Under New Stroke Guidelines, More Patients Will be Eligible for Emergency Treatments

'Guidelines' NOT protocols.
https://newswise.com/articles/under-new-stroke-guidelines,-more-patients-will-be-eligible-for-emergency-treatments-

Article ID: 688526

Released: 25-Jan-2018 4:45 PM EST

Source Newsroom: Loyola University Health System

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Stroke

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Healthcare, Neuro, Local - Illinois, Local - Chicago Metro, All Journal News

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Stroke, Ischemic Stroke, mechanical thromectomy, tPA, Tpa Treatment,

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Newswise — MAYWOOD, IL –  Loyola Medicine neurologist José Biller, MD, is a co-author of new national guidelines for treating stroke patients during the critical first hours after a stroke.

The guidelines, issued by the American Heart Association/American Stroke Association, are published in the association's journal Stroke.

In a video posted on the association's website, Dr. Biller explains two of the most important points of the guidelines:

• More stroke patients now will be able to benefit from a clot-busting drug called alteplase, when administered during the first 4½ hours of the onset of a stroke.
• In certain patients, mechanically removing blood clots to restore blood flow in the brain can be effective for up to 24 hours after the stroke's onset. In previous guidelines, the treatment window was six hours.

Dr. Biller, chair of Loyola's department of neurology, is an internationally known expert on stroke care.

The new guidelines are titled, "2018 Guidelines for the Early Management of Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association." The guidelines writing group was chaired by neurologist William J. Powers, MD, of the University of North Carolina in Chapel Hill.

The guidelines apply to ischemic strokes, which account for about 85 percent of all strokes. An ischemic stroke typically is caused by a blood clot that blocks blood flow to a region of the brain. Without blood supply, brain cells begin to die. Timely treatment to remove the clot and restore blood flow can minimize stroke damage.

One treatment involves intravenous administration of alteplase (also known as tPA), which can dissolve clots. The new guidelines broaden treatment criteria to include select patients with mild strokes, who previously were not eligible for this treatment. Doctors should weigh the risks and benefits in individual patients.

A second treatment is a procedure called mechanical thrombectomy that physically removes the clot. The physician inserts a catheter in the patient's groin and guides the thin tube through various blood vessels up to the brain. Once the catheter reaches the blockage, the physician deploys a device through the catheter that removes the clot, either by grabbing and pulling it out or suctioning it out.

Mechanical thrombectomy is indicated for clots blocking large blood vessels. The new guidelines say the procedure can be done as long as 16 hours after a stroke in selected patients. Under certain conditions, based on advanced brain imaging, the time window can be extended to 24 hours.

The guidelines also recommend "telestroke" programs for hospitals that don't have access to neurologists or emergency room doctors trained to use the clot-busting drug. Such programs use real-time videoconferencing to connect hospitals to stroke experts. Research shows that telestroke patients receive the same quality of care as if they were treated at a stroke center with a neurologist on call.

Loyola Medicine operates a growing telestroke network that serves 10 centers in Illinois, Indiana and Iowa. Loyola stroke specialists are on call 24/7 to examine patients remotely and recommend treatments to physicians at the bedside.

One critical guideline has not changed: The recommendation for fast action when a person first shows stroke symptoms.

"Time is brain," Dr. Biller said. "In the right patient, treatment with a clot-busting drug or mechanical thrombectomy has the potential to significantly limit stroke damage. Every effort should be made to treat these patients as early as possible with a multidisciplinary and integrated team of experts."

A simple way to remember the signs of a stroke is to think of the word FAST:

F – Face drooping: Does one side of the face droop or is it numb? Ask the person to smile. A – Arm weakness: Is one arm weak or numb? Ask the person to raise both arms. Does one arm drift downward? S – Speech difficulty: Is speech slurred, are they unable to speak or are they hard to understand? T – Time to call 911. If the person shows any if these symptoms, even if the symptoms go away, call 911 and bring them to the hospital immediately.

Evidence Based Medicine - stroke

You'll have to ask your doctor where everything in your therapy recommendations falls. I assume anecdotes are at the lowest level and hopefully your doctors aren't using those as basis for your recovery.

Functional impacts of exoskeleton-based rehabilitation in chronic stroke: multi-joint versus single-joint robotic training

Will your therapist change your stroke protocols based on this? If you are lucky enough to have a robotic exoskeleton.
http://www.jneuroengrehab.com/content/10/1/113/abstract

Giuliana Grimaldi¹ and Mario Manto^12*

• * Corresponding author: Mario Manto mmanto@ulb.ac.be

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Journal of NeuroEngineering and Rehabilitation 2013, 10:113  doi:10.1186/1743-0003-10-113
Published: 19 December 2013

Abstract

Stroke is a major cause of disability in the world. The activities of upper limb segments are often compromised following a stroke, impairing most daily tasks. Robotic training is now considered amongst the rehabilitation methods applied to promote functional recovery. However, the implementation of robotic devices remains a major challenge for the bioengineering and clinical community. Latest exoskeletons with multiple degrees of freedom (DOF) may become particularly attractive, because of their low apparent inertia, the multiple actuators generating large torques, and the fact that patients can move the arm in the normal wide workspace. A recent study published in JNER by Milot and colleagues underlines that training with a 6-DOF exoskeleton impacts positively on motor function in patients being in stable phase of recovery after a stroke. Also, multi-joint robotic training was not found to be superior to single-joint robotic training. Although it is often considered that rehabilitation should start from simple movements to complex functional movements as the recovery evolves, this study challenges this widespread notion whose scientific basis has remained uncertain.

