Combined with traditional physiotherapy, virtual reality can help stroke patients

 What will it take to get to 100% recovery? If you didn't have that as an objective your mentors and senior researchers are BLITHERING IDIOTS! 

Can help is NOT GOOD ENOUGH! Deliver EXACT REHAB PROTOCOLS so survivors will exactly recover. None of this wishy-washy crapola like this.

You'll want that 100% recovery when you are the 1 in 4 per WHO that has a stroke

 Comeuppance will be a bitch for them knowing they could have solved stroke while still working!

And this earlier research on virtual reality was unknown to you! My god, the incompetence in stroke is world class!

• virtual reality (199 posts to September 2011)
• immersive virtual reality (15 posts to January 2021)

Combined with traditional physiotherapy, virtual reality can help stroke patients

Virtual reality technology has shown promising results for helping stroke patients regain arm movements, according to a new study led by the University of Reading and Royal Berkshire NHS Foundation Trust.

The research, published in the journal Displays, shows that combining immersive virtual reality with traditional physiotherapy could significantly improve upper limb function in stroke patients.

This innovative approach, developed by a team from the University's School of Biological Sciences and Royal Berkshire Hospital's Stroke Unit, offers new hope for local stroke survivors.

"This research represents an important step forward in stroke rehabilitation," says Dr. Yoshikatsu Hayashi from the University of Reading's Biomedical Sciences and Biomedical Engineering department. "By using virtual reality technology, we can create an engaging environment that encourages patients to perform their exercises while receiving enhanced visual feedback."

The study involved 18 local patients who received either traditional physiotherapy alone or combined with the new virtual reality treatment. Those who received the combined therapy showed marked improvement in their arm function, as measured by standardized assessments.

Key findings from the study include:

• Significant improvement in arm movement for patients using the virtual reality system
• High levels of patient engagement with the therapy
• No serious adverse effects reported during the trial
• Potential for wider implementation in stroke rehabilitation programs.

Samirah Altukhaim, who studied for her Ph.D. at Reading and led the study, said, "Patients described the therapy as fun and motivating, encouraging greater use of the affected hand. They noted improvements in hand coordination and control, making movements feel natural, as if full control had been regained."

Dr. Kiruba Nagaratnam, from the University Department of Stroke Medicine at Royal Berkshire Hospital, said, "This collaboration between the University of Reading and our department has allowed us to explore innovative ways to enhance stroke rehabilitation. The results are particularly encouraging as they show how local research can directly benefit our patients."

The research team emphasizes that while these results are promising, further studies will be needed to fully understand the potential of this technology.

More information: Samirah Altukhaim et al, Immersive virtual reality enhanced reinforcement induced physical therapy (EVEREST), Displays (2025). DOI: 10.1016/j.displa.2024.102962

Mirror Symmetric Bimanual Movement Priming Can Increase Corticomotor Excitability and Enhance Motor Learning

What will it take for our researchers to move from wishy-washy terms like 'can' increase to will do this? I don't see that occurring until we get survivors in charge who won't fund research that doesn't directly lead to 100% recovery.  You'll have to ask your doctor to demonstrate repetitive active-passive bimanual wrist flexion and extension

Mirror Symmetric Bimanual Movement Priming Can Increase Corticomotor Excitability and Enhance Motor Learning

• Winston D. Byblow ,
• Cathy M. Stinear,
• Marie-Claire Smith,
• Lotte Bjerre,
• Brian K. Flaskager,
• Alana B. McCambridge

• Published: March 22, 2012
• https://doi.org/10.1371/journal.pone.0033882
• 
  

• Article
• Authors
• Metrics
• Comments
• Media Coverage

• 
  

Abstract

Repetitive mirror symmetric bilateral upper limb may be a suitable priming technique for upper limb rehabilitation after stroke. Here we demonstrate neurophysiological and behavioural after-effects in healthy participants after priming with 20 minutes of repetitive active-passive bimanual wrist flexion and extension in a mirror symmetric pattern with respect to the body midline (MIR) compared to an control priming condition with alternating flexion-extension (ALT). Transcranial magnetic stimulation (TMS) indicated that corticomotor excitability (CME) of the passive hemisphere remained elevated compared to baseline for at least 30 minutes after MIR but not ALT, evidenced by an increase in the size of motor evoked potentials in ECR and FCR. Short and long-latency intracortical inhibition (SICI, LICI), short afferent inhibition (SAI) and interhemispheric inhibition (IHI) were also examined using pairs of stimuli. LICI differed between patterns, with less LICI after MIR compared with ALT, and an effect of pattern on IHI, with reduced IHI in passive FCR 15 minutes after MIR compared with ALT and baseline. There was no effect of pattern on SAI or FCR H-reflex. Similarly, SICI remained unchanged after 20 minutes of MIR. We then had participants complete a timed manual dexterity motor learning task with the passive hand during, immediately after, and 24 hours after MIR or control priming. The rate of task completion was faster with MIR priming compared to control conditions. Finally, ECR and FCR MEPs were examined within a pre-movement facilitation paradigm of wrist extension before and after MIR. ECR, but not FCR, MEPs were consistently facilitated before and after MIR, demonstrating no degradation of selective muscle activation. In summary, mirror symmetric active-passive bimanual movement increases CME and can enhance motor learning without degradation of muscle selectivity. These findings rationalise the use of mirror symmetric bimanual movement as a priming modality in post-stroke upper limb rehabilitation.

