Exploring the experience of psychological morbidity and service access in community dwelling stroke survivors: a follow-up study.

PURPOSE: Post-stroke depression occurs in one-third of stroke survivors with a similar risk of development across short, intermediate and long-term recovery stages. Knowledge of factors influencing psychological morbidity beyond the first year post-stroke can inform long-term interventions and improve community service access for stroke survivors. This paper aimed to identify the physical and psycho-social functioning status of stroke survivors beyond 12 months post-stroke. Qualitative processes explored the longer term experiences of psychological morbidity and service access needs. METHOD: A cross-sectional follow-up of participants from a prospective cohort study. In that study, patients and were followed for 12 months post-stroke. In this study, participants from that cohort study were interviewed up to five years post-stroke. Data generation and analysis were concurrent and were analysed thematically, employing a process of constant comparison. RESULTS: Our sample included 14 participants, aged 58-89 years at an average of three years post-stroke (range 18 months to five years). Our qualitative key themes emerged as follows: physical impacts on post-stroke psychological morbidity, the experience of psychological distress, factors attenuating distress and service delivery implications. CONCLUSIONS: The experience of psychological morbidity persists beyond 12 months post-stroke, having a profound impact on community access, and social participation. Clinical implications are a need for long-term psychological monitoring post-stroke and for ongoing rehabilitation that addresses disability, community participation and social support.

A multicentre, randomized, double-blinded, placebo-controlled Phase III study to investigate EXtending the time for Thrombolysis in Emergency Neurological Deficits (EXTEND).

BACKGROUND AND HYPOTHESIS: Thrombolytic therapy with tissue plasminogen activator is effective for acute ischaemic stroke within 4·5 h of onset. Patients who wake up with stroke are generally ineligible for stroke thrombolysis. We hypothesized that ischaemic stroke patients with significant penumbral mismatch on either magnetic resonance imaging or computer tomography at three- (or 4·5 depending on local guidelines) to nine-hours from stroke onset, or patients with wake-up stroke within nine-hours from midpoint of sleep duration, would have improved clinical outcomes when given tissue plasminogen activator compared to placebo. STUDY DESIGN: EXtending the time for Thrombolysis in Emergency Neurological Deficits is an investigator-driven, Phase III, randomized, multicentre, double-blind, placebo-controlled study. Ischaemic stroke patients presenting after the three- or 4·5-h treatment window for tissue plasminogen activator and within nine-hours of stroke onset or with wake-up stroke within nine-hours from the midpoint of sleep duration, who fulfil clinical (National Institutes of Health Stroke Score ≥4-26 and prestroke modified Rankin Scale <2) will undergo magnetic resonance imaging or computer tomography. Patients who also meet imaging criteria (infarct core volume <70 ml, perfusion lesion : infarct core mismatch ratio >1·2, and absolute mismatch >10 ml) will be randomized to either tissue plasminogen activator or placebo. STUDY OUTCOME: The primary outcome measure will be modified Rankin Scale 0-1 at day 90. Clinical secondary outcomes include categorical shift in modified Rankin Scale at 90 days, reduction in the National Institutes of Health Stroke Score by 8 or more points or reaching 0-1 at day 90, recurrent stroke, or death. Imaging secondary outcomes will include symptomatic intracranial haemorrhage, reperfusion and or recanalization at 24 h and infarct growth at day 90.