Controlled Education of patients after Stroke (CEOPS)- nurse-led multimodal and long-term interventional program involving a patient's caregiver to optimize secondary prevention of stroke: study protocol for a randomized controlled trial.

BACKGROUND: Setting up a follow-up secondary prevention program after stroke is difficult due to motor and cognitive impairment, but necessary to prevent recurrence and improve patients' quality of life. To involve a referent nurse and a caregiver from the patient's social circle in nurse-led multimodal and long-term management of risk factors after stroke could be an advantage due to their easier access to the patient and family. The aim of this study is to compare the benefit of optimized follow up by nursing personnel from the vascular neurology department including therapeutic follow up, and an interventional program directed to the patient and a caregiving member of their social circle, as compared with typical follow up in order to develop a specific follow-up program of secondary prevention of stroke. METHODS/DESIGN: The design is a randomized, controlled, clinical trial conducted in the French Stroke Unit of the Strokavenir network. In total, 410 patients will be recruited and randomized in optimized follow up or usual follow up for 2 years. In both group, patients will be seen by a neurologist at 6, 12 and 24 months. The optimized follow up will include follow up by a nurse from the vascular neurology department, including therapeutic follow up, and a training program on secondary prevention directed to the patient and a caregiving member of their social circle. After discharge, a monthly telephone interview, in the first year and every 3 months in the second year, will be performed by the nurse. At 6, 12 and 24 month, the nurse will give the patient and caregiver another training session. Usual follow up is only done by the patient's general practitioner, after classical information on secondary prevention of risk factors during hospitalization. The primary outcome measure is blood pressure measured after the first year of follow up. Blood pressure will be measured by nursing personnel who do not know the group into which the patient has been randomized. Secondary endpoints are associated mortality, morbidity, recurrence, drug side-effects and medico-economic analysis. DISCUSSION: The result of this trial is expected to provide the benefit of a nurse-led optimized multimodal and long-term interventional program for management of risk factors after stroke, personalizing the role of the nurse and including the patient's caregiver. TRIAL REGISTRATION: ClinicalTrials.gov, NCT 02132364. Registered on 7 May 2014. EUDRACT, A 00473-40.

Cognitive impairment and dementia after intracerebral hemorrhage: a cross-sectional study of a hospital-based series.

BACKGROUND: Frequencies of cognitive impairment and dementia have not been assessed in spontaneous intracerebral hemorrhage (ICH). The objective of this study was to determine the frequencies and patterns of cognitive impairment and dementia in a cross-sectional study of consecutive patients hospitalized in a single university medical center. METHODS: Of 183 consecutive patients hospitalized between 2002 and 2006, 80 survivors were contacted and 78 were included (mean time since stroke 40 months). Thirty patients were scored with the Informant Questionnaire on Cognitive Decline in the Elderly and Instrumental Activities of Daily Living in a telephone interview, and 48 underwent a comprehensive clinical and neuropsychological assessment. RESULTS: Dementia was observed in 18 of 78 patients (23%; 95% confidence interval [CI] 13-32%) and cognitive impairment without dementia was seen in 37 of 48 patients (77%; 95% CI 65-89%). The cognitive disorders mainly concerned episodic memory (52%), psychomotor speed (44%), and executive function (37%), followed by language and visuoconstructive abilities. In a logistic regression analysis, Rankin score >1 at discharge and hemorrhage volume were the initial factors to be selected as a predictor of long-term dementia. CONCLUSIONS: This single-center, cross-sectional study revealed that the prevalence of dementia and cognitive impairment without dementia after ICH are high and are similar to those observed in cerebral infarct. Further longitudinal, prospective studies are required to assess accurately the prevalence, mechanisms and predictors of post-ICH dementia.

NIHSS and acute complications after anterior and posterior circulation strokes.

BACKGROUND: The purpose of this study was to determine whether the National Institutes of Health Stroke Scale (NIHSS) score was associated with inhospital neurological and medical complications (NMC) in patients with posterior circulation infarction. METHODS: This retrospective study included all patients admitted to our stroke unit during a one-year period (n = 289). NMC included neurological deterioration (ie, worsening by 4 points or more of the NIHSS score during the hospital stay) and all other medical complications based on what was recorded in the patients' charts. RESULTS: Seventy-nine patients (27%) experienced NMC. In posterior circulation infarction patients (n = 90), patients with NMC had a higher baseline NIHSS score (10.9 versus 2.2, P = 0.004) and a baseline NIHSS score >2 (78% versus 36%, P = 0.003). In stepwise logistic regression, an NIHSS score >2 (odds ratio: 8.2; 95% confidence interval: 1.64-41.0; P = 0.01) was associated with NMC. Similar results were observed for anterior circulation infarction patients but with a higher cutoff value for NIHSS score. CONCLUSION: In ischemic stroke patients, an increased baseline NIHSS score was associated with an increased risk of NMC. This association applied to anterior-circulation as well as posterior circulation stroke, although zero on the NIHSS for posterior circulation stroke does not mean the absence of NMC during hospitalization. The clinical significance of these findings requires further evaluation in larger prospective studies.