Figures

   

Citation: Byblow WD, Stinear CM, Smith M-C, Bjerre L, Flaskager BK, McCambridge AB (2012) Mirror Symmetric Bimanual Movement Priming Can Increase Corticomotor Excitability and Enhance Motor Learning. PLoS ONE 7(3): e33882. https://doi.org/10.1371/journal.pone.0033882

Editor: Alessio Avenanti, University of Bologna, Italy

Received: June 6, 2011; Accepted: February 23, 2012; Published: March 22, 2012

Copyright: © 2012 Byblow et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: The authors have no support or funding to report.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Repetitive transcranial magnetic stimulation (rTMS) offers promise for increasing or decreasing M1 excitability to promote recovery of motor function after stroke [1]–[9], but a practical limitation is that it requires expensive equipment, a medical environment and is contraindicated for people with a history of seizure, metal implants, cardiac pacemaker, or who are taking certain common medications [10], [11]. Compared with rTMS, transcranial direct current stimulation (tDCS) has fewer contraindications but still requires the use of medically certified electrical equipment and application by a skilled operator [12]. Motor point stimulation [13], [14] and combined peripheral nerve and TMS can enhance or suppress M1 excitability through presumed spike-timing dependent mechanisms [15]–[17] but also require expensive equipment, skilled operators, or lengthy treatment periods and also has potential contraindications. The present study explores an alternative method for increasing M1 excitability by using patterned repetitive movement, without brain or nerve stimulation per se [18], [19].

It is well known that mirror symmetric bimanual movements, with homologous muscles activated simultaneously, are more stable than any other pattern [20]–[22]. Enhanced M1 excitability and presumed GABAergic M1 disinhibition have been noted during production of mirror symmetric active-passive bimanual movement [23], [24] and may facilitate upper limb recovery after stroke by acting as a neurophysiological priming mechanism [18], [19]. Until now, there has been no direct examination of M1 excitability and inhibition immediately after repetitive active-passive bimanual movement and no examination of the immediate behavioural consequences of active-passive movement priming.

To address these issues we first examined corticomotor excitability (CME), M1 intracortical and interhemispheric inhibition and H-reflex excitability, in healthy participants before and after 20 minutes (1200 cycles) of active-passive movement made in either a mirror symmetric (MIR) pattern, or an alternating (ALT) pattern. We hypothesised that MIR but not ALT movements would facilitate corticomotor excitability within forearm flexor and extensor representations of the passive left M1. We also predicted that any difference in CME noted between patterns would be accompanied by differences in intracortical inhibition. To examine this we obtained measures of short afferent inhibition (SAI), long-latency intracortical inhibition (LICI), interhemispheric inhibition (IHI) across two experiments, and examined H-reflex excitability in a third experiment. In a separate study we examined the behavioural consequences of active-passive movement priming and hypothesised that MIR priming would facilitate motor learning. Finally we examined whether increases in CME obtained after MIR would be associated with persistent reductions in short-latency intracortical inhibition that could potentially interfere with selective voluntary muscle activation.

 

More at link.

 

 

Anticoagulation Type and Early Recurrence in Cardioembolic Stroke

So we still know nothing and have NO PROTOCOL. Hope you are OK with your doctor making a wild-assed guess on what to do. This is precisely why we need survivors in charge, we would actually demand results instead of this wishy-washy crapola. 

Oops, I'm not playing by the polite rules of Dale Carnegie,  'How to Win Friends and Influence People'. 

Politeness will never solve anything in stroke. Yes, I'm a bomb thrower and proud of it. Someday a stroke 'leader' will ream me out for making them look bad by being truthful , I look forward to that day.

Anticoagulation Type and Early Recurrence in Cardioembolic Stroke

The IAC Study

Shadi Yaghi

,

Eva Mistry

,

Ava L. Liberman

,

James Giles

,

Syed Daniyal Asad

,

Angela Liu

,

Muhammad Nagy

,

Ashutosh Kaushal

,

Idrees Azher

,

Brian Mac Grory

,

Hiba Fakhri

, … See all authors

Originally published6 Aug 2020https://doi.org/10.1161/STROKEAHA.120.028867Stroke. 2020;51:2724–2732

• This article is commented on by the following:

Abstract

Background and Purpose:

In patients with acute ischemic stroke and atrial fibrillation, treatment with low molecular weight heparin increases early hemorrhagic risk without reducing early recurrence, and there is limited data comparing warfarin to direct oral anticoagulant (DOAC) therapy. We aim to compare the effects of the treatments above on the risk of 90-day recurrent ischemic events and delayed symptomatic intracranial hemorrhage.

