Predicting 90-Day Outcome After Thrombectomy: Baseline-Adjusted 24-Hour NIHSS Is More Powerful Than NIHSS Score Change

In what parallel universe do you live where you think that predicting failure to recover is of any interest or help to survivors? 

 

Predicting 90-Day Outcome After Thrombectomy: Baseline-Adjusted 24-Hour NIHSS Is More Powerful Than NIHSS Score Change

Eva A. Mistry

,

Sharon Yeatts

,

Adam de Havenon

,

Tapan Mehta

,

Niraj Arora

,

Felipe De Los Rios La Rosa

,

Amy K. Starosciak

,

James E. Siegler III

,

Akshitkumar M. Mistry

,

Shadi Yaghi

,

Pooja Khatri

Originally published18 May 2021https://doi.org/10.1161/STROKEAHA.120.032487Stroke. 2021;52:2547–2553

Abstract

Background and Purpose:

The National Institutes of Health Stroke Scale (NIHSS) measured at an early time point is an appealing surrogate marker for long-term functional outcome of stroke patients treated with endovascular therapy. However, definitions and analytical methods for an early NIHSS-based outcome measure that optimize power and precision in clinical studies are not well-established.

Methods:

In this post-hoc analysis of our prospective observational study that enrolled endovascular therapy-treated patients at 12 comprehensive stroke centers across the US, we compared the ability of 24-hour NIHSS, ΔNIHSS (baseline minus 24-hour NIHSS), and percentage change (NIHSS×100/baseline NIHSS), analyzed as continuous and dichotomous measures, to predict 90-day modified Rankin Scale (mRS) using logistic regression (adjusted for age, baseline NIHSS, glucose, hypertension, Alberta Stroke Program Early CT Score, time to recanalization, recanalization status, and intravenous thrombolysis) and Spearman ρ.

Results:

Of 485 patients in the BEST (Blood Pressure After Endovascular Stroke Therapy) cohort, 446 (92%) with 90-day follow-up data were included. An absolute 24-hour NIHSS, adjusted for baseline in multivariable modeling, had the highest predictive power of all definitions evaluated (aR² 0.368 and adjusted odds ratio 0.79 [0.75–0.84], P<0.001 for mRS score 0–2; aR² 0.444 and adjusted odds ratio 0.84 [0.8–0.86] for ordinal mRS). For predicting mRS score of 0–2 with a cut point, the second most efficient approach, the optimal threshold for 24-hour NIHSS score was ≤7 (sensitivity 80.1%, specificity 80.4%; adjusted odds ratio 12.5 [7.14–20], P<0.001), followed by percent change in NIHSS (sensitivity 79%, specificity 58.5%; adjusted odds ratio 4.55 [2.85–7.69], P<0.001).

Conclusions:

Twenty-four–hour NIHSS, adjusted for baseline, was the strongest predictor of both dichotomous and ordinal 90-day mRS outcomes for endovascular therapy-treated patients. A dichotomous 24-hour NIHSS score of ≤7 was the second-best predictor. Although ΔNIHSS, continuous and dichotomized at ≥4, predicted 90-day outcomes, absolute 24-hour NIHSS definitions performed better.

Footnotes

This manuscript was sent to Ajay K. Wakhloo, Guest Editor, for review by expert referees, editorial decision, and final disposition.

The Data Supplement is available with this article at https://www.ahajournals.org/doi/suppl/10.1161/STROKEAHA.120.032487.

 

 

Do somatosensory deficits predict efficacy of neurorehabilitation using neuromuscular electrical stimulation for moderate to severe motor paralysis of the upper limb in chronic stroke?

In what parallel universe do you live where you think that predicting failure to recover is of any interest to survivors?  Except maybe to fire you and get someone competent instead?

Do somatosensory deficits predict efficacy of neurorehabilitation using neuromuscular electrical stimulation for moderate to severe motor paralysis of the upper limb in chronic stroke?

