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Trunk performance after stroke and the relationship with balance, gait and functional ability.

Clin Rehabil. 2006 May;20(5):451-8

Authors: Verheyden G, Vereeck L, Truijen S, Troch M, Herregodts I, Lafosse C, Nieuwboer A, De Weerdt W

OBJECTIVE: To evaluate trunk performance in non-acute and chronic stroke patients by means of the Trunk Control Test and Trunk Impairment Scale and to compare the Trunk Control Test with the Trunk Impairment Scale and its subscales in relation to balance, gait and functional ability after stroke. Subjects: Fifty-one stroke patients, attending a rehabilitation programme, participated in the study. MAIN MEASURES: Subjects were evaluated with the Trunk Control Test, Trunk Impairment Scale, Tnetti balance and gait subscales, Functional Ambulation Category, 10-m walk test, Timed Up and Go Test and motor part of the Functional Independence Measure. RESULTS: Participants obtained a median score of 61 out of 100 on the Trunk Control Test and 11 out of 23 for the Trunk Impairment Scale. Twelve participants (24%) obtained the maximum score on the Trunk Control Test; no subject reached the maximum score on the Trunk Impairment Scale. Measures of trunk performance were significantly related with values of balance, gait and functional ability. Multivariate linear regression analysis showed an additional, significant contribution of the dynamic sitting balance subscale of the Trunk Impairment Scale in addition to the Trunk Control Test total score for measures of gait and functional ability (model R2 = 0.55-0.62). CONCLUSIONS: This study clearly indicates that trunk performance is still impaired in non-acute and chronic stroke patients. When planning future follow-up studies, use of the Trunk Impairment Scale has the advantage that it has no ceiling effect.

PMID: 16774097 [PubMed - in process]

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Does clinic-measured gait speed differ from gait speed measured in the community in people with stroke?

Clin Rehabil. 2006 May;20(5):438-44

Authors: Taylor D, Stretton CM, Mudge S, Garrett N

OBJECTIVE: To compare the extent to which gait speed measured in the clinic setting differs from that measured in the community. DESIGN: Participants completed the 10-m walk test at a self-selected speed in a clinic SETTING. Following this they completed a 300-m community-based walking circuit that covered a variety of environmental conditions. Gait velocity was sampled at different points in the circuit. The same circuit and sampling points were used for all participants. Clinic gait velocity was compared to gait velocity measured on five occasions during the community-based circuit. SETTING: Physiotherapy clinic and local shopping mall. PARTICIPANTS: Twenty-eight chronic stroke patients who regularly accessed the community divided into two groups based on their gait velocity in the clinic. MAIN OUTCOME MEASURES: Walking velocity. RESULTS: Spearman rank correlation coefficient indicated that there was a strong correlation between the total time taken to walk the 300-m course and the clinic-based gait velocity (r = -0.88, P < 0.0001). A linear mixed model with repeated measures analysis revealed significant interaction between community measures for group A versus group B (F4,26 = 4.49, P = 0.0068) and significant differences across community conditions (F4,26 = 7.12, P = 0.0005). CONCLUSION: The clinic-based 10-m walk test is able to predict walking velocity in a community setting in chronic stroke patients who score 0.8 m/s or faster. However, for those who score less than 0.8 m/s in the clinic test, gait velocity in the community may be overestimated.

PMID: 16774095 [PubMed - in process]

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Psychometric properties of the modified Emory Functional Smbulation Profile in stroke patients.

Clin Rehabil. 2006 May;20(5):429-37

Authors: Liaw LJ, Hsieh CL, Lo SK, Lee S, Huang MH, Lin JH

OBJECTIVE: To examine the test-retest reliability, convergent and predictive validity and responsiveness of the modified Emory Functional Ambulation Profile (mEFAP) in assessing gait function in stroke patients undergoing rehabilitation. SUBJECTS: Forty subacute stroke inpatients were enrolled in the validity and responsiveness study. Twenty chronic patients participated in the reliability study. SETTING: Rehabilitation department of a medical centre. DESIGN: In the validity and responsiveness study, patients were tested using the mEFAP, 10-m walking speed test, Barthel Index and Rivermead Mobility Index at admission and at discharge. For the reliability study, the patients completed the mEFAP twice one week apart. RESULTS: The patients’ performances on the mEFAP were moderately to highly correlated with results of the 10-m walking speed test and Rivermead Mobility Index (absolute correlation coefficients > or = 0.67), indicating good convergent validity. Patients’ performance on the mEFAP at admission was moderately correlated with the Barthel Index and Rivermead Mobility Index scores at discharge (Spearman’s rank correlation coefficients = -0.52 and -0.78, respectively), indicating good predictive validity. The standardized response mean of the mEFAP was 1.1 (P < 0.0001), suggesting good responsiveness. The intraclass correlation coefficient ICC(3,1) for the mEFAP was 0.997, indicating excellent test retest reliability. CONCLUSIONS: Our results provide strong evidence that the mEFAP has good reliability, validity and responsiveness for assessing stroke patients undergoing rehabilitation. The mEFAP is a useful scale for measuring walking function and recovery in stroke patients.

