Predictors of post stroke cognitive impairment: VITATOPS cognition substudy.

INTRODUCTION: Post stroke cognitive impairment (PSCI) is a common complication of ischemic stroke. PSCI can involve different depending on clinical and stroke related characteristics. The aim of this study is to determine the factors associated with impairments in specific cognitive domains. METHODS: The Vitamins to Prevent Stroke (VITATOPS) trial is a large, multinational randomised controlled trial. In this substudy, consecutive patients admitted for ischaemic stroke or transient ischaemic attack (TIA) at a tertiary hospital in Singapore were included. PSCI was defined as impairment of any of the six cognitive subgroups - visuoconstruction, attention, verbal memory, language, visual memory and visuomotor function - that were assessed annually for up to five years. Univariate and multivariate Cox proportional hazard models were used to determine factors associated with impairments in each of these cognitive domains. RESULTS: A total of 736 patients were included in this study, of which 173 (23.5 %) developed cognitive impairment. Out of the six cognitive domains, the greatest proportion of patients had an impairment in visuoconstruction (26.4 %) followed by attention (19.8 %), verbal memory (18.3 %), language (17.5 %), visual memory (17.3 %) and visuomotor function (14.8 %). Patients with posterior circulation cerebral infarction (POCI) as the index stroke subtype had higher rates of cognitive impairment. Further subgroup analyses show that Indian race and advanced age were predictive of language impairment, whilst fewer years of education and POCI were predictive of verbal memory impairment. POCI was predictive of visual memory impairment, and advanced age and POCI were predictive of visuomotor function impairment. CONCLUSION: We identified visuoconstruction and attention domains to be the most affected in our Asian cohort of PSCI. Advanced age, lower levels of education, posterior circulation strokes and concomitant comorbidities such as peripheral artery disease are independent predictors of PSCI.

Protocol of the development of a core outcome set for stroke in multidimensional value assessment of traditional Chinese medicine.

INTRODUCTION: Stroke is the most common cause of death in China. In Chinese clinical practise, traditional Chinese medicine (TCM) and integrative medicine have been widely used as adjuvant therapies for the treatment of stroke. However, their clinical effectiveness, particularly their clinical value, has been inconsistent in the literature mainly because various outcome measures have been used and reported in clinical research. Hence, obtaining a comprehensive list of outcomes for TCM value assessment is crucial for a multidimensional value assessment. Therefore, the main objective of this protocol was to develop an outcome set used in health technology assessment (HTA) decision-making for TCM treatment of stroke. METHODS AND ANALYSIS: The outcome set will be developed in four phases: (1) we will perform a systematic literature review to identify candidate outcomes that have been previously measured in published studies; (2) we will develop a comprehensive list of outcome measures by conducting a multistakeholder semistructured interview; (3) we will conduct two-round Delphi surveys to prioritise outcomes for each HTA domain; and (4) we will finalise the outcome sets by holding a ratification meeting with multiple stakeholder groups. The developed outcome set should be measured and reported as the minimum set of outcomes for HTA assessment for the TCM treatment of acute ischaemic stroke (AIS). ETHICS AND DISSEMINATION: This protocol was reviewed and approved by the Institutional Review Board of the Minhang Hospital of Fudan University. Our findings will be shared at academic conferences and in peer-reviewed publications.

Transferring a deep learning model from healthy subjects to stroke patients in a motor imagery brain-computer interface.

Objective.Motor imagery (MI) brain-computer interfaces (BCIs) based on electroencephalogram (EEG) have been developed primarily for stroke rehabilitation, however, due to limited stroke data, current deep learning methods for cross-subject classification rely on healthy data. This study aims to assess the feasibility of applying MI-BCI models pre-trained using data from healthy individuals to detect MI in stroke patients.Approach.We introduce a new transfer learning approach where features from two-class MI data of healthy individuals are used to detect MI in stroke patients. We compare the results of the proposed method with those obtained from analyses within stroke data. Experiments were conducted using Deep ConvNet and state-of-the-art subject-specific machine learning MI classifiers, evaluated on OpenBMI two-class MI-EEG data from healthy subjects and two-class MI versus rest data from stroke patients.Main results.Results of our study indicate that through domain adaptation of a model pre-trained using healthy subjects' data, an average MI detection accuracy of 71.15% (±12.46%) can be achieved across 71 stroke patients. We demonstrate that the accuracy of the pre-trained model increased by 18.15% after transfer learning (p<0.001). Additionally, the proposed transfer learning method outperforms the subject-specific results achieved by Deep ConvNet and FBCSP, with significant enhancements of 7.64% (p<0.001) and 5.55% (p<0.001) in performance, respectively. Notably, the healthy-to-stroke transfer learning approach achieved similar performance to stroke-to-stroke transfer learning, with no significant difference (p>0.05). Explainable AI analyses using transfer models determined channel relevance patterns that indicate contributions from the bilateral motor, frontal, and parietal regions of the cortex towards MI detection in stroke patients.Significance.Transfer learning from healthy to stroke can enhance the clinical use of BCI algorithms by overcoming the challenge of insufficient clinical data for optimal training.

