Including isolated aphasia improves sensitivity and negative predicative value for large vessel occlusion screening.

BACKGROUND: Large Vessel Occlusion (LVO) screening tools provide objective assessments to guide diagnostic decisions during acute stroke activations. The Stroke VAN screening tool includes weakness, vision, aphasia, and neglect; however, only screens positive if weakness is present regardless of presence of other symptoms including isolated aphasia. The purpose of this project was to evaluate wAve, a modified Stroke VAN screening tool. WAve includes components of VAN with emphasis on isolated aphasia. METHODS: We conducted a retrospective cohort study on 376 persons who presented with stroke symptoms within 24 h of last known well (LKW) to the Emergency Department of an urban comprehensive stroke center in north central Texas between July 2019 and January 2020. Comparison of VAN and wAve predictive values was calculated using Chi square analysis. Sensitivity and specificity was checked by using MedCalc software. Data from the electronic medical record was obtained for analysis including a documented wAve score and a calculated VAN score. Results of CT angiogram diagnostic testing was used to determine congruence of screening results with evidence of LVO. Power analysis described by Hajian- Tilaki was used to estimate study size. RESULTS: Results included 192 positive wAve screens and 184 negative wAve screens compared to 152 positive VAN screens and 224 negative VAN screens. The sensitivities for wAve and VAN were 89 % and 80 % respectively. Negative predictive values for wAve and VAN were 97 % and 95 % respectively. In isolated aphasic person, one of eight presented with a LVO and received intervention. CONCLUSION: The team discovered more LVOs were identified with wAve than VAN in persons exhibiting isolated aphasia symptoms. Larger studies are needed to understand the role isolated aphasia plays in LVO detection.

Post Stroke Visual Impairment: Interdisciplinary Collaborative Program - Canadian Perspective.

Post-stroke visual impairment (PSVI) affects more than 60% of the people who have a stroke but visual function is not routinely assessed in most stroke units. Recent high-quality research in this field has produced evidence-based assessment and management practices for PSVI. Orthoptists have integrated into the stroke care team in the United Kingdom (UK) to provide this valuable service. This paper outlines the development and implementation of the first known orthoptic PSVI service in North America. A pilot program was developed between the Ophthalmology, Neurology, and Physical Medicine and Rehabilitation Departments in Saskatoon, Saskatchewan, Canada. A new referral pathway was established to refer stroke patients with PSVI directly to an orthoptist with specialization in PSVI. Clinical findings from the first year of operation are reported. One hundred and seven visual deficits were suspected by the referring service. Visual field deficits were the most commonly reported PSVI. Diplopia was the most commonly reported oculomotor deficit in this cohort, and visual neglect/inattention was the most common visual perceptual deficit reported. Reading issues were the most commonly reported functional issues. Following assessment by an orthoptist, 45 additional visual deficits were identified and addressed. Stroke patients require assessment and treatment for PSVI. Orthoptists are perfectly suited to PSVI assessment and management. There is an opportunity to increase orthoptists' scope of practice in North America to ensure stroke patients receive specialized vision assessment and treatment.

Reliability of the National Institutes of Health (NIH) Stroke Scale Between Emergency Room and Neurology Physicians for Initial Stroke Severity Scoring.

INTRODUCTION: In patients with acute ischemic stroke (AIS), the National Institutes of Health Stroke Scale (NIHSS) is essential to establishing a patient's initial stroke severity. While previous research has validated NIHSS scoring reliability between neurologists and other clinicians, it has not specifically evaluated NIHSS scoring reliability between emergency room (ER) and neurology physicians within the same clinical scenario and timeframe in a large cohort of patients. This study specifically addresses the key question: does an ER physician's NIHSS score agree with the neurologist's NIHSS score in the same patient at the same time in a real-world context? METHODS: Data was retrospectively collected from 1,946 patients being evaluated for AIS at Houston Methodist Hospital from 05/2016 - 04/2018. Triage NIHSS scores assessed by both the ER and neurology providers within one hour of each other under the same clinical context were evaluated for comparison. Ultimately, 129 patients were included in the analysis. All providers in this study were NIHSS rater-certified. RESULTS: The distribution of the NIHSS score differences (ER score - neurology score) had a mean of -0.46 and a standard deviation of 2.11. The score difference between provider teams ranged ±5 points. The intraclass correlation coefficient (ICC) for the NIHSS scores between the ER and neurology teams was 0.95 (95% CI, 0.93 - 0.97) with an F-test of 42.41 and a p-value of 4.43E-69. Overall reliability was excellent between the ER and neurology teams. CONCLUSION: We evaluated triage NIHSS scores performed by ER and neurology providers under matching time and treatment conditions and found excellent interrater reliability. The excellent score agreement has important implications for treatment decision-making during patient handoff and further in stroke modeling, prediction, and clinical trial registries where missing NIHSS scores may be equivalently substituted from either provider team.