Methods:

We included consecutive patients with acute ischemic stroke and atrial fibrillation from the IAC (Initiation of Anticoagulation after Cardioembolic) stroke study pooling data from stroke registries of 8 comprehensive stroke centers across the United States. We compared recurrent ischemic events and delayed symptomatic intracranial hemorrhage between each of the following groups in separate Cox-regression analyses: (1) DOAC versus warfarin and (2) bridging with heparin/low molecular weight heparin versus no bridging, adjusting for pertinent confounders to test these associations.

Results:

We identified 1289 patients who met the bridging versus no bridging analysis inclusion criteria and 1251 patients who met the DOAC versus warfarin analysis inclusion criteria. In adjusted Cox-regression models, bridging (versus no bridging) treatment was associated with a high risk of delayed symptomatic intracranial hemorrhage (hazard ratio, 2.74 [95% CI, 1.01–7.42]) but a similar rate of recurrent ischemic events (hazard ratio, 1.23 [95% CI, 0.63–2.40]). Furthermore, DOAC (versus warfarin) treatment was associated with a lower risk of recurrent ischemic events (hazard ratio, 0.51 [95% CI, 0.29–0.87]) but not delayed symptomatic intracranial hemorrhage (hazard ratio, 0.57 [95% CI, 0.22–1.48]).

Conclusions:

Our study suggests that patients with ischemic stroke and atrial fibrillation would benefit from the initiation of a DOAC without bridging therapy. Due to our study limitations, these findings should be interpreted with caution pending confirmation from large prospective studies.

 

Brain activation is related to smoothness of upper limb movements after stroke

I absolutely hate the wishy-washy words being used. That signals to me that this is nowhere close to being a useful protocol.  

unclear,can,suggests,seems,variable,may.

Brain activation is related to smoothness of upper limb movements after stroke

 Floor E. Buma 1,2

Joost van Kordelaar 3

Matthijs Raemaekers 2

Erwin E. H. van Wegen 3

Nick F. Ramsey 2

Gert Kwakkel 3,4
 1  Center of Excellence for Rehabilitation, Rehabilitation Centre De Hoogstraat, Rembrandtkade 10, 3583TM Utrecht, The Netherlands
2  Department of Neurology and Neurosurgery, Rudolf Magnus Institute of Neuroscience, UMC Utrecht, PO Box 85060, 3508AB Utrecht, The Netherlands
3  Department of Rehabilitation Medicine, MOVE Research Institute Amsterdam, VU University Medical Center, PO Box 7057, 1007MB Amsterdam, The Netherlands
4  Amsterdam Rehabilitation Research Center, Reade Centre for Rehabilitation and Rheumatology, PO Box 58271, 1040HG Amsterdam, The Netherlands
Received: 9 June 2015 / Accepted: 20 December 2015 © The Author(s) 2016. This article is published with open access at Springerlink.com
 Abstract
 It is unclear whether additionally recruited sensorimotor areas in the ipsilesional and contralesional hemisphere and the cerebellum can compensate for lost neuronal functions after stroke. The objective of this study was to investigate how increased recruitment of second-ary sensorimotor areas is associated with quality of motor control after stroke. In seventeen patients (three females, fourteen males; age: 59.9
±

 12.6 years), cortical activation levels were determined with functional magnetic resonance imaging (fMRI) in 12 regions of interest during a finger flexion–extension task in weeks 6 and 29 after stroke. At the same time points and by using 3D kinematics, the quality of motor control was assessed by smoothness of the grasp aperture during a reach-to-grasp task, quantified by normalized jerk.

