Relationship Between Brainstem Auditory Evoked Potentials and Clinical Function in Patients With Cerebral Infarction.

PURPOSE: The purpose of this study was to analyze the association between the brainstem auditory evoked potential (BAEP) and clinical outcomes at discharge in patients who have had subacute ischemic stroke. METHODS: A total of 210 patients who have had ischemic stroke, confirmed by MRI within 3 months after onset, were enrolled. Demographics and stroke-related clinical assessment scales, such as the modified Barthel index and National Institute of Health Stroke Scale (NIHSS), were collected. Recorded latencies of waveforms I, III, and V of BAEP were bilaterally collected and analyzed. The results of the patients with supratentorial brain lesions were further analyzed. RESULTS: The mean BAEP latencies of waveforms I, III, and V in the subjects were 1.84 ± 0.22, 4.07 ± 0.27, and 6.07 ± 0.33 ms, respectively. As the modified Barthel index and NIHSS scores at discharge functionally worsened, the latencies of all lesion-side BAEP waveforms were significantly delayed. In patients with supratentorial brain lesions only, there was a significant delay in the latency of waveform V at the lesion side as modified Barthel index severity increased ( P = 0.048). As the NIHSS score functionally worsened, BAEP latencies III and V recorded at the lesion side significantly delayed ( P = 0.023 and P = 0.003, respectively). In multivariate linear regression models, latency V was found to be a significant factor in predicting outcome at discharge, among other factors. CONCLUSIONS: In patients with ischemic stroke with the poor clinical outcome at discharge, there were delayed latencies of waveforms I, III, and V of BAEP performed in the early phase of stroke.

Machine-Learning-Based Rehabilitation Prognosis Prediction in Patients with Ischemic Stroke Using Brainstem Auditory Evoked Potential.

To evaluate the feasibility of brainstem auditory evoked potential (BAEP) for rehabilitation prognosis prediction in patients with ischemic stroke, 181 patients were tested using the Korean version of the modified Barthel index (K-MBI) at admission (basal K-MBI) and discharge (follow-up K-MBI). The BAEP measurements were performed within two weeks of admission on average. The criterion between favorable and unfavorable outcomes was defined as a K-MBI score of 75 at discharge, which was the boundary between moderate and mild dependence in daily living activities. The changes in the K-MBI scores (discharge-admission) were analyzed by nonlinear regression models, including the artificial neural network (ANN) and support vector machine (SVM), with the basal K-MBI score, age, and interpeak latencies (IPLs) of the BAEP (waves I, I-III, and III-V). When including the BAEP features, the correlations of the ANN and SVM regression models increased to 0.70 and 0.64, respectively. In the outcome prediction, the ANN model with the basal K-MBI score, age, and BAEP IPLs exhibited a sensitivity of 92% and specificity of 90%. Our results suggest that the BAEP IPLs used with the basal K-MBI score and age can play an adjunctive role in the prediction of patient rehabilitation prognoses.

Attentional and neurophysiologic effects of repetitive transcranial magnetic stimulation.

Twenty-seven healthy subjects were randomly assigned to 1 of 2 equal groups : (1) experimental group (active stimulation) and (2) control group (sham stimulation). A total of 10 Hz repetitive transcranial magnetic stimulation was delivered to the left dorsolateral prefrontal cortex at 80% of the resting motor threshold. The reaction time of the correct response, omission error, and commission error of the auditory and visual continuous performance test scores were measured. The motor evoked potentials, resting motor threshold, short-interval intracortical inhibition, and intracortical facilitation was recorded in the right first dorsal interosseous muscle to determine motor cortex excitability. The reaction time and commission error of the auditory continuous performance test were reduced significantly after 10 Hz repetitive transcranial magnetic stimulation (P < 0.05). Resting motor threshold and short-interval intracortical inhibition was significantly decreased after active repetitive transcranial magnetic stimulation (P < 0.05), with no changes in the latency and amplitude of the motor evoked potentials and intracortical facilitation. In conclusion, high-frequency repetitive transcranial magnetic stimulation to the left dorsolateral prefrontal cortex is shown to improve the attentional function and may be simultaneously associated with changes in neurophysiological activity.