General anesthesia vs. conscious sedation and local anesthesia for endovascular treatment in patients with posterior circulation acute ischemic stroke: An updated systematic review and meta-analysis.

INTRODUCTION: The best anesthetic choice for patients with acute posterior circulation stroke during endovascular treatment (EVT) remains uncertain. METHOD: We searched five databases to identify studies that met the inclusion criteria. Our primary outcome measure was functional independence (FI). Secondary outcomes were 3-month mortality, any intracranial hemorrhage (ICH), symptomatic ICH (sICH), successful reperfusion, and procedure- and ventilator-associated complications. RESULTS: A total of 10 studies were included in our meta-analysis. No significant differences were detected between the general anesthesia (GA) and conscious sedation and local anesthesia (CS/LA) groups in 3-month FI (nine studies; OR=0.69; 95% CI 0.45-1.06; P=0.083; I2=66%;), 3-month mortality (nine studies; OR=1.41; 95% CI 0.94-2.11; P=0.096; I2=61.2%;), any ICH (three studies; OR=0.75; 95% CI 0.44-1.25; P=0.269; I2=0%;), or sICH (six studies; OR=0.64; 95% CI 0.40-1.04; P=0.073; I2=0%;). No significant differences were observed for successful reperfusion (10 studies; OR=1.17; 95% CI 0.91-1.49; P=0.219; I2=0%;), procedure-related complications (four studies; OR=1.14; 95% CI 0.70-1.87; P=0.603; I2=7.9%;), or respiratory complications (four studies; OR=1.19; 95% CI 0.61-2.32; P=0.616; I2=64.9%;) between the two groups. CONCLUSIONS: Our study showed no differences in 3-month FI, 3-month mortality, and successful reperfusion between patients treated with GA and those treated with CS/LA. Additionally, no increased risk of hemorrhagic transformation or pulmonary infection was observed in the CS/LA group. These results indicate that CS/LA may be an EVT option for acute posterior circulation stroke patients.

Risk of Incident Atrial Fibrillation and Subsequent Use of Oral Anticoagulants in Patients with Dementia.

BACKGROUND: Dementia and atrial fibrillation (AF) have many shared risk factors. Besides, patients with dementia are under-represented in randomized trials, and even if AF is present, oral anticoagulants (OACs) are not prescribed frequently. This study aimed to report the incidence of newly diagnosed AF in dementia patients, and the impacts of use of vitamin K antagonist (VKA; e.g., warfarin) and non-VKA OAC (NOACs) on stroke and bleeding outcomes. METHODS: Our study utilized the Taiwan National Health Insurance Research Database. A total of 554,074 patients with dementia were compared with 554,074 age- and sex-matched patients without dementia regarding the risk of incident AF. Among patients with dementia who experienced incident AF, the risks of clinical events of patients treated with warfarin or NOACs were compared with those without OACs (reference group). RESULTS: The risk of incident AF was greater for patients with dementia compared with those without (adjusted hazard ratio [aHR]: 1.054; 95% confidence interval [CI]: 1.040-1.068 for all types of dementia, aHR: 1.035; 95% CI: 1.020-1.051 for presenile/senile dementia, and aHR: 1.125; 95% CI: 1.091-1.159 for vascular dementia). Among patients with dementia and experienced incident AF, warfarin use was associated with a higher risk of ischemic stroke (aHR: 1.290; 95% CI: 1.156-1.440), intracranial hemorrhage (ICH; aHR: 1.678; 95% CI: 1.346-2.090), and major bleeding (aHR: 1.192; 95% CI: 1.073-1.323) compared with non-OACs. NOAC use was associated with a lower risk of ischemic stroke (aHR: 0.421; 95% CI: 0.352-0.503) and composite risk of ischemic stroke or major bleeding (aHR: 0.544; 95% CI: 0.487-0.608) compared with non-OACs. These results were consistent among the patients after the propensity matching. CONCLUSION: In this large nationwide cohort, the risk of newly diagnosed AF was higher in patients with dementia (all dementia, presenile/senile dementia, and vascular dementia) compared with those without dementia. For patients with dementia who experienced incident AF, NOAC use was associated with a better clinical outcome compared with non-OAC. Patients with dementia require a holistic approach to their care and management, including the use of NOACs to reduce the risks of clinical events.