 cerebellum, as well as the contralesional supplementary motor area, insula and cerebellum, correlated significantly and positively with the normalized jerk of grasp aperture at week 6 after stroke. A positive trend towards this correlation was observed in week 29. This study suggests that recruitment of secondary motor areas at 6 weeks after stroke is highly associated with increased jerk during reaching and grasping. As jerk represents the change in acceleration, the recruitment of additional sensorimotor areas seems to reflect a type of control in which deviations from an optimal movement pattern are continuously corrected. This relationship suggests that additional recruitment of sensorimotor areas after stroke may not correspond to restitution of motor function, but more likely to adaptive motor learning strategies to compensate for motor impairments.
 Introduction
Outcomes of neurorehabilitation after stroke are variable and depend largely on the intensity and task specificity of the intervention applied as well as the severity of initial impairment at stroke onset (Langhorne et al. 2011). For the paretic upper limb in particular, treatment effects are mainly restricted to patients with some voluntary control of finger extension after stroke (Kwakkel and Kollen 2013; Langhorne et al. 2011). These findings suggest that there is a need for a better understanding of the neuronal mechanisms underlying functional recovery after stroke.Task-related recruitment of secondary sensorimotor areas in the affected and non-affected hemisphere has been associated with poor motor recovery in terms of body  functions and activities (Buma et al. 2010; Ward et al. 2004). It is therefore unlikely that secondary sensorimotor areas are able to take over the functions of the primary injured motor areas (Buma et al. 2010; Ward et al. 2004). Recruitment of these additional areas may rather reflect support in the execution of compensatory motor control while performing a motor task with the paretic upper limb.However, it is still unclear how brain activation pat-terns are associated with quality of upper limb control after stroke (Buma et al. 2013). Most traditional clinical assess-ment scales are not suitable for capturing
how
 patients perform functional tasks. By contrast, 3D kinematics can assess intralimb coordination and smoothness of movement patterns, which are important characteristics of quality of motor control.A recent study with intensive repeated 3D kinematic measurements in the first 6 months after stroke suggested that basic synergistic couplings between the shoulder and elbow during a functional reaching task diminished as a function of time after stroke (van Kordelaar et al. 2013). This suggests that the ability to plan movements in advance (i.e. feed forward motor control) may improve, thereby decreasing the continuous online corrections based on proprioceptive feedback (van Kordelaar et al. 2014; Meu-lenbroek et al. 2001). Such corrections based on afferent information have been shown to negatively affect the smoothness of hand and finger movements (Merdler et al. 2013). An important measure to quantify smoothness is normalized jerk. Jerk is the third time derivative of the position of a particular body part. Normalized jerk is obtained by correcting for differences in movement duration and movement distance (Caimmi et al. 2008). As high smoothness is reflected by minimal changes in position, smoothness is inversely related to normalized jerk. We have recently shown that this jerk measure decreases (i.e. smoothness increases) substantially in the first 8 weeks after stroke (van Kordelaar et al. 2014) and levels off up to 26 weeks after stroke, suggesting that jerkiness is a sensitive measure to investigate time-dependent changes in quality of motor control, particularly early after stroke. However, due to a lack of studies combining imaging techniques with kinematic analyses, the neurological mechanisms underlying the recovery of smoothness of upper limb movements are still largely unknown.We hypothesized that elevated recruitment of secondary sensorimotor areas would be associated with jerky movements. This hypothesis was tested by investigating the association between smoothness of finger movements during a reach-to-grasp task, measured with 3D kinematics, and activation levels in sensorimotor networks of the brain during a finger flexion–extension task, measured with functional MRI (fMRI) (Buma et al. 2010). There are strong indications that the potential for neural adaptation is mainly limited to a time window of 10 weeks after stroke in which most spontaneous neurological recovery occurs (Murphy and Corbett 2009; Langhorne et al. 2011). We tested the association between brain activation and smoothness of finger movements at 6 and 29 weeks after stroke, to assess whether this association changes with time after stroke (Buma et al. 2010; van Kordelaar et al. 2014). 

Neurocognitive robot-assisted rehabilitation of hand function: a randomized control trial on motor recovery in subacute stroke

 I wish they would say in exact words; 'This failed at 100% recovery, we don't have any clue how to get you recovered.' I hate the term, non-inferior, fucking wishy-washy word.

Neurocognitive robot-assisted rehabilitation of hand function: a randomized control trial on motor recovery in subacute stroke

• Raffaele Ranzani,
• Olivier Lambercy,
• Jean-Claude Metzger,
• Antonella Califfi,
• Stefania Regazzi,
• Daria Dinacci,
• Claudio Petrillo,
• Paolo Rossi,
• Fabio M. Conti &
• Roger Gassert 

Journal of NeuroEngineering and Rehabilitation volume 17, Article number: 115 (2020) Cite this article

• 1 Altmetric

• Metrics details

Abstract

Background

Hand function is often impaired after stroke, strongly affecting the ability to perform daily activities. Upper limb robotic devices have been developed to complement rehabilitation therapy offered to persons who suffered a stroke, but they rarely focus on the training of hand sensorimotor function. The primary goal of this study was to evaluate whether robot-assisted therapy of hand function following a neurocognitive approach (i.e., combining motor training with somatosensory and cognitive tasks) produces an equivalent decrease in upper limb motor impairment compared to dose-matched conventional neurocognitive therapy, when embedded in the rehabilitation program of inpatients in the subacute stage after stroke.

Methods

A parallel-group, randomized controlled trial was conducted on subjects with subacute stroke receiving either conventional or robot-assisted neurocognitive hand therapy using a haptic device. Therapy was provided for 15, 45-min sessions over four weeks, nested within the standard therapy program. Primary outcome was the change from baseline in the upper extremity part of the Fugl-Meyer Assessment (FMA-UE) after the intervention, which was compared between groups using equivalence testing. Secondary outcome measures included upper limb motor, sensory and cognitive assessments, delivered therapy dose, as well as questionnaires on user technology acceptance.

Results

Thirty-three participants with stroke were enrolled. 14 subjects in the robot-assisted and 13 subjects in the conventional therapy group completed the study. At the end of intervention, week 8 and week 32, the robot-assisted/conventional therapy group improved by 7.14/6.85, 7.79/7.31, and 8.64/8.08 points on the FMA-UE, respectively, establishing that motor recovery in the robot-assisted group is non-inferior to that in the control group.

Conclusions

Neurocognitive robot-assisted therapy of hand function allows for a non-inferior motor recovery compared to conventional dose-matched neurocognitive therapy when performed during inpatient rehabilitation in the subacute stage. This allows the early familiarization of subjects with stroke to the use of such technologies, as a first step towards minimal therapist supervision in the clinic, or directly at home after hospital discharge, to help increase the dose of hand therapy for persons with stroke.

