Risk factors for dysphagia in patients with acute and chronic ischemic stroke: A retrospective cohort study.

Background: Dysphagia is a common and clinically significant complication of ischemic stroke. The prevalence and risk factors for dysphagia may vary at different stages following an ischemic stroke. Methods: This study included patients with acute and chronic ischemic stroke who were treated at the Department of Rehabilitation, First Affiliated Hospital, Zhejiang University School of Medicine from 2019 to 2022. Various demographic, clinical, and laboratory parameters were collected, and statistical analyses were performed to investigate their association with dysphagia. Results: Among the 399 ischemic stroke patients included in the study, 165 (41.4 %) experienced dysphagia, with 72 (38.7 %) in the acute phase and 93 (43.7 %) in the chronic phase. Univariate analysis revealed significant associations (p < 0.05) between dysphagia and factors such as pulmonary infection, aphasia, NIHSS score, ADL score, NLR score, lower extremity Brunnstrom's stages, and sit-to-stand balance. Multiple logistic regression analysis, after adjusting for confounding factors, identified the ADL score as an independent predictor of dysphagia. These findings were consistent across three time-windows: the acute phase, the chronic phase, and 180 days after stroke onset. Additionally, the lymphocyte count and pulmonary infection were identified as potential independent indicators. Conclusions: This study investigated the prevalence and risk factors for dysphagia in ischemic stroke patients at different time-windows. A low ADL score (<40) may serve as a valuable and reliable predictor for poststroke dysphagia in clinical settings.

Post-stroke Everything.

PURPOSE OF REVIEW: This review aims at providing updates on selected post-stroke complications. We examined recent advances in diagnosing and treating the following post-stroke complications: cognitive impairment, epilepsy, depression, fatigue, tremors, dysphagia, and pain. RECENT FINDINGS: Advances in understanding the mechanisms of post-stroke complications, in general, are needed despite advances made in understanding, treating, and preventing these complications. There are growing progresses in integrating new tools to diagnose post-stroke cognitive impairment. The potential role of acute stroke reperfusion treatment in post-stroke epilepsy and its impact on other stroke complications is getting more transparent. Post-stroke depression remains underestimated and new tools to diagnose depression after stroke are being developed. New promising pharmacological approaches to treating post-stroke pain are emerging. Tremors related to stroke are poorly understood and under-evaluated, while treatment towards post-stroke dysphagia has benefited from new non-pharmacological to pharmacological approaches. CONCLUSIONS: An integrative approach to stroke complications and collaborations between providers across specialties are more likely to improve stroke outcomes.

Admission chest CT findings and risk assessment for stroke-associated pneumonia.

INTRODUCTION: Stroke-associated pneumonia (SAP) is a significant cause of morbidity and mortality after stroke. Various factors, including dysphagia and stroke severity, are closely related to SAP risk; however, the contribution of the baseline pulmonary parenchymal status to this interplay is an understudied field. Herein, we evaluated the prognostic performance of admission chest computed tomography (CT) findings in predicting SAP. METHODS: We evaluated admission chest CT images, acquired as part of a COVID-19-related institutional policy, in a consecutive series of acute ischemic stroke patients. The pulmonary opacity load at baseline was quantified using automated volumetry and visual scoring algorithms. The relationship between pulmonary opacities with risk of pneumonia within 7 days of symptom onset (i.e., SAP) was evaluated by bivariate and multivariate analyses. RESULTS: Twenty-three percent of patients in our cohort (n = 100) were diagnosed with SAP. Patients with SAP were more likely to have atrial fibrillation, COPD, severe neurological deficits, and dysphagia. The visual opacity score on chest CT was significantly higher among patients who developed SAP (p = 0.014), while no such relationship was observed in terms of absolute or relative opacity volume. In multivariate analyses, admission stroke severity, presence of dysphagia and a visual opacity score of ≥ 3 (OR 6.37, 95% CI 1.61-25.16; p = 0.008) remained significantly associated with SAP risk. CONCLUSIONS: Pulmonary opacity burden, as evaluated on admission chest CT, is significantly associated with development of pneumonia within initial days of stroke. This association is independent of other well-known predisposing factors for SAP, including age, stroke severity, and presence of dysphagia.

