Functional Status and Disability in Patients After Acute Stroke: A Longitudinal Study.

BACKGROUND: Stroke is a major public health problem. OBJECTIVE: To use the Barthel Index to evaluate basic activities of daily living in stroke survivors and detect any predictors of functional outcome at 6 months after stroke. METHODS: In an observational longitudinal study, data were gathered on consecutive patients admitted to the comprehensive stroke unit at Hospital San Pedro de Alcantara, Cáceres, Spain. Sociodemographic and clinical data were obtained prospectively at hospital admission and during follow-up 6 months later. Information on type of stroke, score on the Barthel Index, findings from the neurological evaluation, and other relevant data were collected. RESULTS: Of 236 patients admitted, 175 participated in the study. Mean age was 69.60 (SD, 12.52) years, 64.6% were men, and mortality was 12.8%. Six months after experiencing a stroke, 84.8% of patients had returned to their own homes, 8.0% were institutionalized, and the others were residing at a family member's home. Scores on the Barthel Index 6 months after stroke correlated with baseline scores on the National Institute of Health Stroke Scale (r = -0.424; P < .001) and with depressive mood 6 months after stroke (r = -0.318; P < .001). Age was negatively associated with Barthel Index scores at the time of hospital discharge and 6 months after stroke. CONCLUSIONS: Functional status 6 months after stroke was influenced by age, sex, stroke severity, type of stroke, baseline status, mood, and social risk. Comorbid conditions, socioeconomic level, and area of residence did not affect patients' functional status.

Limb shaking. descripción de un caso desde la perspectiva / Limb Shaking: description of a case from a nursing perspective

Introducción. El limb shaking, descrito por Miller Fisher en 1962, se caracteriza por movimientos involuntarios, irregulares y estereotipados de un hemicuerpo desencadenados por la hipoperfusión hemisférica contralateral. Se asocia a una oclusión o estenosis crítica de la arteria carótida interna (ACI) extracraneal contralateral a los movimientos y a una pobre circulación colateral. Esto causa una isquemia que da lugar a las manifestaciones clínicas típicas de un ictus y estos movimientos anormales. Objetivo. Describir el caso clínico de un paciente con limb shaking. Descripción del caso. Varón de 59 años, con factores de riesgo cardiovascular, que acude a Urgencias por un cuadro súbito de afasia motora y pérdida de fuerza en extremidades derechas de predominio braquial distal. Ingresa en la Unidad de Ictus para monitorización neurológica y hemodinámica, donde, coincidiendo con el inicio de la sedestación, presenta estos movimientos involuntarios. Resultados. Las pruebas diagnósticas confirman un ictus isquémico cortical frontal izquierdo. El electroencefalograma muestra una actividad bioeléctrica de fondo normal. Es en la angio-RMN y la arteriografía donde se halla una estenosis crítica de la ACI izquierda. Discusión. Se establece el diagnóstico de limb shaking de acuerdo con los hallazgos del examen clínico y las pruebas complementarias, que confirman la presencia de una pseudooclusión de la ACI izquierda y la refractariedad al tratamiento antiepiléptico. Conclusión. El limb shaking es un síndrome raro, que debe reconocerse y diferenciarse precozmente de otros procesos para tratarlo de forma adecuada. El tratamiento está destinado a restaurar el flujo sanguíneo cerebral, mediante la revascularización quirúrgica o endovascular del hemisferio isquémico (AU)

Introduction. Limb shaking, which was described by Miller Fisher in 1962, is characterized by involuntary, irregular, stereotyped a hemibody triggered by the contralateral hemisphere hypoperfusion. It is associated with an occlusion or stenosis preoclusive of the extracranial internal carotid artery (ICA) contralateral to the movements, and poor circulation contralateral. This causes ischemia resulting in typical clinical manifestations of stroke and these abnormal movements. Objective. To describe a case of limb shaking. Materials and methods. 59 years old man, with cardiovascular risk factors, who go to the Emergency room with symptoms and motor dysphasia and sudden loss of strength in right limbs, with distal brachial predominance. Admitted to Stroke Unit for neurological and hemodynamic monitoring, which coincides with the beginning of the sitting have an episode of these involuntary movements. Results. Diagnostic tests confirm a left frontal cortical ischemic stroke. The EEG shows a normal background bioelectric activity. The angio-MRI and angiography showed a left ICA pseudoocclusion Discussion. A diagnosis of limb shaking based in the clinical examination and additional tests, which confirm the finding of a left ICA pseudo-occlusion and refractory to antiepileptic treatment. Conclusion. The limb shaking is a rare syndrome, which must be recognized and differentiated early from other processes to treat it properly. Treatment is aimed at restoring cerebral blood flow through the ischemic hemisphere revascularization (AU)

Determinants of Quality of Life in Stroke Survivors After 6 Months, from a Comprehensive Stroke Unit: A Longitudinal Study.