Comparative safety of tenecteplase vs alteplase for acute ischemic stroke.

INTRODUCTION: Tenecteplase has been compared to alteplase in acute stroke randomized trials, with similar outcomes and safety measures, but higher doses of tenecteplase have been associated with higher hemorrhage rates in some studies. Limited data are available on the safety of tenecteplase outside of clinical trials. METHODS: We examined the safety measures of intracranial hemorrhage, angioedema, and serious extracranial adverse events in a 21-hospital integrated healthcare system that switched from alteplase (0.9 mg/kg, maximum dose 90 mg) to tenecteplase (0.25 mg/kg, maximum dose 25 mg) for acute ischemic stroke. RESULTS: Among 3,689 subjects, no significant differences were seen between tenecteplase and alteplase in the rate of intracranial hemorrhage (ICH), parenchymal hemorrhage, or volume of parenchymal hemorrhage. Symptomatic hemorrhage (sICH) was not different between the two agents: sICH by NINDS criteria was 2.0 % for alteplase vs 2.3 % for tenecteplase (P = 0.57), and sICH by SITS criteria was 0.8 % vs 1.1 % (P = 0.39). Adjusted logistic regression models also showed no differences between tenecteplase and alteplase: the odds ratio for tenecteplase (vs alteplase) modeling sICH by NINDS criteria was 0.9 (95 % CI 0.33 - 2.46, P = 0.83) and the odds ratio for tenecteplase modeling sICH by SITS criteria was 1.12 (95 % CI 0.25 - 5.07, P = 0.89). Rates of angioedema and serious extracranial adverse events were low and did not differ between tenecteplase and alteplase. Elapsed door-to-needle times showed a small improvement after the switch to tenecteplase (51.8 % treated in under 30 min with tenecteplase vs 43.5 % with alteplase, P < 0.001). CONCLUSION: In use outside of clinical trials, complication rates are similar between tenecteplase and alteplase. In the context of a stroke telemedicine program, the rates of hemorrhage observed with either agent were lower than expected based on prior trials and registry data. The more easily prepared tenecteplase was associated with a lower door-to-needle time.

Recovery needs and psychosocial rehabilitation trajectory of stroke survivors (PReTS): A qualitative systematic review of systematic reviews.

OBJECTIVE: Stroke has a major impact on a person's life. While much research exists on stroke prevention and treatment, explorations into psychosocial recovery needs are lacking. This review critically consolidates the challenges and needs of stroke survivors and develops a trajectory that encapsulates their journey from illness to recovery. DATA SOURCES: Six major databases were searched, including Academic Search Premier, CINAHL, Global Health, Medline, PsycArticles, and PsycINFO. METHODS: This review adhered to the PRISMA guidelines and employed the PICo (population, phenomena of interest, context) framework to screen for relevant qualitative reviews published between 1 January 2010 and 31 August 2023. Following full-text screening and the assessment of methodological quality using a modified version of the Assessment of Multiple Systematic Reviews scale, a total of 17 reviews were included for thematic synthesis. RESULTS: Included reviews referenced 400 qualitative primary studies involving more than 5623 stroke survivors. Data synthesis revealed 18 themes that were further organized into six conceptual categories: (1) The unfamiliar body, (2) compassionate healthcare system, (3) holistic rehabilitation, (4) intrapersonal strength, (5) interpersonal relations, and (6) thriving forward to form the psychosocial rehabilitation trajectory of stroke survivor (PReTS) model. The model recognizes the losses that can occur after a stroke and emphasizes the essentiality of addressing psycho-socio-emotional and spiritual needs alongside physical impairments. CONCLUSION: The PReTS model is the first to highlight stroke survivors' losses, recovery journeys, and psychosocial needs. The conceptualization serves to inform and advance stroke rehabilitation practices with holistic and wellness recovery research.

