably moving toward sophisticated
multimodality brain monitoring. The foundation of this approach involves
initiating long‐term continuous video electroencephalogram monitoring, a
practice that should be maintained for at least 48 hours in all
comatose patients, including those with HG‐aSAH.6
Studies
have indicated that nonconvulsive seizures are more prevalent in this
patient population than previously thought, with a frequency ranging
from 10% to 30%.7
Importantly, there is substantial evidence to suggest that
electrographic seizure activity can significantly impact the patient's
level of consciousness and exacerbate secondary brain injury.
Furthermore, nonconvulsive seizures have been identified as potential
mimics of delayed cerebral ischemia (DCI) after aSAH.8, 9
In
recent years, there has been a notable surge in interest and research
dedicated to neuromonitoring techniques, encompassing both invasive and
noninvasive approaches. One particularly intriguing noninvasive method
is transcranial Doppler, often likened to a highly sophisticated
ultrasound for the brain. It stands out with an impressive sensitivity
exceeding 90%, making it a valuable bedside tool for detecting cerebral
abnormalities. However, it is equally important to acknowledge the
inherent limitations of this technique. While it excels in sensitivity,
it exhibits a specificity of 71% and is also limited by a positive
predictive value of 57%. These statistics underscore the need for
cautious interpretation and consideration of other clinical factors when
using transcranial Doppler data.
Quantitative electroencephalogram patterns have emerged as another noninvasive neuromonitoring approach with great potential.1
These patterns have shown promise in detecting DCI, with supporting
evidence from prospective studies suggesting their clinical relevance.
The ability to noninvasively identify DCI is a significant step forward
in managing patients with complex neurological conditions.
Invasive
neuromonitoring tools, such as brain tissue oxygen monitoring, cerebral
microdialysis, and electrocorticography, have also found their place in
the realm of DCI detection.1
This assertion is supported by a comprehensive review encompassing 47
studies. These invasive techniques provide valuable insights into
cerebral physiology and can be instrumental in tailoring treatment
strategies for individual patients.
In
summary, it is important to recognize that the optimal indications and
best practices for these neuromonitoring methods are still under
investigation. The field continues to evolve as researchers refine their
understanding of when and how to deploy these techniques most
effectively. Moreover, while these tools hold great promise, their
ultimate impact on clinical outcomes in the context of subarachnoid
hemorrhage and other neurological conditions remains an area of active
exploration.
Antiseizure Medication Controversy
One
contentious topic within the management of aSAH that the guidelines
grapple with is the use of prophylactic antiseizure medications.1
While the guidelines do recommend against their routine administration,
they do so with an understanding that numerous medical centers continue
to adopt a universal approach in administering these medications to
patients with aSAH. This disparity in practice highlights the ongoing
debate surrounding the benefits and risks associated with prophylactic
antiseizure medications in this patient population, particularly in
relation to cognitive outcomes.
The rationale
for administering prophylactic antiseizure medications stems from
concerns about the heightened risk of seizures in patients with aSAH due
to the brain's exposure to blood and potential irritants from the
hemorrhage. Consequently, some medical institutions have chosen to err
on the side of caution by providing antiseizure medications to all
patients with aSAH, regardless of their individual risk factors.
Although antiseizure medications can effectively reduce the risk of
seizures, they are not without their own set of adverse effects. These
medications may lead to side effects such as sedation, impaired
cognition, and even delirium.
There is a
growing body of evidence suggesting that long‐term use of certain
antiseizure medications, particularly phenytoin, may be associated with
negative cognitive outcomes in patients with aSAH.1
This raises concerns about whether the potential benefits in terms of
seizure prevention outweigh the risks, especially when it comes to the
patient's overall cognitive function and quality of life. The cumulative
risk of convulsive seizures in hospitalized patients with aSAH has been
reported to be 4%. Could the risk of delirium or oversedation from
routine antiseizure medication use be higher? It has been reported that
continued phenytoin use after discharge in patients with aSAH is
associated with worse cognitive outcomes that then improve when the
medication is stopped. We do not anticipate any change in practice until
clinical trials are conducted to address the issue of antiseizure
medication use after aSAH.
The guidelines acknowledge this contentious landscape and the need for further clarity.1
They highlight the importance of conducting additional clinical trials
to better understand the impact of prophylactic antiseizure medications
on cognitive outcomes in patients with aSAH. This research would aim to
provide concrete evidence regarding the risk–benefit balance,
potentially informing more precise recommendations in the future.
Caution Against Hemodynamic Prophylaxis and Hypervolemia
The
cautionary approach to hemodynamic augmentation and hypervolemia in the
2023 AHA Guidelines for aSAH management signifies another notable
departure from previous strategies.1
This shift aligns with a broader principle in critical care medicine:
the recognition that sometimes less intervention can yield better
outcomes. It reflects the acknowledgment that excessive medical
interventions, even with the best intentions, can lead to unintended
complications that may worsen the patient's condition.
