Effects of mechanical thrombectomy for post-stroke patients with upper limb hemiparesis: Use of Propensity Score Matching.

BACKGROUND: Mechanical Thrombectomy (MT) is a recommended approach for post-cerebral ischemia in acute settings. Although a large amount of evidence suggests the use of MT, existing evidence has primarily focused on assessing lower limb performance or gait performance as an outcome measure. METHODS: This study was to investigate whether MT would be an effective approach for improving upper limb performance in post-stroke patients.This case control was divided into two groups: 154 patients as a control group only given conventional rehabilitation; and 25 patients as an intervention group given MT and conventional rehabilitation. Outcome variables were measured by calculating the change of Fugl-Meyer Assessment score at the last intervention compared with the beginning of the intervention. RESULT: By comparing the FMA scores after, the propensity matching compared between before receiving therapy intervention and after, the intervention group showed as follows: 30.4 ± 26.4-44.3 ± 25.4, p = 0.0019, r = 0.59. The control group showed as follows: 39.9 ± 24.1-49.1 ± 21.3, p = 0.002, r = 0.69. Lastly, a comparison of the intervention group with the control group about their FMA score change indicates as follows: intervention group: 13.9 ± 19.4, control group 9.2 ± 10.0, p = 0.2967, r = 0.15. CONCLUSION: This study indicated that there was no significant difference between MT and a conventional approach for improving UE function. However, this is the first study to investigate the course of recovery of UE function in the acute phase after MT, and this finding supports the need for further research.

Possible affective cognitive cerebellar syndrome in a young patient with COVID-19 CNS vasculopathy and stroke.

Early case series suggest that about one-third of patients with COVID-19 present with neurological manifestations, including cerebrovascular disease, reported in 2%-6% of hospitalised patients. These are generally older patients with severe infection and comorbidities. Here we discuss the case of a previously fit and well 39-year-old man who presented with fever and respiratory symptoms, evolving in pneumonia with hypoxia but only requiring continuous positive airway pressure. After resolution of the respiratory disease, the patient developed focal neurology and was found to have bilateral occipital, thalamic and cerebellar infarcts. A diagnosis of COVID-19 central nervous system vasculopathy was made. He developed a florid neuropsychiatric syndrome, including paranoia, irritability, aggression and disinhibition, requiring treatment with antipsychotics and transfer to neurorehabilitation. Neuropsychometry revealed a wide range of cognitive deficits. The rapid evolution of the illness was matched by fast resolution of the neuropsychiatric picture with mild residual cognitive impairment.

Functional near-infrared-spectroscopy-based measurement of changes in cortical activity in macaques during post-infarct recovery of manual dexterity.

Because compensatory changes in brain activity underlie functional recovery after brain damage, monitoring of these changes will help to improve rehabilitation effectiveness. Functional near-infrared spectroscopy (fNIRS) has the potential to measure brain activity in freely moving subjects. We recently established a macaque model of internal capsule infarcts and an fNIRS system for use in the monkey brain. Here, we used these systems to study motor recovery in two macaques, for which focal infarcts of different sizes were induced in the posterior limb of the internal capsule. Immediately after the injection, flaccid paralysis was observed in the hand contralateral to the injected hemisphere. Thereafter, dexterous hand movements gradually recovered over months. After movement recovery, task-evoked hemodynamic responses increased in the ventral premotor cortex (PMv). The response in the PMv of the infarcted (i.e., ipsilesional) hemisphere increased in the monkey that had received less damage. In contrast, the PMv of the non-infarcted (contralesional) hemisphere was recruited in the monkey with more damage. A pharmacological inactivation experiment with muscimol suggested the involvement of these areas in dexterous hand movements during recovery. These results indicate that fNIRS can be used to evaluate brain activity changes crucial for functional recovery after brain damage.

An Animal Trial on the Optimal Time and Intensity of Exercise after Stroke.