Functional Ability and Health Problems of Stroke Survivors: An Explorative Study.

Background A stroke is an emergency medical condition that needs to be treated promptly. Patients who suffer from stroke frequently experience varying degrees of impairment, necessitating emergency hospital treatment and prolonged home care. It can lower the quality of life which leads to social isolation and makes it harder to function independently. The purpose of this research was to assess the health issues and functional capacity of individuals living with stroke. Methodology An exploratory study was conducted in the neurological outpatient department of tertiary care hospitals in Chennai. A total of 30 post-stroke participants were selected using a convenient sampling technique. Data were collected by structured interviews using the Post-Stroke Checklist and Barthel Index. The data were analyzed through descriptive and inferential statistics. Results The majority of the patients were (86.7%) men in the age group of 55-65 years. Regarding the health problems identified with the Post-Stroke Checklist, the activities of daily living (80%) were the most common, and spasticity (48%) and pain (34%) were the least common. However, 60% of the participants had new problems related to vision, 66% had problems with hearing, 76% had problems with getting around inside or outside, and 60% had a history of a recent fall. Further, 52% had problems with remembering and concentrating on things, 72% had problems sleeping, and 45% were worried about their relationship with their spouse after the stroke. The median Barthel Index score was 43.5. Conclusions More than half of all stroke survivors were dependent on others for everyday activities. We recommend that a well-designed and focused assessment is needed to identify the functional ability and stroke-related health problems among individuals by all healthcare professionals for the successful rehabilitation of stroke survivors.

Assessment of Neurological Impairment and Recovery Using Statistical Models of Neurologically Healthy Behavior.

While many areas of medicine have benefited from the development of objective assessment tools and biomarkers, there have been comparatively few improvements in techniques used to assess brain function and dysfunction. Brain functions such as perception, cognition, and motor control are commonly measured using criteria-based, ordinal scales which can be coarse, have floor/ceiling effects, and often lack the precision to detect change. There is growing recognition that kinematic and kinetic-based measures are needed to quantify impairments following neurological injury such as stroke, in particular for clinical research and clinical trials. This paper will first consider the challenges with using criteria-based ordinal scales to quantify impairment and recovery. We then describe how kinematic-based measures can overcome many of these challenges and highlight a statistical approach to quantify kinematic measures of behavior based on performance of neurologically healthy individuals. We illustrate this approach with a visually-guided reaching task to highlight measures of impairment for individuals following stroke. Finally, there has been considerable controversy about the calculation of motor recovery following stroke. Here, we highlight how our statistical-based approach can provide an effective estimate of impairment and recovery.

Research and application advances in rehabilitation assessment of stroke.

Stroke has a high incidence and disability rate, and rehabilitation is an effective means to reduce the disability rate of patients. To systematize rehabilitation assessment, which is the foundation for rehabilitation therapy, we summarize the assessment methods commonly used in research and clinical applications, including the various types of stroke rehabilitation scales and their applicability, and related biomedical detection technologies, including surface electromyography (sEMG), motion analysis systems, transcranial magnetic stimulation (TMS), magnetic resonance imaging (MRI), and combinations of different techniques. We also introduce some assessment techniques that are still in the experimental phase, such as the prospective application of artificial intelligence (AI) with optical correlation tomography (OCT) in stroke rehabilitation. This review provides a useful bibliography for the assessment of not only the severity of stroke injury, but also the therapeutic effects of stroke rehabilitation, and establishes a solid base for the future development of stroke rehabilitation skills.

Cincinnati Prehospital Stroke Scale Implementation of an Urban County Severity-Based Stroke Triage Protocol: Impact and Outcomes on a Comprehensive Stroke Center.