PMID: 16774094 [PubMed - in process]

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Jump training is feasible for nearly ambulatory patients after stroke.

Clin Rehabil. 2006 May;20(5):406-12

Authors: Mehrholz J, Rutte K, Pohl M

OBJECTIVE: To evaluate the feasibility of jump training for nearly ambulatory patients after stroke. DESIGN: Case series. SETTING: A rehabilitation centre for adult people with neurological disorders. SUBJECTS: Six subacute, nearly ambulatory patients with hemiparesis due to stroke. INTERVENTIONS: A modified form of jump training performed over a period of six weeks. MEASURES: Impairments: We used the Motricity Index to measure strength, the Fugl-Meyer subtest passive joint motion/pain for range of motion and pain and the modified Tardieu Scale to measure spasticity at baseline and after six weeks. Activity level: To assess walking ability we used the Functional Ambulation Category, to measure walking quality we used 10-m gait velocity, stride length and Rivermead Visual Gait Index and to assess walking capacity we used the six-minute walk test. RESULTS: No severe adverse events were observed during the study period. Motricity Index sum score of the affected leg increased from 38 +/- 11 points (mean +/- SD) to 56 +/- 15 points; P = 0.028. Modified Tardieu Scale and Fugl-Meyer subtest passive joint motion/pain remained unchanged over time (P = 1.0; P = 0.157, respectively). All patients were able to walk at the end of training (median Functional Ambulation Category grade five, P= 0.023). Gait quality improved as shown in increased gait velocity (from 0.3 +/- 0.1 to 1.1 +/- 0.5 m/s; P = 0.028), improved stride length (from 0.3 +/- 0.1 to 0.6 +/- 0.2 m; P = 0.028) and improved Rivermead Visual Gait Index score (from 38.7 +/- 5.6 points to 24.8 +/- 7.0 points; P = 0.027). All patient increased gait capacity (from 97 +/- 33 m to 289 +/- 134 m; P = 0.028). CONCLUSION: Jump exercises are feasible for selected subacute stroke patients with hemiparesis.

PMID: 16774091 [PubMed - in process]

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Metabolic cost of overground gait in younger stroke patients and healthy controls.

Med Sci Sports Exerc. 2006 Jun;38(6):1041-6

Authors: Platts MM, Rafferty D, Paul L

PURPOSE:: Locomotor impairment, such as that which may occur following a stroke, results in increased energy expenditure during walking. Previous research quantifying this increased metabolic demand has focused on older people; thus, the aim of this study was to investigate the physiological cost of walking in younger patients following stroke. METHODS:: Thirteen stroke patients (mean age of 40.7 +/- 10.0 yr) and 13 age- and sex-matched controls participated. Each subject walked for 5 min around an elliptical course (two cones set 9.5 m apart) at their own preferred walking speed (PWS). The percentage of expired oxygen was measured using a portable gas analyzer. Following a 5-min rest, the control subjects repeated the procedure, but at the PWS of the patient to whom they were matched. RESULTS:: The PWS of the stroke patients was significantly lower than that of the controls (P < 0.001); however, there was no significant difference in terms of oxygen uptake (P = 0.403). When the distance walked was considered, there was a statistically significant difference in oxygen uptake per unit of distance between the two groups (P < 0.001) and also between the patients PWS and the controls walking at the PWS of the patients. CONCLUSION:: The high metabolic cost of walking would suggest that, even for younger stroke patients, early rehabilitation should consider aerobic evaluation and training with the aim of optimizing functional independence.

PMID: 16775542 [PubMed - in process]

Coexistence of Angiotensin II Type-1 Receptor A1166C and Angiotensin-Converting Enzyme D/D Polymorphism Suggests Susceptibility for Small-Vessel-Associated Ischemic Stroke.