BACKGROUND: In the social model of stroke, health-related quality of life (HRQoL) is the result of interplay among stroke severity, social support, and health-promoting behaviors. Our objective was to identify determinants of HRQoL in stroke survivors. METHODS: Ischemic stroke patients were evaluated at 6 months with the Short Form 12 Health Survey, including physical component survey (PCS) and mental health component survey (MCS) summary scores. Multivariate stepwise regression analyses determined independent predictors of scores. Models included age, gender, socioeconomic class, education, residential environment, social support, previous comorbidity (Charlson Index), previous stroke, side of stroke, National Institutes of Health Stroke Scale (NIHSS) score at admission, Barthel Index (BI) and modified Rankin Scale (mRS) scores at discharge, and length of stay. RESULTS: A total of 131 patients participated (mean age 70.1, SD = 12.5; 62.6% males). In all, 33.6% had a BI score <90 and an mRS score >2 (poor outcome). The mean (SD) PCS score was 39.46 (9.3) and mean (SD) MCS score was 34.86 (10.1). Lower PCS score was associated with female sex (ß = 0.204, p = .009), poor social support (ß = -0.225, p = .003), and poor Charlson Index (ß = -0.162, p = .032) and BI scores (ß = 0.384, p < .0001). Lower MCS score was associated with female sex (ß = 0.162, p = .062) and poor NIHSS (ß = -0.265, p = .019) and BI scores (ß = 0.203, p < .071). CONCLUSION: Stroke severity, disability, gender, social support, and previous stroke have significant impacts on the physical and mental domains of generic HRQoL.

[LIMB SHAKING: DESCRIPTION OF A CASE FROM A NURSING PERSPECTIVE]. / Limb shaking: DESCRIPCIÓN DE UN CASO DESDE LA PERSPECTIVA ENFERMERA.

INTRODUCTION: Limb shaking, which was described by MillerFisher in 1962, is characterized by involuntary, irregular, stereotyped a hemibody triggered by the contralateral hemisphere hypoperfusion. It is associated with an occlusion or stenosis preoclusive of the extracranial internal carotid artery (ICA) contralateral to the movements, and poor circulation contralateral. This causes ischemia resulting in typical clinical manifestations of stroke and these abnormal movements. OBJECTIVE: To describe a case of limb shaking. MATERIALS AND METHODS: 59 years old man, with cardiovascular risk factors, who go to the Emergency room with symptoms and motor dysphasia and sudden loss of strength in right limbs, with distal brachial predominance. Admitted to Stroke Unit for neurological and hemodynamic monitoring, which coincides with the beginning of the sitting have an episode of these involuntary movements. RESULTS: Diagnostic tests confirm a left frontal cortical ischemic stroke. The EEG shows a normal background bioelectric activity. The angio-MRI and angiography showed a left ICA pseudoocclusion. DISCUSSON: A diagnosis of limb shaking based in the clinical examination and additional tests, which confirm the finding of a left ICA pseudo-occlusion and refractory to antiepileptic treatment. CONCLUSION: The limb shaking is a rare syndrome, which must be recognized and differentiated early from other processes to treat it properly. Treatment is aimed at restoring cerebral blood flow through the ischemic hemisphere revascularization.

Malformación de Dandy-Walker de diagnóstico tardío revelada por hipertensión intracraneal / Late diagnosis of Dandy-Walker’s malformation revealed by intracranial hypertension

La malformación de Dandy-Walker se ha descrito clásicamente por la triada de dilatación quística del cuarto ventrículo, hipoplasia del vermis cerebeloso e hidrocefalia. Los síntomas suelen aparecer en la infancia precoz. La presentación en la edad adulta es extremadamente rara, aunque puede ocurrir de forma espontánea o tras un traumatismo craneal. Caso clínico. Varón de 24 años que acude a urgencias por un cuadro compatible con hipertensión intracraneal. El TAC craneal reveló una malformación de Dandy-Walker. Comentario y Conclusiones. Aproximadamente el 80% de los pacientes con esta malformación se presentan durante le primer año de vida, principalmente con marcrocrania secundaria a la hidrocefalia. Por el contrario, en la edad adulta suelen presentarse con síntomas de disfunción de estructuras posteriores dando lugar a nistagmus, alteración de la marcha y ataxia, aunque también podrían presentar síntomas de hipertensión intracraneal...