An Evidence-Based Nursing Intervention Decreases Anxiety, Depression, Sleep Quality and Somatic Symptoms of Patients with Acute Ischemic Stroke.

Purpose: This study aimed to explore the effects of evidence-based nursing (EBN) intervention on anxiety, depression, sleep quality and somatic symptoms of patients with acute ischemic stroke (AIS). Methods: The eligible AIS patients were randomized into the intervention group and control group in a 1:1 ratio. Patients in both groups received routine nursing care. On the basis of routine nursing, patients in the intervention group also received EBN. Self-rating anxiety scale (SAS), self-rating depression scale (SDS), Pittsburgh Sleep Quality Index (PSQI), and the Patient Health Questionnaire-15 (PHQ-15) were used to assess patients' anxiety, depression, sleep quality, and somatic symptoms at baseline (T0) and 6 months after intervention (T1), respectively. Results: There was no difference in SAS, SDS, PSQI, and PHQ-15 scores at T0 between the 2 groups (all P > 0.05). Comparing to the control group, the intervention group had significantly lower SAS and SDS scores at T1 (P = 0.002, P < 0.001, respectively). The SAS and SDS score changes (T1-T0) were more evident in the intervention group than in the control group (all P < 0.001). No difference of PSQI or PHQ-15 score between the 2 groups was observed at T1. However, the PSQI and PHQ-15 score changes were more evident in the intervention group than in the control group (P = 0.044 and P = 0.007, respectively). Conclusion: EBN invention significantly improved anxiety, depression, sleep quality and somatic symptoms of patients with AIS.

Neurosteroids: A novel promise for the treatment of stroke and post-stroke complications.

Stroke is the primary reason for death and disability worldwide, with few treatment strategies to date. Neurosteroids, which are natural molecules in the brain, have aroused great interest in the field of stroke. Neurosteroids are a kind of steroid that acts on the nervous system, and are synthesized in the mitochondria of neurons or glial cells using cholesterol or other steroidal precursors. Neurosteroids mainly include estrogen, progesterone (PROG), allopregnanolone, dehydroepiandrosterone (DHEA), and vitamin D (VD). Most of the preclinical studies have confirmed that neurosteroids can decrease the risk of stroke, and improve stroke outcomes. In the meantime, neurosteroids have been shown to have a positive therapeutic significance in some post-stroke complications, such as epilepsy, depression, anxiety, cardiac complications, movement disorders, and post-stroke pain. In this review, we report the historical background, modulatory mechanisms of neurosteroids in stroke and post-stroke complications, and emphasize on the application prospect of neurosteroids in stroke therapy.

Trial design and pilot phase results of a cluster-randomised intervention trial to improve stroke care after hospital discharge - The structured ambulatory post-stroke care program (SANO).

INTRODUCTION: Previous studies showed insufficient control of cardiovascular risk factors (CVRF) and high stroke recurrence rates among ischemic stroke patients in Germany. Currently, no structured secondary prevention program exists in clinical routine. We present the trial design and pilot phase results of a complex intervention to improve stroke care after hospital discharge in Germany. PATIENTS AND METHODS: SANO is a cluster-randomized trial with 30 participating regions across Germany aiming to enrol 2,790 patients (drks.de, DRKS00015322). Study intervention combines both structural and patient-centred elements. Study development was based on the Medical Research Council framework for complex interventions. In 15 intervention regions, a cross-sectoral multidisciplinary network is established to enhance CVRF control as well as detection and treatment of post-stroke complications. Recommendations on CVRF are based on high-quality secondary prevention guidelines. Study physicians use motivational interviewing and agree with patients on therapeutic targets. While hospitalised, patients also receive dietary counselling and a health-passport to track their progress. During regular visits, CVRF management and potential complications are monitored. The intervention is compared to 15 regions providing usual care. The primary endpoint is the combination of recurrent stroke, myocardial infarction and death assessed 12 months after enrolment and adjudicated in a blinded manner. RESULTS: Eighteen patients were enrolled in a pilot phase that demonstrated feasibility of patient recruitment and study procedures. CONCLUSION: SANO is investigating a program to reduce outcome events after ischemic stroke by implementing a complex intervention. If successful, the program may be implemented in routine care on national level in Germany.