Trial registration

EUDAMED database (CIV-13-02-009921), clinicaltrials.gov (NCT02096445). Registered 26 March 2014 – Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT02096445

Background

Upper-limb robot-assisted therapy has been established as a safe and feasible treatment to complement rehabilitation after neurological injury, such as stroke [1]. Robots can precisely control the interaction with the user (e.g., supporting or resisting in an assist-as-needed manner) and render virtual environments both visually and mechanically, making them ideal tools for sensorimotor training, providing engaging and challenging therapy [2, 3]. Over the past two decades, several robotic devices to train the proximal upper extremity [4] were developed and clinically evaluated, achieving outcomes comparable to dose-matched conventional therapy [1,2,3, 5,6,7,8,9,10].

However, distal arm function is essential for the execution of activities of daily living (e.g., eating, dressing) and is often severely impaired after stroke [11], with low probability of regaining its full functional use [12]. Several studies have shown that functional motor training at the level of the hand with robotic devices can be beneficial and positively translate into recovery of proximal arm function [13, 14]. Despite recent investigations to develop novel robots to train hand function [9, 15, 16], only few systems took advantage of the haptic rendering capabilities of robots to support somatosensory training, nor evaluated this in clinical trials. As such, most systems for robot-assisted therapy developed to date focus on movement practice without incorporating an established therapy concept adapted to the capabilities of the respective technology.

In this work, the clinical equivalence of sensorimotor, robot-assisted rehabilitation of hand function is investigated within a four-week randomized controlled trial (RCT) on subacute stroke participants. The neurocognitive rehabilitation method proposed by Perfetti [17] was selected as reference therapy approach. It focuses on the training of sensorimotor functions as well as cognition, which is fundamental during functional interactions between body and environment (e.g., information perception, as well as elaboration, selection and execution of motor plans) [18,19,20]. Because of the relevance of the cognitive processing of sensory inputs, this approach is particularly interesting for hand rehabilitation. Moreover, the integration of multisensory inputs promotes the involvement of associative cortices that play a key role in learning and consequently in neuronal plasticity and recovery [21]. While only a few studies compared neurocognitive therapy to other rehabilitative approaches [18, 22], some promising work suggested that it can significantly improve upper-limb function, ability to perform activities of daily living and quality of life compared to conventional task-oriented training [22]. Consequently, this approach has recently found increasing interest in the scientific community, applied both in conventional [23,24,25] and in technology-assisted therapy [26, 27], but has so far not been evaluated in the context of a robot-assisted RCT. The therapy concept inspired by the neurocognitive approach was implemented on a high-fidelity 2 degrees of freedom end-effector haptic device to train hand function (i.e., the ReHapticKnob [28]). The therapy exercises focused on grasping and pronosupination (e.g., tactile discrimination tasks, teach and reproduce tasks, haptic exploration tasks, [29]) and were performed using virtual objects rendered both visually and haptically by the robot, mimicking the physical objects used in conventional therapy. The primary objective of this RCT was to investigate if the implemented robot-assisted hand therapy concept could be integrated into the rehabilitation program of participants with subacute stroke during their inpatient stay (i.e., replace one conventional neurocognitive therapy session on each intervention day) and if, at precisely matched dose, an equivalent reduction in upper limb motor impairment could be achieved. This study design was motivated by the need to establish non-inferiority in terms of rehabilitation outcomes when comparing the proposed intervention to conventional neurocognitive therapy. This is an important first step towards the investigation of more specific robot-assisted protocols that could further take advantage of the abilities of the robotic device, such as increasing dose through semi-supervised therapy. As secondary objectives, we hypothesized that neurocognitive robot-assisted therapy of the hand would lead to improvements in motor, sensory and cognitive functions in participants with subacute stroke.

 

Medical therapy may prevent strokes in asymptomatic carotid stenosis

 I personally think that the proper solution to this is:

1. Determine if Circle of Willis is complete.

2. If yes, then close up the offending artery, no chance of throwing clots to brain, no stroke risk from carotid endarterectomy.

But I'm not medically trained so don't listen to me, but have your doctor GUARANTEE NO STROKE FROM ANY INTERVENTION CHOSEN. 

'May' is way too wishy-washy.

Medical therapy may prevent strokes in asymptomatic carotid stenosis

Absolute risk reduction for fatal and nonfatal strokes in patients who underwent early carotid endarterectomy was less than half the risk difference from trials initiated 20 years ago, researchers found.

The study published in JAMA Neurology also determined that this absolute reduction was no longer statistically significant when accounting for the competing risk for nonstroke deaths.

 

“Given the upfront perioperative risks associated with carotid endarterectomy, initial medical therapy may be an equally acceptable treatment strategy for the management of patients with asymptomatic carotid stenosis,” Salomeh Keyhani, MD, MPH, professor of medicine at University of California, San Francisco, School of Medicine, and colleagues wrote.

