Updated society guidelines address prevention of second stroke

Guidelines barely do any good at all, protocols are needed but you will continue to get guidelines because that allows your medical team to blame you for your stroke - you didn't follow the guidelines closely enough.

Updated society guidelines address prevention of second stroke

Health care providers should perform diagnostic tests to determine the cause of a first stroke within 48 hours of symptom onset, according to an updated American Heart Association and American Stroke Association Clinical Practice Guideline.

The guideline also provides treatment recommendations based upon the cause of a first stroke or transient ischemic attack. Potential causes may include, but not limited to, blockages in large arteries in the neck or brain, damage to the small arteries in the brain from high blood pressure or diabetes, or irregular heart rhythms.

An updated American Heart Association and American Stroke Association Clinical Practice Guideline focuses on prevention of a second stroke. Source: Adobe Stock

The treatment recommendations include:

• The use of multidisciplinary care teams for personalization of patient care and employment of shared decision-making with the patient to ensure that care plans incorporate the patient’s wishes, goals and concerns;

• Screening for and diagnose atrial fibrillation and initiating medications to reduce recurrence;

• Prescribing antithrombotic therapy for most patients without contraindications. Of note, antiplatelets combined with anticoagulants are typically not recommended for the prevention of a second stroke; dual antiplatelet therapy is only recommended short-term for patients with early arriving minor stroke and high-risk TIA or severe symptomatic stenosis;

• Carotid endarterectomy, or in certain cases stent placement in the carotid artery, should be considered for patients with narrowing of the arteries in the neck; and

• Aggressive medical management of risk factors and short-term dual anti-platelet therapy are ideal for individuals with severe intracranial stenosis thought to have caused the stroke.

In addition, the guideline states that it is now reasonable to consider percutaneously closing a patent foramen ovale.

“It is critically important to understand the best ways to prevent another stroke once someone has had a stroke or a TIA,” Dawn O. Kleindorfer, MD, FAHA, chair of the guideline writing group and professor and chair of the department of neurology at the University of Michigan School of Medicine, said in a press release. “If we can pinpoint the cause of the first stroke or TIA, we can tailor strategies to prevent a second stroke.”

Also included in the update are secondary guidelines for patients who survived a stroke or TIA. These include:

• Managing the patient’s vascular risk factors, such as high blood pressure, type 2 diabetes, cholesterol, triglyceride levels and smoking cessation;

• Limiting salt intake and/or following a Mediterranean diet; and

• Participating in 10-minute, four-times weekly moderate-intensity aerobic activity or 20-minute, twice-weekly vigorous-intensity aerobic activity for those who are capable of physical activity.

“The secondary prevention of stroke guideline is one of the American Stroke Association’s ‘flagship’ guidelines, last updated in 2014,” Kleindorfer said in the release. “There are also a number of changes to the writing and formatting of this guideline to make it easier for professionals to understand and locate information more quickly, ultimately greatly improving patient care and preventing more strokes in our patients.”

 

 

What you should know about strokes

That your doctor, stroke hospital and therapists have no clue how to get you 100% recovered.  They will talk a good game but when you ask for specifics you will find out the hideous truth. You're screwed, they aren't because they will get paid regardless of your lack of recovery.  A perverse incentive to not even try to do the difficult work of finding out how to get you 100% recovered.
http://www.ejinsight.com/20180112-what-you-should-know-about-strokes/?
A stroke can cause serious disabilities, so we should pay attention to our body to see if there is any symptom.
Although losing strength in arms or legs is one of the signs of stroke, what degree of the fatigue is considered a symptom? If you do not know, you may become afraid of your own shadow.
Recently, a retired senior teacher came to me for a medical examination. She worried that she might have symptoms of a stroke as her hands sometimes lose strength and she felt pain on her forehead and temples.
A stroke refers to a sudden occlusion or rupture of blood vessels, causing interruption of blood supply to part of your brain, depriving brain tissue of oxygen. Within minutes, brain cells begin to die.
The blood vessels involved in stroke are usually distributed in either the left or right brain, so the patient will most likely have paralysis or weakness on one side of the body.
If it is a hemorrhagic stroke, the situation will be very serious and the patient needs to be admitted to hospital. If a patient reports feeling fatigue on both sides of the body but at the same time is able to go to a clinic, the chance of it being a stroke is very low.
Blood vessels are very fragile. Even if the patient has a temporary stroke, the blood vessels can at most withstand two or three short-term occlusions. It is impossible to have numerous brief occlusions in blood vessels and then miraculously heal. (Except for this hard to believe research;

