In randomized controlled trials of secondary prevention after stroke, the risk of hemorrhage varies between 1% and 5% per year in patients with antithrombotic therapy, i.e. anticoagulants and antiplatelets.Aim
To explore the rate and the risk of hemorrhage after stroke in a nationwide cohort.Methods
We identified 58 868 first ever ischemic stroke patients in the Swedish Stroke Register during 2001 to 2005 (=index stroke) and followed them by record linkage to the National Patient Register. Rates of hemorrhage and hazard ratios, for comparisons of rates between subgroups, were calculated.Results
Of the 58 586 ischemic stroke patients identified, 5527 (9·4%) had a history of hemorrhage. During follow-up (mean 2·0 years), 2876 patients endured a hemorrhage, giving an average hemorrhage rate of 2·6 (95% confidence interval 2·5–2·7) per 100 person-years. After index stroke, 11% of the patients were discharged with anticoagulants, and 79% with antiplatelets. Given the differences in baseline characteristics, the hemorrhage rates (per 100 person-years) were 2·5 (95% confidence interval 2·2–2·8), 2·4 (95% confidence interval 2·3–2·5), and 3·8 (95% confidence interval 3·5–4·2) in patients prescribed anticoagulants, antiplatelets, and no antithrombotics, respectively. There was an increased risk of hemorrhage in patients ≥75 years compared with those <75 years (hazard ratio = 1·61, 95% confidence interval 1·49–1·73) and in patients with previous hemorrhages compared with those without (hazard ratio = 1·82, 95% confidence interval 1·64–2·02).Conclusions
When antithrombotics were used in large-scale clinical practice, the observed rates of hemorrhage were similar with anticoagulant therapy but increased with antiplatelet therapy compared with rates reported in randomized controlled trials. Old age and previous hemorrhage were associated with an increased risk of hemorrhage after an ischemic stroke.
International guidelines recommend oral anticoagulation in patients with atrial fibrillation according to their level of stroke risk. This study aimed to determine oral anticoagulation use in atrial fibrillation patients with recent ischemic stroke and examine factors that impact such management in China.Methods
Among the patients with acute ischemic stroke (n = 4782) from the China QUality Evaluation of Stroke Care and Treatment study, a multicenter, prospective, 62-hospital registry in China, there were 499 (10%) (mean age 70 ± 12 years, 49% female) with documented atrial fibrillation with outcome data over 12 months of follow-up. Logistic regression analysis was used to identify the independent predictors of oral anticoagulation use in these patients.Results
Of the 499 stroke patients with atrial fibrillation, oral anticoagulation use was 20% overall but varied from 8% prestroke and 11% in-hospital (poststroke), to 13% and 10% at three-months and 12 months, respectively. Oral anticoagulation use was independently associated with younger age (odds ratio 0·95, 95% confidence interval 0·93–0·97, P < 0·001), nonmanual occupation (odds ratio 0·44, 95% confidence interval 0·25–0·80, P = 0·006), and less cardiovascular risk factors (odds ratio 0·81, 95% confidence interval 0·68–0·96, P = 0·02).Conclusions
These data indicate oral anticoagulation use is lower in stroke patients with atrial fibrillation in China than that in Western countries, being applied more often in those of younger age, nonmanual occupation, and having less cardiovascular risk factors.
Thrombolysis with intravenous alteplase has been proven an effective treatment for patients with acute ischemic stroke in randomized clinical trials. In daily practice, the effect of thrombolysis may be less, and complications may occur more often.Aims
The aim of this study was to assess effectiveness and safety of thrombolysis in an unselected observational cohort of patients.Methods
During a two-year period, all patients over 18 years with acute stroke who were admitted within four-hours from onset of symptoms in 12 centers were registered. We compared outcomes in patients who were treated with alteplase with patients who were not treated with alteplase. The primary outcome was good functional outcome at three-months measured with the modified Rankin Scale ≤2). The safety end point was symptomatic intracranial hemorrhage and mortality. We used a multivariable logistic regression model to adjust for baseline imbalances and multilevel analysis to take into account within center correlations.Results
Overall, 1657 patients with ischemic stroke were admitted within four-hours from onset of symptoms and 696 (42%) were treated with alteplase. Treatment with alteplase was associated with a favorable outcome (adjusted odds ratio 1·3; 95% confidence interval 1·0 to 1·7). After further adjustment for potential clustering effects, the adjusted odds ratio for good outcome was 1·4 (95% confidence interval 1·0 to 1·8). Thirty-six (5%) of the 696 patients treated with alteplase had a symptomatic intracranial bleeding complication.Conclusions
Thrombolysis for ischemic stroke with intravenous alteplase is an effective treatment also in an unselected observational cohort of patients.