In this comparative effectiveness study, researchers assessed data from 5,221 veterans aged at least 65 years who underwent carotid imaging from 2005 to 2009. Patients were excluded if they had carotid stenosis less than 50%, hemodynamically insignificant stenosis and a history of transient ischemic attack or stroke 6 months before imaging was performed.

Two cohorts were formed: patients assigned initial medical therapy (n = 2,509; mean age, 74 years; 99% men) and those assigned carotid endarterectomy (n = 2,712; mean age, 74 years; 99% men). Both treatment options were given within 1 year after index carotid imaging. Follow-up was conducted for 5 years. Analyses used in the Asymptomatic Carotid Surgery Trial were emulated in this trial to estimate the comparative effectiveness of carotid endarterectomy and initial medical therapy to prevent nonfatal and fatal strokes.

The rate of stroke or death within 30 days of carotid endarterectomy was 2.5% (95% CI, 2-3.1). At 5 years, the risk for fatal and nonfatal stroke was lower in the carotid endarterectomy group vs. the initial medical therapy group (5.6% vs. 7.8%; risk difference, 2.3%; 95% CI, 4 to 0.3).

When the competing risk for death was incorporated, the risk difference between patients assigned carotid endarterectomy and those assigned initial medical therapy was lower and not statistically significant (risk difference, 0.8%; 95% CI, 2.1 to 0.5).

In patients who met randomized controlled trial inclusion criteria, the risk for fatal and nonfatal strokes at 5 years was 5.5% (95% CI, 4.5-6.5) for the carotid endarterectomy group and 7.6% (95% CI, 5.7-9.5) for the initial medical therapy group (risk difference, 2.1%; 95% CI, 4.4 to 0.2). A risk difference of 0.9% resulted when accounting for competing risks (95% CI, 2.9 to 0.7).

“The decreased stroke risk in patients with carotid artery stenosis, the persistent upfront perioperative risks and the small difference in stroke risk between the two treatment strategies suggest that patients treated with carotid endarterectomy would now require a longer time to accrue enough stroke reduction benefit to justify the upfront risks of the surgical procedure,” Keyhani and colleagues wrote.

 

The Effect of Priming on Outcomes of Task-Oriented Training for the Upper Extremity in Chronic Stroke: A Systematic Review and Meta-analysis

All this earlier research and we still don't know what the fuck we are doing with priming? Can be a promising intervention strategy is woefully useless.  The objective should be to come up with EXACT STROKE PROTOCOLS not wishy-washy shit like; 'can', 'maybe', 'could', 'further research','improve' etc.

• bilateral priming (7) 

• motor priming (6)

• neuropriming (1)

• priming (10)

The Effect of Priming on Outcomes of Task-Oriented Training for the Upper Extremity in Chronic Stroke: A Systematic Review and Meta-analysis

Show all authors

Erika Shirley Moreira da Silva, MSc, Gabriela Nagai Ocamoto, PT, Gabriela Lopes dos Santos-Maia, PhD, ...

First Published May 26, 2020 Review Article Find in PubMed

https://doi.org/10.1177/1545968320912760

Article information

Abstract

Background.
Priming results in a type of implicit memory that prepares the brain for a more plastic response, thereby changing behavior. New evidence in neurorehabilitation points to the use of priming interventions to optimize functional gains of the upper extremity in poststroke individuals.  
Objective.
To determine the effects of priming on task-oriented training on upper extremity outcomes (body function and activity) in chronic stroke.  
Methods.
The PubMed, CINAHL, Web of Science, EMBASE, and PEDro databases were searched in October 2019. Outcome data were pooled into categories of measures considering the International Classification Functional (ICF) classifications of body function and activity. Means and standard deviations for each group were used to determine group effect sizes by calculating mean differences (MDs) and 95% confidence intervals via a fixed effects model. Heterogeneity among the included studies for each factor evaluated was measured using the I² statistic.  
Results.
Thirty-six studies with 814 patients undergoing various types of task-oriented training were included in the analysis. Of these studies, 17 were associated with stimulation priming, 12 with sensory priming, 4 with movement priming, and 3 with action observation priming. Stimulation priming showed moderate-quality evidence of body function. Only the Wolf Motor Function Test (time) in the activity domain showed low-quality evidence. However, gains in motor function and in use of extremity members were measured by the Fugl-Meyer Assessment (UE-FMA). Regarding sensory priming, we found moderate-quality evidence and effect size for UE-FMA, corresponding to the body function domain (MD 4.77, 95% CI 3.25-6.29, Z = 6.15, P < .0001), and for the Action Research Arm Test, corresponding to the activity domain (MD 7.47, 95% CI 4.52-10.42, Z = 4.96, P < .0001). Despite the low-quality evidence, we found an effect size (MD 8.64, 95% CI 10.85-16.43, Z = 2.17, P = .003) in movement priming. Evidence for action observation priming was inconclusive.  

Conclusion.
Combining priming and task-oriented training for the upper extremities of chronic stroke patients can be a promising intervention strategy. Studies that identify which priming techniques combined with task-oriented training for upper extremity function in chronic stroke yield effective outcomes in each ICF domain are needed and may be beneficial for the recovery of upper extremities poststroke.