INTRODUCTION: Although exercise is a safe, cost-effective, and therapeutic poststroke therapy, the proper time window and dosage of exercise are still unknown. We aim to determine the optimal combination of time window and intensity of exercise by assessing infarct volume, neurological recovery, and underlying mechanisms in middle cerebral artery occlusion rats. METHODS: The study contains two parts: the time-window and the dosage experiments. The time-window experiment assessed the effects of moderate-intensity exercise that was initiated at 24, 48, 72, 96 h and the control. In the dosage experiment, moderate and another two intensity exercise groups (low, high) were assessed. Forced wheel running was the exercise technique used. Infarct volume and neurological function (modified neurological severity scores [mNSS]) were measured. Inflammatory cytokines, cell death, and proliferation were further detected in the ischemic penumbra. RESULTS: The time window part revealed that neither infarct volume nor mNSS was reduced in the exercise group initiated at 24 h. The other three groups with exercise initiated after 24 h had reduced infarct volume and reduced mNSS but those outcomes do not differ from each other. In the dosage part, the low- and moderate-intensity groups with exercise initiated at 48 h were both better than the high-intensity group in terms of infarct volume and mNSS at 14 d; however, there was no statistical difference between these low and moderate groups. Exercise initiated at 24 h or high-intensity promoted proinflammatory cytokines and cell death. CONCLUSIONS: Exercise at 24 h is harmful. Low- and moderate-intensity exercise initiated at 48 h poststroke appears to be the optimal combination for maximal functional recovery.

Feasibility trial of an early therapy in perinatal stroke (eTIPS).

BACKGROUND: Perinatal stroke (PS) affects up to 1/2300 infants and frequently leads to unilateral cerebral palsy (UCP). Preterm-born infants affected by unilateral haemorrhagic parenchymal infarction (HPI) are also at risk of UCP. To date no standardised early therapy approach exists, yet early intervention could be highly effective, by positively influencing processes of activity-dependent plasticity within the developing nervous system including the corticospinal tract. Our aim was to test feasibility and acceptability of an "early Therapy In Perinatal Stroke" (eTIPS) intervention, aiming ultimately to improve motor outcome. METHODS: Design: Feasibility trial, North-East England, August 2015-September 2017. Participants were infants with PS or HPI, their carers and therapists. The intervention consisted of a parent-delivered lateralised therapy approach starting from term equivalent age and continuing until 6 months corrected age. The outcome measures were feasibility (recruitment and retention rates) and acceptability of the intervention (parental questionnaires including the Warwick-Edinburgh Mental Wellbeing Scale (WEBWMS), qualitative observations and in-depth interviews with parents and therapists). We also reviewed clinical imaging data and undertook assessments of motor function, including the Hand Assessment for Infants (HAI). Assessments were also piloted in typically developing (TD) infants, to provide further information on their ease of use and acceptability. RESULTS: Over a period of 18 months we screened 20 infants referred as PS/HPI: 14 met the inclusion criteria and 13 took part. At 6 months, 11 (85%) of those enrolled had completed the final assessment. Parents valued the intervention and found it acceptable and workable. There were no adverse events related to the intervention. We recruited 14 TD infants, one of whom died prior to undertaking any assessments and one of whom was subsequently found to have a condition affecting neurodevelopmental progress: thus, data for 12 TD infants was analysed to 6 months. The HAI was well tolerated by infants and highly valued by parents. Completion rates for the WEBWMS were high and did not suggest any adverse effect of engagement in eTIPS on parental mental wellbeing. CONCLUSION: The eTIPS intervention was feasible to deliver and acceptable to families. We plan to investigate efficacy in a multicentre randomised controlled trial. TRIAL REGISTRATION: ISRCTN12547427 (registration request submitted 28/05/2015; retrospectively registered, 30/09/2015).

Comparative study of ipsilesional and contralesional repetitive transcranial magnetic stimulations for acute infarction.

