Intensified post-stroke care improves long-term dysphagia recovery after acute ischemic stroke: Results from the STROKE CARD trial.

INTRODUCTION: Dysphagia is common after acute ischemic stroke and entails considerable morbidity and mortality. Here, we investigated the impact of intensified care on swallowing recovery after stroke. PATIENTS AND METHODS: In this secondary analysis of STROKE-CARD, a randomized intervention trial of intensified post-stroke care, dysphagia was assessed by speech therapists at admission for acute ischemic stroke, at hospital discharge, and after 12-months. Patients randomized to STROKE-CARD care additionally received a detailed dysphagia follow-up at 3-months, including a standardized dysphagia examination, instructions on further exercises and compensation mechanisms and, if necessary, referral for further speech therapy. RESULTS: Dysphagia was present initially after stroke in 236 (16.6%; median age 82 (73-88), 44.1% female) of 1419 patients, with similar prevalence in both study groups at hospital admission (p = 0.239) and discharge (p = 0.870). At follow up, 14 (9.5%) of 147 in the intervention group and 18 (20.2%) of 89 in the control group suffered from persistent dysphagia (p = 0.020). There was better dysphagia recovery in the intervention group also under multivariable adjustment for age, sex, functional disability at 12-months, severe dysphagia at hospitalization, mode of feeding, cognitive impairment, thrombolysis, and stroke localization (odds ratio, 0.41, 95% confidence interval: 0.17 to 0.96). DISCUSSION AND CONCLUSION: Intensified post-stroke care improved dysphagia recovery within 1 year after acute ischemic stroke, highlighting the potential of targeted interventions for enhancing stroke outcomes.

Comorbidities associated with dysphagia after acute ischemic stroke.

BACKGROUND: Pre-existing comorbidities increase the likelihood of post-stroke dysphagia. This study investigates comorbidity prevalence in patients with dysphagia after ischemic stroke. METHODS: The data of patients with acute ischemic stroke from two large representative cohorts (STROKE-CARD trial 2014-2019 and STROKE-CARD registry 2020-2022 - both study center Innsbruck, Austria) were analyzed for the presence of dysphagia at hospital admission (clinical swallowing examination). Comorbidities were assessed using the Charlson Comorbidity Index (CCI). RESULTS: Of 2054 patients with ischemic stroke, 17.2% showed dysphagia at hospital admission. Patients with dysphagia were older (77.8 ± 11.9 vs. 73.6 ± 14.3 years, p < 0.001), had more severe strokes (NIHSS 7(4-12) vs. 2(1-4), p < 0.001) and had higher CCI scores (4.7 ± 2.1 vs. 3.8 ± 2.0, p < 0.001) than those without swallowing impairment. Dysphagia correlated with hypertension (p = 0.034), atrial fibrillation (p < 0.001), diabetes (p = 0.002), non-smoking status (p = 0.014), myocardial infarction (p = 0.002), heart failure (p = 0.002), peripheral arterial disease (p < 0.001), severe chronic liver disease (p = 0.002) and kidney disease (p = 0.010). After adjusting for relevant factors, the associations with dysphagia remained significant for diabetes (p = 0.005), peripheral arterial disease (p = 0.007), kidney disease (p = 0.014), liver disease (p = 0.003) and overall CCI (p < 0.001). CONCLUSIONS: Patients with multiple comorbidities have a higher risk of developing post-stroke dysphagia. Therefore, early and thorough screening for swallowing impairment after acute ischemic stroke is crucial especially in those with multiple concomitant diseases. TRIAL REGISTRATION: Stroke Card Registry (NCT04582825), Stroke Card Trial (NCT02156778).

A narrative review on cervical artery dissection-related cranial nerve palsies.