Electroacupuncture combined with wet compress formula ameliorates upper limb dysfunction associated with stroke: A retrospective analysis of 126 cases.

OBJECTIVES: Upper limb motor dysfunction (ULMD) is one of the most common complications of ischemic stroke (IS). Electroacupuncture (EA) is a noninvasive procedure that has the potential to manage symptoms associated with IS. To improve the treatment effects of EA, our hospital performed combined treating strategy against ULMD by subjecting IS patients to both EA and external application of wet compress formula (WCF). In the current analysis, the potential improving effects of the combined treatment against ULMD were evaluated. MATERIALS AND METHODS: 126 patients with ULMD induced by IS handled with normal rehabilitation treatment, EA treatment alone, and EA combined with WCF respectively were enrolled in the current analysis. The clinicopathological information and changes in motor function assessment scales, including Visual analogue (VAS), Fugl-Meyer assessment-upper extremity (FMA-UA), and Modified Barthel index (MBI) scales were collected and the difference between different treating strategies was assessed. RESULTS: All the treating strategies improved the values of VAS, FMA-UA, and MBI scales, with combined treating strategy showing the strongest improving effects, and traditional rehabilitation strategy showing the weakest effects. Moreover, the assessment of hand and wrist motor function by FMA-UE also showed that the combined treatment strategy has significantly stronger improving effects against ULMD compared with other strategies. CONCLUSIONS: The current analysis showed that the use of external application of WCF could substantially increase the treating effects of EA on ULMD induced by IS without severe side effects, which could guide the future clinical management of motor dysfunction.

A Phase-based EEG Epoch Selection Method for Decoding Bi-directional Hand Movement Imagination in Stroke Patients.

Electroencephalogram (EEG) based non-invasive Brain Computer Interface (BCI) system is gaining significant attention as a promising solution for stroke rehabilitation. Accurate selection of informative EEG time segment, that accommodates the specific neural activity patterns associated with the underlying mental task can help to improve the efficacy of the BCI system. In this work, we propose a phase-based EEG epoch selection algorithm to extract the discriminative EEG time segment corresponding to bi-directional hand motor imagery. The imagined center-out hand movement in two directions is decoded using the selected epoch of the EEG, recorded from 16 stroke patients with hemiparesis and specifically hand weakness. Phase Lock Value (PLV) EEG features extracted from the selected EEG epoch is used as discriminative feature for binary classification of imagined hand movement direction using Linear Discriminant Analysis. The use of selected EEG epoch yielded an improvement of 11.5% and 11.7% in the average direction classification accuracy of calibration and feedback session data respectively, compared to the baseline method employing the whole EEG signal. In addition to improvement in decoding accuracy, the epoch selection also yielded an average Information Transfer Rate (ITR) of 39.8±24.6 bits per minute, which is 86% improvement compared to the baseline method.Clinical Relevance- The proposed Motor Imagery (MI)-BCI system may be of clinical relevance as an active rehabilitation tool for stroke-affected patients, to enhance neural plasticity and recovery of centre-out activities of affected hand and forms a strong platform for MI-BCI coupled with exoskeletons or prosthesis rehabilitation.

Neurobiomechanical mechanism of Tai Chi to improve upper limb coordination function in post-stroke patients: a study protocol for a randomized controlled trial.

BACKGROUND: Upper limb dysfunction seriously affects the ability of stroke patients to perform activities of daily living. As a popular exercise therapy, Tai Chi may become an alternative intervention. However, the neurophysiological mechanism by which Tai Chi improves upper limb dysfunction in stroke patients is still unclear, which limits its further promotion and application. Therefore, conducting a strict randomized clinical trial is necessary to observe how Tai Chi affects upper limb dysfunction in stroke patients and to explore its neurophysiological mechanism. METHODS/DESIGN: This report describes a randomized, parallel-controlled trial with distributive concealment and evaluator blinding. A total of 84 eligible participants will be randomly assigned to the Tai Chi group or the control group in a 1:1 ratio. The participants in the Tai Chi group will receive 4 weeks of Tai Chi training: five 60-min sessions a week for a total of 20 sessions. The participants in the control group will not receive Tai Chi training. Both groups will receive medical treatment and routine rehabilitation training. The primary outcome measure is the mean change in the Fugl-Meyer Assessment Upper Extremity (FMA-UE) scale score between baseline and 4 weeks; the secondary outcomes are the mean changes in kinematic characteristics and the Wolf Motor Function Test (WMFT) and Stroke Impact Scale (SIS) scores. In addition, the corticomuscular coupling level and near-infrared brain functional imaging will be monitored to explore the mechanism by which Tai Chi improves upper limb function of stroke patients. DISCUSSION: This randomized controlled trial will examine the effectiveness of Tai Chi in stroke patients with upper limb dysfunction and explore the neurophysiological mechanism. Positive results will verify that Tai Chi can improve upper limb function of stroke patients. TRIAL REGISTRATION: Chinese Clinical Trial Registration Center, ChiCTR2200061376 (retrospectively registered). Registered June 22, 2022. http://www.chictr.org.cn/listbycreater.aspx . Manuscript Version: 3.0 Manuscript Date: October 10, 2023.