Neuromolecular Med. 2006;8(3):353-60

Authors: Szolnoki Z, Maasz A, Magyari L, Horvatovich K, Farago B, Somogyvari F, Kondacs A, Szabo M, Fodor L, Bodor A, Hadarits F, Melegh B

The renin-angiotensin system plays an important role in the maintenance of blood pressure homeostasis. The angiotensin-converting enzyme (ACE) converts angiotensin I into angiotensin II. Angiotensin II, which binds the angiotensin II type-1 receptor (AT1R), is a potent vasoconstrictor. On a pathophysiological basis, both ACE I/D and AT1R A1166C polymorphism lead to an enhanced activity of the angiotensin II-AT1R axis, thereby possibly contributing to circulatory disturbances. A mutually facilitatory effect may be presumed between the two polymorphisms. We examined whether this synergistic effect is involved in the evolution of different types of ischemic stroke. Genetic and clinical data on 308 consecutive patients with acutely developing ischemic stroke were analyzed. Atotal of 272 stroke and neuroimaging alteration-free subjects served as a control group. Univariate and logistic regression statistical approaches were used. The ACE D allele combined with the AT1R 1166C allele did not yield a risk of ischemic stroke. However, the co-occurrence of the homozygous ACE D/D and at least one AT1R 1166C allele was more frequent in the ischemic stroke group than in the control group (22.4 vs 11%, p < 0.005, OR, 2.33; 95% CI, 1.46-3.7). After specific subgroup analysis, this synergistic association was even stronger for small-vessel ischemic stroke (OR, 3.44; 95% CI, 1.9-6.24; p < 0.0005). Multivariate logistic regression analysis of the data confirmed this association (adjusted OR, 3.54, 95% CI, 1.88-7.16; p < 0.0005). Our results demonstrate that ACE D/D and AT1R 1166C polymorphism were associated with the development of small-vessel ischemic stroke through a mutually facilitatory interplay between them. Genetic interactions might contribute to the altered functional network in renin-angiotensin system in vascular disorders.

PMID: 16775386 [PubMed - in process]

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A dedicated animal model for mechanical thrombectomy in acute stroke.

AJNR Am J Neuroradiol. 2006 Jun;27(6):1357-61

Authors: Gralla J, Schroth G, Remonda L, Fleischmann A, Fandino J, Slotboom J, Brekenfeld C

BACKGROUND: Recent studies have focused on mechanical thrombectomy as a means to reduce the time required for revascularization and increase the revascularization rate in acute stroke. To date no systematic evaluation has been made of the different mechanical devices in this novel and fast-developing field of endovascular interventions. To facilitate such evaluations, we developed a specific in vivo model for mechanical thrombectomy that allows visualization of dislocation or fragmentation of the thrombus during angiographic manipulation. METHODS: Angiography and embolization with a preformed thrombus was performed in 8 swine. The thrombus was generated by mixing 25 IU bovine thrombin and 10 mL autologous blood. For visualization during angiography, 1 g barium sulfate was added. RESULTS: The preformed thrombus exhibited mechanical stability, reproducibility, and high radiographic absorption, providing excellent visibility during angiography. The setting allowed selective embolization of targeted vessels without thrombus fragmentation. Despite the application of barium sulfate no local or systemic reaction occurred. Histologic evaluation revealed no intimal damage caused by the thrombus or contrast agent washout. CONCLUSION: The model presented here allows selective and reliable thromboembolization of vessels that reproduce the anatomic and hemodynamic situation in acute cerebrovascular stroke. It permits visualization of the thrombus during angiography and intervention, providing unique insight into the behavior of both thrombus and device, which is potentially useful in the development and evaluation of mechanical clot retrieval in acute cerebrovascular stroke.

PMID: 16775297 [PubMed - in process]

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Diffusion-Weighted MR Imaging Lesions after Filter-Protected Stenting of High-Grade Symptomatic Carotid Artery Stenoses.

AJNR Am J Neuroradiol. 2006 Jun;27(6):1321-5

Authors: du Mesnil de Rochemont R, Schneider S, Yan B, Lehr A, Sitzer M, Berkefeld J

BACKGROUND AND PURPOSE:The clinical efficacy of filter devices in internal carotid artery (ICA) stent placement has been a matter of controversy. The aim of this retrospective study was to assess the number and extent of cerebral emboli, as represented by new lesions on diffusion-weighted MR imaging (DWI), in patients treated with filter-protected carotid stent placement. METHODS:Standard DWI (B0 = 1000) was performed within 48 hours before and 48 hours after filter-protected carotid stent placement in 50 patients with symptomatic, high grade (>70%), atherosclerotic ICA stenosis. Number, extent, and vascular territory of new DWI lesions after stent placement were assessed by consensus of 2 experienced neuroradiologists. Multifactorial statistical analysis was performed to determine risk factors associated with DWI lesions. RESULTS:New punctate DWI lesions with a median diameter of 2 mm were detected in 14 of 50 cases in the territory of the stented ICA and in 7 of 50 cases in other vascular territories. Median lesion load was 1 lesion (range, 1-15) per positive case in the stented ICA and 1 lesion (range, 1-7) in other vascular territories. All DWI lesions were clinically asymptomatic. Because of 1 hyperperfusion syndrome with temporary brain swelling, the 30-day stroke and death rate was 2%. Age >/=70 years was the only significant predictor for new DWI lesions, whereas sex, degree and site of stenosis, vascular risk factors, and stent and filter type showed no significant correlation. CONCLUSIONS: New DWI lesions after filter-protected carotid stent placement are substantially more frequent in the ipsilateral ICA territory compared with other vascular territories. Therefore, intraluminal filters cannot completely protect the brain from procedure-related embolization. However, individual lesion load and the risk of clinically relevant ischemia is low.