BACKGROUND AND PURPOSE: Screening scales are recommended to assist field-based triage of acute stroke patients to designated stroke centers. Cincinnati prehospital stroke scale (CPSS) is a commonly used prehospital stroke screening tool and has been validated to identify large vessel occlusion (LVO). This study addresses the impact of county-based CPSS implementation to triage suspected LVO patients to a comprehensive stroke center (CSC). MATERIALS AND METHODS: Dekalb County in Atlanta, Georgia, implemented CPSS-based protocol with score of 3 and last seen normal time < 24 h mandating transfer to the nearest CSC if the added bypass time was <15 min. Frequency of stroke codes, LVO, IV-tPA use, and thrombectomy treatment were compared six months before and after protocol change (November 1, 2020). RESULTS: During the study period, 907 stroke patients presented to the CSC by EMS, including 289 (32%) with CPSS score 3. There was an increase in monthly ischemic stroke volume (pre-16 ± 2 vs.19 ± 3 p = 0.03), LVO (pre-4.3 ± 1.7 vs. post-7.0 ± 2.4; p = 0.03), EVT (pre-15% vs. post-30%; p = 0.001), without significant increase in stroke mimic volume or delay in mean time from last seen normal to IV-tPA (pre-165 ± 66, post-158 ± 49 min; p = 0.35). CPSS score 3 was associated with increased likelihood of LVO diagnosis (OR 8.5, 95% CI 5.0-14.4; p = 0.001) and decreased the likelihood of stroke mimics (OR 0.66, 95% CI 0.50-0.88; p = 0.004). CONCLUSION: CPSS is a quick, easy to implement, and reliable prehospital severity scale for EMS to triage LVO to CSC without delaying IV-tPA treatment or significantly increasing stroke mimics.

Comparing Sources of Disruptions to Telemedicine-Enabled Stroke Care in an Ambulance.

OBJECTIVE: The purpose of this study is to understand the nature and source of disruptions in an ambulance during the telemedicine-based caregiving process for stroke patients to enhance the ambulance design for supporting telemedicine-based care. BACKGROUND: Telemedicine is emerging as an efficient approach to provide timely remote assessment of patients experiencing acute stroke in an ambulance. These consults are facilitated by connecting the patient and paramedic with a remotely located neurologist and nurse using cameras, audio systems, and computers. However, ambulances are typically retrofitted to support telemedicine-enabled care, and the placement of these systems inside the ambulance might lead to spatial challenges and disruptions during patient evaluation. METHOD: Video recordings of 13 simulated telemedicine-based stroke consults were coded and analyzed using an existing systems-based flow disruption (FD) taxonomy. For each observed disruption-the type, severity or impact, location in the ambulance, and equipment involved in the disruption were recorded. RESULTS: Seat size, arrangement of assessment equipment, location of telemedicine equipment (computer workstation), and design of telemedicine camera were among the factors that impacted telemedicine-related disruptions. The left ambulance seat zone and head of the patient bed were more involved in environmental hazard-related disruptions, while the right zone of the ambulance was more prone to interruptions and communication-related disruptions. CONCLUSION: Adequate evaluation space for the paramedic, proper placement of evaluation equipment, and telemedicine computer location could facilitate the stroke care evaluation process and reduce FDs in the ambulance.

Introducing Adam's Scale of Posterior Stroke (ASPOS): A Novel Validated Tool to Assess and Predict Posterior Circulation Strokes.