BACKGROUND AND PURPOSE: Repetitive transcranial magnetic stimulation (rTMS) is reported to improve chronic post-stoke hemiparesis. However, application of rTMS during the acute phase of post-stroke has not fully been investigated. We investigated the safety and the efficacy of intermittent theta-burst stimulation (iTBS) of the affected motor cortex and 1-Hz stimulation of the unaffected hemisphere during the acute phase in patients with hemiparesis due to capsular infarction. METHODS: Twenty one patients who met the study criteria were randomly assigned to receive, starting within 7days after stroke onset and for a period of 10days, iTBS of the affected motor cortex hand area (n=8), 1-Hz stimulation of the unaffected motor cortex hand area (n=7), or sham stimulation (n=6). Upper limb motor function was evaluated before rTMS and 12weeks after onset of the stroke. Evaluation was based on the Fugl-Meyer Assessment (FMA), Stroke Impairment Assessment Set (SIAS), Modified Ashworth Scale (MAS), grip strength, and motor evoked potential (MEP) amplitude in the first dorsal interosseous (FDI) muscle. RESULTS: Both iTBS applied to the affected motor cortex hand area and 1-Hz stimulation applied to the unaffected motor cortex hand area enhanced motor recovery. In comparison to sham stimulation, iTBS increased the SIAS finger-function test score, and 1-Hz stimulation decreased the MAS wrist and finger score. CONCLUSIONS: Ipsilesional iTBS and contralesional 1-Hz stimulation applied during the acute phase of stroke have different effects: ipsilesional iTBS improves movement of the affected limb, whereas contralesional 1-Hz stimulation reduces spasticity of the affected limb.

Delayed recovery of the affected finger extensors at chronic stage in a stroke patient: A case report.

RATIONALE: A 33-year-old male presented with complete weakness of the right extremities due to corona radiata infarct. PATIENT CONCERNS: The main concerns of the patient is recovery of hand function especially related to finger extension. DIAGNOSES: Right corona radiata infarct. INTERVENTIONS: He underwent physical therapy and occupational therapy at the outpatient clinic of the rehabilitation department of the same university hospital until 2 years after onset. In addition, he underwent neuromuscular electrical stimulation for the right finger extensors continuously until 4 years after onset. OUTCOMES: At 6 months after onset, the weakness of his right side recovered to subnormal state except for the right finger extensors which were completely weak. At 1.5 years after onset, the right finger extensors began to show slow and continuous recovery. At 4 years after onset, the patient showed motor recovery in the right finger extensors to the extent that he was able to move against gravity. Discontinuation of the left corticospinal tract was observed on 2-month diffusion tensor tractography (DTT); however, the integrity of this discontinuation had recovered to the primary motor cortex on 4-year DTT. On 2-month transcranial magnetic stimulation (TMS), no motor-evoked potential was evoked; in contrast, motor-evoked potentials were obtained at the right-hand muscle on 4-year TMS study. LESSONS: We demonstrated unusual delayed and long-term recovery of the affected finger extensors in a patient with corona radiata infarct using DTT and TMS.

Association of high waist-to-height ratio with functional outcomes in patients with acute ischemic stroke: A report from the ACROSS-China study.

The aim of our study was to investigate the relationship between the waist-to-height ratio (WHR) and all-cause mortality and functional outcomes after acute ischemic stroke in a prospective cohort study.A total of 2076 patients (36.66% females) with ischemic stroke were analyzed from ACROSS-China, which is a nationwide, prospective, hospital-based stroke registry aimed to detect the glucose abnormality in China. One-year follow-up evaluation was done by telephone interview. Outcome measures were all-cause mortality and functional outcome defined as modified Rankin score being 6 and from 0 to 6, respectively. We identified predictors for functional outcomes using logistic regression analysis, and mortality outcome using Cox proportional hazards model which incorporated covariates with P value of < 0.2 in the univariate analysis and those of clinical importance.The higher WHR was associated with worse functional outcome, but not predictive of the patients' mortality outcomes. Compared with the first quartile (≤0.48), the fourth quartile of the WHR was more likely to be associated with poor functional recovery (fourth quartile (≥0.56), OR = 1.38, CI: 1.08-1.77, P = 0.01; third quartile OR = 1.10, CI: 0.86-1.40, P = 0.45; second quartile OR = 1.05, CI: 0.83-1.33, P = 0.71).Our findings suggest that abdominal fat accumulation may be associated with functional recovery after stroke, and is not associated with mortality after stroke. Compared with the lowest quartile, the highest quartile of WHR at admission was possibly associated with worse postacute ischemic stroke functional recovery.

