Stroke Recovery Program with Modified Cardiac Rehabilitation Improves Mortality, Functional & Cardiovascular Performance.

BACKGROUND: Physical activity and exercise after stroke is strongly recommended, providing many positive influences on function and secondary stroke prevention. The purpose of this study was to investigate the effect of a stroke recovery program (SRP) integrating modified cardiac rehabilitation on mortality and functional outcomes for stroke survivors. METHODS: This study used a retrospective analysis of data from a prospectively collected stroke rehabilitation database which followed 449 acute stroke survivors discharged from an inpatient rehabilitation facility between 2015 and 2020. For 1-year post-stroke, 246 SRP-participants and 203 nonparticipants were compared. The association of the SRP including modified cardiac rehabilitation with all-cause mortality and functional performance was assessed using the following statistical techniques: log rank test, Cox proportional hazard model and linear mixed effect models. Cardiovascular performance over 36 sessions of modified cardiac rehabilitation was assessed using linear effect model with Tukey procedure. The primary outcome measure was 1-year all-cause mortality rate. Secondary outcomes were functional performance measured in Activity Measure of Post-Acute Care scores and cardiovascular performance measured in metabolic equivalent of tasks times minutes. RESULTS: The SRP-participants had: (1) a significantly reduced 1-year post-stroke mortality rate from hospital admission corresponding to a four-fold reduction in mortality (P = 0.005, CI for risk ratio = [0.08, 0.71]), (2) statistically and clinically significant improvement of function in all Activity Measure of Post-Acute Care domains (P < 0.001 for all, 95% CI for differences in Basic Mobility [5.9, 10.1], Daily Activity [6.2, 11.8], and Applied Cognitive [3.0, 6.8]) compared to the matched cohort and (3) an improvement in cardiovascular performance over 36 sessions with an increase of 78% metabolic equivalent of tasks times minutes (P < 0.001, 95% CI [70.6, 85.9%]) compared to baseline. CONCLUSIONS: Stroke survivors who participated in a comprehensive stroke recovery program incorporating modified cardiac rehabilitation had decreased all-cause mortality, improved overall function, and improved cardiovascular performance.

An observational epidemiological study to analyze intracerebral hemorrhage across the United States: Incidence and mortality trends from 1990 to 2017.

OBJECTIVES: Intracerebral Hemorrhage (ICH) accounts for 10% of strokes annually in the United States (US). Up-to-date trends in disease burden and regional variations remain unknown. Our study reports updated trends of ICH incidence, mortality, and mortality to incidence ratio (MIR) across the US. MATERIALS AND METHODS: Observational study to evaluate the incidence and mortality from ICH across the US. Data was obtained from Global Burden of Disease (GBD) database. Age-Standardized Incidence (ASIRs) and Death (ASDRs) Rates, as well as the Mortality- to-Incidence ratios (MIRs) for ICH in the US overall and state-wise from 1990-2017. Joinpoint regression analysis was used, with presentation of estimated annual percentage changes (EAPCs). RESULTS: Overall decrease in ASIRs, ASDRs, and MIRs in the US for both sexes. The 2017 mean ASIR was 25.67/100,000 for men and 19.17/100,000 for women, whereas mean ASDR was 13.96/100,000 for men and 11.35/100,000 for women. District of Columbia had greatest decreases in ASIR EAPCs for both men and women at -41.25% and -40.58%, respectively, and greatest decreases in ASDR EAPCs for men and women at -55.38% and -48.51%, respectively. MIR between 1990-2017 decreased in men by -12.12% and women by -7.43%. MIR increased in men from 2014-2017 (EAPC +2.2%) and in women from 2011-2017 (EAPC +1.0%). CONCLUSION: Decreasing trends in incidence, mortality, and MIR. No significant trends in mortality were found in the last 6 years of the study period. MIR worsened in males from 2014-2017 and females from 2011-2017, suggesting decreased ICH-related survival lately.