PMID: 16775290 [PubMed - in process]

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Safety of Mechanical Thrombectomy and Intravenous Tissue Plasminogen Activator in Acute Ischemic Stroke. Results of the Multi Mechanical Embolus Removal in Cerebral Ischemia (MERCI) Trial, Part I.

AJNR Am J Neuroradiol. 2006 Jun;27(6):1177-82

Authors: Smith WS

BACKGROUND: The MERCI (Mechanical Embolus Removal in Cerebral Ischemia) trial reported efficacy of the Merci Retriever for opening intracranial vessels in patients ineligible for intravenous (IV) tissue plasminogen activator (tPA). Patients who receive IV tPA but do not recanalize may also benefit from thrombectomy, but the revascularization efficacy and safety of this strategy has not been reported. METHODS: Multi MERCI is an ongoing international, multicenter, prospective, single-arm trial of patients with large vessel stroke treated within 8 hours of symptom onset. Patients were enrolled who had received IV tPA but did not recanalize or who were ineligible for IV tPA. Primary outcome was vascular recanalization (Thrombolysis in Myocardial Infarction [TIMI] score II/III) and safety. RESULTS: One hundred eleven patients received the thrombectomy procedure. Mean age +/- SD was 66.2 +/- 17.0 years, and baseline National Institutes of Health Stroke Scale (NIHSS) score was 19 +/- 6.3. Thirty patients (27%) received IV tPA before intervention. Treatment with the Retriever alone resulted in successful recanalization in 60 of 111 (54%) treatable vessels and in 77 of 111 (69%) after adjunctive therapy (IA tPA, mechanical). Symptomatic intracranial hemorrhage (ICH) occurred in 10 of 111 (9.0%). Clinically significant procedural complications occurred in 5 of 111 (4.5%) patients. The symptomatic ICH rate was 2 of 30 (6.7%) in patients pretreated with IV tPA and 8 of 81 (9.9%) in those without (P > .99). CONCLUSIONS: Mechanical thrombectomy after IV tPA seems as safe as mechanical thrombectomy alone. Mechanical thrombectomy with both first- and second-generation Merci devices is efficacious in opening intracranial vessels during acute ischemic stroke in patients who are either ineligible for IV fibrinolytic therapy or have failed IV fibrinolytic therapy.

PMID: 16775259 [PubMed - in process]

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Subventricular zone-derived neuroblasts migrate and differentiate into mature neurons in the post-stroke adult striatum.

J Neurosci. 2006 Jun 14;26(24):6627-36

Authors: Yamashita T, Ninomiya M, Hernández Acosta P, García-Verdugo JM, Sunabori T, Sakaguchi M, Adachi K, Kojima T, Hirota Y, Kawase T, Araki N, Abe K, Okano H, Sawamoto K

Recent studies have revealed that the adult mammalian brain has the capacity to regenerate some neurons after various insults. However, the precise mechanism of insult-induced neurogenesis has not been demonstrated. In the normal brain, GFAP-expressing cells in the subventricular zone (SVZ) of the lateral ventricles include a neurogenic cell population that gives rise to olfactory bulb neurons only. Herein, we report evidence that, after a stroke, these cells are capable of producing new neurons outside the olfactory bulbs. SVZ GFAP-expressing cells labeled by a cell-type-specific viral infection method were found to generate neuroblasts that migrated toward the injured striatum after middle cerebral artery occlusion. These neuroblasts in the striatum formed elongated chain-like cell aggregates similar to those in the normal SVZ, and these chains were observed to be closely associated with thin astrocytic processes and blood vessels. Finally, long-term tracing of the green fluorescent-labeled cells with a Cre-loxP system revealed that the SVZ-derived neuroblasts differentiated into mature neurons in the striatum, in which they expressed neuronal-specific nuclear protein and formed synapses with neighboring striatal cells. These results highlight the role of the SVZ in neuronal regeneration after a stroke and its potential as an important therapeutic target for various neurological disorders.