The influence of lesion size and laterality on each component of the National Institutes of Health Stroke Scale has not been delineated. The objective of this study was to use perfusion-weighted imaging to characterize the association of ischaemic volume and laterality on each component item and the total score of the <National Institutes of Health Stroke Scale.Methods
We analysed consecutive right-handed patients with first-ever supratentorial acute ischaemic strokes who underwent acute perfusion-weighted imaging at a single centre. Perfusion deficits were defined as mean transit time > 10 s. Ordinal regression was used to clarify the relationship between ischaemic volume, laterality, and <National Institutes of Health Stroke Scale scores.Results
Among 111 patients, 58 were left-hemisphere stroke, and 53 right-hemisphere stroke. Median ischaemic volume was 53 ml in left-hand stroke and 65 ml in right-hand stroke and median total National Institutes of Health Stroke Scale was 10 in left-hand stroke and eight in right-hand stroke. For individual National Institutes of Health Stroke Scale items, ischaemic volume correlated most closely with commands and visual field and most weakly with ataxia and neglect. Left-hand stroke predicted higher scores of total National Institutes of Health Stroke Scale and National Institutes of Health Stroke Scale items of questions, commands, right limb weakness, and language. Right-hand stroke predicted higher scores of left limb weakness and extinction.Conclusions
Larger perfusion defects contribute to higher scores on the total and most individual items of the National Institutes of Health Stroke Scale. However, lesion laterality contributes substantially to half the item scores, with greater association of left than right-brain side. These findings indicate that imaging-deficit correlations will be improved by designating lesions into an atlas, taking into account side in addition to size.
Chronic low bone mineral density is associated with an increased risk of stroke. However, little is known about the influence of bone mineral density at the time of stroke on clinical outcome. We investigated the association between bone mineral density and functional disability at three-months in patients with acute ischemic stroke.Methods
We retrospectively examined consecutive acute ischemic stroke patients who underwent bone densitometry tests within seven-days of stroke symptom onset. Patient demographics, risk factors, and initial National Institute of Health Stroke Scale scores were assessed. Bone mineral density was measured at the lumbar spine and bilateral femoral necks. Osteoporosis was defined as bone mineral density ≤–2·5 T-scores at each site. The primary outcome was modified Rankin Scale at 90 days poststroke. A favorable outcome was defined as modified Rankin Scale 0–1 and poor outcome as modified Rankin Scale 2–6.Results
Of the 191 patients included, 61 (31·9%) were men. Mean age (±standard deviation) was 69·8 ± 11·1 years. Patients with osteoporosis of the right femoral neck were more likely to have poor outcome (25/82; 30·5%) than those without (12/109; 11·0%, P = 0·001). After adjustment for age, sex, and initial National Institute of Health Stroke Scale score, osteoporosis of the right femoral neck was significantly associated with poor outcome (odds ratio, 2·97; 95% confidence interval 1·21 to 7·32, P = 0·018).Conclusions
Low bone mineral density of the right femur in the acute poststroke period is associated with poor outcome at three-months. Assessment of bone mineral density in acute stroke patients may be a useful prognosticator and facilitate early intervention.