Paradoxical Motor Recovery From a First Stroke After Induction of a Second Stroke Reopening a Postischemic Sensitive Period)

Coming to my patient, her symptoms were not of stroke, but her look of sadness and anxiety gave me some clues. The signs are just a result of her body reacting to stress.
It turned out that her first grandchild was born two months ago. She was very excited at the age of seventy to embrace such news. However, at the same time she felt stressed that she would have to help in taking care of her grandchild.
The lady had graduated from the University of Hong Kong in the late 1960s. She is definitely an elite. Her career was amazing and after retirement, she still keeps learning and enhancing herself.
With her education and upbringing, she ought not be troubled by a “trivial matter”, but we can understand her situation because we are all just human.
When we encounter major life events, such as bereavement, unemployment, etc., we will inevitably be at a loss. Having a newborn in the family is amazing, but it made her be on her guard.
As one of her relatives had a stroke recently, she couldn’t help but interpret her stress and unease as a sign of stoke. After reassurance from me, she finally felt relieved.
This article appeared in the Hong Kong Economic Journal on Jan 4
Translation by John Chui
[Chinese version 中文版]
– Contact us at english@hkej.com

Paradoxical Motor Recovery From a First Stroke After Induction of a Second Stroke Reopening a Postischemic Sensitive Period

I would never voluntarily do a second stroke and I doubt this would ever get enough test subjects to prove if this works in humans. I would really question the conclusion that came out of this. Have you proven that the same exact area was infarcted?
Earlier reported here: But it seems to be the same research, just now in print.

'Window of recovery' can reopen after stroke

Paradoxical Motor Recovery From a First Stroke After Induction of a Second Stroke Reopening a Postischemic Sensitive Period

1. Steven R. Zeiler, MD, PhD1⇑
2. Robert Hubbard1
3. Ellen M. Gibson1
4. Tony Zheng1
5. Kwan Ng, MD, PhD2
6. Richard O’Brien, MD, PhD3
7. John W. Krakauer, MD1

1. ¹Johns Hopkins University, Baltimore, MD, USA
2. ²UCLA, Los Angeles CA, USA
3. ³Duke University, Durham, NC, USA

1. Steven R. Zeiler, MD, PhD, The Johns Hopkins Hospital, Department of Neurology, Phipps 443, 600 N. Wolfe Street, Baltimore, MD 21287, USA Email: sz@jhmi.edu

Abstract

Background and objective. Prior studies have suggested that after stroke there is a time-limited period of increased responsiveness to training as a result of heightened plasticity—a sensitive period thought to be induced by ischemia itself. Using a mouse model, we have previously shown that most training-associated recovery after a caudal forelimb area (CFA) stroke occurs in the first week and is attributable to reorganization in a medial premotor area (AGm). The existence of a stroke-induced sensitive period leads to the counterintuitive prediction that a second stroke should reopen this window and promote full recovery from the first stroke. To test this prediction, we induced a second stroke in the AGm of mice with incomplete recovery after a first stroke in CFA.  

Methods. Mice were trained to perform a skilled prehension (reach-to-grasp) task to an asymptotic level of performance, after which they underwent photocoagulation-induced stroke in CFA. After a 7-day poststroke delay, the mice were then retrained to asymptote. We then induced a second stroke in the AGm, and after only a 1-day delay, retrained the mice.  

Results. Recovery of prehension was incomplete when training was started after a 7-day poststroke delay and continued for 19 days. However, a second focal stroke in the AGm led to a dramatic response to 9 days of training, with full recovery to normal levels of performance.  

Conclusions. New ischemia can reopen a sensitive period of heightened responsiveness to training and mediate full recovery from a previous stroke.