Cilostazol and outcome in outpatients with peripheral artery disease.

BACKGROUND: Cilostazol increases the walking distance in patients with intermittent claudication, but there is scarce evidence of any effect on the risk for subsequent ischemic events, bleeding or death. PATIENTS AND METHODS: We used data from the FRENA Registry to compare the clinical outcome in stable outpatients with intermittent claudication, according to the use of cilostazol. RESULTS: As of January 2013, 1,317 patients with intermittent claudication were recruited in FRENA, of whom 191 (14.5%) received cilostazol. Over a mean follow-up of 18months, 39 patients developed myocardial infarction, 23 ischemic stroke, 20 underwent limb amputation, 15 had major bleeding and 70 died. There were no significant differences in the rate of subsequent ischemic events, major bleeding or death between patients receiving or not receiving cilostazol. On multivariate analysis, the use of cilostazol had no influence on the risk for subsequent myocardial infarction (hazard ratio [HR]: 0.97; 95% CI: 0.33-20.8), ischemic stroke (HR: 1.46; 95% CI: 0.48-4.43), limb amputation (HR: 0.34; 95% CI: 0.04-20.6), major bleeding (HR: 1.52; 95% CI: 0.33-7.09) or death (HR: 0.90; 95% CI: 0.40-20.0). CONCLUSIONS: In stable outpatients with intermittent claudication, the use of cilostazol was not associated with increased rates of subsequent ischemic events, major bleeding or death.

Peripheral endothelial function and arterial stiffness in patients with chronic migraine: a case-control study.

BACKGROUND: Migraine is a complex and disabilitating neurovascular disorder predominantly affecting women. There is strong evidence that nitric oxide is critically involved in migraine pathophysiology. The aim of the present study was to test the hypothesis that chronic migraine is associated with ultrasonographic endothelial dysfunction and increase in arterial stiffness. These parameters were assessed using a novel plethysmograph by peripheral arterial tonometry. METHODS: Twenty-one patients with chronic migraine and twenty-one healthy controls matched by sex and gender were recruited. Measurement of the ultrasonographic endothelial function and augmentation index were made according to manufacturer's protocol. RESULTS: The mean of patient's peripheral arterial tonometry ratios was 1.93 ± 0.39 and for healthy control 2.21 ± 0.44 (p=0.040). The median of patients' augmentation index was -6,0 (IQR: 6.5 to -15) in healthy controls and 9.0 (IQR: 4 to 12) in chronic migraine, (p=0.002). CONCLUSIONS: Patients with chronic migraine have ultrasonographic endothelial dysfunction and increase in the arterial stiffness. An improved understanding of the role in the endothelial system of migraine may provide a basis for preventive drugs in migraine and restore the endothelial function.

Cerebral hemodynamic changes in obstructive sleep apnea syndrome after continuous positive airway pressure treatment.

BACKGROUND: Patients with obstructive sleep apnea syndrome (OSAS) are at increased risk for cerebrovascular diseases. The underlying mechanisms remain obscure. It may occur through a reduction in cerebral vascular reactivity. Continuous positive airway pressure (CPAP) is effective in reducing the occurrence of apneas. We hypothesized that treatment with CPAP improves cerebral vascular reactivity. METHODS: This is a prospective study with OSAS patients. The apnea test (ApT) was calculated as an increase of mean artery velocity during apnea: [Artery velocity in apnea minus Resting artery velocity]/Resting artery velocity expressed as percentage. After 2 years of CPAP treatment, the test was repeated. RESULTS: Seventy-six patients represented the study pool. After 2 years of treatment with CPAP, we were able to conduct a reassessment in 65 patients. Of the 65 patients who finished the clinical study, 56 were men, and 9 were women, with an average age of 48.1 ± 10.4 years. There was an improvement in the ApT after CPAP treatment (30.8 ± 12.1 vs 39.8 ± 15.1; p:0.000). The values of cerebral blood flow velocities, diastolic blood pressure in apnea, and basal heart rate decreased. CONCLUSIONS: Cerebral vascular reactivity in OSAS patients measured by ApT improved after 2 years of CPAP.

Recurrent transient ischaemic attack and early risk of stroke: data from the PROMAPA study.