Show all authors

Keita Tsuzuki, Michiyuki Kawakami, Takuya Nakamura, ...

First Published August 25, 2021 Research Article 

https://doi.org/10.1177/17562864211039335

Article information

Abstract

Background:

Various neurorehabilitation programs have been developed to promote recovery from motor impairment of upper extremities. However, the response of patients with chronic-phase stroke varies greatly. Prediction of the treatment response is important to provide appropriate and efficient rehabilitation. This study aimed to clarify whether clinical assessments, such as motor impairments and somatosensory deficits, before treatment could predict the treatment response in neurorehabilitation.

Methods:

The data from patients who underwent neurorehabilitation using closed-loop electromyography (EMG)-controlled neuromuscular electrical stimulation were retrospectively analyzed. A total of 66 patients with chronic-phase stroke with moderate to severe paralysis were included. The changes from baseline in the Fugl-Meyer Assessment–Upper Extremity (FMA-UE) and the Motor Activity Log-14 (MAL-14) of amount of use (AOU) and quality of movement (QOM) were used to assess treatment response, and multivariate logistic regression analysis was performed using the extracted candidate predictors, such as baseline clinical assessments, to identify predictors of FMA-UE and MAL-14 improvement.

Results:

FMA-UE and MAL-14 scores improved significantly after the intervention (FMA-UE p < 0.01, AOU p < 0.01, QOM p < 0.01). On multivariate logistic regression analysis, tactile sensory (p = 0.043) and hand function (p = 0.030) were both identified as significant predictors of FMA-UE improvement, tactile sensory (p = 0.047) was a significant predictor of AOU improvement, and hand function (p = 0.026) was a significant predictor of QOM improvement. The regression equations explained 71.2% of the variance in the improvement of FMA-UE, 69.7% of AOU, and 69.7% of QOM.

Conclusion:

Both motor and tactile sensory impairments predict improvement in motor function, tactile sensory impairment predicts improvement in the amount of paralytic hand use, and motor impairment predicts improvement in the quality of paralytic hand use following neurorehabilitation treatment in patients with moderate to severe paralysis in chronic-phase stroke. These findings may help select the appropriate treatment for patients with more severe paralysis and to maximize the treatment effect.

Keywords

chronic stroke, motor function, motor recovery, neurorehabilitation, prediction model, somatosensory function

Introduction

Motor impairment of the upper extremities is one of the major symptoms in patients with stroke. Motor impairment occurs in approximately 70% or more of patients,^1,2 and various rehabilitation programs have been developed to promote recovery from motor impairment after stroke.³ In addition, with the recent development of neurorehabilitation, reports of interventions for residual motor paralysis in the chronic phase are increasing. However, the response to rehabilitation therapy of patients with chronic stroke varies greatly from patient to patient. Therefore, it is important to define an individualized rehabilitation treatment program according to the severity of stroke to provide appropriate and efficient rehabilitation. For this purpose, accurate prediction of the treatment response is necessary.

Somatosensory deficits, as well as motor impairments, are major symptoms in patients with stroke. Somatosensory deficits occur in more than 60% of patients⁴ and remain in about 40% of patients in the chronic phase.⁵ Along with motor impairments, somatosensory deficits affect motor functions and activities of daily living (ADLs), such as hand dexterity^6,7 and grasping and manipulating objects.^8–10 Although both motor and somatosensory functions are considered important predictors of motor function recovery in rehabilitation, many reports of patients with chronic stroke have focused only on motor function before intervention. In addition, reports using other clinical assessments, including of somatosensory deficits, are limited to mild to moderate paralysis.¹¹ Thus, whether somatosensory impairment has an impact on the recovery of motor function in neurorehabilitation of patients with chronic stroke who have more severe paralysis remains unclear.