Dose-Response Effect of Daily Rehabilitation Time on Functional Gain in Stroke Patients.

OBJECTIVE: To demonstrate the effect of daily treatment time on recovery of functional outcomes and how each type of rehabilitation treatment influences the improvement of subgroups of functional outcomes in stroke patients. METHODS: We conducted a retrospective study in 168 patients who were admitted to the Department of Rehabilitation Medicine between 2015 and 2016. Patients who experienced their first-ever stroke and unilateral lesions were included. All patients underwent conventional rehabilitation treatment, and each treatment was administered one to two times a day depending on individual and treatment room schedules. Based on the mean daily treatment time, patients were divided into two groups: a high-amount group (n=54) and low-amount group (n=114). Outcomes were measured through the Korean version of Modified Barthel Index (MBI), FuglMeyer Assessment of the upper extremity, Trunk Impairment Scale (TIS), and Berg Balance Scale (BBS) scores on admission and at discharge. RESULTS: The functional change and scores at discharge of MBI, TIS, and BBS were greater in the high-amount group than in the low-amount group. Among various types of rehabilitation treatments, occupational therapy training showed significant correlation with MBI, TIS, and BBS gain from admission to discharge. CONCLUSION: The amount of daily mean treatment in post-stroke patients plays an important role in recovery. Mean daily rehabilitation treatment time seems to correlate with improved balance and basic activities of daily living after stroke.

Frequency of and Reasons for Unplanned Transfers From the Inpatient Rehabilitation Facility in a Tertiary Hospital.

OBJECTIVE: To characterize the patients in the inpatient rehabilitation facility who were transferred to acute care facilities and identify the frequency of and reasons for the unplanned transfer. METHODS: Medical records of patients admitted to the inpatient rehabilitation facility from October 2017 to December 2018 were reviewed. Patients were categorized according to their diagnoses. The included patients were divided into the unplanned transfer and control groups based on whether they required to transfer to another department for acute care before completing an uninterrupted rehabilitation course. The groups were compared in terms of sex, age, length of stay, admission sources, and disease groups. The reasons for unplanned transfers were classified based on medical or surgical conditions. RESULTS: Of the 1,378 patients were admitted to the inpatient rehabilitation facility, 1,301 satisfied inclusion criteria. Among them, 121 (9.3%) were unexpectedly transferred to the medical or surgical department. The unplanned transfer group had a higher age (69.54±12.53 vs. 64.39±15.32 years; p=0.001) and longer length of stay (85.69±66.08 vs. 37.81±31.13 days; p<0.001) than the control group. The top 3 reasons for unplanned transfers were infectious disease, cardiopulmonary disease, and orthopedic problem. CONCLUSION: The unplanned transfer group had a significantly higher age and longer length of stay. The most common reason for the unplanned transfer was infectious disease. However, the proportions of those with orthopedic and neurological problems were relatively high. Therefore, further studies of these patient populations may help organize systematic strategies that are needed to reduce unplanned transfers to acute facilities for patients in rehabilitation facilities.

Effects of Repetitive Transcranial Magnetic Stimulation (rTMS) Combined with Aerobic Exercise on the Recovery of Motor Function in Ischemic Stroke Rat Model.