Impact of Modified Cardiac Rehabilitation Within a Stroke Recovery Program on All-Cause Hospital Readmissions.

OBJECTIVE: A Stroke Recovery Program (SRP) including cardiac rehabilitation demonstrated lower all-cause mortality rates, improved cardiovascular function, and overall functional ability among stroke survivors. Neither an effect of SRP on acute care hospital readmission rates nor cost savings have been reported. DESIGN: This prospective matched cohort study included 193 acute stroke survivors admitted to an inpatient rehabilitation facility between 2015 and 2017. The 105 SRP participants and 88 nonparticipants were matched exactly for stroke type, sex, and race and approximately for age, baseline functional scores, and medical complexity scores. Primary outcome measured acute care hospital readmission rate up to 1 yr post-stroke. Secondary outcomes measured costs. RESULTS: A 22% absolute reduction (P = 0.006) in hospital readmissions was observed between the SRP participant (n = 47, or 45%) and nonparticipant (n = 59, or 67%) groups. This resulted in significant cost savings. The conventional care cost to the Center for Medicare and Medicaid Services for stroke patients for both readmissions and outpatient therapy is estimated at $9.67 billion annually. The yearly cost for these services with utilization of the SRP is $8.55 billion. CONCLUSION: Acute care hospital readmissions were reduced in stroke survivors who participated in SRP. Future study is warranted to examine whether widespread application of a similar program may improve quality of life and decrease cost.

Surgical Masks May Hide Neurological Diagnoses.

COVID-19 has disrupted the routine flow of patients through emergency departments (EDs) across the globe, including the need to consider COVID-19 for nearly all presenting complaints. The constraints of mask wearing and isolation have created inherent barriers to timely stroke care. We present a case that highlights one of the many ways in which the pandemic has negatively impacted the care of the non-COVID patient. A patient presented to the ED with a chief complaint of diffuse weakness and a new-onset cough on awakening. His daughter noted that he was slurring his words. An emergency medicine resident evaluated him, ordered laboratory studies, and decided to monitor the patient. The same resident later noted the patient veering to the left when walking, prompting a more detailed neurological examination. On removing the patient's facemask, a left lower facial weakness was evident. The resident called a Code Stroke roughly 50 min after the patient initially presented to the ED. The patient proved to have an acute infarct at the right thalamocapsular junction. Universal masking policies during the COVID-19 pandemic should not prevent the routine assessment of cranial nerve function for all patients presenting to an ED.

Impact of a Stroke Recovery Program Integrating Modified Cardiac Rehabilitation on All-Cause Mortality, Cardiovascular Performance and Functional Performance.

OBJECTIVE: Using a feasibility analysis and matched subgroup analysis, this study investigated the implementation/safety/outcomes of a stroke recovery program (SRP) integrating modified cardiac rehabilitation for stroke survivors. DESIGN: This prospective cohort study of 783 stroke survivors were discharged from an inpatient rehabilitation facility to an outpatient setting; 136 SRP-participants completed a feasibility study and received the SRP including modified cardiac rehabilitation, 473 chose standard of care rehabilitation (nonparticipants), and a group (n = 174) were excluded. The feasibility study assessed the following: safety/mortality/pre-post cardiovascular performance/pre-post function/patient/staff perspective. In addition to the feasibility study, a nonrandomized subgroup analysis compared SRP-participants (n = 76) to matched pairs of nonparticipants (n = 66, with 10 nonparticipants used more than once) for mortality/pre-post function. RESULTS: The feasibility study showed the SRP to have the following (a) excellent safety, (b) markedly low 1-yr poststroke mortality from hospital admission (1.47%) compared with national rate of 31%, (c) improved cardiovascular performance over 36 sessions (103% increase in metabolic equivalent of tasks times minutes), (d) improved function in Activity Measure of Post-Acute Care domains (P < 0.001), (e) positive reviews from SRP-participants/staff. Subgroup analysis showed the SRP to (a) positively impact mortality, nonparticipants had a 9.09 times higher hazard of mortality (P = 0.039), and (b) improve function in Activity Measure of Post-Acute Care domains (P < 0.001). CONCLUSIONS: Stroke survivors receiving a SRP integrating modified cardiac rehabilitation may potentially benefit from reductions in all-cause mortality and improvements in cardiovascular performance and function.