BACKGROUND: Assessing the severity of posterior circulation strokes, due to the variety of symptoms, is a significant clinical problem. Current clinimetric scales show lower accuracy in the measurement of posterior stroke severity, compared with that of anterior strokes. The aim of the study was to design a validated tool, termed Adam's Scale of Posterior Stroke (ASPOS), for better assessment and prediction of posterior stroke. METHODS: This prospective, observational study involved 126 posterior circulation ischemic stroke subjects. Four researchers, previously trained in ASPOS, randomized the stroke severity using a novel tool and other appropriate stroke scales (The National Institute of Health Stroke Scale-NIHSS, modified Rankin Scale-mRS, Glasgow Coma Scale, Barthel Index, or Israeli Vertebrobasilar Stroke Scale-IVBSS) to assess the psychometric properties, reliability, and validity of ASPOS and investigate its predictive value. RESULTS: ASPOS reached a Cronbach's alpha coefficient of 0.7449, indicating good internal consistency. The Bland-Altman analysis showed a good coefficient of repeatability (CR) of 0.46, a 95% confidence interval (CI) of 0.41-0.53, and excellent intraclass correlation coefficients or weighted kappa values (>0.90), reflecting high reliability and reproducibility. Highly significant correlations with other scales confirmed the construct and predictive validity of ASPOS. A total ASPOS score of three points indicated a significantly increased probability of severe stroke based on the NIHSS, compared to a total ASPOS of 1-2 points (odds ratio (OR) 141; 95% CI: 6.72-2977.66; p = 0.0014). CONCLUSIONS: We developed a novel, valid, and reliable tool to assess posterior circulation strokes. This can contribute to a more comprehensive estimation of posterior stroke and, additionally, due to its predictive properties, it can be used to more accurately select candidates for specific treatments.

Cerebral infarct site and affected vascular territory as factors in breathing weakness in patients with subacute stroke.

OBJECTIVE: A better understanding of factors influencing breathing weakness in stroke survivors would help in planning rehabilitation therapies. The main objective of this study was to determine whether the location of cerebral infarct is associated with breathing weakness in patients with subacute stroke. DESIGN: Cross-sectional analysis of a prospective cohort. PATIENTS: Consecutive patients admitted to a neurology rehabilitation unit with first-time ischaemic stroke (n?=?170). METHODS: Breathing weakness was defined as >?70% reduction in maximal inspiratory and expiratory pressures (PImax and PEmax, respectively) compared with reference values. Computed tomography and magnetic resonance imaging were used to locate stroke lesions, which were classified as cortical, subcortical, cortico-subcortical, brainstem, or cerebellum. The affected cerebrovascular territory was identified to classify stroke subtype. The association between maximal respiratory pressure and affected brain area was studied using median regression analysis. RESULTS: Breathing weakness was detected in 151 (88.8%) patients. Those with cortical and cortico-subcortical stroke location had the lowest PImax and PEmax values (median 33 cmH2O). This value differed significantly from maximal respiratory pressures of patients with strokes located in the brainstem and the cerebellum, with PImax median differences (?) of 16 cmH2O (95% confidence interval (95% CI) 4.127.9) and 27 cmH2O (95% CI 7.846.2), respectively, and PEmax median differences of 27 cmH2O (95% CI 11.442.7) and 49 cmH2O (95% CI 23.774.3), respectively, both of which remained significant after adjustments. CONCLUSION: The prevalence of breathing weakness was very high in stroke patients admitted to a neurorehabilitation ward, being more severe in cortical or cortico-subcortical stroke.

Clinical Localization of Stroke.

Acute stroke assessment is classically supported by clinical localization whereby presenting disabilities are associated with key arterial territories in the brain. Clinical localization skills are rarely taught to nonneurologists; yet, these skills are essential to the provision of evidence-based nursing care of stroke, enabling rapid patient identification, diagnosis, and ultimately, the delivery of acute treatment. This article explores the process of clinical localization in relation to the physiology affected by stroke vascular insufficiency. Elements of the neurologic examination are described as they relate to discreet areas in the brain and the National Institutes of Health Stroke Scale.

Stroke in a resource-constrained hospital in Madagascar.

BACKGROUND: Stroke is reported as the most frequent cause of in-hospital death in Madagascar. However, no descriptive data on hospitalized stroke patients in the country have been published. In the present study, we sought to investigate the feasibility of collecting data on stroke patients in a resource-constrained hospital in Madagascar. We also aimed to characterize patients hospitalized with stroke. METHODS: We registered socio-demographics, clinical characteristics, and early outcomes of patients admitted for stroke between 23 September 2014 and 3 December 2014. We used several validated scales for the evaluation. Stroke severity was measured by the National Institutes of Health Stroke Scale (NIHSS), disability by the modified Rankin Scale (mRS), and function by the Barthel Index (BI). RESULTS: We studied 30 patients. Sixteen were males. The median age was 62.5 years (IQR 58-67). The NIHSS and mRS were completed for all of the patients, and BI was used for the survivors. Three patients received a computed tomography (CT) brain scan. The access to laboratory investigations was limited. Electrocardiographs (ECGs) were not performed. The median NIHSS score was 16.5 (IQR 10-35). The in-hospital stroke mortality was 30%. At discharge, the median mRS score was 5 (IQR 4-6), and the median BI score was 45 (IQR 0-72.5). CONCLUSIONS: Although the access to brain imaging and supporting investigations was deficient, this small-scale study suggests that it is feasible to collect essential data on stroke patients in a resource-constrained hospital in Madagascar. Such data should be useful for improving stroke services and planning further research. The hospitalized stroke patients had severe symptoms. The in-hospital stroke mortality was high. At discharge, the disability category was high, and functional status low.