PMID: 16775151 [PubMed - in process]

Early outcomes in the elderly: a meta-analysis of 4921 patients undergoing coronary artery bypass grafting - a comparison between off-pump and on-pump techniques.

Heart. 2006 Jun 14;

Authors: Panesar SS, Athanasiou T, Nair S, Rao C, Jones C, Nicolaou M, Darzi A

BACKGROUND: The elderly patients undergoing coronary artery bypass grafting constitute a challenging group due to increased risk of particular postoperative complications which are directly related to age. This study aims to assess these early outcomes in the elderly population undergoing coronary revascularization with and without cardiopulmonary bypass. METHODS: A meta-analysis of all retrospective, non-randomized studies comparing OPCAB (off-pump coronary artery bypass) and CPB (cardiopulmonary bypass) techniques in the elderly (>70 years) between 1999 and 2005 was performed. Age-related early outcomes of interest were mortality, stroke, atrial fibrillation, renal failure and length of stay in hospital. The random effects model was used. Sensitivity and heterogeneity were analysed. RESULTS: Analysis of fourteen non-randomized studies comprising 4921 patients [OPCAB=1533(31.1%) and CPB=3388(68.9%)], showed a significantly lower incidence of mortality in the OPCAB group (OR 0.48[95%CI 0.28 to 0.84]). This effect was greater in OPCAB octogenarians (OR 0.26[95%CI 0.12 to 0.57]). A similar pattern was detected in the incidence of stroke amongst the OPCAB octogenarians (OR 0.19[95%CI 0.07 to 0.56]). The incidence of atrial fibrillation was lower in the OPCAB group (OR 0.77[95%CI 0.61 to 0.97]). No difference was identified in the incidence of renal failure. Length of hospital stay was shorter in the OPCAB group although significant heterogeneity was identified. CONCLUSIONS: Our study demonstrates that OPCAB may be associated with lower incidence of mortality, stroke and AF in the elderly which may result in shorter length of hospital stay. A large randomized trial would confirm whether the elderly will benefit more from OPCAB surgery.

PMID: 16775087 [PubMed - as supplied by publisher]

Anticoagulation in women with non-valvular atrial fibrillation in the stroke prevention using an oral thrombin inhibitor (SPORTIF) trials.

Eur Heart J. 2006 Jun 14;

Authors: Gomberg-Maitland M, Wenger NK, Feyzi J, Lengyel M, Volgman AS, Petersen P, Frison L, Halperin JL

AIMS: The risk of stroke is greater among women with atrial fibrillation (AF) than men. Warfarin protects against stroke, but treatment-related bleeding occurs more often in women than in men. METHODS AND RESULTS: SPORTIF III (open label, n=3410) and V (double-blind, n=3922) included 2257 women with AF and one or more stroke risk factors randomized to warfarin [target international normalized ratio (INR) 2.0-3.0] or ximelagatran (36 mg twice daily). Primary outcomes were all stroke (ischaemic/haemorrhagic) and systemic embolic event. Women were older, on average, than men, 73.4 +/- 8.0 vs. 69.8 +/- 9.0 years (P<0.0001). More women were >75-years old and women had more risk factors than men had (P<0.0001). The INR on warfarin (mean 2.5 +/- 0.7) was within target range for 67% of follow-up regardless of gender. Women more often developed primary events [2.08%/year, 95% confidence interval (CI) 1.60-2.56%/year vs. 1.44%/year, 95% CI 1.18-1.71%/year in men; P=0.016). Major bleeding rates were similar (P=0.766) but women experienced more overall (major/minor) bleeding (P<0.001). Warfarin was associated with more overall bleeding in both genders and more major bleeding in women than in men (P=0.001). CONCLUSION: When compared with men with AF, women in these studies were older and had more stroke risk factors. Women were more prone to anticoagulant-related bleeding; the higher rate of thrombo-embolism among women was related to more frequent interruption of anticoagulant therapy.

PMID: 16774980 [PubMed - as supplied by publisher]

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Impact of intensity of practice after stroke: Issues for consideration.