Comorbidities confounding the outcomes of surgery for third window syndrome: Outlier analysis.

Objective: Patients with third window syndrome and superior semicircular canal dehiscence (SSCD) symptoms whose surgical outcomes placed them as outliers were systematically studied to determine comorbidities that were responsible for their poor outcomes due to these confounding factors. Study Design: Observational analytic case-control study in a tertiary referral center. Methods: Twelve adult patients with clinical SSCD syndrome underwent surgical management and had outcomes that did not resolve all of their subjective symptoms. In addition to one of the neurotologists, 2 neurologists (one specializing in migraine and the other a neuro-ophthalmologist), and a psychologist clinician-investigator completed comprehensive evaluations. Neuropsychology test batteries included: the Millon Behavioral Medicine Diagnostic; Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder Screener (GAD-7); Adverse Childhood Experiences Scale; the Wide Range Assessment of Memory and Learning, including the 3 domains of verbal memory, visual memory, and attention/concentration; Wechsler Adult Intelligence Scale; and the Delis-Kaplan Executive Function System. The control cohort was comprised of 17 participants who previously underwent surgery for third window syndrome that resulted in the expected outcomes of resolution of their third window syndrome symptoms and cognitive dysfunction. Results: There was a high rate of psychological comorbidity (n = 6) in the outlier cohort; multiple traumatic brain injuries were also a confounding element (n = 10). One patient had elevated cerebrospinal fluid (CSF) pressure requiring ventriculoperitoneal shunting to control the recurrence of dehiscence and one patient with a drug-induced Parkinson-like syndrome and idiopathic progressive neurological degenerative process. Conclusions: Components of the Millon Behavioral Medicine Diagnostic, PHQ-9 and GAD-7 results suggest that these instruments would be useful as screening tools preoperatively to identify psychological comorbidities that could confound outcomes. The identification of these comorbid psychological as well as other neurological degenerative disease processes led to alternate clinical management pathways for these patients. Level of Evidence: 2b.

A familial form of benign paroxysmal positional vertigo maps to chromosome 15.

AIM: Benign positional paroxysmal vertigo (BPPV) is characterized by short-lived episodes of vertigo in association with rapid changes in head position, most commonly extension and rotation of the neck while supine. It has been clinically observed that there is a subgroup of patients in whom the BPPV disease is inherited in an autosomal dominant fashion. However, little is known about the familial/genetic factors that may contribute to a predisposition to develop the disease. MATERIALS AND METHODS: We ascertained and performed a genome-wide scan on a three-generation family in which multiple family members developed BPPV. We performed whole genome mapping with 400 microsatellite repeat markers and analyzed this trait using both autosomal dominant and recessive models of inheritance. RESULTS: Two point linkage analysis showed LOD scores of one or greater than one on chromosomes 7, 15, 16 and 20. Independent of the model of inheritance, the highest two-point LOD scores localized to same marker on chromosome 15. Multipoint linkage analysis showed the highest LOD score of 2.84 to markers on chromosome 15 with the autosomal dominant model. Haplotype reconstruction indicates that the BPPV gene in this family maps to a critical chromosomal 15 interval between markers GATA151F03N and GATA85D02. CONCLUSIONS: Discovery of a BPPV gene (or genes) will facilitate a better understanding of not only BPPV, but also the vestibular system. In addition, with improved understanding of the pathophysiology the potential development of alternative therapies for BPPV may be possible.

Risk factors for acute stroke among South Asians compared to other racial/ethnic groups.