Heat as a stroke therapy

I guess I've been missing this the past 7 years. In Tampa in 100 degree weather is great. Extra sensation therapy by feeling all that sweat on your skin, including it running down your back and armpits. You can practice new movements, wiping sweat from your brow with your affected hand.  I'm surprised my therapists didn't know about this stroke protocol.
You might want to be concerned about this though;

California climate linked to ER visits The risk of heading to the ER for certain conditions, such as heart disease, diabetes, stroke, kidney disease and low blood pressure rises slightly as temperature and humidity increase, according to a new study. 

But what the hell do you think your doctor is for except to answer conundrums like this. They went to medical school, you didn't. So ask whether the better sensation therapy offsets the stroke risk.

Corticospinal responses of quadriceps are abnormally coupled with hip adductors in chronic stroke survivors

So ask your therapist what therapy protocol will correct that problem. You do expect them to know how to fix it, don't you? Sounds right up your alley Amy. And I know I'm being a bastard. I expect a lot from myself and even more from my medical team.
http://search.naric.com/research/rehab/redesign_record.cfm?search=2&type=all&criteria=J65578&phrase=no&rec=120874

NARIC Accession Number: J65578.  What's this?
ISSN: 0014-4886.
Author(s): Krishnan, Chandramouli; Dhaher, Yasin.
Project Number: H133E070013.
Publication Year: 2012.
Number of Pages: 8.
Abstract: Study investigated whether the neural substrates mediating abnormal activation patterns after stroke are of cortical origin. Eight chronic stroke survivors, seven able-bodied young control subjects and four older adults participated in this research study. Data from older adults were used to evaluate whether aging contributes to abnormal coupling of the corticospinal responses. A novel transcranialmagnetic stimulation (TMS) protocol was developed to evaluate the extent of abnormal across-joint coupling of corticospinal responses in chronic stroke survivors. It was hypothesized that the stroke subjects would demonstrate abnormal higher corticospinal responses of the quadriceps muscle group during an isometric hip adduction task. TMS-elicited motor evoked potentials (MEPs) were recorded from the paretic leg of the stroke survivors and from the dominant leg of the control subjects using surface electromyography. Results indicated that, in stroke survivors, the magnitudes of MEPs of the vastus lateralis and vastus medialis during isometric hip adduction were significantly higher than those recorded during knee extension at similar background activity. Furthermore, MEP coupling ratios of the quadriceps muscles were significantly different than those observed in healthy controls. No significant differences in MEP coupling ratios were observed between the younger and older adults. These findings provide evidence for the first time that stroke subjects exhibit abnormal excitability of the quadricepsmuscle corticospinal neurons when performing isometric hip adduction. Importantly, the abnormal corticospinal responses observed in stroke subjects were not mediated by aging.

Quantifying nonuse in chronic stroke patients: A study into paretic, nonparetic, and bimanual upper-limb use in daily life

You'll have to ask your therapist what usefulness this has in your therapy protocol.
http://search.naric.com/research/rehab/redesign_record.cfm?search=2&type=all&criteria=J64925&phrase=no&rec=120160
Archives of Physical Medicine and Rehabilitation , Volume 93(11) , Pgs. 1975-1981.

NARIC Accession Number: J64925.  What's this?
ISSN: 0003-9993.
Author(s): Michielsen, Marian E.; Selles, Ruud W.; Stam, Henk J.; Ribbers, Gerard M.; Bussmann, Johannes B..
Publication Year: 2012.
Number of Pages: 7.
Abstract: This study measured uni- and bimanual upper-limb use in 38 patients with chronic stroke in daily life compared with 18 healthy controls. Upper-limb use in daily life was measured with an accelerometry-based upper-limb activity monitor, an accelerometer based measurement device. Unimanual use of the paretic and the nonparetic side and bimanual upper-limb use were measured for a period of 24 hours. Outcomes were expressed in terms of both duration and intensity. Patients used their unaffected limb much more than their affected limb (5.3 versus 2.4 hours), while controls used both limbs a more equal amount of time (5.4 versus 5.1 hours). Patients used their paretic side less than controls used their nondominant side and their nonparetic side more than controls their dominant side. The intensity with which patients used their paretic side was lower than that with which controls used their nondominant side, while that of the nonparetic side was higher than that of the dominant side of controls. Finally, patients used their paretic side almost exclusively in bimanual activities. During bimanual activities, the intensity with which they used their affected side was much lower than that of the nonaffected side. The findings show considerable nonuse of the paretic side, both in duration and in intensity, and both during unimanual and bimanual activities in patients with chronic stroke. Patients do compensate for this with increased use of the nonparetic side.