Of the stroke types, intracerebral hemorrhage is the most debilitating and fatal. The aim of the current study was to determine factors that influence the severity and in-hospital mortality after primary intracerebral hemorrhage.Methods
Data were collected retrospectively on 1268 patients with primary intracerebral hemorrhage admitted to stroke units at participating hospitals in Guangzhou between January 2005 and August 2008. Logistic regression analysis was used to determine factors associated with severity on admission and in-hospital mortality.Results
Of the 1268 patients, 20·4% were reported to have a severe stroke on admission, and the in-hospital mortality rate was 12·5%. Severity on admission was strongly associated with Glasgow Coma Scale score on admission (odds ratio = 0·89, 95% confidence interval 0·85–0·94) and hematoma location. Notably, basal ganglia hemorrhages were associated with increased severity (odds ratio = 1·40, 95% confidence interval 1·03–1·90), and cerebellar hemorrhages were associated with reduced severity (odds ratio = 0·29, 95% confidence interval 0·10–0·84). In-hospital mortality was not only correlated with Glasgow Coma Scale score on admission (odds ratio = 0·79, 95% confidence interval 0·74–0·84) and basal ganglia location (odds ratio = 0·47, 95% confidence interval 0·26–0·83), but also with dysnatremia (odds ratio = 1·91, 95% confidence interval 1·08–3·40) and comorbidities such as upper gastrointestinal hemorrhage (odds ratio = 2·28, 95% confidence interval 1·33–3·91), pneumonia (odds ratio = 3·50, 95% confidence interval 2·17–5·63), urinary incontinence (odds ratio = 2·22, 95% confidence interval 1·40–3·51), and renal dysfunction (odds ratio = 2·28, 95% confidence interval 1·42–3·65).Conclusion
Glasgow Coma Scale score and hematoma locations were independently associated with severity on admission and in-hospital mortality after primary intracerebral hemorrhage. The study also highlights the deleterious effect of comorbidities on in-hospital mortality following primary intracerebral hemorrhage in China.
Models of intraluminal middle cerebral artery occlusion present an intrinsic variability in infarct size. Behavioral evaluation is frequently performed during arterial occlusion to confirm success of surgery.Aims and/or hypothesis
We compared the value of behavioral testing and multimodal magnetic resonance imaging performed during arterial occlusion for identifying successfully operated animals.Methods
Rats were tested with behavioral assessment (using three scoring scales and the adhesive removal test) and multimodal magnetic resonance imaging (including magnetic resonance angiography, diffusion-weighted and perfusion-weighted imaging), both performed during the two-hours of middle cerebral artery occlusion using the intraluminal suture model. Behavioral assessment was repeated 24 h after reperfusion, followed by sacrifice.Results
Acute apparent diffusion coefficient lesion volume was correlated with both 2,3,5-triphenyl tetrazolium chloride infarct size (r = 0·75, P = 0·02) and behavioral status (r = 0·66, P = 0·05) on day one. Conversely, no correlation was found between acute behavioral examination and day one outcomes (2,3,5-triphenyl tetrazolium chloride infarct volume, r = 0·40, P = 0·28; behavioral examination, r = 0·39, P = 0·30). Day zero apparent diffusion coefficient volumes (P = 0·04), but not behavioral assessment (P = 0·60), discriminated animals with day one corticostriatal infarcts from these with subcortical infarcts.Conclusions
Acute behavioral testing performed during arterial occlusion fails to identify successfully operated animals. Acute diffusion magnetic resonance imaging may be more appropriate to assess and reduce infarct size variability in this model.