Gaps in guideline-recommended anticoagulation in patients with atrial fibrillation and elevated thromboembolic risk within an integrated healthcare delivery system.

BACKGROUND: Atrial Fibrillation (AF) is the leading cause of stroke, which can be reduced by 70% with appropriate oral anticoagulation (OAC) therapy. Nationally, appropriate anticoagulation rates for patients with AF with elevated thromboembolic risk are as low as 50% even across the highest stroke risk cohorts. This study aims to evaluate the variability of appropriate anticoagulation rates among patients by sex, ethnicity, and socioeconomic status within the Kaiser Permanente Mid-Atlantic States (KPMAS). METHODS: This retrospective study investigated 9513 patients in KPMAS's AF registry with CHADS2 score ≥ 2 over a 6-month period in 2021. RESULTS: Appropriately anticoagulated patients had higher rates of diabetes, prior stroke, and congestive heart failure than patients who were not appropriately anticoagulated. There were no significant differences in anticoagulation rates between males and females (71.8% vs. 71.6%%, [OR] 1.01; 95% CI, 0.93-1.11; P = .76) nor by SES-SVI quartiles. There was a statistically significant difference between Black and White patients (70.8% vs. 73.1%, P = .03) and Asian and White patients (68.3% vs. 71.6%, P = .005). After adjusting for CHADS2, this difference persisted for Black and White participants with CHADS2 scores of ≤3 (62.6% vs. 70.6%, P < .001) and for Asian and White participants with CHADS2 scores > 5 (68.0% vs. 79.3%, P < .001). CONCLUSIONS: Black and Asian patients may have differing rates of appropriate anticoagulation when compared with White patients. Characterizing such disparities is the first step towards addressing treatment gaps in AF.

Effectiveness and safety of digital rectal stimulation and abdominal massage for neurogenic bowel dysfunction in stroke patients: a randomized controlled trial protocol.

BACKGROUND: Neurogenic bowel dysfunction (NBD) is a prevalent complication among stroke patients, significantly affecting their quality of life, duration of hospitalization, medical expenses, and even mortality. Although current guidelines suggest a conservative strategy for addressing bowel dysfunction, which includes techniques such as digital rectal stimulation (DRS) and abdominal massage, the availability of interventions remains limited in healthcare facilities. METHODS: This study follows a prospective randomized controlled parallel-group clinical trial design. The control group will receive standard care, while the intervention group will undergo a program that combines DRS and abdominal massage in addition to standard care. The duration of the intervention for both groups will be 6 weeks. The primary outcome measures will be the Wexner score. Furthermore, secondary outcomes measure will be assessed, including Bristol score, Patient Assessment of Constipation-Quality of Life (PAC-QoL), and Fecal Incontinence Quality of Life (FI-QoL). DISCUSSION: This study aims to evaluate the effectiveness and safety of a bowel rehabilitation program for stroke patients with NBD. The findings will provide information that can contribute to the formulation of bowel management strategies. TRIAL REGISTRATION: The study has been registered in the Chinese Clinical Registry under the number ChiCTR2300071709. This registration was completed on May 23, 2023. All items from the World Health Organization Trial Registration Data set are described in this manuscript.

Validation of ICD-10 hospital discharge diagnosis codes to identify incident and recurrent ischemic stroke from a US integrated healthcare system.