Discrepancy between post-treatment infarct volume and 90-day outcome in the ESCAPE randomized controlled trial.

BACKGROUND: Some patients with ischemic stroke have poor outcomes despite small infarcts after endovascular thrombectomy, while others with large infarcts sometimes fare better. AIMS: We explored factors associated with such discrepancies between post-treatment infarct volume (PIV) and functional outcome. METHODS: We identified patients with small PIV (volume ≤ 25th percentile) and large PIV (volume ≥ 75th percentile) on 24-48-h CT/MRI in the ESCAPE randomized-controlled trial. Demographics, comorbidities, baseline, and 24-48-h stroke severity (NIHSS), stroke location, treatment type, post-stroke complications, and other outcome scales like Barthel Index, and EQ-5D were compared between "discrepant cases" - those with 90-day modified Rankin Scale(mRS) ≤ 2 despite large PIV or mRS ≥ 3 despite small PIV - and "non-discrepant cases". Multi-variable logistic regression was used to identify pre-treatment and post-treatment factors associated with small-PIV/mRS ≥ 3 and large-PIV/mRS ≤ 2. Sensitivity analyses used different definitions of small/large PIV and good/poor outcome. RESULTS: Among 315 patients, median PIV was 21 mL; 27/79 (34.2%) patients with PIV ≤ 7 mL (25th percentile) had mRS ≥ 3; 12/80 (15.0%) with PIV ≥ 72 mL (75th percentile) had mRS ≤ 2. Discrepant cases did not differ by CT versus MRI-based PIV ascertainment, or right versus left-hemisphere involvement (p = 0.39, p = 0.81, respectively, for PIV ≤ 7 mL/mRS ≥ 3). Pre-treatment factors independently associated with small-PIV/mRS ≥ 3 included older age (p = 0.010), cancer, and vascular risk-factors; post-treatment factors included 48-h NIHSS (p = 0.007) and post-stroke complications (p = 0.026). Absence of vascular risk-factors (p = 0.004), CT-based lentiform nucleus sparing (p = 0.002), lower 24-hour NIHSS (p = 0.001), and absence of complications (p = 0.013) were associated with large-PIV/mRS ≤ 2. Sensitivity analyses yielded similar results. CONCLUSIONS: Discrepancies between functional ability and PIV are likely explained by differences in age, comorbidities, and post-stroke complications, emphasizing the need for high-quality post-thrombectomy stroke care. CLINICAL TRIAL REGISTRATION: https://clinicaltrials.gov/ct2/show/NCT01778335.

A Narrative Review of Persistent Post-Stroke Headache - A New Entry in the International Classification of Headache Disorders, 3rd Edition.

BACKGROUND: Persistent post-stroke headache is a clinical entity that has recently entered the International Classification of Headache Disorders, 3rd edition. In contrast to acute headache attributed to stroke, the epidemiology, clinical features, potential pathophysiology, and management of persistent post-stroke headache have not been reviewed. METHODS: We summarize the literature describing persistent headache attributed to stroke. RESULTS: Persistent headache after ischemic or hemorrhagic stroke affects up to 23% of patients. These persistent headaches tend to have tension-type features and are more frequent and severe than acute stroke-related headaches. Risk factors include younger age, female sex, pre-existing headache disorder, and comorbid post-stroke fatigue or depression. Other factors including obstructive sleep apnea or musculoskeletal imbalances may contribute to headache persistence. Although more evidence is needed, it may be reasonable to treat persistent post-stroke headache according to headache semiology. CONCLUSION: Recognition of persistent post-stroke headache as a separate clinical entity from acute stroke-attributed headache is the first step toward better defining its natural history and most effective treatment strategies.

The integrated care pathway for post stroke patients (iCaPPS): a shared care approach between stakeholders in areas with limited access to specialist stroke care services.