The study aims to examine the association between major depression, healthcare behaviors, and quality of life indices among adults with stroke.Methods
Data from 5869 participants with stroke in the 2006 Behavioral Risk Factor Surveillance Survey were examined. Multiple logistic regression was used to assess the independent association between depression status, self-care and preventive health behaviors, and quality of life indices, after accounting for relevant covariates.Results
In multivariate models, individuals with major depression were less likely to engage in physical activity (odds ratio 0·41; 95% confidence interval 0·29, 0·56) than those without major depression. Women with major depression were also less likely to have received a mammogram in the past two-years (odds ratio 0·61; 95% confidence interval 0·40, 0·96 for women ≥ age 40 and odds ratio 0·58; 95% confidence interval 0·36, 0·72 for women ≥ age 50) and a pap smear in the past three-years (odds ratio 0·40; 95% CI 0·22, 0·72). In comparisons of quality of life, individuals with major depression were less likely to perceive their health as excellent/very good/good (odds ratio 0·36; 95% confidence interval 0·25, 0·53), to report being satisfied with life (odds ratio 0·13; 95% confidence interval 0·08, 0·20), and to report receiving needed social support (odds ratio 0·42; 95% confidence interval 0·28, 0·63). Individuals who were depressed were also more likely to report one or more poor physical and poor mental health days in the past 30 days (odds ratio 4·56; 95% confidence interval 3·08, 6·76 and odds ratio 10·97; 95% confidence interval 7·75, 15·52, respectively).Conclusions
In adults with stroke, major depression is associated with decreased engagement in stroke-specific and gender-specific self-care and preventive health behaviors, as well as a broad range of quality of life indices.
Differences in risk factor profiles between patients with ischemic and hemorrhagic stroke may have an impact on subsequent mortality.Aim
To explore cardiovascular disease risk factors, including the CHADS2 score, with survival after ischemic or hemorrhagic stroke.Methods
Between 2001 and 2005, 87 111 (83%) ischemic stroke, 12 497 (12%) hemorrhagic stroke, and 5435 (5%) patients with unspecified stroke were identified in the Swedish Stroke Register. Data on gender, age, and cardiovascular disease risk factors were linked to the Swedish Hospital Discharge and Cause of Death Registers. Adjusted odds and hazard ratios and 95% confidence interval were calculated using logistic and Cox proportional hazard regression models.Results
Hemorrhagic stroke patients were younger than ischemic stroke patients. All cardiovascular disease risk factors studied, alone or combined in the CHADS2 score, were associated with higher odds ratios for ischemic stroke vs. hemorrhagic stroke. Higher CHADS2 scores and all studied risk factors except hypertension were associated with higher odds ratio for death by ischemic stroke than hemorrhagic stroke. Ischemic stroke was associated with lower early mortality (within 30 days) vs. hemorrhagic stroke (hazard ratio = 0·28, confidence interval 0·27 to 0·29).Conclusions
Patients with hemorrhagic stroke had a higher risk of dying within the first 30 days after stroke, but the risk of death was similar in the two groups after one-month. Hypertension was the only cardiovascular disease risk factor associated with an increased mortality rate for hemorrhagic stroke as compared to ischemic stroke.
We analyzed early diffusion-weighted magnetic resonance imaging of patients with acute basilar artery occlusion by applying different lesion scoring systems and determined their predictive value for favorable outcome.Methods
Between 1998 and 2010, patients with confirmed basilar artery occlusion were entered in a local database. magnetic resonance imaging angiography was performed for diagnosis of basilar artery occlusion and/or during initiated recanalization therapy. We analyzed the patients’ clinical and radiological baseline data, recanalization, and favorable outcome modified Rankin Scale 0–2 after three-months. Diffusion weighted imaging findings were categorized into lesions in vascular territories as well as by two previously published scores for ischemic damage in the posterior circulation, the Renard score and posterior circulation Acute Stroke Prognosis Early computed tomography Score.Results
Fifty patients with basilar artery occlusion received an early MRI, and in 30 of those, a follow-up MRI was performed. Median time to baseline MRI was 5·5 h (one-hour to 24 h). Median baseline Renard score and posterior circulation Acute Stroke Prognosis Early CT Score were 2·75 (0–10) and 7 (0–10), respectively. Of the patients, 82% received an acute recanalization therapy and in 78% of those, the basilar artery recanalized. Median time to therapy was five-hours (1·25–20 h). 24% of all patients had a favorable outcome (mRS 0–2). Patients with a favorable outcome had a lower Renard score and higher pcASPECTS, a lower rate of complete basilar artery occlusion, a higher Glasgow coma scale on admission, and a higher rate of successful recanalization (all P < 0·05). After logistic regression, the only independent predictor for favorable outcome was a posterior circulation Acute Stroke Prognosis Early CT Score of 8 or more points (odds ratio 3·9, 95% confidence interval 1·4–11·7, P < 0·05).Conclusion
In patients with acute basilar artery occlusion, posterior circulation Acute Stroke Prognosis Early CT Score of 8 or more points on early diffusion weighted imaging is an independent predictor for favorable outcome.