BACKGROUND: Studies of racial/ethnic variations in stroke rarely consider the South Asian population, one of the fastest growing sub-groups in the United States. This study compared risk factors for stroke among South Asians with those for whites, African-Americans, and Hispanics. METHODS: Data on 3290 stroke patients were analyzed to examine risk differences among the four racial/ethnic groups. Data on 3290 patients admitted to a regional stroke center were analyzed to examine risk differences for ischemic stroke (including subtypes of small and large vessel disease) among South Asians, whites, African Americans and Hispanics. RESULTS: South Asians were younger and had higher rates of diabetes mellitus, blood pressure, and fasting blood glucose levels than other race/ethnicities. Prevalence of diabetic and antiplatelet medication use, as well as the incidence of small-artery occlusion ischemic stroke was also higher among South Asians. South Asians were almost a decade younger and had comparable socioeconomic levels as whites; however, their stroke risk factors were comparable to that of African Americans and Hispanics. DISCUSSION: Observed differences in stroke may be explained by dietary and life style choices of South Asian-Americans, risk factors that are potentially modifiable. Future population and epidemiologic studies should consider growing ethnic minority groups in the examination of the nature, outcome, and medical care profiles of stroke.

Lipid profiles and ischemic stroke risk: variations by sex within racial/ethnic groups.

Evidence implicates lipid abnormalities as important but modifiable risk factors for stroke. This study assesses whether hypercholesterolemia can be used to predict the risk for etiologic subtypes of ischemic stroke between sexes within racial/ethnic groups. Data elements related to stroke risk, diagnosis, and outcomes were abstracted from the medical records of 3,290 acute stroke admissions between 2006 and 2010 at a regional stroke center. Sex comparison within racial/ethnic groups revealed that South Asian and Hispanic men had a higher proportion of ischemic stroke than women, while the inverse was true for Whites and African Americans (P=0.0014). All women, except South Asian women, had higher mean plasma total cholesterol and higher blood circulating low-density lipoprotein levels (≥100 mg/dL) than men at the time of their admissions. The incidence of large-artery atherosclerosis (LAA) was more common among women than men, except among Hispanics, where men tended to have higher incidences. A regression analysis that considered patients diagnosed with either LAA or small-artery occlusion etiologic subtype as the outcomes and high-density lipoproteins and triglycerides as predictors showed inconsistent associations between lipid profiles and the incidence of these subtypes between the sexes within racial/ethnic groups. In conclusion, our investigation suggests that women stroke patients may be at increased risk for stroke etiologic subtype LAA than men. Although the higher prevalence of stroke risk factors examined in this study predicts the increase in the incidence of the disease, lack of knowledge/awareness and lack of affordable treatments for stroke risk factors among women and immigrants/non-US-born subpopulations may explain the observed associations.

Compliance with joint commission measures in state-designated stroke centers.

BACKGROUND: Comparison of state-designated primary and comprehensive stroke centers (PSCs and CSCs) with regard to adherence to nationally accepted performance standards are scarce. The objective of this study was to examine if a significant association exists between level of designation and fulfillment of Joint Commission (JC) stroke core measures. METHODS: A retrospective comparative data analysis of the New Jersey acute stroke registry for the calendar years 2010 and 2011 was performed. JC core measures were compared by hospital level (PSCs vs CSCs). Adjusted odds ratios (aOR) were estimated for association between hospital levels and fulfillment of JC core measures. Median door-to-thrombolytic time was also compared. RESULTS: There were 36,892 acute stroke admissions. PSCs had 60% of the patients, whereas CSCs had 40%. Hemorrhagic stroke admissions were about 2 times more frequent at CSCs than PSCs (13.3% and 7.1%, respectively). CSCs adhered better to 6 of the 8 JC measures than PSCs. Of eligible patients, 19.5% received thrombolytic therapy at CSCs compared to 9.6% at PSCs, with a 44% difference in provision of thrombolytic therapy (aOR = 0.28, 95% confidence interval: 0.24-0.34). Median door-to-thrombolytic drug times was 65 minutes at CSCs compared to 74.0 minutes at PSCs (P < 0.0001). CONCLUSIONS: New Jersey state-designated CSCs are better at adhering to the JC core stroke measures and have shorter door-to-thrombolytic drug times.