High-Frequency Repetitive Transcranial Magnetic Stimulation (rTMS) Improves Functional Recovery by Enhancing Neurogenesis and Activating BDNF/TrkB Signaling in Ischemic Rats.

Repetitive transcranial magnetic stimulation (rTMS) has rapidly become an attractive therapeutic approach for stroke. However, the mechanisms underlying this remain elusive. This study aimed to investigate whether high-frequency rTMS improves functional recovery mediated by enhanced neurogenesis and activation of brain-derived neurotrophic factor (BDNF)/tropomyosin-related kinase B (TrkB) pathway and to compare the effect of conventional 20 Hz rTMS and intermittent theta burst stimulation (iTBS) on ischemic rats. Rats after rTMS were sacrificed seven and 14 days after middle cerebral artery occlusion (MCAO), following evaluation of neurological function. Neurogenesis was measured using specific markers: Ki67, Nestin, doublecortin (DCX), NeuN and glial fibrillary acidic protein (GFAP), and the expression levels of BDNF were visualized by Western blotting and RT-PCR analysis. Both high-frequency rTMS methods significantly improved neurological function and reduced infarct volume. Moreover, 20 Hz rTMS and iTBS significantly promoted neurogenesis, shown by an increase of Ki67/DCX, Ki67/Nestin, and Ki67/NeuN-positive cells in the peri-infarct striatum. These beneficial effects were accompanied by elevated protein levels of BDNF and phosphorylated-TrkB. In conclusion, high-frequency rTMS improves functional recovery possibly by enhancing neurogenesis and activating BDNF/TrkB signaling pathway and conventional 20 Hz rTMS is better than iTBS at enhancing neurogenesis in ischemic rats.

Enriched rehabilitation promotes motor recovery in rats exposed to neonatal hypoxia-ischemia.

Despite continuous improvement in neonatology there is no clinically effective treatment for perinatal hypoxia ischemia (HI). Therefore, development of a new therapeutic intervention to minimize the resulting neurological consequences is urgently needed. The immature brain is highly responsive to environmental stimuli, such as environmental enrichment but a more effective paradigm is enriched rehabilitation (ER), which combines environmental enrichment with daily reach training. Another neurorestorative strategy to promote tissue repair and functional recovery is cyclosporine A (CsA). However, potential benefits of CsA after neonatal HI have yet to be investigated. The aim of this study was to investigate the effects of a combinational therapy of CsA and ER in attempts to promote cognitive and motor recovery in a rat model of perinatal hypoxic-ischemic injury. Seven-day old rats were submitted to the HI procedure and divided into 4 groups: CsA+Rehabilitation; CsA+NoRehabilitation; Vehicle+Rehabilitation; Vehicle+NoRehabilitation. Behavioural parameters were evaluated pre (experiment 1) and post 4 weeks of combinational therapy (experiment 2). Results of experiment 1 demonstrated reduced open field activity of HI animals and increased foot faults relative to shams in the ladder rung walking test. In experiment 2, we showed that ER facilitated acquisition of a staircase skilled-reaching task, increased number of zone crosses in open-field exploration and enhanced coordinated limb use during locomotion on the ladder rung task. There were no evident deficits in novel object recognition testing. Delayed administration of CsA, had no effect on functional recovery after neonatal HI. There was a significant reduction of cortical and hemispherical volume and hippocampal area, ipsilateral to arterial occlusion in HI animals; combinational therapy had no effect on these morphological measurements. In conclusion, the present study demonstrated that ER, but not CsA was the main contributor to enhanced recovery of motor ability after neonatal HI.

Improvements in bimanual hand function after baby-CIMT in two-year old children with unilateral cerebral palsy: A retrospective study.