An ankle–foot cast may enable people to repeatedly practice walking with a more normal movement pattern early after stroke.Aims
To evaluate the clinical efficacy of using an ankle–foot cast [soft scotch ankle-foot (SWIFT) Cast] to enhance walking recovery and to find whether site of stroke lesion and/or baseline biomechanical characteristics predict response to a SWIFT Cast.Design
Randomized, controlled, observer-blind trial.Study
Participants (n = 120), 3–42 days after stroke with walking difficulty. All will receive conventional physical therapy. Those allocated to the experimental group will also receive a SWIFT Cast for up to six-weeks. During therapy sessions, the SWIFT Cast will be worn for retraining of walking as clinically appropriate. Outside therapy sessions, participants will initially wear the SWIFT Cast for the whole of their waking day, and this will be adjusted as clinically appropriate.Outcomes
Measures will be undertaken before randomization, six-weeks thereafter and six-months after stroke. Primary outcome will be walking speed. Secondary outcomes will include the Functional Ambulation Category and efficiency of gait (e.g. step-time symmetry). Structural brain imaging using magnetic resonance imaging (standard fluid attenuated inversion recovery and T1-weighted high-resolution ‘volume’ spoiled gradient) will be undertaken at baseline. The clinical efficacy analysis will use analysis of covariance. The relationship between clinical response to therapy and biomechanical data will use correlation and multivariate regression techniques as required. For neuroimaging data, the relationship to clinical response to therapy will be computed using voxel-based lesion-symptom mapping. An interaction test across groups will identify which voxels are associated with different mean levels of treatment efficacy.
The late 1990s/early 2000s was a time of change in both the prevention and acute care of ischemic stroke, with primary prevention driven by increased utilization of antihypertensive, antiplatelet, anticoagulation, and lipid-lowering agents.Aim
To examine whether ischemic stroke hospitalization rates and outcomes in the United States have changed.Method
We retrospectively identified 894 169 hospitalizations with a primary diagnosis of ischemic stroke from 1 January 1998 through to 31 December 2007 in the Nationwide Inpatient Sample, the largest all-payer healthcare database in the United States. Annual, national case estimates were combined with US Census data to derive age-adjusted and age-specific population hospitalization rates. Temporal trends were tested using linear regression.Results
From 1998 through 2007, there were an estimated 4 382 336 ischemic stroke hospitalizations in the United States. Overall, the age-adjusted rate of ischemic stroke hospitalization decreased from 184 to 128 per 100 000 (P < 0·0001). Age-specific rates decreased among those 55+ years old (P < 0·0001), but increased among those 25–34 and 35–44 years old (P < 0·001 and P < 0·0001, respectively). Rates among those <25 and 45–54 years old were unchanged. In-hospital mortality decreased from 7·0% (standard error 0·1) to 5·4% (standard error 0·1) (P < 0·0001). Case proportion at the highest quintile of hospitals by annual caseload increased from 54·0% (standard error 2·1) to 61·8% (standard error 2·0) (P < 0·0001). Mean adjusted hospitalization costs increased from $9273 (standard deviation 199) to $10 524 (standard deviation 77) (P < 0·0001).Conclusion
In 1998 through to 2007, the overall rate of ischemic stroke hospitalization in the United States decreased. However, rates among young adults increased. In-hospital mortality rates decreased over the study period.