Introduction: This study aimed to emphasize the importance of cranial nerve (CN) palsies in spontaneous cervical artery dissection (sCeAD). Methods: A search term-based literature review was conducted on "cervical artery dissection" and "cranial nerve palsy." English and German articles published until October 2023 were considered. Results: Cranial nerve (CN) palsy in sCeAD is evident in approximately 10% of cases. In the literature, isolated palsies of CN II, III, VII, IX, X, and XII have been reported, while CN XI palsy only occurs in combination with other lower cranial nerve palsies. Dissection type and mural hematoma localization are specific to affected CN as CN palsies of II or III are solely evident in those with steno-occlusive vessel pathologies located at more proximal segments of ICA, while those with CN palsies of IX, X, XI, and XII occur in expansive sCeAD at more distal segments. This dichotomization emphasizes the hypothesis of a different pathomechanism in CN palsy associated with sCeAD, one being hypoperfusion or microembolism (CN II, III, and VII) and the other being a local mass effect on surrounding tissue (CN IX, X, XI, and XII). Clinically, the distinction between peripheral palsies and those caused by brainstem infarction is difficult. This differentiation is key, as, according to the reviewed cases, peripheral cranial nerve palsies in sCeAD patients mostly resolve completely over time, while those due to brainstem stroke do not, making cerebrovascular imaging appraisal essential. Discussion: It is important to consider dissections as a potential cause of peripheral CN palsies and to be aware of the appropriate diagnostic pathways. This awareness can help clinicians make an early diagnosis, offering the opportunity for primary stroke prevention.

Association between dysphagia and symptoms of depression and anxiety after ischemic stroke.

BACKGROUND AND PURPOSE: Dysphagia is associated with poor outcome, higher mortality, reduced quality of life, and social isolation. We investigate the relationship between swallowing impairment and symptoms of anxiety and depression after ischemic stroke. METHODS: Consecutive patients with ischemic stroke participating in the prospective STROKE-CARD Registry study from 2020 to 2022 were assessed for dysphagia on hospital admission (clinical swallowing assessment) and for persistence until discharge and 3-month follow-up (SINGER Independency Index). Anxiety and depression symptoms were recorded using Beck Depression Inventory (BDI) and Hospital Anxiety and Depression Scale (HADS) at 3-month follow-up. RESULTS: Of 648 patients, 19.3% had dysphagia on admission, persisting in 14.8% at discharge and 6.8% at 3-month follow-up. With the presence or duration of dysphagia (no dysphagia, dysphagia at baseline, at discharge, at 3 months), score (mean ± SD) increased on the BDI (7.9 ± 6.7, 12.5 ± 8.7, 13.5 ± 9.0, 16.5 ± 10.2), HADS-D (4.4 ± 3.7, 7.1 ± 4.2, 7.7 ± 4.4, 9.8 ± 4.3), and HADS-A (4.4 ± 3.5, 5.4 ± 3.6, 6.0 ± 3.6, 7.0 ± 3.6). In linear regression analysis adjusting for age, sex, diabetes, dementia, and either functional disability or stroke severity, BDI and HADS-D scores were significantly higher in patients with dysphagia across all points in time (admission, discharge, 3-month follow-up). An independent association with HADS-A scores was only evident in patients with persisting dysphagia after 3 months. Patients with dysphagia were more likely to receive antidepressants, antipsychotics, or benzodiazepines at discharge and 3-month follow-up. CONCLUSIONS: Dysphagia after stroke is common and severely affects psychosocial functioning of individuals. Our results highlight swallowing impairment as an independent predictor for poststroke depressive and, to a lesser extent, anxiety symptoms.

No association between SARS-CoV-2 vaccination and ischaemic stroke or high-risk transient ischaemic attack.

BACKGROUND: Initiation of SARS-CoV-2 (Severe acute respiratory syndrome coronavirus type 2) vaccinations aroused scepticism within the general-public about risks including stroke. Our aim was to explore temporal associations between vaccination and cerebrovascular events through an analysis of a prospective large-scale cohort of consecutive stroke and high-risk TIA (transitory ischaemic attack) patients. METHODS: We prospectively recruited a cohort of consecutive ischaemic stroke and high-risk TIA (ABCD2-Score ≥ 4) patients treated at the Innsbruck University Hospital (STROKE-CARD Registry Study, NCT04582825) from December 2020 until February 2022. SARS-CoV-2 vaccination status and the time of administration was ascertained by electronic health-data. A Cox model with vaccination status as time-dependent co-variable was employed to examine its association with ischaemic events. RESULTS: Data on 572 participants were available with 355 (62.1%) vaccinated against SARS-CoV-2 before suffering cerebral ischaemia. In our cohort, no temporal association between vaccination and cerebrovascular event was detected (HR 1.06 [0.85-1.34; p = 0.60]) and this also applies to TIA (HR [0.82 0.37-1.85; p = 0.64]) or minor stroke (HR 1.18 [0.89-1.56; p = 0.26]) and subgroups defined by sex and age. Neither vector-based (HR 1.11 [0.79-1.56; p = 0.55]) nor mRNA-based (HR 1.06 [0.84-1.34; p = 0.61]) vaccinations were associated with the occurrence of cerebral ischaemia. CONCLUSION: Among patients with stroke or high-risk TIA, SARS-CoV-2 vaccination was not associated with cerebral ischaemia.