BACKGROUND: Lack of intersectoral collaboration within public health sectors compound efforts to promote effective multidisciplinary post stroke care after discharge following acute phase. A coordinated, primary care-led care pathway to manage post stroke patients residing at home in the community was designed by an expert panel of specialist stroke care providers to help overcome fragmented post stroke care in areas where access is limited or lacking. METHODS: Expert panel discussions comprising Family Medicine Specialists, Neurologists, Rehabilitation Physicians and Therapists, and Nurse Managers from Ministry of Health and acadaemia were conducted. In Phase One, experts chartered current care processes in public healthcare facilities, from acute stroke till discharge and also patients who presented late with stroke symptoms to public primary care health centres. In Phase Two, modified Delphi technique was employed to obtain consensus on recommendations, based on current evidence and best care practices. Care algorithms were designed around existing work schedules at public health centres. RESULTS: Indication for patients eligible for monitoring by primary care at public health centres were identified. Gaps in transfer of care occurred either at post discharge from acute care or primary care patients diagnosed at or beyond subacute phase at health centres. Essential information required during transfer of care from tertiary care to primary care providers was identified. Care algorithms including appropriate tools were summarised to guide primary care teams to identify patients requiring further multidisciplinary interventions. Shared care approaches with Specialist Stroke care team were outlined. Components of the iCaPPS were developed simultaneously: (i) iCaPPS-Rehab© for rehabilitation of stroke patients at community level (ii) iCaPPS-Swallow© guided the primary care team to screen and manage stroke related swallowing problems. CONCLUSION: Coordinated post stroke care monitoring service for patients at community level is achievable using the iCaPPS and its components as a guide. The iCaPPS may be used for post stroke care monitoring of patients in similar fragmented healthcare delivery systems or areas with limited access to specialist stroke care services. TRIAL REGISTRATION: No.: ACTRN12616001322426 (Registration Date: 21st September 2016).

The impact of intravenous thrombolysis on outcome of patients with acute ischemic stroke after 90 years old.

BACKGROUND: Age increases the risk of mortality and poor prognosis following stroke. The benefit of intravenous thrombolysis in very old patients remains uncertain. The purpose of the study was to evaluate the efficacy and safety of thrombolysis in very old patients considering their perfusion-imaging profile. METHODS: We conducted a retrospective study including patients older than 90 y.o. admitted for an acute ischemic stroke. A computed tomography perfusion-imaging (CTP) was performed in patients who received thrombolysis. Primary outcome was the functional status at 3 months, assessed by the modified Rankin scale (mRS). Secondary outcomes were the rate of hemorrhagic transformations, duration of hospitalization and the rate of death in the first 7 days. Patients receiving thrombolysis were compared with an age-matched group of non-thrombolysed patients. RESULTS: 78 patients were included (31 % male, aged 92 ± 1.7 y.o). 37 patients received thrombolysis and among them, 30 had CTP with a mismatch. The three months mRS was not significantly different in the two groups (mRS 0-2: 5 % and 7 % in the thrombolysed and non-thrombolysed group, respectively). Hemorrhagic transformations were more frequent in the thrombolysed group (54 % versus 12 %, p = 0.002) and symptomatic intracranial hemorrhage tended to be associated with mRS at three months and death in the first 7 days. Duration of hospitalization was longer in the thrombolysed group (10 days ± 12 versus 7 days ± 9, p = 0.046). CONCLUSIONS: Patients who received thrombolysis did not have a better functional prognosis than non-thrombolysed patients.