The therapeutic benefits of repetitive transcranial magnetic stimulation (rTMS) combined with rehabilitation therapy on recovery after stroke have not been fully elucidated. This study aimed to explore the therapeutic effects of rTMS followed by aerobic exercise on neuroplasticity and recovery of motor function in a rat model of permanent middle cerebral artery occlusion (MCAO). Rats were randomized into sham operation (N = 10, sham op), MCAO (N = 10, control group), rTMS (N = 10, MCAO and rTMS therapy), and combination groups (N = 10, MCAO and combination therapy). High-frequency rTMS (10 Hz) was applied on the ipsilesional forepaw motor cortex, and aerobic exercise training on the rotarod was performed for two weeks. The rotarod and Garcia tests were conducted to evaluate changes in behavioral function. Motor evoked potentials (MEPs) were used to evaluate electrophysiological changes. Stroke severity was assessed using infarction volume measurement. Neuronal recovery was explored with western blot for brain-derived neurotrophic factor (BDNF) pathway proteins. Compared with control therapy, combination therapy was significantly more effective than rTMS therapy for improving function on the rotarod test (p = 0.08), Garcia test (p = 0.001), and MEP amplitude (p = 0.001) In conclusion, combination therapy may be a potential treatment to promote recovery of motor function and neuroplasticity in stroke patients.

Improvement of Cognitive Function after Continuous Positive Airway Pressure Treatment for Subacute Stroke Patients with Obstructive Sleep Apnea: A Randomized Controlled Trial.

Background: Obstructive sleep apnea (OSA) is common after stroke. Various studies on continuous positive airway pressure (CPAP) therapy for OSA after stroke have been published. However, there have been no studies from Korea and Asia. The present Korean study aimed to determine whether CPAP treatment during inpatient rehabilitation of stroke patients with sleep disorders, especially OSA, improves function, cognition, sleep quality, and daytime sleepiness. Methods: This single-blind randomized controlled study included 40 stroke patients with OSA between November 2017 and November 2018. The patients were divided into the CPAP treatment group (CPAP and rehabilitation; n = 20) and control group (only rehabilitation; n = 20). The intervention period was 3 weeks. The primary outcomes were function and cognition improvements, and the secondary outcomes were sleep-related improvements. Results: CPAP treatment started at an average of 4.6 ± 2.8 days after admission. Both groups showed improvements in stroke severity, function, and cognition after the 3-week intervention. However, after the intervention, the degree of change in attention and calculation was significantly higher in the CPAP treatment group than in the control group. Additionally, the improvements in sleep quality and daytime sleepiness were greater in the CPAP treatment group than in the control group. Conclusion: CPAP treatment can improve cognitive function, sleep quality, and daytime sleepiness, and it should be considered as part of the rehabilitation program for patients with stroke. Our findings might help in the treatment of stroke patients with OSA in Korea.

Efficacy of Early Endoscopic Intervention for Restoring Normal Swallowing Function in Patients with Lateral Medullary Infarction.

Dysphagia is considered to be a significant barrier for recovery after lateral medullary infarction (LMI). However, there is still no gold standard treatment for dysphagia. The aim of this study was to explore an effect of an early treatment options for swallowing dysfunction after acute LMI. Medical records of acute LMI patients who had been admitted to the department of rehabilitation medicine from January 2014 to December 2017 were reviewed retrospectively. We compared the clinical efficacy of conventional dysphagia rehabilitation to early endoscopic intervention using either botulinum toxin injection into cricopharyngeal muscle or endoscopic balloon dilatation of the muscle. Outcomes, such as duration of parental feeding, albumin level at diet transition to enteral feeding, and complications, were analyzed. A total of 18 patients with LMI were included. While eight patients (8/9, 88.89%) in the endoscopic group were capable of orally ingesting their diet after intervention, the conversion from tube feeding to an oral diet was possible in only five patients (5/9, 55.56%) of the conventional group during hospitalization. However, the difference between the two groups was not significant (p-value ≤ 0.147, chi-square test). Only the final dietary level at the time of discharge was higher level in endoscopic group. The conversion interval from tube feeding to oral diet was also comparable between groups. There was no re-conversion from the oral diet to tube feeding in patients of either group during the median follow-up period of 20 months. Early endoscopic intervention may be a better option for dysphagia with LMI, compared to conventional dysphagia rehabilitation. However, a larger and prospective trial may be needed to confirm our observations.