Disabil Rehabil. 2006 Jul;28(13):823-830

Authors: Kwakkel G

Purpose. The present debate paper addresses four relevant issues related to the impact of intensity of practice after stroke. First, the best way to define intensity of practice is discussed. Second, the paper describes the evidence that exists for a dose-response relationship in stroke rehabilitation. Third, the relevance of an appropriate patient selection for a meaningful intensive practice is explored. Finally, the paper raises the question of what it is that patients actually learn when they improve their functional skills.Search strategy. For this purpose articles from MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, PEDro, DARE and PiCarta and references presented in relevant publications were examined.Discussion and conclusion. Although, there is strong evidence that early augmented exercise therapy time (expressed as time dedicated to practice) may enhance functional recovery, there is a discrepancy between the evidence for the benefits of intensive practice, on the one hand, and, the implementation of intensive rehabilitation treatment programmes in the current healthcare system on the other. Further emphasis should be given on a better understanding of the time-dependency of prognostic factors that determine the effectiveness of intensive practice in patients with stroke. In addition, a better understanding is needed of the neurophysiological and biomechanical mechanisms that underlie compensation-related learning of functional tasks after stroke.

PMID: 16777769 [PubMed - as supplied by publisher]

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Recovery plateau following stroke: Fact or fiction?

Disabil Rehabil. 2006 Jul 6;28(13):815-21

Authors: Demain S, Wiles R, Roberts L, McPherson K

Purpose. ‘Plateau’ is an expression frequently used in relation to decisions to discharge patients from physiotherapy following stroke. This paper critically considers the concept of recovery plateau in stroke, exploring (i) the evidence for plateau, (ii) potential contributing factors, and (iii) the consequences for patients, therapists and services.Search strategy. The concept of recovery plateau in stroke was reviewed drawing on standard critical appraisal methodology for the search strategy and critique. Electronic searches using Web of Knowledge, MEDLINE, CINAHL, Department of Health Website and the Cochrane Library from the earliest dates of coverage until February 2005 identified quantitative and qualitative literature related to stroke, plateau, recovery, outcome, rehabilitation and physiotherapy.Discussion. The concept of plateau is ambiguous. Recovery has been considered to plateau within the first 6 months, yet recent studies indicate later recovery is possible. We suggest that ‘plateau’ relates not only to the patient’s physical potential, but is influenced by how recovery is measured, the intensity and type of therapy, patients’ actions and motivations, therapist values, and service limitations.Conclusion. ‘Plateau’ is conceptually more complex than previously considered. Current conceptualizations may limit potential recovery and hinder service development. Research into plateau which takes account of contextual issues of therapy provision is required.

PMID: 16777768 [PubMed - in process]

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TRPM2 Is Elevated in the tMCAO Stroke Model, Transcriptionally Regulated, and Functionally Expressed in C13 Microglia.

J Recept Signal Transduct Res. 2006;26(3):179-98

Authors: Fonfria E, Mattei C, Hill K, Brown JT, Randall A, Benham CD, Skaper SD, Campbell CA, Crook B, Murdock PR, Wilson JM, Maurio FP, Owen DE, Tilling PL, McNulty S

We report the detailed expression profile of TRPM2 mRNA within the human central nervous system (CNS) and demonstrate increased TRPM2 mRNA expression at 1 and 4 weeks following ischemic injury in the rat transient middle cerebral artery occlusion (tMCAO) stroke model. Microglial cells play a key role in pathology produced following ischemic injury in the CNS and possess TRPM2, which may contribute to stroke-related pathological responses. We show that TRPM2 mRNA is present in the human C13 microglial cell line and is reduced by antisense treatment. Activation of C13 cells by interleukin-1beta leads to a fivefold increase of TRPM2 mRNA demonstrating transcriptional regulation. To confirm mRNA distribution correlated with functional expression, we combined electrophysiology, Ca2+ imaging, and antisense approaches. C13 microglia exhibited, when stimulated with hydrogen peroxide (H2O2), increased [Ca2+]i, which was reduced by antisense treatment. Moreover, patch-clamp recordings from C13 demonstrated that increased intracellular adenosine diphosphoribose (ADPR) or extracellular H2O2 induced an inward current, consistent with activation of TRPM2. In addition we confirm the functional expression of a TRPM2-like conductance in primary microglial cultures derived from rats. Activation of TRPM2 in microglia during ischemic brain injury may mediate key aspects of microglial pathophysiological responses.

PMID: 16777714 [PubMed - in process]

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Routine Completion Angiography during Carotid Endarterectomy is not Mandatory.