Stroke Chameleons and Stroke Mimics in the Emergency Department.

PURPOSE OF REVIEW: We discuss the frequency of stroke misdiagnosis in the emergency department (ED), identify common diagnostic pitfalls, describe strategies to reduce diagnostic error, and detail ongoing research. RECENT FINDINGS: The National Academy of Medicine has re-defined and highlighted the importance of diagnostic errors for patient safety. Recent rates of stroke under-diagnosis (false-negative cases, "stroke chameleons") range from 2-26% and 30-43% for stroke over-diagnosis (false-positive cases, "stroke mimics"). Failure to diagnosis stroke can preclude time-sensitive treatments and has been associated with poor outcomes. Strategies have been developed to improve detection of posterior circulation stroke syndromes, but ongoing work is needed to reduce under-diagnosis in other atypical stroke presentations. The published rates of harm associated with stroke over-diagnosis, particularly thrombolysis of stroke mimics, remain low. Additional strategies to improve the accuracy of stroke diagnosis should focus on rapid clinical reasoning in the time-sensitive setting of acute ischemic stroke and identifying imperfections in the healthcare system which may contribute to diagnostic error.

Can the Montreal Cognitive Assessment predict discharge destination in a stroke population in the hospital?

BACKGROUND: To decide on an appropriate discharge destination for stroke survivors from hospital, factors such as activities of daily living and age are often taken into account as predictors. Cognition has been found to support the decision whether to send a patient home or to a dependent living situation. The Montreal Cognitive Assessment (MOCA) has been proven to be a suitable cognitive screening instrument in the acute phase after stroke. However, its predictive value in the determination of discharge destination is unknown. The aim of the present study was to examine whether cognitive functioning, as measured with the MOCA, in the acute phase after stroke could predict discharge destination. METHODS: The study involved 211 patients with a first-ever cerebral stroke within the first week after stroke. Demographic and stroke-specific data, cognitive functioning (MOCA), and level of functional disability (Barthel Index [BI]) were collected. Multivariate logistic regression analyses were used to predict discharge destination (dependent versus independent living situation). RESULTS: Both age (B = -.05; P < .01) and BI score (B = .33; P < .001) were found to be significantly related to discharge destination with explained variance of 43%. Adding MOCA score as a predictor variable to the model resulted in a nonsignificant improvement of the model, explaining 44% of the variance. CONCLUSIONS: Cognitive functioning, as measured by a single screening instrument such as the MOCA, in the acute phase after stroke is not predictive for discharge destination.

Advance in Evaluation and Rehabilitation of Mild Cognitive Impairment after Stroke(review) / 中国康复理论与实践

@#This paper reviewed the Methods of evaluation and rehabilitation of mild cognitive impairment (MCI) after stroke. The Results showed that the Methods of evaluation included Mini Mental State Examination(MMSE), three Methods designed by The National Institute for Neurological Disorders and Stroke(NINDS) and The Canadian Stroke Network(CSN), and Montreal Cognitive Assessment (MoCA) and category test. The MoCA as the focus is brief, practical and effective as the major advantages. Many Methods of rehabilitation existed are still lack of evidence to support their efficacy.

Silent microbleeds and hemorrhagic conversion of an embolic infarction.

We report a patient with multiple simultaneous embolic infarctions with localized hemorrhagic conversion. A 75-year-old male patient had several silent microbleeds (SMBs) exclusively in the cerebral cortex, and underwent angioplasty and stenting for bilateral carotid stenosis. He subsequently experienced embolic infarctions in the cortex and the striatum: the cortical infarction, where an SMB had been present, showed hemorrhagic conversion, whereas the striatal infarction did not. This case suggests that SMBs are indicators of an underlying hemorrhage-prone state.