In addition to recovery of motor function, increasing the AOU and improving the quality of movement (QOM) of the paralyzed hand are also major goals of neurorehabilitation.^12,13 It has been reported that baseline motor and somatosensory functions can both be used as predictors of the AOU and improvement in the QOM of the paralyzed hand by neurorehabilitation in subacute stroke patients.¹⁴ A report on chronic stroke patients also showed that both motor and somatosensory functions have a significant impact on prediction.¹⁵ However, similar to the recovery of motor function, reports on the AOU and QOM of the paralyzed hand are limited to mild to moderate paralysis.

This study aimed to determine the effects of clinical assessments of motor impairments and somatosensory deficits on the prediction of treatment response, such as recovery of motor impairments (increases in the amount of use and in the QOM of the paralyzed hand) in rehabilitation of patients with moderate to severe paralysis in chronic-phase stroke. We hypothesized that both pretreatment motor and somatosensory functions would be useful predictors of recovery of motor impairments (increased amount of use and improved QOM of the paralyzed hand).

 

TSU developed a way to monitor the migration of young neurons

In what parallel universe do you live in if you think our fucking failures of stroke associations  will instruct researchers to use this to validate that their neurogenesis experiments are working as expected?

TSU developed a way to monitor the migration of young neurons

TSU neuroscientists and colleagues from Belgium and the USA have created a non invasive tool to track the movement of young neurons. To do this, scientists mark new brain cells with a special marker that can be seen on MRT (magnetic resonance tomography). Viral vectors - inactivated viruses that can easily enter the cell, act as delivery couriers of markers. The new tool, created with the support of the Russian Science Foundation, will help to predict the dynamics of patient recovery and assess the pace of rehabilitation after stroke and traumatic brain injury.

- It is known that after a stroke, in special zones of neurogenesis, there is an active production of young neurons. They migrate to the affected area to replace the dead neurons, - explains Marina Khodanovich, head of the Laboratory of Neurobiology at the TSU Biological Institute. - But before there were methods to track these cells in a living brain, this could only be understood postmortem. To see how young neurons travel, we and colleagues from the University of Leuven (Belgium) - Irina Thiry and Veronique Daniels - designed special vectors based on lentiviruses and adenoassociated viruses. Genetic engineers extracted a pathogenic component from them and inserted a gene that increases the production of ferritin, and also a special genetic sequence (promoter), thanks to which the production of ferritin will increase only in young neurons. Young neurons store ferritin, and therefore iron, which makes them visible. 

The researchers tested the new tool on rats. They simulated ischemic cerebral stroke in laboratory animals, introduced a genetic tag, and tracked the process of neurogenesis. The rats' brains were scanned on the most powerful high-field magnetic resonance imaging machine in Russia, designed for research on small laboratory animals.

- As part of the experiment, the condition of 40 stroke survivors was assessed, says Marina Khodanovich. During the month, each of them had several scans. On the MRT scans, we saw changes characteristic of iron accumulation. Then we examined sections of animal brains and identified cells that had accumulated ferritin. It turned out that the localization of changes in the MRT signal and the neurons that accumulated ferritin coincide well, and not only with young but also with adult neurons that are included in the neural network. This suggests that the first non invasive way to track new neurons using viral vectors is indeed effective.

According to the neurobiologist, this method cannot be used in humans, because an increase in ferritin content affects cell metabolism. But the new approach helps to understand and trace in animals how the brain recovers from stroke, injury, and other diseases. This knowledge will help create new therapies and predict brain recovery after severe disorders.

In the near future, scientists to analyze a large amount of information obtained during the experiment. This will make it possible not only to reveal new data on neurons but also to evaluate the functional characteristics of vectors, to choose the most effective and safe ones for changing the functions of neurons.

The new method makes it possible to monitor other cells of the nervous system that cannot yet be seen on MRT. For example, with ischemia, a glial scar appears around the focus - a kind of barrier that encloses the area in which the dead cells are located. Until a certain time, until the immune cells remove the "garbage" in the form of dead neurons, this scar is even useful, but later it interferes with the germination of axons (processes along which nerve impulses travel) and the restoration of the activity of the central nervous system.