BACKGROUND: Many guidelines recommend urgent intervention for patients with two or more transient ischaemic attacks (TIAs) within 7 days (multiple TIAs) to reduce the early risk of stroke. OBJECTIVE: To determine whether all patients with multiple TIAs have the same high early risk of stroke. METHODS: Between April 2008 and December 2009, we included 1255 consecutive patients with a TIA from 30 Spanish stroke centres (PROMAPA study). We prospectively recorded clinical characteristics. We also determined the short-term risk of stroke (at 7 and 90 days). Aetiology was categorised using the TOAST (Trial of Org 10172 in Acute Stroke Treatment) classification. RESULTS: Clinical variables and extracranial vascular imaging were available and assessed in 1137/1255 (90.6%) patients. 7-Day and 90-day stroke risk were 2.6% and 3.8%, respectively. Large-artery atherosclerosis (LAA) was confirmed in 190 (16.7%) patients. Multiple TIAs were seen in 274 (24.1%) patients. Duration <1 h (OR=2.97, 95% CI 2.20 to 4.01, p<0.001), LAA (OR=1.92, 95% CI 1.35 to 2.72, p<0.001) and motor weakness (OR=1.37, 95% CI 1.03 to 1.81, p=0.031) were independent predictors of multiple TIAs. The subsequent risk of stroke in these patients at 7 and 90 days was significantly higher than the risk after a single TIA (5.9% vs 1.5%, p<0.001 and 6.8% vs 3.0%, respectively). In the logistic regression model, among patients with multiple TIAs, no variables remained as independent predictors of stroke recurrence. CONCLUSIONS: According to our results, multiple TIAs within 7 days are associated with a greater subsequent risk of stroke than after a single TIA. Nevertheless, we found no independent predictor of stroke recurrence among these patients.

Charlson comorbidity index in ischemic stroke and intracerebral hemorrhage as predictor of mortality and functional outcome after 6 months.

BACKGROUND: The Charlson Comorbidity Index (CCI) is commonly used in outcome and mortality studies. Our aim was to investigate the association between CCI score and the functional outcome and mortality 6 months after ischemic stroke (IS) or intracerebral hemorrhage. METHODS: This was a prospective observational cohort of patients with spontaneous intracerebral hemorrhage and IS admitted to the stroke unit during 18 months. The modified Rankin scale (mRS) score was obtained for subjects 6 months after event. The CCI score was dichotomized (low comorbidity 0 or 1 versus high ≥ 2) for analysis. The mRS score was also dichotomized (good outcome, mRS score 0 or 1 versus poor outcome, mRS score ≥ 2). RESULTS: In all, 175 patients were enrolled in the study. Logistic regression showed that those with a high CCI score (≥ 2) had 37.3% increased odds of having a poor outcome (≥ 2) at 6 months and 68.4% greater odds of death at 6 months. CONCLUSIONS: Comorbid medical conditions independently influence outcome after IS or intracerebral hemorrhage.

Cerebral hemodynamic changes at basilar artery in obstructive sleep apnea syndrome after continuous positive airway pressure treatment.

BACKGROUND: Cerebral vasoreactivity in obstructive sleep apnea syndrome is altered. Continuous positive airway pressure is effective in the reduction of the occurrence of apneas. We studied whether this treatment also improves cerebral vasoreactivity. METHODS: The breath-holding maneuver was performed and assessed by apnea test with transcranial Doppler in the basilar artery. After 2 years of continuous positive airway pressure treatment, the test was repeated. RESULTS: There is an improvement in the apnea test after continuous positive airway pressure. There are increases in the pulsatility index, diastolic blood pressure, and basal heart rate. The improvement in the apnea test depends on the body mass index of the patient. CONCLUSIONS: Cerebral vasoreactivity as measured by the apnea test improves after 2 years of continuous positive airway pressure. This improvement depends of the body mass index of the patient.

[Evaluation of the instrumental activities of daily living following a stroke by means of the Lawton and Brody scale]. / Valoración de las actividades instrumentales de la vida diaria tras un ictus mediante la escala de Lawton y Brody.

INTRODUCTION: The instrumental activities of daily living are activities that are somewhat more complex than basic activities of daily living, and being able to perform them allows a person to be independent within a community. They include housework, tasks involving mobility, managing the home and property; catching the bus; cooking meals and going shopping, among other things. AIMS: To evaluate these activities using the Lawton and Brody scale following an ischaemic stroke or intraparenchymatous haemorrhage and to analyse the factors that have an influence on the functional status at six months. PATIENTS AND METHODS: We conducted a prospective study of patients admitted to the stroke unit between September 2010 and June 2011 diagnosed with ischaemic strokes and spontaneous intraparenchymatous haemorrhages. A series of clinical and demographic variables were collected. In the follow-up visit at six months, the patients were re-evaluated by measuring their score on the Lawton and Brody scale again. RESULTS: The percentages of the Lawton and Brody scale at six months were as follows: 28.9% of patients were highly dependent, 45.4% were moderately dependent and 25.6% were dependent. There were differences according to age, severity and the type of stroke, and also depending on the presence of aphasia or hemiparesis. CONCLUSIONS: Patients who have suffered an ischaemic stroke or haemorrhage present a poorer score in instrumental activities of daily living when age is more advanced, the stroke is more severe and when aphasia or hemiparesis are present.