The common assumption that early-onset intensive intervention positively affects motor development has rarely been investigated for hand function in children with unilateral cerebral palsy (CP). This retrospective study explored the possible impact of baby constraint-induced movement therapy (baby-CIMT) on hand function at two years of age. We hypothesized that baby-CIMT in the first year of life would lead to better bimanual hand use at two years of age than would not receiving baby-CIMT. The Assisting Hand Assessment (AHA) was administered at age 21 months (SD 2.4 months) in 72 children with unilateral CP, 31 of who received baby-CIMT. When dividing the children into four functional levels based on AHA, the proportional distribution differed between the groups in favour of baby-CIMT. Logistic regression analysis indicated that children in the baby-CIMT group were more likely than were children in the no baby-CIMT group to have a high functional level, even when controlling for the effect of brain lesion type (OR 5.83, 95% CI 1.44-23.56, p = 0.001). However, no difference was found between groups in the odds of having a very low functional level (OR 0.31, 95% CI 0.08-1.17, p = 0.084). The result shows that baby-CIMT at early age can have a positive effect. Children who received baby-CIMT were six times more likely to have a high functional level at two years of age than were children in the no baby-CIMT group.

Home-based tele-supervising rehabilitation for brain infarction patients (HTRBIP): study protocol for a randomized controlled trial.

BACKGROUND: With high morbidity, mortality and disability rate, brain infarction brings a huge economic and health burden to the whole society in China. Although some previous studies suggested that telerehabilitation may facilitate rehabilitation for stroke survivors at home, the evidence is insufficient for clinical application; additionally, as yet no trial evaluates efficacy of telerehabilitation for brain infarction patients. Therefore, more high quality trials are needed to provide practice evidence for this novel rehabilitation strategy. METHODS/DESIGN: Based on recruitment criteria, this assessor blinded, paralleled randomized controlled trial will recruit 210 brain infarction patients. After being randomly allocated into two groups, participants will receive home-based tele-supervising rehabilitation or conventional rehabilitation. Outcome measurement will be conducted at the end of intervention and 90-day follow-up. Among which, Barthel index assessment will be considered as primary outcome measurement, secondary outcome measurements include NIHSS score, mRS score, 3-oz water swallow test and surface electromyography. Adverse events will also be recorded during the whole process of the trial for safety assessment. DISCUSSION: The HTRBIP trial will evaluate efficacy and safety of home-based tele-supervising rehabilitation for brain infarction patients. It is expected to provide new evidence for telerehabilitation application. TRIAL REGISTRATION: Registration date: 17 September 2014; REGISTRATION NUMBER: ChiCTR-TRC-14005233.

The role of the speech-language pathologist in home care.

Speech language pathologists play an important role in the care of patients with speech, language, or swallowing difficulties that can result from a variety of medical conditions. This article describes how speech language pathologists assess and treat these conditions and the red flags that suggest a referral to a speech language pathologist is indicated.

Changes in serum growth factors in stroke rehabilitation patients and their relation to hemiparesis improvement.

Predicting recovery from hemiparesis after stroke is important for rehabilitation. A few recent studies reported that the levels of some growth factors shortly after stroke were positively correlated with the clinical outcomes during the chronic phase. The aim of this study was to examine the relationships between the serum levels of growth factors (vascular endothelial growth factor [VEGF], insulin-like growth factor-I [IGF-I], and hepatocyte growth factor [HGF]) and improvement in hemiparesis in stroke patients who received rehabilitation in a postacute rehabilitation hospital. Subjects were 32 stroke patients (cerebral infarction: 21 and intracerebral hemorrhage [ICH]: 11). We measured serum levels of VEGF, IGF-I, and HGF and 5 items of the Stroke Impairment Assessment Set (SIAS) for hemiparesis on admission and at discharge. Age-matched healthy subjects (n=15) served as controls. Serum levels of VEGF and HGF in cerebral infarct patients on admission were higher than those in control subjects, and the serum levels of IGF-I in stroke patients were lower than those in controls. The level of HGF in ICH patients on admission was negatively correlated with gains in SIAS, and higher outliers in HGF concentration were correlated with lower gains in SIAS. Focusing on the extremely high levels of these factors may be a predictor of the low recovery from hemiparesis after stroke.

Diffusion tensor imaging predicts the outcome of constraint-induced movement therapy in chronic infarction patients with hemiplegia: A pilot study.