One
of the critical aspects of this cautionary approach is the recognition
of potential complications associated with aggressive hemodynamic
management.10
By attempting to artificially increase blood pressure or volume in
patients with aSAH, health care providers may inadvertently trigger an
adverse event. In certain circumstances, we may develop a strong
fixation on pursuing active interventions, making it quite tempting to
deviate from established protocols. For instance, one might consider, “I
know that per the guidelines we're only supposed to induce hypertension
in the face of symptomatic vasospasm, but I'm concerned about this
particular patient.” In addition to potentially fatal complications such
as myocardial infarction and pulmonary edema, the guidelines highlight
the risk of exacerbating intracranial pressure, which can be detrimental
in patients with aSAH, who are already at risk of elevated pressure
within the skull. Additionally, there is the practice of
prophylactically inducing hypertension to arbitrary blood pressure
targets in every patient. This is a common occurrence.
Another
noteworthy concern is the possibility of inducing posterior reversible
encephalopathy syndrome, a neurological condition characterized by
symptoms such as headache, altered mental status, seizures, and visual
disturbances. Posterior reversible encephalopathy syndrome can occur
when there is a sudden increase in blood pressure, which can result from
aggressive attempts to elevate it in patients aSAH. Recognizing the
potential harm of such interventions is crucial in avoiding these
complications.
As a final deterrent from aggressive hemodynamic management, the guidelines draw attention to the concept of pressor dependence.1
This phenomenon is thought to occur when patients are subjected to
aggressive blood pressure management, resulting in their bodies becoming
reliant on medications to sustain blood pressure within a reasonable
target range. This can make it challenging to wean patients off these
medications without their blood pressure dropping below the desired
threshold. Even if only occurring in the thoughts and concerns of the
neuro‐ICU team, this phenomenon can lead to prolonged hospital stays and
increased health care resource usage.
More Oral Nimodipine?
With
a continuance of the 2012 recommendations, the updated guidelines stamp
the significance of early enteral nimodipine initiation in preventing
DCI and enhancing functional outcomes in cases of aSAH.1
In
clinical practice, the administration of oral nimodipine occurs along a
schedule of 60 mg every 4 hours, following the precedent set by the
British Nimodipine Trial in 1989.11
Unfortunately, this regimen often gets discontinued as soon as patients
with aSAH exhibit symptomatic vasospasm due to its tendency to cause
systemic hypotension. As a result, health care providers often resort to
halving the dosage or, more commonly, suspending nimodipine altogether.
The
question that has persisted over time is whether there might be
superior agents or administration protocols for arterial vasodilators
that could provide more effective alternatives.1
Examples include continuous intravenous infusion of nimodipine, a
practice prevalent in Europe, or the use of fasudil and clazosentan,
which are favored in Japan. However, it is crucial to note that the
current body of evidence does not support an immediate shift in US
clinical practice. This underscores the dynamic nature of medical
practice, with a recognition that as science advances, treatment
strategies may evolve to provide better outcomes for patients with aSAH.
Taking the Guidelines Into Practice
In
managing cases of aSAH, it is crucial to recognize that there is not a
definitive volume threshold that guides treatment decisions. Each
patient's condition must be carefully evaluated, highlighting the
importance of individualized care. Timely transfer of patients
presenting with acute severe headaches or new neurological deficits is
paramount to ensure they undergo appropriate diagnostic assessments and
receive specialized care as needed. Patients presenting >6 hours
after the onset of severe headaches or those with new neurological
deficits should undergo a noncontrast head computed tomography. If this
initial scan is negative for aSAH, lumbar puncture becomes essential to
confirm or exclude the presence of subarachnoid blood. Similarly, for
individuals with spontaneous aSAH and a strong suspicion of aneurysmal
involvement but inconclusive results from computed tomography
angiography, digital subtraction angiography is the recommended
diagnostic tool to identify or rule out cerebral aneurysms promptly.
Prompt identification of aneurysmal sources remains a paramount concern for clinical management.1
Comprehensive use of advanced imaging methods, such as CT angiography,
can significantly aid in this regard. Furthermore, using established
grading scales can aid in outcome prediction and guide discussions with
patients, families, and surrogates regarding treatment choices.
Decisions regarding the treatment of ruptured aneurysms should be made
by specialists well versed in both endovascular and surgical approaches.