- There is no way to non-invasively look at astrocytes - those cells that form a glial scar, but the use of viral vectors can solve this problem, - adds Marina Khodanovich. -– After labels are delivered to astrocytes, it will be possible to see their behavior. In the future, it is possible to find a way to change their morphology in order to destroy the glial scar and accelerate the patient's recovery process. This is just one use case for vectors. The potential of the new instrument is much broader.

As part of further research, neuroscientists of TSU intend to obtain a whole series of important data to find out the functional characteristics of new neurons and how fully they are included in the work of the neural network.

Provided by Tomsk State University 

Occupational therapy leadership: promoting an autonomy-supportive environment based on self-determination theory, to improve patient outcomes in acute and post-acute stroke rehabilitation

I see nothing in stroke healthcare that suggests a rapid and successful rehabilitation process. All I see is complete failure.  What parallel universe are you living in? 

The current state of stroke is a complete failure. None of the following have cures. 

1. 30% get spasticity NOTHING THAT WILL CURE IT.

2. At least half of all stroke survivors experience fatigue Or is it 70%?

Or is it 40%?

NOTHING THAT WILL CURE IT.

3. Over half of stroke patients have attention problems.

NOTHING THAT WILL CURE IT.

NO PROTOCOLS THAT WILL CURE IT.

4.  The incidence of constipation was 48%.

NO PROTOCOLS THAT WILL CURE IT.

5. No EXACT stroke protocols that address any of your muscle limitations.

6. Poststroke depression(33% chance)

NO PROTOCOLS THAT WILL ADDRESS IT. 

7.  Poststroke anxiety(20% chance) NO PROTOCOLS THAT WILL ADDRESS IT. 

8. Posttraumatic stress disorder(23% chance)  NO PROTOCOLS THAT WILL ADDRESS IT.

  9.  12% tPA efficacy for full recovery NO ONE IS WORKING ON SOMETHING BETTER.

10.  10% seizures post stroke NO PROTOCOLS THAT WILL ADDRESS IT. 

11. 21% of patients had developed cachexia NO PROTOCOLS THAT WILL ADDRESS IT. 

 

12. You lost 5 cognitive years from your stroke  NO PROTOCOLS THAT WILL ADDRESS IT.

13.  33% dementia chance post-stroke from an Australian study?

       Or is it 17-66%?

       Or is it 20% chance in this research?

NO PROTOCOLS THAT WILL ADDRESS THIS 

The wishful thinking here:

 

Occupational therapy leadership: promoting an autonomy-supportive environment based on self-determination theory, to improve patient outcomes in acute and post-acute stroke rehabilitation

Permanent Link

https://hdl.handle.net/2144/38178

Abstract

A major dilemma that is being addressed in the current project is the discrepancies between healthcare system's expectations for a rapid and successful rehabilitation process and patients after having a stroke ability to meet these expectations while striving to adapt to the calamitous event in their life. Emphasizing a more biomedical approach and under implementation of psychosocial approaches, poor acknowledging of patients' basic psychological needs lead to poor motivation, therapeutic disengagement and may lead to a rehabilitation failure. To cope with this gap in the process of stroke rehabilitation, an educational program aiming for occupational therapists working with patients after having a stroke in their acute and post-acute rehabilitation phases was constructed. The program guides practitioners for effective communication with their patients, building a needs-supportive environment and addressing their patients' basic psychological needs in light of the selfdetermination theory, theories of adaptation from occupational therapy perspectives and considering occupational justice and the ICF model. A clinical reasoning, step-by-step problem solving is introduced using adaptation of known models and innovated models for interventions that were created for this purpose. Program delivery through a series of 4-webinar modules is illustrated with their learning objectives, assignments and discussions. The program evaluation and implementation are expected to be the initiator of a change in the health and rehabilitation climate and in Israel.

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Attribution-NonCommercial-NoDerivatives 4.0 International

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