PURPOSE: This study validated incident and recurrent ischemic stroke identified by International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10) hospital discharge diagnosis codes. METHODS: Using electronic health records (EHR) of adults (≥18 years) receiving care from Kaiser Permanente Southern California with ICD-10 hospital discharge diagnosis codes of ischemic stroke (I63.x, G46.3, and G46.4) between October 2015 and September 2020, we identified 75 patients with both incident and recurrent stroke events (total 150 cases). Two neurologists independently evaluated validity of ICD-10 codes through chart reviews. RESULTS: The positive predictive value (PPV, 95% CI) for incident stroke was 93% (95% CI: 88%, 99%) and the PPV for recurrent stroke was 72% (95% CI: 62%, 82%). The PPV for recurrent stroke improved after applying a gap of 20 days (PPV of 75%; 95% CI: 63%, 87%) or removing hospital admissions related to stroke-related procedures (PPV of 78%; 95% CI: 68%, 88%). CONCLUSION: The ICD-10 hospital discharge diagnosis codes for ischemic stroke showed a high PPV for incident cases, while the PPV for recurrent cases were less optimal. Algorithms to improve the accuracy of ICD-10 codes for recurrent ischemic stroke may be necessary.

Feasibility of advanced composite endpoint analysis: Post-hoc insights from the vitamin intervention for stroke prevention randomized control trial.

BACKGROUND AND AIMS: Stroke is a major cause of mortality and disability, highlighting the importance of prevention. Clinical trials play an important role in evaluating interventions that can maximize stroke prevention. Traditional composite endpoints (TCE) used in clinical trials have limitations, as they pool together events of varying clinical importance. Weighted composite endpoints (WCE) have emerged as a solution to address these limitations and provide more accurate assessments of outcomes. In this study, we investigate the use of WCE in a previously reported negative clinical trial for stroke prevention. METHODS AND RESULTS: We analyzed data from the Vitamin Intervention for Stroke Prevention (VISP) trial, which compared high dose and low dose multivitamin therapy. We utilized weighted methods to analyze time-to-event outcomes with censoring. The primary outcomes of interest were time to nonfatal stroke, nonfatal coronary events, and death. We calculated modified Kaplan-Meier (KM) curves for each intervention group. We also performed a modified log-rank test to assess significant differences based on the weighted KM curves. The analysis included 3668 VISP trial participants, and most remained event-free throughout the study period. The TCE KM curve showed no significant difference in outcomes between high dose and low dose groups. Similarly, the WCE KM curves, with different weights assigned to each outcome, did not reveal significant differences in outcomes between the studied groups. CONCLUSION: This post-hoc analysis confirms the negative trial results of VISP and demonstrates the feasibility of using WCE in assessing nutrition-based interventions for stroke prevention.

Utility of Trimethylamine Oxide (TMAO) in Predicting Early Neurological Deterioration after Acute Ischemic Stroke.

OBJECTIVE:  To investigate whether plasma trimethylamine N-oxide (TMAO) levels might predict early neurological deterioration (END) in individuals with acute ischemic stroke. STUDY DESIGN: Cohort study. Place and Duration of the Study: Jiulongpo District Hospital of Traditional Chinese Medicine, Chongqing City, China, from January 2020 to December 2021. METHODOLOGY:  Patients presenting with ischemic stroke were classified into the END group and the non-END group. The National Institutes of Health Stroke Scale (NIHSS) total increasing by 2 points or more within 72 hours of admission was the definition of the END. Plasma TMAO levels were determined by high-performance liquid chromatographic and tandem mass spectrometry. RESULTS:  Twenty-six (25%) of the 104 patients, diagnosed with END exhibited higher TMAO levels after admission (median 1.438 vs. 0.449 nmol/mL, p=0.001). Elevated plasma TMAO levels were significant predictors of END in univariate logistic analysis. After controlling for age, gender, and cardiovascular risk factors in the multivariate conditional logistic regression model, the plasma TMAO levels in the END group remained significantly higher than those in the non-END group (OR=6.646, 95% CI 2.434-18.147, p<0.001). In receiver operator characteristic (ROC) analysis, the sensitivity and specificity of TMAO in distinguishing the END group and the non-END group at 0.564 nmol/mL cutoff value were 0.885 and 0.679, respectively. CONCLUSION: According to this research, the development of END on admission in patients with acute ischemic stroke may be positively correlated with the elevation in plasma TMAO levels. KEY WORDS:  Trimethylamine N-oxide level, Acute ischemic stroke, Early neurological deterioration, NIHSS score.

A comparative effectiveness study of carotid intervention for long-term stroke prevention in patients with severe asymptomatic stenosis from a large integrated health system.