Eur J Vasc Endovasc Surg. 2006 Jun 12;

Authors: Pratesi C, Dorigo W, Troisi N, Fargion A, Innocenti AA, Pratesi G, Barbanti E, Pulli R

OBJECTIVE: Intraoperative quality control after carotid endarterectomy (CEA) has been advocated to improve the results of surgical treatment of extracranial carotid artery disease. The aim of this study was to evaluate the usefulness of completion angiography (CA) in prevention of stroke and restenosis after CEA in a single center experience. MATERIALS AND METHODS: Data concerning 914 consecutive CEAs performed in 3 years (2000-2002) were prospectively collected in a dedicated database. Patients were divided into two groups: in the first group (mandatory-CA group; 430 cases) CA was routinely carried out, except in presence of contraindications to iodinate contrast agents; in the second group (selective-CA group, 484 cases) CA was performed only in selected cases, at surgeon’s discretion. RESULTS: There were no significant differences between the two groups in terms of neurological complications at awakening (0.5% in mandatory-CA group and 0.4% in selective-CA group; p=n.s.) and in 30-day stroke and death rate (1.9% and 1.4%, respectively; p=n.s.). A surgical revision on the basis of CA findings was performed in 5 cases in mandatory-CA group and in 2 cases in selective-CA group (1.2% and 0.4%, respectively; p=n.s.). In the second group, the conditions significantly associated with the need for CA examination were internal carotid near-occlusion, preoperative symptoms, shunt insertion, kind of surgical reconstruction, redo surgery. Estimated absence of ipsilateral stroke and absence of restenosis at 18 months was 98.9% and 89.7% in mandatory-CA group and 99.3% and 93.4% in selective-CA group (p=n.s.) respectively. CONCLUSIONS: Based on our experience, routine CA following CEA is not suggested. A policy of selected CA at the surgeon’s discretion seems to make the intervention safe and durable as well.

PMID: 16777443 [PubMed - as supplied by publisher]

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Gesture imitation with lower limbs following left hemisphere stroke.

Arch Clin Neuropsychol. 2006 Jun 13;

Authors: Ambrosoni E, Sala SD, Motto C, Oddo S, Spinnler H

Ideomotor apraxia (IMA) of lower limbs has rarely been investigated systematically. This is the aim of the current study. Thirty-five patients with a unilateral stroke in the left hemisphere were tested within 30 days from onset with an upper limb IMA test and with a newly devised test assessing leg IMA. Seventeen patients presented with arm apraxia, six of them also showed severe leg apraxia. Results suggest that IMA of lower limbs emerges in association with severe arm IMA in patients with large lesions, and is a sign of general severity of the patient’s conditions.

PMID: 16777371 [PubMed - as supplied by publisher]

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Estrogen preconditioning protects the hippocampal ca1 against ischemia.

Neuroscience. 2006 Jun 12;

Authors: Raval AP, Bramlett H, Perez-Pinzon MA

Estrogen is neuroprotective against ischemia in both in vivo and in vitro injury models. Because of the promising preclinical data on neuroprotection, the Women’s Estrogen for Stroke Trial was initiated. The outcomes from this trial were, however, unsuccessful and questions emerged about the safety of chronic estrogen treatment in women. In contrast to the chronic estrogen treatment strategy, the present study aims to investigate: (1) the neuroprotective efficacy of single estrogen pretreatment/preconditioning; and (2) the existence of a similarity between estrogen- and ischemic preconditioning-induced neuroprotection against cerebral ischemia. The efficacy of estrogen was tested in an in vitro model of cerebral ischemia using hippocampal organotypic slice culture system. The hippocampal organotypic slice cultures were generated from female neonatal (9-11 days old) Sprague-Dawley rats. The slices were exposed to estradiol-17beta (0.5, 1, 5 nM) for various durations (1, 2 or 4 h) 48 h prior to ischemia (40 min of oxygen-glucose deprivation). For ischemic preconditioning, slices were exposed to sublethal oxygen-glucose deprivation (15 min), 48 h prior to lethal oxygen-glucose deprivation. Quantification of cell death in hippocampal CA1 region was conducted by using propidium iodide fluorescence staining technique. Results demonstrated that estrogen preconditioning significantly protects the hippocampal CA1 region against ischemia (P<0.001) and mimicked ischemic preconditioning-induced neuroprotection. The propidium iodide fluorescence values of estrogen preconditioning, ischemic preconditioning and ischemia groups were 21+/-2 (mean+/-S.E.M.) (1 nM; 2 h; n=15), 18+/-2 (5 nM; 4 h; n=12), 32+/-3 (n=8), 65+/-3 (n=27), respectively. Further, estrogen preconditioning initiated a calcium-mediated signaling pathway leading to protection of CA1 neurons against ischemia. Future investigations in estrogen preconditioning may suggest new estrogen regimens that avoid potential side effects of chronic estrogen treatment for stroke patients.

PMID: 16777351 [PubMed - as supplied by publisher]

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Hormone replacement therapy: time to move on?