'Window of recovery' can reopen after stroke

I would never do this and I doubt this would ever get enough test subjects to prove if this works in humans.
http://www.eurekalert.org/pub_releases/2016-01/jhm-or010716.php
Using mice whose front paws were still partly disabled after an initial induced stroke, Johns Hopkins researchers report that inducing a second stroke nearby in their brains let them "rehab" the animals to successfully grab food pellets with those paws at pre-stroke efficiency.
The findings, described online Dec. 31, 2015, in Neurorehabilitation and Neural Repair, show that the "window of opportunity" for recovering motor function after a stroke isn't permanently closed after brain damage from an earlier stroke and can reopen under certain conditions, in conjunction with rapid rehabilitation efforts.
The investigators strongly emphasize that their experiments do not and will never make a case for inducing strokes as a therapy in people with stroke disability. But they do suggest the mammalian brain may be far more "plastic" in such patients, and that safe and ethical ways might be found to better exploit that plasticity and reopen the recovery window for people who have never fully regained control of their motor movements.
"If we can better understand how to reopen or extend the optimal recovery period after a stroke, then we might indeed change how we treat patients for the better," says Steven Zeiler, M.D., Ph.D., assistant professor of neurology at the Johns Hopkins University School of Medicine. "Our study adds new strong and convincing evidence that there is a sensitive period following stroke where it's easiest to relearn motor movements -- a topic that is still debated among stroke researchers."
The new mouse experiments build on a previous study at Johns Hopkins, which found that the window of optimal recovery following a stroke in mice was within the first seven days, but this time period could be extended by giving mice the common antidepressant fluoxetine immediately after the stroke. The investigators suspected that the antidepressant increased the brain's response to learning. Until now, however, the researchers say, there was no evidence that once the optimal period was over -- with or without fluoxetine -- the potential for recovery could be reopened.
For the new research, which did not involve the use of the antidepressant, the researchers -- as in their first experiments -- taught mice to reach through a slit in their cage with their front paw to grasp food pellets affixed to a bar, a task that four-legged animals don't naturally perform.
See an animation of the experiment here.
Once the mice became efficient at the task -- it took about 10 days of training -- the researchers measured their individual success rates. On average, they found the mice successfully grabbed pellets just over 50 percent of the time.
The researchers then induced a stroke in the motor cortex of the mice's brains, making them unable to perform the task. After waiting a week -- well beyond the known "optimal" window during which rehab training will work -- they put the mice through almost three weeks of task training, during which the mice successfully grabbed the pellets again, but only about 30 percent of the time.
For the next phase of the experiment, the scientists built on previous research and observations in mice that brain ischemia -- the cutoff or reduction of oxygen to the brain during a stroke or other insult to the cortex -- under certain conditions increased brain plasticity, the ability of the brain to compensate for injury and form new connections.
To that end, the scientists induced a second stroke in the lab mice either in the secondary motor cortex near the first stroke site or, for purposes of a control group, in the visual cortex, located far from the original site.
Instead of waiting days, the investigators began retraining these mice the next day and found that mice with the follow-up stroke in the motor cortex relearned to grasp the food pellets just as well as they did before the first stroke, with success more than 50 percent of the time.
Mice in the control group never did any better, even with extended training, suggesting that the motor cortex may be the only part of the brain with this type of "reopening" capability for motor movements, the investigators say.
Zeiler plans to investigate other ways to reopen the window of recovery and make use of the optimal recovery window. The lead investigator of the study, John Krakauer, M.D., M.A., professor of neurology, directs the Brain, Learning, Animation and Movement Lab, which uses basic science data, like that in this study, to develop new patient therapies. Currently, the lab is investigating the importance of early and intense rehabilitation in patients to enhance brain plasticity after stroke.
According to the Centers for Disease Control and Prevention, in the U.S., stroke is the No. 1 cause of disability and costs $34 billion each year in in health care, medications and missed days of work.

###

Other authors on the study include Robert Hubbard, Ellen Gibson and Tony Zheng of Johns Hopkins Medicine; Kwan Ng of the University of California, Los Angeles; and Richard O'Brien of Duke University.
Funding for the study was provided by grants from the National Institute of Neurological Disorders and Stroke (grant numbers 1K08 NS085033-01, R01 NS052804-05 and R01 120 86264), the Eunice Kennedy Shriver National Institute of Child Health and Human Development (R01 HD073147), and the James S. McDonnell Foundation.