OBJECTIVE: The results of current prospective trials comparing the effectiveness of carotid endarterectomy (CEA) vs standard medical therapy for long-term stroke prevention in patients with asymptomatic carotid stenosis (ACS) will not be available for several years. In this study, we compared the observed effectiveness of CEA and standard medical therapy vs standard medical therapy alone to prevent ipsilateral stroke in a contemporary cohort of patients with ACS. METHODS: This cohort study was conducted in a large integrated health system in adult subjects with 70% to 99% ACS (no neurologic symptom within 6 months) with no prior ipsilateral carotid artery intervention. Causal inference methods were used to emulate a conceptual randomized trial using data from January 1, 2008, through December 31, 2017, for comparing the event-free survival over 96 months between two treatment strategies: (1) CEA within 12 months from cohort entry vs (2) no CEA (standard medical therapy alone). To account for both baseline and time-dependent confounding, inverse probability weighting estimation was used to derive adjusted hazard ratios, and cumulative risk differences were assessed based on two logistic marginal structural models for counterfactual hazards. Propensity scores were data-adaptively estimated using super learning. The primary outcome was ipsilateral anterior ischemic stroke. RESULTS: The cohort included 3824 eligible patients with ACS (mean age: 73.7 years, 57.9% male, 12.3% active smokers), of whom 1467 underwent CEA in the first year, whereas 2297 never underwent CEA. The median follow-up was 68 months. A total of 1760 participants (46%) died, 445 (12%) were lost to follow-up, and 158 (4%) experienced ipsilateral stroke. The cumulative risk differences for each year of follow-up showed a protective effect of CEA starting in year 2 (risk difference = 1.1%, 95% confidence interval: 0.5%-1.6%) and persisting to year 8 (2.6%, 95% confidence interval: 0.3%-4.8%) compared with patients not receiving CEA. CONCLUSIONS: In this contemporary cohort study of patients with ACS using rigorous analytic methodology, CEA appears to have a small but statistically significant effect on stroke prevention out to 8 years. Further study is needed to appropriately select the subset of patients most likely to benefit from intervention.

Integrated Nursing and Targeted Functional Training for Cerebral Hemorrhage Recovery.

Objective: This study aimed to investigate the impact of integrating medical nursing with targeted functional training interventions on neurological and limb motor function and self-care ability in patients diagnosed with cerebral hemorrhage. Methods: A retrospective cohort study was conducted, including 100 patients diagnosed with cerebral hemorrhage who received interventions at our hospital between January 2020 and June 2022. The patients were divided into two groups: the research group (50 cases) and the reference group (50 cases), based on different intervention methods. The reference group received targeted functional training intervention, while the research group implemented the integration of medical nursing in addition to the reference group intervention. Differences in the National Institutes of Health Stroke Scale (NIHSS) score, Barthel index, Modified Barthel Index (MBI) score, Glasgow Coma Scale (GCS) score, Edinburgh Speech Scale (ESS) score, Fugl-Meyer score, Ability of Daily Living (ADL) score, and efficacy evaluation were observed and compared between the two groups of patients. Results: After nursing, the Fugl-Meyer score and Barthel index score were significantly higher in both groups compared to before nursing, with the research group showing higher scores than the reference group (P < 0.05). There was no significant difference in limb motor function scores between the two groups before nursing (P > 0.05). After the integrated nursing intervention, the NIHSS and ADL scores of both groups were significantly higher than before nursing, with the research group demonstrating higher scores than the reference group (P < 0.05). Conclusions: Integrating medical nursing with targeted functional training interventions has the potential to significantly improve cognitive function, neurological function, and daily activity engagement in patients with cerebral hemorrhage, thereby enhancing their overall quality of life.

Efficacy and safety of acupuncture combined with rehabilitation training for poststroke cognitive impairment: A systematic review and meta-analysis.