Silent Microbleeds and Hemorrhagic Conversion of an Embolic Infarction

We report a patient with multiple simultaneous embolic infarctions with localized hemorrhagic conversion. A 75-year-old male patient had several silent microbleeds (SMBs) exclusively in the cerebral cortex, and underwent angioplasty and stenting for bilateral carotid stenosis. He subsequently experienced embolic infarctions in the cortex and the striatum: the cortical infarction, where an SMB had been present, showed hemorrhagic conversion, whereas the striatal infarction did not. This case suggests that SMBs are indicators of an underlying hemorrhage-prone state.

Silent Microbleeds and Hemorrhagic Conversion of an Embolic Infarction

We report a patient with multiple simultaneous embolic infarctions with localized hemorrhagic conversion. A 75-year-old male patient had several silent microbleeds (SMBs) exclusively in the cerebral cortex, and underwent angioplasty and stenting for bilateral carotid stenosis. He subsequently experienced embolic infarctions in the cortex and the striatum: the cortical infarction, where an SMB had been present, showed hemorrhagic conversion, whereas the striatal infarction did not. This case suggests that SMBs are indicators of an underlying hemorrhage-prone state.

Validity and Reliability of Retrospective NIH Stroke Scale Assessment for Initial Stroke Severity

BACKGROUND: The retrospective severity scoring system of NIHSS for acute stroke patients was found to be valid and reliable by using patients' medical records in studies abroad. However, in Korea, medical records are often summarized and contain missing information which makes it difficult to conduct a restropective outcome study. The purpose of this research was to evaluate the validity and reliability of the retrospective NIHSS scoring system according to patients' medical records with written clinical histories and physical admission notes. METHODS: An algorithm for the retrospective NIHSS scoring system was developed and applied to 75 patients with acute ischemic stroke. Missing data on physical examination results were scored as normal. One neurologist who was blinded to this study measured the NIHSS score prospectively on the initial patient examination. After the patient's discharge, two other neurologists, blinded to the patient's clinical condition, evaluated the NIHSS score independently based on the information collected from the patient's physical admission notes. The criterion-related validity was evaluated by the Pearson Correlation Coefficient, and the measure of agreement between two raters was evaluated by the Kappa Statistic. RESULTS: The criterion-related validities of the retrospective NIHSS scoring system were high in the total and each itemized scores, except for the items of LOC command, limb ataxia, dysarthria, and neglect. The interrater reliabilities were also high except for the items of LOC command, limb ataxia, and dysarthria. CONCLUSIONS: The retrospective NIHSS scoring algorithm was found to be a reliable and unbiased tool even when some physical examination elements are missing from the written medical records.

Comparison of the NIH Stroke Scale and the Modified NIH Stroke Scale by Classification and Location of Cerebral Infarction

BACKGROUND: The National Institutes of Health Stroke Scale (NIHSS) is regarded as a valid and reliable tool to measure the severity of neurological deficits in acute stroke, but has been criticized for its complexity and variability. Therefore, the modified NIHSS (mNIHSS) was developed, eliminating redundant and less reliable items from the full version of the NIHSS. The aim of the present study was to evaluate the validity of the mNIHSS according to the subtypes of stroke and the location of affected arterial territories. METHODS: The severity of stroke in 155 patients with acute cerebral infarction was measured. Each patient was evaluated by two neurologists using both the NIHSS and mNIHSS, and the stroke subtype was determined according to the TOAST classification. The vascular territory of lesion was classified into an anterior and posterior circulation. The criterion-related validity was evaluated by the Pearson Correlation Coefficient between the NIHSS and mNIHSS scores. RESULTS: When considering the NIHSS scores as the gold criteria, the Pearson correlation coefficients of the mNIHSS were 0.96 in the subtype of large artery atherosclerosis, 0.91 in small vessel occlusion, 0.98 in cardioembolism, and 0.99 in undetermined etiology. On the other hand, the correlation coefficient was 0.98 in patients with an anterior circulation infarction, and was 0.94 in patients with a posterior circulation infarction. CONCLUSIONS: The criterion-related validity of the mNIHSS scoring system was very high in general. However, the correlations were relatively low in patients with the TOAST subtype of small vessel occlusion and also a posterior circulation infarction.