Inability to recognize stroke warning signs and delay in seeking medical attention for recognized symptoms contribute to treatment delay, thus limiting the potential for intervention and impacting negatively on potential stroke outcome.Aim
To examine knowledge of stroke risk factors and warning signs in the adult population in Ireland.Methods
In 2009, 1000 members of the general public were interviewed by telephone using quota-based population sampling of adults (≥18 years). Information was gathered using the Stroke Awareness Questionnaire (SAQ).Results
71% of participants could correctly list two or more risk factors for stroke, typically generic lifestyle risk factors. Two-thirds could not identify two warning signs for stroke. While 31% could identify two or more stroke warning signs, there was no consistency in warning signs identified. Less than 50% stated they would call an ambulance if having a stroke. Overall, there were significant gaps in knowledge, with poorest levels evident in those aged ≥65 years.Conclusions
Survey findings provide first evidence on levels of knowledge of stroke risk factors and warning signs in the Irish adult population. Awareness of stroke warning signs was poor, as was awareness of the need to call emergency services and the potential for acute stroke intervention. These factors contribute to delay in seeking medical attention following stroke, with resulting implications for stroke outcome.
In patients with >50% carotid artery stenosis (as measured by North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria) suffering a transient ischemic attack or a minor ipsilateral stroke, carotid endarterectomy exerts maximum benefits, when performed within the first 15 days from the initial ischemic symptom. It is also known that the probability of a major stroke spikes within the first few days after a transient ischemic attack/minor stroke and then flattens out in the following days and weeks. It could be hypothesized that urgent carotid endarterectomy has greater benefit than delayed procedure.Aims
Demonstrate that urgent carotid endarterectomy is more effective than delayed interventions.Design
Centers employing neurolgist/stroke physicians and vascular surgeons will enroll TIA or minor stroke patients with >50 % carotid artery stenosis (Nascet criteria), randomized in two groups:
Risk factors will be evaluated at enrollment.
TIA will be classified by ABCD2 scoring system,and minor stroke by National Institutes of Health Stroke Scale (NIHSS) scores.
The study will last 90 days per patient,starting from their initial symptom,and the follow-up will be performed by an indipendent neurologist.
A total of 456 patients (228 / group) is needed to observe an absolute difference of 10% between groups.Outcomes
Primary end-point is reduction in all types of stroke, AMI or death in urgent endarterectomy groupo compared to delayed ones.
Secondary end-points are:
Background Number-needed-to-treat describes the magnitude of the effect of an intervention, underpins health economic analyses, and is typically calculated for binary events. Ordered categorical outcomes provide more clinical information and their analysis using ordinal approaches is usually more efficient statistically. However, to date, techniques to calculate number-needed-to-treat based on ordinal outcomes for parallel group trials have had important limitations.
Aims Numbers-needed-to-treat may be calculated for ordinal data from parallel group trials by using an unmatched comparison of all subjects or by generating matched pairs of patients nested within the study.
Methods The above approaches were assessed and compared with numbers-needed-to-treat calculated for binary outcomes using individual patient data from acute and prevention stroke trials testing the effect of interventions of varying utility and efficacy.
Results Numbers-needed-to-treat were generally lower numerically for ordinal vs. binary, and matched vs. unmatched analyses, and the lowest in highly efficacious interventions: hemicraniectomy, ordinal matched 2·4 vs. ordinal unmatched 2·5 vs. binary matched 12 vs. binary unmatched 9 (one trial, 12 month outcome); alteplase, 4·5 vs. 6·6 vs. 8·4 vs. 8·4 (one trial with two parts, three-months); aspirin, 42 vs. 58 vs. 76 vs. 80 (one trial, six-months); and stroke units, 3·6–5·3 vs. 6·2 vs. 4·7–5·9 vs. 6·3–7·0 (two trials, three- to 60 months). Similar trends were seen for aspirin/dipyridamole vs. aspirin in secondary prevention, 22 vs. 20 vs. 31 vs. 31 (one trial, 24 months).
Conclusions Number-needed-to-treat may be calculated for ordinal outcome data derived from parallel group stroke trials; such numbers-needed-to-treat are lower than those calculated for binary outcomes. Their use complements the use of ordinal statistical approaches in the analysis of ordered categorical data.