BACKGROUND: Accumulated evidence has proven that both acupuncture and rehabilitation therapy are beneficial for stroke sequelae. However, there is no systematic review to identify the efficacy and safety of acupuncture combined with rehabilitation training for poststroke cognitive impairment (PSCI). Therefore, the aim of this study was to assess the efficacy and safety of acupuncture combined with rehabilitation therapy for patients with PSCI. METHODS: We searched nine databases, including PubMed, Embase, Scopus, Web of Science, EBSCO, Cochrane Library, China National Knowledge Infrastructure (CNKI), China Science and Technology Journal Database (VIP), and Wan Fang, from their inception to September 2022. Randomized controlled trials (RCTs) examining the effect of acupuncture combined with rehabilitation on PSCI were included. The primary outcomes were the Mini-Mental State Examination (MMSE) score, Montreal Cognitive Assessment (MoCA) score, Modified Barthel Index (MBI) score, and Fugl-Meyer Assessment (FMA) score. The quality of the methodology was evaluated by Cochrane's risk of bias tool. Meta-analyses were performed by Revman 5.3 software. RESULTS: A total of 18 RCTs involving 1654 patients were included. The overall methodological quality of the included studies was low. Pooled results demonstrated that acupuncture combined with rehabilitation could significantly improve the clinical efficacy of PSCI (OR=3.23, 95% CI: 2.13 to 4.89), MMSE score (MD= 2.85, 95% CI: 2.56 to 3.15), MoCA score (MD= 2.18, 95% CI: 1.38 to 2.97), MBI score (MD= 9.23, 95% CI: 5.62 to 12.84), and FMA score (MD=5.72, 95% CI: 3.48 to 7.96). CONCLUSIONS: Acupuncture combined with rehabilitation may produce better outcomes than rehabilitation alone in the treatment of PSCI. However, the safety of combined interventions is still unclear. Therefore, research with more rigorous study designs and RCTs with larger sample sizes is still needed.

A systematic review examining the effect of vitamin D supplementation on functional outcomes post-stroke.

OBJECTIVE: The objective of this systematic review was to explore the effect of vitamin D supplementation on functional outcomes (motor function, mobility, activities of daily living and stroke impairment) among individuals post-stroke (PROSPERO CRD42022296462). DATA SOURCES: MEDLINE, PsycINFO, EMBASE, and CINAHL were searched for all articles published up to March 5, 2023. METHODS: Only interventional studies assessing vitamin D supplementation compared to placebo or usual care in adult stroke patients were selected. After duplicate removal, 2912 studies were screened by two independent reviewers. A total of 43 studies underwent full text review; 10 studies met inclusion criteria (8 randomized controlled trials and 2 non-randomized studies of intervention). Data were extracted by two independent reviewers using Covidence software. Motor function (Brunnstrom Recovery Stage, Berg Balance Score), mobility (Functional Ambulation Category), activities of daily living (Barthel Index, Functional Independence Measure) and stroke impairment (modified Rankin Scale, National Institutes for Health Stroke Severity, Scandinavian Stroke Severity) were the outcome measures of interest reported in the included studies. RESULTS: In total, 691 patients were studied for which 11 of 13 outcome measures showed improvement with vitamin D supplementation. CONCLUSIONS: The majority of studies showed a statistical improvement in motor function, mobility, and stroke impairment with vitamin D supplementation; however, the evidence did not support an improvement in activities of daily living with treatment. Despite this, there may not be clinical significance. Strong, methodologically sound, randomized controlled trials are required to verify these findings.

Effects of programmed flexor-extensor alternating electrical acupoint stimulation on upper limb motor functional reconstruction after stroke: study protocol for a double-blind, randomized controlled trial.

BACKGROUND: Stroke's prevalence and morbidity are increasing (Guano, et al. Neuro 89:53-61, 2017), and limb motor dysfunction is left in most patients (Gittler, et al. JAMA 319:820-821, 2018). Particularly, the rehabilitation of upper limbs is more difficult and time-consuming (Borges, et al. The Cochrane database of systematic reviews 10:CD011887, 2018). METHODS: A double-blind randomized controlled trial (RCT) will be conducted to investigate whether a new functional electrical stimulation (FES) combined with acupoint therapy is more effective in the rehabilitation of upper limb motor dysfunction after stroke. Patients who meet the inclusion criteria will be randomly divided into two groups: programmed flexor-extensor alternating electrical acupoint stimulation group (PES group) and conventional flexor-extensor alternating electrical acupoint stimulation group (CES group), which will be treated for 3 weeks. The primary outcome measures are electroencephalogram (EEG) and surface electromyogram (sEMG). The secondary outcome variables include MBI (modified Barthel index), China Stroke Scale (CSS), FMA-U (Fugl-Meyer assessment upper limb), MMT (manual muscle testing), and Brunnstrom. DISCUSSION: The results of this study are expected to verify the efficacy of PES therapy in the rehabilitation of upper limb motor function after stroke. This may promote the widespread use of the therapy in hospitals, communities, and homes for early and continuous treatment. TRIAL REGISTRATION: ClinicalTrials.gov NCT05333497. Registered on April 11, 2022.