Seven Capital Devices for the Future of Stroke Rehabilitation

See what your doctor can use of these to help you recovery via your stroke protocol. The results are truly pathetic.
http://scholar.google.com/scholar_url?hl=en&q=http://downloads.hindawi.com/journals/srt/2012/187965.pdf&sa=X&scisig=AAGBfm0Ch_idBqapaRz-T_iJzQT7bG4-WA&oi=scholaralrt
1. Introduction
In the last decade, the manual conventional therapy for
people affected by stroke has been often integrated with
the use of technological devices specifically developed for
increasing rehabilitative outcomes. Does the manual therapy
really need this support? A study of 2008 showed that at
dismissal from a hospital of rehabilitation, about half of
patients with stroke are on wheelchair, whereas less than
15% are able to walk inside without aids, less than 10%
are able to walk outside, and less than 5% are able in stair
climbing [1]. Recovery of upper limb motor functions is
even poorer, leading to suppose that upper limb recovery
could be mainly intrinsic and slightly improved by therapy
[2–4]. Furthermore, the need of more therapies performed
in a more adequate and appropriate manner has been
claimed [5]. In fact, the recovery has been shown to depend
on the intensity of therapy, repetition of specified skilled
movements directed towards the motor deficits and rewarded
with performance-dependent feedback [6–8].
These are the main reasons for purposing the use of
technological devices in order to increase intensity, repetitions,
specificity, and feedback during rehabilitation. Many
reviews have already summarised the results of previous
studies on the efficacy of these technologically supported
treatments (for a recent one see Belda-Lois et al. [5]).
In this paper, we provided our point of view on seven
specific technological devices designed for supporting motor
recovery after stroke. These technologies for rehabilitation
of people affected by stroke are robots, brain computer
interfaces, neuroprosthesis, noninvasive brain stimulators,
wearable devices, virtual reality, and tablet-pc.

Helping stroke patients put best foot forward

This would be wonderful to have objective analysis of your gait problems and then your therapists could work on those specific problems. That will require more research on protocols to address specific problems
http://www.healthcanal.com/blood-heart-circulation/34096-Helping-stroke-patients-put-best-foot-forward.html
Stroke patients and people whose legs have been amputated could benefit from the collaboration between an RMIT University researcher and the University of Delaware in the United States.
Dr Gita Pendharkar from the School of Engineering TAFE will travel to the United States early next year to further her gait monitoring sensor research, thanks to a Sir Keith Murdoch Fellowship from the American Australian Association.
Dr Pendharkar, who teaches electrotechnology, has a research specialty in biomedical engineering.
"I had developed a sensor-based miniature system for my doctorate research project, which was embedded in the heel of boots and used to analyse a person's gait pattern while walking, in order to distinguish toe walking gait from normal gait," she said.
"Since my doctorate research, I have updated the gait monitoring system using RFID technology and now have a wireless gait monitoring system which can transmit the signals within a distance of 900m-1km to the receiver.
"The University of Delaware, in a larger project, has developed a robotic exoskeleton with motorised control for not only gait training of stroke patients and other motor impaired patients, but retraining the brain in using the correct movement required for a normal gait.
"This research collaboration aims to integrate the robotic active leg exoskeleton developed at the University of Delaware with the wireless gait monitoring system in order to accurately assess stroke patients' foot movement during rehabilitation."
The technology could be put to use in rehabilitation centres, hospitals, aged care, and other medical diagnostic and treatment centres.
"Based on this technology, rehabilitation centres in Australia can be developed to train not only gait impaired people, such as stroke patients, but even amputee soldiers from the Australian Armed Forces, and for the wider Australian community," Dr Pendharkar said.

Dynamic Roles of microRNAs in Neurogenesis

If only there was open access to scientific journals. I would take it on myself to solve the questions. Someone needs to translate this stuff into a therapy protocol or at least postulate a theory that can be tested.
http://www.frontiersin.org/Neurogenesis/10.3389/fnins.2012.00071/abstract
MicroRNAs (miRNAs) are short non-coding RNAs that regulate gene expression at the post-transcriptional level by mediating mRNA degradation or translational inhibition. MiRNAs are implicated in many biological functions, including neurogenesis. It has been shown that miRNAs regulate multiple steps of neurogenesis, from neural stem cell proliferation to neuronal differentiation and maturation. MiRNAs execute their functions in a dynamic and context-dependent manner by targeting diverse downstream target genes, from transcriptional factors to epigenetic regulators. Identifying context-specific target genes is instrumental for understanding the roles that miRNAs play in neurogenesis. This review summarizes our current state of knowledge on the dynamic roles that miRNAs play in neural stem cells and neurogenesis.