Clinical characteristics and outcome in expansive compared with steno-occlusive mural hematoma in spontaneous cervical artery dissection.

BACKGROUND: Spontaneous cervical artery dissection (sCeAD) is one of the prime causes of ischemic stroke in young adults. Based on vessel wall imaging, steno-occlusive or expansive wall hematomas can be distinguished. It is unclear whether these two distinct morphological phenotypes reflect different pathophysiological processes. AIM: We aim to evaluate differences in clinical characteristics and long-term recurrence between patients with expansive and steno-occlusive mural wall hematoma in the acute phase. METHODS: Participants of the ReSect-study, one of the largest single-center cohort studies with long-term follow-up of sCeAD patients, with sufficient magnetic resonance imaging (MRI) were included. All available MRI scans were retrospectively evaluated for patients dichotomized to two groups: (1) mural hematoma causing steno-occlusive pathologies without expansion of total vessel diameter (steno-occlusive hematoma), and (2) mural hematoma causing vessel diameter expansion without lumen stenosis (expansive hematoma). Patients with mixed steno-occlusive and expansive vessel pathologies were excluded from the analysis. RESULTS: In total, 221 individuals were available for analysis. The pathognomonic vessel wall hematoma was steno-occlusive in 187 (84.6%) and expansive in 34 (15.4%). No difference was seen in patient demographics, clinical status at admission, laboratory parameters, family history, or the frequency of clinical stigmata for connective tissue disorders. Both patients with expansive and steno-occlusive mural hematoma had a high likelihood of suffering cerebral ischemia (64.7 vs 79.7). Still, time from symptom onset to diagnosis was significantly longer in those with expansive dissection (17.8 vs 7.8 days, p = 0.02). Those with expansive dissections were more likely to have upper respiratory infection within 4 weeks prior to dissection (26.5% vs 12.3%, p = 0.03). Upon follow-up, functional outcome was identical and groups did not differ in rate of sCeAD recurrence, but those with expansive mural hematoma at baseline more frequently had residual aneurysmal formation (41.2% vs 11.5%, p < 0.01). CONCLUSIONS: As cerebral ischemia was frequent in both, our clinical results do not advise for differential treatment or follow-up based on the acute morphological phenotype. There was no clear evidence of a different aetiopathogenesis between patients with steno-occlusive or expansive mural hematoma in the acute phase. More mechanistic approaches are needed to elucidate potential differences in pathomechanism between both entities. DATA ACCESS: Anonymized data not published within this article will be made available by request from any qualified investigator.

Smartwatch-derived heart rate variability: a head-to-head comparison with the gold standard in cardiovascular disease.

Aims: We aimed to investigate the concordance between heart rate variability (HRV) derived from the photoplethysmographic (PPG) signal of a commercially available smartwatch compared with the gold-standard high-resolution electrocardiogram (ECG)-derived HRV in patients with cardiovascular disease. Methods and results: We prospectively enrolled 104 survivors of acute ST-elevation myocardial infarction, 129 patients after an ischaemic stroke, and 30 controls. All subjects underwent simultaneous recording of a smartwatch (Garmin vivoactive 4; Garmin Ltd, Olathe, KS, USA)-derived PPG signal and a high-resolution (1000 Hz) ECG for 30 min under standardized conditions. HRV measures in time and frequency domain, non-linear measures, as well as deceleration capacity (DC) were calculated according to previously published technologies from both signals. Lin's concordance correlation coefficient (ρc) between smartwatch-derived and ECG-based HRV markers was used as a measure of diagnostic accuracy. A very high concordance within the whole study cohort was observed for the mean heart rate (ρc = 0.9998), standard deviation of the averages of normal-to-normal (NN) intervals in all 5min segments (SDANN; ρc = 0.9617), and very low frequency power (VLF power; ρc = 0.9613). In contrast, detrended fluctuation analysis (DF-α1; ρc = 0.5919) and the square mean root of the sum of squares of adjacent NN-interval differences (rMSSD; ρc = 0.6617) showed only moderate concordance. Conclusion: Smartwatch-derived HRV provides a practical alternative with excellent accuracy compared with ECG-based HRV for global markers and those characterizing lower frequency components. However, caution is warranted with HRV markers that predominantly assess short-term variability.