Effect of Muscle-region Alignment Electroacupuncture in Treating Post-stroke Shoulder Pain and on the Levels of Serum ;IL-6, TNF-?, and NO / 上海针灸杂志

Objective To observe the therapeutic efficacy and action mechanism of muscle-region alignment electroacupuncture in treating post-stroke shoulder pain. Method Eighty patients were randomized into a muscle-region alignment needling group and a conventional acupuncture group. The Short-form McGill Pain Questionnaire (SF-MPQ), and serum levels of IL-6, TNF-?, and NO were majorly observed before and after the treatment. Result The muscle-region alignment electroacupuncture and conventional acupuncture both obviously reduced the SF-MPQ score and down-regulated the serum levels of IL-6, TNF-?, and NO, and the decreases by the muscle-region alignment electroacupuncture were more significant than that by the conventional acupuncture. Conclusion The action of muscle-region alignment electroacupuncture in treating post-stroke shoulder pain is plausibly by down-regulating serum levels of IL-6, TNF-?, and NO, reducing or inhibiting the production of inflammatory factors and restraining inflammation.

Clinical Observation of Yang-supplementing Thread-embedding for Shoulder-hand Syndrome After Cerebral Stroke / 上海针灸杂志

Objective To observe the clinical efficacy of yang-supplementing thread-embedding (acupoint embedded with catgut soaked in Shenfu injection) in treating shoulder-hand syndrome after cerebral stroke. Method Totally 120 patients were randomized into a treatment group and a control group, 60 cases in each group. The treatment group was intervened by acupoint thread-embedding, while the control group was by conventional acupuncture. The changes of symptoms, joint range of motion (ROM), pain, and Fugl-Meyer Assessment (FMA), and general therapeutic efficacy were observed after 30 d treatment. Result The total effective rate was 95.0% in the treatment group versus 85.0% in the control group, and the difference was statistically significant (P<0.05). Conclusion Yang-supplementing thread-embedding and conventional acupuncture both can mitigate pain induced by shoulder-hand syndrome, increase the range of motion, and significantly improve the upper-limb motor function, while the effect of yang-supplementing thread-embedding is superior to that of conventional acupuncture.

Clinical Study on Acupuncture at Different Groups of Acupoints for Post-stroke Depression / 上海针灸杂志

Objective To select the optimal acupoints formula by evaluating the efficacy of different groups of acupoints in the treatment of post-stroke depression (PSD) with acupuncture. Method Totally 108 PSD patients were randomized into 3 groups, i.e. Neiguan (PC6) group, Taichong (LR3) group, and Baihui (GV20) group, 36 cases each. The acupuncture treatment was given once a day, 5 sessions a week, 3 weeks as a treatment course. The clinical efficacies were compared among the 3 groups after the intervention. The 3 groups were evaluated by the Hamilton Depression Scale (HAMD), National Institute of Health Stroke Scale (NIHSS), and Quality of Life Scale (QOL) before and after the treatment, and the results were statistically analyzed. Result The effective rates were respectively 72.2%, 75.0%, and 86.1%in Neiguan group, Taichong group, and Baihui group, and the inter-group differences were statistically significant (P0.05). Conclusion The three groups of acupoints are effective in improving the depression symptoms, neural defect and QOL, while Baihui group can produce a more significant efficacy in improving the depression symptoms compared to Neiguan and Taichong groups;the effects in improving neural defect and QOL are equivalent among the 3 groups of acupoints.

Therapeutic Observation of Electroacupuncture plus Rehabilitation for Post-stroke Shoulder-hand Syndrome / 上海针灸杂志

Objective To explore the effect of electroacupuncture plus rehabilitation on shoulder-hand syndrome (SHS). Method Eighty SHS patients were randomized into an experimental group and a control group, 40 cases in each group. The experimental group was intervened by electroacupuncture plus rehabilitation training and basic Western medicine treatment, while the control group was by rehabilitation training and Western medicine treatment, 3 sessions a week, 4 weeks in total. The pain intensity of the affected shoulder and upper-limb motor function were observed before and after the treatment. The therapeutic efficacy was also evaluated. Result The Visual Analogue Scale (VAS) score of the shoulder pain and Fugl-Meyer Assessment (FMA) score of the upper-limb motor function were significantly improved after the intervention in the two groups (P<0.01), and the improvements of VAS and FMA in the experimental group were more significant than that in the control group (P<0.01). Conclusion Based on the basic treatment of Western medicine, electroacupuncture plus rehabilitation training can markedly improve the pain intensity of the affected shoulder and upper-limb motor function in post-stroke shoulder-hand syndrome.