Background Intravenous thrombolysis for acute stroke is more efficient the earlier the treatment is initiated. In-hospital delays account for a significant proportion of avoidable time loss before treatment is initiated. Paradoxically, studies have reported longer door-to-needle times the earlier the patients arrive (‘three-hour effect’).
Hypothesis We hypothesized that a standardized thrombolysis procedure carried out in a specialized neurological emergency room can minimize in-hospital delays and erase the ‘three-hour effect’.
Methods Onset-to-door and door-to-needle times of 246 consecutive thrombolysis patients were analyzed. A standardized protocol designed to minimize in-hospital delays was tested using a resident-based stroke team within a neurological emergency room. Correlation of onset-to-door and door-to-needle times was measured as well as differences in treatment times for daytime versus night hours and weekend vs. weekday. Outcome, rate of symptomatic intracranial hemorrhage and mortality were compared with the results of SITS-MOST.
Results Median door-to-needle time was 25 min compared with a mean of 68 min in SITS-MOST. door-to-needle time did not correlate with onset-to-door time (Pearson's r=−0·097; P=0·13) and patients arriving within 90 min from symptom onset showed comparable door-to-needle times with patients arriving within 90–180 min. Neither treatment on weekends nor during night hours led to significant in-hospital treatment delays. Outcome and safety parameters were comparable with those observed in SITS-MOST.
Conclusions By applying a standardized and diligently monitored thrombolysis protocol, carried out by a specialized stroke team within a neurological emergency room, in-hospital delays can be minimized. This allows improvement of door-to-needle times irrespective of the time to arrival and treatment during off-hours.
Background Cerebral microbleeds may contribute to cognitive deficits in stroke. Cognitive impairment that does not meet the criteria for dementia (cognitive impairment no dementia) is common in stroke, and patients with such impairment can revert to normal cognition.
Aims and hypothesis This study examined the association between cerebral microbleeds and the reversion of cognitive impairment no dementia.
Method A total of 328 Chinese patients with acute ischemic stroke admitted to the acute stroke unit of a university-affiliated regional hospital in Hong Kong participated in the study. All subjects were assessed for cognitive impairment no dementia with a neuropsychological test battery at three- and 15 months following the index stroke. Of the 180 patients with cognitive impairment no dementia at three-months poststroke, 143 (79·4%) attended the 15-month follow-up. Twenty-nine subjects had reverted from cognitive impairment no dementia to normal cognitive status (reverters), 98 were nonreverters and 16 had progressed to dementia.
Results In univariate analysis, the reverters were found to be younger, less likely to have hypertension and cerebral microbleeds, and to have smaller white matter hyperintensity volumes. In multivariate analysis, the absence of cerebral microbleeds remained an independent predictor of reversion with an odds ratio of 4·3. Absence of deep cerebral microbleeds predicted the reversion of the language domain, whereas the absence of lobar cerebral microbleeds predicted the reversion of the visuomotor speed domain.
Conclusions The results suggest that the absence of cerebral microbleeds may be associated with a higher likelihood of a reversible cognitive impairment in stroke patients. The mechanism of how this occurs is not well understood.
Stroke survivors experience marked reduction in physical activity and fitness. Regular physical fitness training, started early poststroke, could help recovery in the long term and is recommended in many clinical guidelines. However, implementation of programs is hampered by our current lack of knowledge about what interventions are most effective and how best to support stroke survivors to exercise. In the United Kingdom and Australia, there are educational programs for exercise professionals to enable them to safely and effectively deliver exercise to stroke survivors; and in the United Kingdom, community exercise training programs are being developed to follow-on from usual rehabilitation. As with many areas of life after stroke, further research is still needed. We need to know more about the effect of exercise training on common poststroke problems such as fatigue, depression and falls. Importantly, we need to understand the perceived barriers and motivators to exercise after stroke, and how to enhance adherence to the exercise programs that are in current development. However, these knowledge gaps should not prevent us from implementing what we know; and we would urge health professionals to work with exercise professionals to develop pathways into exercise for stroke survivors.