Central neuropathic pain after cerebral venous thrombosis is not so uncommon: an observational study.

Central neuropathic pain (CNP) after stroke has not been studied in sufficient detail and published studies have only included patients with cerebral artery infarct or hemorrhage. This study evaluates the prevalence and factors associated with CNP after cerebral venous (and sinus) thrombosis (CVT). This observational study included all patients admitted to our stroke unit for CVT between January 2002 and December 2007. Clinical data for each patient were collected prospectively and were combined with retrospective review of neuroradiological imaging. CVT patients were systematically examined at the outpatient clinic at 6 months, 12 months, and annually thereafter, and information on long-term functional outcome, including the presence of CNP, were obtained by open-ended questions. A standardized CNP assessment was performed during the last outpatient visit and was based on the patient's interview and clinical examination. Pain characteristics were assessed by the DN4-questionnaire. CNP was considered when the patient met the following criteria: painful area within the area of sensory abnormalities and follow-up MRI showing brain parenchymal lesion. Among the 43 patients admitted for CVT, seven (16%) developed CNP during the first year of follow-up. Standardized CNP assessment was performed 24.9 ± 11.6 months after CVT: eight patients (19%) suffered from CNP. Initial motor deficit (87 vs. 17%, p < 0.001), initial sensory deficit (62 vs. 20%, p = 0.03), cerebral infarction (75 vs. 23%, p = 0.009), right-sided lesion on initial MRI (62 vs. 17%, p = 0.017), thalamic (37 vs. 0%, p = 0.005) and basal ganglia involvement (25 vs. 0%, p = 0.03) and vein of Galen occlusion (25 vs. 0%) were significantly associated with CNP. Despite several methodological limitations, CNP after CVT seems to be frequent, accounting for one-fifth of all cases of CVT. Some clinical and radiological factors might contribute to the development of CNP.

Aspirin non-responder status and early neurological deterioration: a prospective study.

OBJECTIVES: In acute ischemic stroke, early neurological deterioration (END) has a severe impact on patient outcome. We tested the hypothesis that initial biological aspirin non-responder status (ANRS) helps predict END. METHODS: A total of 85 patients with acute ischemic stroke on 160mg aspirin daily were prospectively included. END was defined as an increase in the National Institutes of Health Stroke Scale (NIHSS) ≥4 points in the first 72h after admission. Platelet responsiveness to aspirin was assessed using the PFA-100 system, and ANRS was defined as a collagen/epinephrine closure time <165ms. RESULTS: END was observed in 10 patients (11.8%). The presumed reasons for END were progressive stroke (40%), recurrent cerebral ischemia (30%), malignant middle cerebral artery infarction (20%) and secondary acute hydrocephalus (10%). Patients with END had a non-significant worse neurological status on the NIHSS at hospital admission (8.4 vs. 4.2; p=0.15). Initial impaired consciousness (30% vs. 3%), visual disturbance (60% vs. 23%) and ANRS (60% vs. 20%) were observed more frequently in patients with END. In multivariate analysis, impaired consciousness (OR: 17.3; 95% CI: 2.0-149.5; p=0.01) and ANRS (OR: 6.4; 95% CI: 1.4-29.6; p=0.017) were found to be independently associated with END. CONCLUSION: ANRS is common in acute ischemic stroke patients and is predictive of END. The clinical significance of these findings requires further evaluation in larger longitudinal studies.

Incomplete posterior circle of willis: a risk factor for migraine?

BACKGROUND: Migraine is associated with vascular risk factors and white matter abnormalities (WMA). Cerebral hypoperfusion is known to be one mechanism underlying WMA and a few studies have shown that an incomplete circle of Willis (CW) may predispose to cerebral hypoperfusion. This study assessed the relationship between the morphologic characteristics of the CW and migraine. METHODS: This case-control study was carried out in the Amiens University Hospital. Patients undergoing 3-dimensional time of flight magnetic resonance angiography of the CW from January 1 to June 30, 2006 were included (n = 124). A definitive diagnosis of migraine was established in 47 patients: 23 (48.9%) experienced migraine without aura and 24 (51.1%) migraine with aura. The remaining 77 patients with other neurologic disorders constituted the control group. The posterior CW was graded as complete when both posterior communicating arteries and the P1 segments of the posterior cerebral artery were present on visual examination and incomplete when one of these vessels was missing (interobserver agreement: K(total) = 0.746). RESULTS: Incomplete posterior CW was significantly more common in migraineurs than in the control group (49% vs 18%; P < .001). On multivariate analysis, incomplete posterior CW was the sole independent factor associated with migraine (OR: 6.5; 95% CI: 2.6-16.2; P < .001). No difference was found between migraineurs with and without aura. CONCLUSIONS: Despite some methodological limitations, our results showed that incomplete posterior CW was associated with migraine.