PURPOSE: To test whether diffusion tensor imaging could evaluate potential motor capability of patients with chronic cerebral infarction. METHODS: We used constraint-induced movement therapy (CIMT) as a rehabilitation, which reveals potential motor capability. We also investigated the relationship between the outcome of CIMT and the ratio between fractional anisotropy values (rFA) in affected and unaffected sites of the corticospinal tract before CIMT. Imaging was performed in cerebral infarction patients (n = 14) and the rFA of the posterior limb of internal capsule (PLIC) was measured before CIMT. Patients were evaluated before and after CIMT using the Fugl-Meyer (F-M) assessment, Wolf Motor Function Test, Action Research Arm Test, and Motor Activity Log and association between PLIC- rFA and these scores was determined. RESULTS: All patients showed an improvement in mobility following the 10-day CIMT session. Strong positive correlation was found only between F-M after CIMT and PLIC-rFA (r = 0.8098, p = 0.0004). A strong linear relationship was observed after CIMT. CONCLUSION: These data support PLIC-rFA as a new marker of the CIMT-induced improvement in motor function (F-M).

Combination treatment with progesterone and rehabilitation training further promotes behavioral recovery after acute ischemic stroke in mice.

PURPOSE: The present study was aimed to investigate whether combination treatment with progesterone and rehabilitation training would be more effective than monotherapy after cerebral ischemia. METHODS: C57BL/6 mice were subjected to focal ischemia by photothrombosis and were treated with progesterone (2 mg/kg), rehabilitation training or their combination. 2,3,5-triphenyltetrazolium chloride (TTC) staining and Nissl staining were used to measure infarct size at day 3 and day 7 after surgery, and rotarod test and grip strength test were conducted to evaluate behavioral outcomes. RESULTS: TTC staining indicated that progesterone, rehabilitation training and their combination produced a different degree of reduction in infarct volume compared with vehicle control at day 3 after ischemia (progesterone: 16.70 ± 0.93 mm³, p < 0.01, rehabilitation training: 22.19 ± 0.93 mm³, p < 0.05, progesterone + rehabilitation training: 14.76 ± 0.92 mm³, p < 0.01, vehicle control: 28.73 ± 1.05 mm³). Nissl staining revealed that prolonged treatment of progesterone, rehabilitation training and their combination led to a significant decrease in infarct volume at day 7 after ischemia (progesterone: 18.64 ± 1.83 mm³, p < 0.01, rehabilitation training: 25.07 ± 1.70 mm³, p < 0.05, progesterone + rehabilitation training: 17.09 ± 0.92 mm3, p < 0.01, vehicle control: 30.31 ± 1.36 mm³). No accumulative effect in the reduction of infarct volume was observed in combination therapy at both day 3 and day 7 after ischemia. However, combination therapy significantly improved behavioral performances in the first week after photothrombosis. Combination treatment significantly enhanced rotarod performance and forelimb grip strength at all time points within 7 days after ischemia compared with rehabilitation alone, and significantly improved rotarod performance and forelimb grip strength from day 2 after ischemia compared with progesterone alone. CONCLUSION: Our results suggested that combination treatment with progesterone and rehabilitation training had no additive effect in reducing infarct volume, but combination therapy exhibited enhanced efficacy in promoting functional recovery after ischemic stroke, suggesting progesterone and rehabilitation training may exert their effects via different mechanisms.

Combined statistical analysis method assessing fast versus slow movement training in a patient with cerebellar stroke: a single-case study.

BACKGROUND: Gold standards of data analysis for single-case research do not currently exist. OBJECTIVE: The purpose of this study was to determine whether a combined statistical analysis method is more effective in assessing movement training effects in a patient with cerebellar stroke. DESIGN: A crossover single-case research design was conducted. METHODS: The patient was a 69-year-old man with a chronic cerebellar infarct who received two 5-week phases of finger tracking training at different movement rates. Changes were measured with the Box and Block Test, the Jebsen-Taylor test, the finger extension force test, and the corticospinal excitability test. Both visual analysis and statistical tests (including split-middle line method, t test, confidence interval, and effect size) were used to assess potential intervention effects. RESULTS: The results of the t tests were highly consistent with the confidence interval tests, but less consistent with the split-middle line method. Most results produced medium to large effect sizes. LIMITATIONS: The possibility of an incomplete washout effect was a confounding factor in the current analyses. CONCLUSIONS: The combined statistical analysis method may assist researchers in assessing intervention effects in single-case stroke rehabilitation studies.