Long-term outcome of a pragmatic trial of multifaceted intervention (STROKE-CARD care) to reduce cardiovascular risk and improve quality-of-life after ischaemic stroke and transient ischaemic attack: study protocol.

BACKGROUND: Patients with ischaemic stroke or transient ischaemic attack (TIA) are at high risk of incident cardiovascular events and recurrent stroke. Despite compelling evidence about the efficacy of secondary prevention, a substantial gap exists between risk factor management in real life and that recommended by international guidelines. We conducted the STROKE-CARD trial (NCT02156778), a multifaceted pragmatic disease management program between 2014 and 2018 with follow-up until 2019. This program successfully reduced cardiovascular risk and improved health-related quality of life and functional outcome in patients with acute ischaemic stroke or TIA within 12 months after the index event. To investigate potential long-term effects of STROKE-CARD care compared to standard care, an extension of follow-up is warranted. METHODS: We aim to include all patients from the STROKE-CARD trial (n = 2149) for long-term follow-up between 2019 and 2021 with the study visit scheduled 3-6 years after the stroke/TIA event. The co-primary endpoint is the composite of major recurrent cardiovascular events (nonfatal stroke, nonfatal myocardial infarction, and vascular death) from hospital discharge until the long-term follow-up visit and health-related quality of life measured with the European Quality of Life-5 Dimensions (EQ-5D-3L) at the final visit. Secondary endpoints include overall mortality, long-term functional outcome, and target-level achievement in risk factor management. DISCUSSION: This long-term follow-up will provide evidence on whether the pragmatic post-stroke/TIA intervention program STROKE-CARD is capable of preventing recurrent cardiovascular events and improving quality-of-life in the long run. Trial registration clinicaltrials.gov: NCT04205006 on 19 December 2019.

Disparities between guideline statements on acute and post-acute management of cervical artery dissection.

Even though cervical artery dissection is one of the main reasons for ischemic stroke in young patients, acute management and post-acute primary or secondary prevention of cerebral ischemia differ significantly in different centers and countries. These discrepancies are reflected by the differences in guideline recommendations of major stroke societies. Our narrative review aims to shed light on the different recommendations in guideline-statements of stroke societies and to give an overview of the current literature concerning acute management and post-acute treatment of cervical artery dissection patients. In general, intravenous thrombolysis and mechanical thrombectomy are recommended, irrespective of stroke etiology, if administered within the label. Secondary prevention of cerebral ischemia can be achieved by antiplatelet intake or anticoagulation, with, to date, neither treatment establishing superiority over the other. Duration of antithrombotic treatment, statin use as well as optimal endovascular approach are still up for debate and need further evaluation. Additionally, it is still unknown, whether the recommendations given in any of the guideline statements are similarly relevant in spontaneous and traumatic cervical artery dissection, as none of the stroke societies differentiates between the two.

Sex-differences in psychosocial sequelae after spontaneous cervical artery dissection.

Short- to mid-term functional outcome in spontaneous cervical artery dissection is favorable, but the concomitant psychosocial impact is underreported. We aimed to determine these possible sequelae, with a special focus on sex differences, in our cohort of spontaneous cervical artery dissection subjects. During a standardized prospective in-house follow-up visit we, among other values, evaluated functional outcome (modified Rankin Scale [mRS]), psychosocial measures (return to work-, divorce rate) and health-related quality of life (WHO-QoL-BREF and SF-36-questionnaires). 145 patients participated in the long-term prospective follow-up. Median follow-up time was 6.5 years and excellent functional outcome (mRS ≤ 1) was achieved in 89.0% subjects. 87.6% returned to work and 17.6% married patients had a divorce during follow-up. Even though relevant baseline-/discharge characteristics and functional outcome did not differ between the sexes, women were less likely to return to work compared to men (79.7% vs. 93.8%; P = 0.010) and divorce rate was considerably higher in women (30.2% vs. 9.2%; P = 0.022). Health related quality of life did not differ significantly between the sexes, but women consistently reported lower values. Even though functional outcome is beneficial in most patients, measures to prevent poor psychosocial outcome should be considered in the long-term care of patients with spontaneous cervical artery dissection, especially women.