Keywords upper extremity, physical functional performance, stroke, priming, task-oriented training

Access Options

A Narrative and Critical Review of Randomized-Controlled Clinical Trials on Patent Foramen Ovale Closure for Reducing the Risk of Stroke Recurrence

Well then do the research that determines what the objective factors are that would lead to PFO closing. PROTOCOLS, not this wishy-washy crapola. 

A Narrative and Critical Review of Randomized-Controlled Clinical Trials on Patent Foramen Ovale Closure for Reducing the Risk of Stroke Recurrence

Apostolos Safouris^1*, Odysseas Kargiotis¹, Klearchos Psychogios^1,2, Pericles Kalyvas³, Ignatios Ikonomidis⁴, Maria Drakopoulou⁵, Konstantinos Toutouzas⁶ and Georgios Tsivgoulis^2,7

• ¹Stroke Unit, Metropolitan Hospital, Pireus, Greece
• ²Second Department of Neurology, School of Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
• ³Cardiology Department, Metropolitan Hospital, Pireus, Greece
• ⁴Department of Echocardiography and Laboratory of Preventive Cardiology, Second Cardiology Department, Attikon Hospital, National and Kapodistrian University of Athens, Athens, Greece
• ⁵First Department of Cardiology, Athens School of Medicine, Hippokration Hospital, Athens, Greece
• ⁶First Department of Cardiology, Medical School of Athens University, Hippokration Hospital, Athens, Greece
• ⁷Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, United States

Patent foramen ovale (PFO) is a common cardiac anatomic variant that has been increasingly found in young (<60 years) cryptogenic stroke patients. Despite initial neutral randomized-controlled clinical trials (RCTs), there have been four recent RCTs providing consistent data in favor of the efficacy and safety of PFO closure compared to medical therapy for secondary stroke prevention. However, taking into consideration the high prevalence of PFO, the low risk of stroke recurrence under medical treatment and the uncommon yet severe adverse events of the intervention, patient selection is crucial for attaining meaningful clinical benefits. Thorough workup to exclude alternative causes of stroke and identification of high-risk PFOs through clinical, neuroimaging and echocardiographic criteria are essential. Cost effectiveness of the procedure cannot be proven for the time being, since there are no robust data on clinical outcome after PFO-associated stroke but only limited anecdotal data suggesting low risk for long-term disability.

Introduction

Foramen ovale is a component of the fetal cardiovascular circulation that during postnatal life closes in ≈70% of subjects, whereas in the remaining 30%, remains patent as a tunnel and converts into a “flap-like” valve that may open every time the right atrial pressure overcomes the left one. Patent foramen ovale (PFO) is therefore a normal variant of the atrial septum rather than a congenital heart defect. PFO has been associated with cryptogenic ischemic stroke especially in younger patients (<60 years) after several seminal epidemiological studies in the 90's have shown a statistically significant association (1–4). Estimates on prevalence vary considerably depending on the population and the diagnostic method used (5). PFO is detected on transesophageal echocardiography in 1 out of 4–5 individuals whereas among younger patients with cryptogenic ischemic stroke, PFOs is present in more than 50% of cases. Transthoracic echocardiography bubble study is commonly used for the diagnosis of PFO in patients with cryptogenic stroke. Transcranial Doppler (TCD) is a bedside, non-invasive investigation of the cerebral blood flow that has also been evaluated as a potential screening tool for the detection of a right-to-left shunt (RLS) (6). TCD showed greater sensitivity and overall diagnostic accuracy but lower specificity compared to transthoracic echocardiography for the detection of PFO in cryptogenic stroke patients in a meta-analysis of prospective observational studies (7). Transesophageal echocardiography (TEE) bubble study is currently considered the gold standard for PFO investigation. A meta-analysis of prospective studies determined that TEE bubble study has a sensitivity of 89% and specificity of 91% when compared to confirmation by autopsy, surgery, and/or right heart catheterization. False negative and false positive results may occur due to technical limitations including patient intolerance for the probe, inadequate Valsalva maneuver during sedation and operator experience (8, 9). TCD is more sensitive (sensitivity: 95–98%) compared with TEE (sensitivity: 80–100%) but carries a lower specificity, diagnosing not PFO per se but only RLS; it also fails to provide any information about other potential cardiac and aortic embolic sources (10, 11).

PFO width ranges widely in adults from 1 to 19 mm (mean 4.9 mm). Depending on its size, which may be echocardiographically evaluated by measuring the maximum opening between septum primum and septum secundum in the left atrium, PFO can be classified as large ≥4 mm, medium 2–3.9 mm and small <2 mm. Certain PFO characteristics as described by TEE may increase the association with cryptogenic stroke (Table 1).

How Do the Controversial BP Targets Stack Up in Stroke?

If you were actually to think about this, lowering blood pressure too far makes no sense for clot strokes. You would be reducing the oxygen supply to the penumbra, increasing the death rate of those neurons. Does anyone in stroke think or have a strategy at all? But you can't listen to me, I'm not medically trained. Your doctor might be so ask her. 