Mixed Results for Low-Dose Statin in Second Stroke - Pravastatin didn't reduce incidence of recurrent stroke, but did offer other benefits

But what about these other benefits of statin therapy immediately post-stroke? Do researchers ever consider the complete environment around their research? Or even know about similar research?
Ask your doctor to resolve these differences, preferably before you have your next stroke. You don't want her/him researching on the internet just as you get out of the ER.  This is what protocols are for; so our doctors don't have to think up individualized responses.

Statins induce angiogenesis, neurogenesis, and synaptogenesis after stroke

Simvastatin attenuates axonal injury after experimental traumatic brain injury and promotes neurite outgrowth of primary cortical neurons 

Acute statin therapy improves survival after ischemic stroke

And the latest research here:

 Mixed Results for Low-Dose Statin in Second Stroke - Pravastatin didn't reduce incidence of recurrent stroke, but did offer other benefits

Treating stroke patients with low-dose pravastatin (Pravachol) did not appear to prevent the occurrence of a second stroke, Japanese researchers reported here.

In patients with noncardioembolic ischemic stroke, the risk of stroke was 2.55% a year among patients taking 10-mg daily pravastatin compared with 2.65% a year for patients taking other medications at the discretion of their physician after a median follow-up of nearly 5 years, said Masayasu Matsumoto, MD, PhD, of the University of Hiroshima, and colleagues.

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However, there appeared to be a decline in atherosclerotic-type strokes among the patients treated with low-dose, Matsumoto noted in a press conference at the International Stroke Conference.
There were no statistically significant differences at baseline in total cholesterol, HDL cholesterol, LDL cholesterol, triglycerides, cause of the index stroke, or in the use of antiplatelet agents, Matsumoto stated.
But after 4.9 years of follow-up, patients taking pravastatin achieved about a 10% reduction in total cholesterol (P<0.001) and significant reductions in LDL cholesterol (P<0.001) and triglycerides, (P=0.006) along with an increase in HDL cholesterol (P=0.004).
Nevertheless, treatment with pravastatin was not potent enough to significantly impact overall stroke occurrence, which was the primary endpoint of the so-called J-STARS trial, Matsumoto said.
"In Japan, it is still unclear if hyperlipidemia is a risk factor of recurrent stroke in the ischemic stroke patients without coronary heart disease," Matsumoto explained. He noted that in other trials, the use of statins decreased the incidence of cardiovascular diseases, including coronary heart disease and ischemic stroke, in this patient population.

He also pointed out that high dose of atorvastatin (Lipitor) decreased the overall incidence of strokes in patients with stroke or transient ischemia attacks (TIA) in the SPARCL (Stroke Prevention by Aggressive Reduction in Cholesterol Levels) Trial.
Matsumoto's group hypothesized that the cholesterol-lowering effects could be expected to attenuate cerebrovascular inflammation and atherosclerosis.
They planned to recruit 3,000 patients for J-STARTS trial, but after 7 years enrollment was truncated at 1,578 patients. They assigned 793 patients to pravastatin and 785 patients to control. Matsumoto pointed out that follow-up was achieved despite earthquakes and a tsunami in the area where many of the patients and researchers lived.
Looking at secondary endpoints, the research team noted that, almost from the start of the follow-up period, the incidence curves separated when atherothrombotic strokes were observed. For patients on pravastatin, the risk of this type of stroke was 0.21% per year compared with a rate of 0.65% a year for controls (hazard ratio 0.33, 95% CI 0.15-0.74). This was a statistically significant finding even after adjustment for the index subtype of stroke, elevated blood pressure, and diabetes status, they reported.
In commenting on the trial, press conference moderator Bruce Obviagele, MD, cautioned that the trial results may not apply to many U.S. patients.

"The dose of pravastatin is lower than we would normally give our patients, but in many cases we have to reduce medication levels in treating people from Asia," he told MedPage Today, adding that the dose used in this study was not inappropriate. "In cholesterol-lowering therapy, we [in the U.S] would use a dose of at least 40 mg a day of pravastatin," he said.
Obviagele, who is professor and chair of neurology at the Medical University of the South Carolina in Charleston, said he was intrigued by the difference in the atherothrombotic-caused strokes. "It makes sense that treatment with a cholesterol-lowering agent might make a difference in these strokes caused by atheromas which are more similar to heart disease," he said. "I think there is something there; something to investigate."