Valoración de las actividades instrumentales de la vida diaria tras un ictus mediante la escala de Lawton y Brody / Evaluation of the instrumental activities of daily living following a stroke by means of the Lawton and Brody scale

Introducción. Las actividades instrumentales de la vida diaria son actividades más complejas que las actividades básicas de la vida diaria, y su realización permite que una persona pueda ser independiente dentro de una comunidad. Incluyen tareas domésticas, de movilidad, de administración del hogar y de la propiedad; coger el autobús; preparar la comida y realizar compras, entre otras. Objetivos. Valorar estas actividades mediante la escala de Lawton y Brody tras un ictus isquémico o hemorragia intraparenquimatosa y analizar los factores que influyen en el estado funcional a los seis meses. Pacientes y métodos. Estudio prospectivo de los pacientes ingresados en la unidad de ictus entre septiembre de 2010 y junio de 2011 con el diagnóstico de ictus isquémico y hemorragias intraparenquimatosas espontáneas. Se recogió una serie de variables clínicas y demográficas. En la visita de control a los seis meses se reevaluó a los pacientes midiendo nuevamente la escala de Lawton y Brody. Resultados. Los porcentajes de la escala de Lawton y Brody a los seis meses fueron los siguientes: un 28,9% de los pacientes con gran dependencia, un 45,4% con dependencia moderada y un 25,6% con independencia. Existen diferencias en función de la edad, la gravedad y el tipo de ictus, así como en función de la presencia de afasia o hemiparesia. Conclusiones. Los pacientes con ictus isquémico o hemorrágico presentan peor puntuación en las actividades instrumentales de la vida diaria en función de la edad avanzada, la gravedad del ictus y la presencia de afasia o hemiparesia (AU)

Introduction. The instrumental activities of daily living are activities that are somewhat more complex than basic activities of daily living, and being able to perform them allows a person to be independent within a community. They include housework, tasks involving mobility, managing the home and property; catching the bus; cooking meals and going shopping, among other things. Aims. To evaluate these activities using the Lawton and Brody scale following an ischaemic stroke or intraparenchymatous haemorrhage and to analyse the factors that have an influence on the functional status at six months. Patients and methods. We conducted a prospective study of patients admitted to the stroke unit between September 2010 and June 2011 diagnosed with ischaemic strokes and spontaneous intraparenchymatous haemorrhages. A series of clinical and demographic variables were collected. In the follow-up visit at six months, the patients were re-evaluated by measuring their score on the Lawton and Brody scale again. Results. The percentages of the Lawton and Brody scale at six months were as follows: 28.9% of patients were highly dependent, 45.4% were moderately dependent and 25.6% were dependent. There were differences according to age, severity and the type of stroke, and also depending on the presence of aphasia or hemiparesis.Conclusions. Patients who have suffered an ischaemic stroke or haemorrhage present a poorer score in instrumental activities of daily living when age is more advanced, the stroke is more severe and when aphasia or hemiparesis are present (AU)

[Description of a series of cases of hypnic headache. Differentiation between sexes]. / Descripcion de una serie de casos de cefalea hipnica. Diferenciacion entre sexos.

INTRODUCTION: Hypnic headache is an infrequent type of primary headache characterised by appearing almost exclusively during sleep and by waking the patient up. The pain is dull (generally bilateral), is not associated to autonomic signs and usually appears from the age of 50 onwards. PATIENTS AND METHODS: A 10-year prospective study was conducted which describes the patients with hypnic headache who were attended in a specialised headache clinic. Data collected include demographic variables, the characteristics of the pain and response to treatment. Data from males and from females were compared. RESULTS: Twenty-four patients were diagnosed with hypnic headache: 15 females and 9 males. There were no differences between sexes as regards the age at onset of the pain, the time elapsed until diagnosis, the number of episodes per month or the amount of time the pain lasted. The males reported a more intense pain (measured by means of the analogical visual scale) than the females. Neither were there any differences in terms of the presence of arterial hypertension or obstructive sleep apnoea syndrome. Response to different symptomatic and preventive treatments was scarce and with no differences between sexes. CONCLUSIONS: The pain in hypnic headaches is more intense in males, although this needs to be corroborated in longer series. Further advances need to be made in the pathophysiology of this kind of headache so as to be able to find more efficient preventive pharmacological agents.