Ultimately, the determination to use clipping, coil embolization, or
even flow diversion should be tailored to the patient's distinctive
characteristics and the aneurysm's unique features. As highlighted by
the current guidelines, there is a growing preference for coil
embolization for good‐grade aSAH cases originating from anterior
circulation ruptured aneurysms.1
Neuro‐ICU
management should encompass preventive measures such as deep vein
thrombosis prophylaxis, maintaining euvolemia, and thoughtful fluid
management.1
While invasive neuromonitoring techniques are increasingly valuable for
detecting DCI in high‐grade aSAH cases, the specific goals for fluid
management require further clarification. Although the risk of rerupture
in aSAH cases is relatively low, the use of imaging to guide treatment
decisions for survivors in the neuro‐ICU is recommended, particularly in
individuals with residual aneurysms. Regular monitoring for the
development of new aneurysms is also essential, especially in younger
patients with multiple aneurysms or a strong family history of aSAH.
Additionally, considerations
such as the timing of cerebrospinal fluid diversion, choice of fluids,
sodium goals, temperature management, glucose control, and monitoring of
intracranial pressure and multimodal monitoring are important aspects
of comprehensive aSAH management that deserve further attention and
investigation.1
Finally, early identification of deficits, especially in behavioral and
cognitive domains, is crucial. Interventions for mood disorders can
significantly improve long‐term outcomes, and providing counseling on
the higher risk of long‐term cognitive dysfunction may prove beneficial
for patients recovering from aSAH.
Impaired
ankle proprioception strongly predicts balance dysfunction in chronic
stroke. However, only sparse data on ankle position sense and no
systematic data on ankle motion sense dysfunction in stroke are
available. Moreover, the lesion sites underlying impaired ankle
proprioception have not been comprehensively delineated. Using robotic
technology, this study quantified ankle proprioceptive deficits
post-stroke and determined the associated brain lesions.
Methods
Twelve
adults with chronic stroke and 13 neurotypical adults participated. A
robot passively plantarflexed a participant’s ankle to two distinct
positions or at two distinct velocities. Participants subsequently
indicated which of the two movements was further/faster. Based on the
stimulus-response data, psychometric just-noticeable-difference (JND)
thresholds and intervals of uncertainty (IU) were derived as measures on
proprioceptive bias and precision. To determine group differences,
Welch’s t-test and the Wilcoxon-Mann-Whitney test were performed for the
JND threshold and IU, respectively. Voxel-based lesion subtraction
analysis identified the brain lesions associated with observed
proprioceptive deficits in adults with stroke.
Results
83%
of adults with stroke exhibited abnormalities in either position or
motion sense, or both. JND and IU measures were significantly elevated
compared to the control group (Position sense: + 77% in JND, + 148% in
IU; Motion sense: +153% in JND, + 78% in IU). Adults with stroke with
both impaired ankle position and motion sense had lesions in the
parietal, frontal, and temporoparietal regions.
Conclusions
This
is the first study to document the magnitude and frequency of ankle
position and motion sense impairment in adults with chronic stroke.
Proprioceptive dysfunction was characterized by elevated JND thresholds
and increased uncertainty in perceiving ankle position/motion.
Furthermore, the associated cortical lesions for impairment in both
proprioceptive senses were largely overlapping.
ACKSON, Miss. (WLBT) - A Raymond man who
suffered a stroke was unable to walk until he was introduced to
life-changing technology.
The avid
runner regained some movement through rehab, but his quality of life was
not the same. His future was uncertain until he said he found the
electronic device that gave him back what he had lost.
“All anybody ever really wants is what you had before this happened,” said Darryl Blakely.
He
is now walking after suffering a stroke last April that left him
paralyzed. He felt a pain in his hip and suddenly lost function on his
right side.
“And
the day before, if you would have told me to run four miles, I would
have said let’s go,” said Blakely. “And then the day this happened I
couldn’t even make two steps.”
Two
months ago, that changed when his Methodist Rehabilitation therapist
suggested the Bioness L300 Go, which uses functional electrical
stimulation. He wears it on his right leg.
“In
a month, I could get around two or three steps, and since then, I’ve
made a dramatic improvement,” said the recovering stroke victim. “Two
weeks ago, I walked four miles. It took two hours, but you know, because
I like to walk and run, I did it.”
The
55-year-old still undergoes therapy for his right arm, but with the
electronic stimulation, he has resumed managing apartments and much of
his daily work activity.
“This thing senses that you want to move, and it sends a signal to the muscle and stimulates it and makes your foot pick up.”
The
husband, father, and grandfather admit the device is expensive, costing
about $10,000, and was purchased through help from vocational rehab.
“I’m just thankful for people who spend the time to think of things to help people get their life back together,” added Blakely.
The
device was developed in 2017. According to Bioness Rehab, the L300 Go
is the world’s first Functional Electronic Stimulation that integrates
proprietary 3D motion detection.
It
detects gait events, providing stimulation precisely when needed making
it easier to clear their foot at varying walking speeds, on stairs,
ramps, and while navigating uneven territory. The L300 Go can help
people with certain medical conditions walk more confidently.