Disparities in acute stroke severity, outcomes, and care relative to health insurance status.

BACKGROUND: To examine the differences in risk factors and length of hospital stay (LOS) between the insured and uninsured stroke patients, identifying the root causes of increasing hospital stay. METHODS: Retrospective analysis of stroke registry data of acute stroke patients (N = 19,255) was analyzed to compare risk factors, severity, outcome, and LOS by insurance status. Chart review of patients from a comprehensive stroke center (N = 3290) was studied in greater detail for causes of extended length of stay. RESULTS: The uninsured patients had poorer control of risk factors and statistically significantly (P < .0001) higher initial stroke severity, mortality, and LOS as compared with insured patients (3.8 versus 4.5 days, respectively). The increased length of stay was largely accounted for by the inability to transfer uninsured patients to inpatient rehabilitation settings. CONCLUSION: This study highlights the need for public policies that provide funding for both primary stroke prevention and poststroke rehabilitation.

Advances in thrombolytics for treatment of acute ischemic stroke.

Over the past 50 years, thrombolytic agents have been devised with the aim of recanalizing occluded coronary vessels, and later on, applied in the setting of acute ischemic stroke. Pharmacologic agents have generally targeted the plasminogen-plasmin transformation, facilitating the natural process of fibrinolysis. Newer agents with varying degrees of fibrin selectivity and pharmacologic half-life have influenced both recanalization rates and hemorrhagic complications, inside and outside the CNS. Intra-arterial (IA) administration of fibrinolytic agents increases delivery of the drug to the thrombus at a higher concentration with smaller quantities and therefore lowers systemic exposure. Mechanical thrombus disruption or extraction allows for drug delivery to a greater surface area of the thrombus. Delays associated with IA therapy may worsen the risk/benefit ratio of thrombolysis; therefore, combinations of IA-IV treatments have been studied. To date, there are no direct comparative trials to show that endovascular administration is more efficacious or carries a lower risk of hemorrhagic complications than IV tissue plasminogen activator.

Reversible cerebral vasoconstriction syndrome in a 35-year-old woman following hysterectomy and bilateral salpingo-oophorectomy.

INTRODUCTION: Reversible cerebral vasoconstriction syndromes (RCVS) have been documented to take place after an inciting event or illness. They present with headache, altered mental status and focal neurologic findings. The differential diagnosis includes primary angiitis of the central nervous system (PACNS) but one major clinical difference is that the symptoms of RCVS usually resolve within days or weeks whereas PACNS is often fatal. Females of childbearing age are most commonly affected with RCVS. Cases of reversible vasculopathy have also been reported in menopausal women. The hormonal and physiologic changes that take place during the postpartum period and menopause may not be very different from those that occur after a hysterectomy and oophorectomy. METHODS: A case is presented of a 35-year-old woman who underwent a hysterectomy with bilateral salpingo-oophorectomy and then began experiencing severe headaches, visual changes and hemi-sensory loss. Physical examination, imaging and laboratory findings were descriptive of RCVS, and the patient's rapid recovery was consistent with the usual disease progression of a reversible vasculopathy. CONCLUSION: A reversible cerebral vasoconstriction syndrome may occur in some circumstances after a hysterectomy with bilateral salpingo-oophorectomy. The mechanisms involved in the development of this condition are explained by current research concerning effects on the vasculature of sudden drops in estrogens and progesterones. More studies are required to further establish the pathophysiology, diagnosis and treatment of this condition.

A case of locked-in syndrome complicated by central deafness.