We need protocols with an objective starting point and EXACT amounts of a SPECIFIC DRUG.  Leaders would make sure all stroke research produces usable protocols. This is too wishy washy.

 

How Do the Controversial BP Targets Stack Up in Stroke?

2017 guidelines dissected by a stroke neurologist

• by Nicole Lou, Contributing Writer, MedPage Today September 09, 2019

NEW ORLEANS -- When it comes to blood pressure (BP) targets, tailoring for certain groups is probably better than specifying a blanket "optimal" level for all stroke patients, clinicians agreed during a debate here.
Current American College of Cardiology/American Heart Association (ACC/AHA) BP guideline recommendations for acute stroke management and secondary prevention are "reasonable" but one "must be careful about lowering BP," according to stroke neurologist Philip Gorelick, MD, MPH, of Thorek Memorial Hospital in Chicago. "It's not just the BP level -- it's the variability of BP."
BP fluctuations have been shown to predict neurological deterioration and worse functional outcomes. "Consider early stabilization of BP in an attempt to avoid variability of BP and persistently elevated BP," he told the audience during a session at the AHA's annual Hypertension meeting.
Gorelick discussed the guidelines alongside Paul Whelton, MD, MSc, of Tulane University School of Medicine in New Orleans, who offered his perspective as the chair of the ACC/AHA guideline writing committee.
Acute Stroke
As in the previous version, the 2017 ACC/AHA guidelines say that acute ischemic stroke patients should be kept at BPs under 185/110 mm Hg before tissue plasminogen activator (tPA) treatment and 180/105 mm Hg in the 24 hours after drug therapy; if there is no alteplase or endovascular treatment, it may be reasonable to lower BP by 15%.
The literature suggests that BP-lowering therapies are generally safe in acute ischemic stroke but do not reduce the risk of death or major disability. And in the absence of these benefits, there's actually concern that secondary outcomes could worsen with BP-lowering medication, according to Gorelick.
It may therefore be reasonable to withhold BP-lowering medication if there is no compelling reason to reduce it, at least until the patient is medically and neurologically stable, he said.
Whelton noted that CATIS, the largest trial to date assessing acute BP lowering in acute ischemic stroke, found that immediate BP reduction made no difference in death or major disability.
But perhaps the investigators intervened too early back then: CATIS-2 is now underway with 5,000 patients getting BP-lowering intervention 24-48 hours after stroke onset, according to the guideline leader.
As for acute intracerebral hemorrhage, the guidelines say that bringing systolic BP under 140 mm Hg is harmful to patients, and Gorelick agreed: "Too precipitous and too low a target may be dangerous," he said, citing the INTERACT-2 and ATACH-2 trials showing no reduction in hematoma growth, death, or disability with intensive BP control.
He suggested modifying the AHA/American Stroke Association systolic BP target to 140-150 or 160 mm Hg in this setting.
Preventing Recurrent Stroke, Dementia
A 130 mm Hg systolic target is now recommended by the ACC/AHA for secondary stroke prevention.
Gorelick said it's reasonable to go down to less than 140 mm Hg or less than 130 mm Hg -- the latter especially after lacunar infarctions -- using diuretics, angiotensin-converting enzyme inhibitors, and other classes of BP-lowering agents.
Most trials in secondary prevention have been underpowered, suggesting trends toward fewer events with intensive BP therapy without reaching statistical significance, according to Whelton.
Recently, however, the RESPECT trial and a recent meta-analysis both showed that intensive BP treatment significantly reduced stroke recurrence over standard treatment.
Meanwhile, the rationale for lowering BP to preserve cognition also remains controversial.
For elderly patients over 80 years old and those with cognitive impairment, Gorelick advised caution, as there is concern about cerebral autoregulation when BP goes too low.
"There's a lot of observational data that patients who start developing cognitive impairment do worse when BP drops. [The question is] whether we need to boost BP to keep it high, so they can perfuse better," according to the stroke neurologist.
Whelton argued that the subgroup of SPRINT participants who were 75 years or older "seemed to do as well as anybody in the trial" on intensive BP control and as a very high-risk cohort even showed low numbers-needed-to-treat.
Concern over the BP "J-curve" has made some people nervous about going too low. However, "I would say as an observational epidemiologist, we see J-curves in everything. Take weight, cholesterol, sodium ... It's almost inevitable. When you look at a J-curve, it's usually reverse causality [driven by] sick people," Whelton said.
"It's not to say you should be cavalier about BP therapy," he clarified. "But the high-risk individuals who benefited most from the intervention are the people who we might be too cautious with."

Gorelick reported financial relationships with Bayer, Novartis, Amgen, and Vindico Medical Education.

• Primary Source

  Hypertension

  Source Reference: Gorelick PB "Is there a best blood pressure target post-stroke for outcome improvement? Neurologist's perspective" Hypertension 2019.

• Secondary Source

  Hypertension

  Source Reference: Whelton PK, et al "Is there a best blood pressure target post-stroke for outcome improvement: ACC/AHA BP guideline perspective" Hypertension 2019.