BACKGROUND: A 53-year-old male with a history of hypertension, diabetes mellitus, and factor V deficiency presented to an emergency room with progressively increasing headache, slurred speech, and left upper extremity weakness. Over the previous 3 months, he had been receiving warfarin for prophylaxis of deep venous thrombosis following knee surgery. After presentation and an initial period of coma, he became tetraplegic and anarthric, requiring intubation and ventilatory assistance. INVESTIGATIONS: Neurological examination, CT scan, electroencephalogram, brainstem auditory and visual evoked potential studies, neuropsychological assessment and functional MRI studies. DIAGNOSIS: Locked-in syndrome following ventral pontine hemorrhage, complicated by central deafness secondary to extension of the lesion to the inferior colliculus. MANAGEMENT: Development of an augmentative communication system designed to exploit the patient's preserved cognitive and motor functions.

Vestibular disease and cognitive dysfunction: no evidence for a causal connection.

OBJECTIVE: To evaluate the contribution of vestibular pathology to cognitive and affective complaints of patients with and without brain trauma. SETTING: An outpatient balance disorders clinic within a tertiary care neuroscience institute. PARTICIPANTS: 200 patients with dizziness--half with a recent history of brain trauma and half without. MAIN OUTCOME MEASURES: The Dizziness Handicap Inventory, the Beck Depression Inventory, and the Neurobehavioral Symptom Inventory were prospectively administered. Neurological examination and vestibular testing were performed to arrive at a diagnosis for the dizziness. Multiple regression analyses were carried out using vestibular diagnosis, psychiatric diagnosis, and trauma history as predictors of the inventory scores. RESULTS: Perceived disability was higher in dizzy patients with a history of brain trauma compared with dizzy patients without a history of trauma. A diagnosis of vestibular disease had no influence on perceived disability. Similarly, cognitive complaints were more common in dizzy patients with a history of brain trauma compared to dizzy patients without a history of trauma, but a diagnosis of vestibular disease had no influence on the frequency of cognitive complaints. CONCLUSIONS: In patients with postconcussive dizziness, cognitive complaints are likely due to neurologic injury or affective disturbance. In dizzy patients without brain trauma, cognitive complaints are likely due to concurrent affective disturbance.

Suppression of the human vestibulo-ocular reflex by visual fixation or forced convergence in the dark, with a model interpretation.

Six normal humans experienced yaw axis steps of velocity at 120 degrees /s in the dark. During the post-rotary period, subjects either had a null-task (do nothing); an ocular motor task (forced convergence: crossing the eyes); or a visual task (fixating a head-stationary target against a background of 10 degrees light/dark bars). Tasks started at 3 s post-rotation, and lasted either 2, 5, 10, or 15 s. Ocular motor and visual tasks were tested on different days. Five repetitions of each task duration were recorded for each subject. A mean VOR gain of 0.52 was observed, which did not vary with experimental conditions. Both convergence and fixation markedly suppressed nystagmus; in fact, the VORs obtained with the two different tasks are superficially similar in appearance. However, mean null-task time-constants were 9.4 s for convergence days, but 8.4 s for fixation days, and there was a small but significant reduction in overall null-task VOR amplitude on fixation days. Also, post-convergence slow-phase velocities were slightly enhanced, while post-fixation velocities were significantly reduced. The time-constant of velocity storage was found to be 10.1 s for convergence responses and 8.2 s for fixation responses. These differences can be understood in terms of modifications in central velocity storage during visual fixation which do not occur with convergence. The mean fixation data were analyzed in the context of a VOR model well-established for monkey data. With appropriate choice of parameters, this model accurately reproduces most features of the human data. An estimate for the human cupula time-constant of 3.3 s is obtained. Compared with the monkey, fixation suppression is greater and post-fixation velocity reduction less. Retinal slip alone accounts well for this; "velocity dumping" by an integrator shunt must be slight if present at all. The model correctly represents the post-fixation VOR for all durations of fixation.