J Br Menopause Soc. 2006 Jun;12(2):75-80

Authors: Davey DA

The risks and benefits of hormone replacement therapy (HRT) need to be put in perspective. In the analysis of clinical trials, emphasis is often placed on relative risks, statistical significance and 95% confidence intervals, whereas, from a clinical perspective, more may be gained from a consideration of the absolute and attributable risks of therapy. The Council for International Organizations of Medical Sciences recommended that the frequency of adverse events be categorized as ‘rare’ if less than 1/1000 but more than 1/10,000, and as ‘very rare’ if less than 1/10,000. In the analyses of the Women’s Health Initiative (WHI), the attributable risks were ‘appreciable’ (i.e. more than 1/1000) only in women aged over 70 years, with the exception of the risks of venous thromboembolism and stroke. The women in the WHI trial do not represent the relatively younger, healthy, postmenopausal women most commonly prescribed HRT, who are probably at much lower risk. Moreover, the WHI trial did not take into account the benefit of relief of menopausal symptoms, which is, for many women, paramount and outweighs the ‘rare’ long-term risks. Age may be a useful guide to risks and some simple guidelines for management, based on age, are suggested. Many women have been denied or have discontinued HRT because of the fear of risks, which may not have been put in perspective or fully understood. The care of postmenopausal women is not static, and sufficient has now been learned to enable each menopausal woman, with the help of her medical adviser, to come to a balanced and reasonable decision.

PMID: 16776859 [PubMed - in process]

Adenoviral human telomerase reverse transcriptase dramatically improves ischemic wound healing without detrimental immune response in an aged rabbit model.

Hum Gene Ther. 2006 Jun;17(6):651-60

Authors: Mogford JE, Liu WR, Reid R, Chiu CP, Said H, Chen SJ, Harley CB, Mustoe TA

Chronic ischemic wounds are major clinical problems, and are especially prevalent in elderly patients. Management of these wounds costs billions of dollars annually in the United States. Because of the severe impairment in tissue repair, ischemic wounds among the aged are major challenges for physicians. For example, transforming growth factor-beta (1) stimulates healing of young patients’ ischemic wounds, but it is totally ineffective in treating the ischemic wounds of aged patients. Therefore, our goal is to develop a better therapeutic strategy for elderly patient ischemic wounds. Because human telomerase reverse transcriptase (hTERT) has emerged as having a role in promoting cell proliferation, we hypothesized that hTERT overexpression may improve ischemic wound healing in the elderly. We successfully tested this hypothesis by demonstrating for the first time that gene delivery of hTERT by adenovirus (Ad-hTERT) dramatically improved ischemic wound healing in an aged rabbit model. Importantly, our histological data indicate that no deleterious immune response was induced in the aged rabbits. This finding has broad implications for the field of gene therapy because the foremost obstacle in the use of adenoviral vectors for gene therapy is that they provoke strong innate and adaptive immune responses in the host. Moreover, Ad-hTERT significantly improved survival of primary rabbit dermal fibroblasts that were treated with hypoxia and hydrogen peroxide (oxidative stress). This model is clinically relevant because it simulates the ischemia cycle of an ischemia-reperfusion injury, which can lead to stroke, myocardial infarction, and other tissue injuries. We conclude that Ad-hTERT is an effective and novel approach to treating the ischemic wounds of elderly patients.

PMID: 16776573 [PubMed - in process]

Effectiveness of a care coordination model for stroke survivors: a randomized study.

Health Soc Work. 2006 May;31(2):87-96

Authors: Claiborne N

This study evaluated the effectiveness of systematically integrating biopsychosocial interventions with coordinated delivery of care for outpatients recovering from stroke. Care coordination coordinates resources across the health care system and routinely addresses the psychological and social risks affecting patient outcomes, while monitoring patient progress. A randomized pre-post comparison group design evaluated the model’s effectiveness with 28 patients (16 intervention group; 12 control group) over a three-month period. The model’s effectiveness was evaluated by monitoring changes in patient quality of life, patient depression, patient psychosocial functioning, and patient adherence to self-care and in meeting patient service needs. Repeated-measures ANOVA showed significant improvement for the intervention group in mental quality of life, depressive symptoms, and adherence to self-care practices. This study provides preliminary data that a standardized, problem-solving care coordination model can improve patient care.

PMID: 16776026 [PubMed - in process]

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The effect of normal saline resuscitation on vital organ blood flow in septic sheep.

Intensive Care Med. 2006 Jun 15;

Authors: Wan L, Bellomo R, May CN

OBJECTIVE: To study the effect of resuscitation with normal saline on vital organ blood flow and renal function in sepsis. DESIGN AND SETTING: Randomized controlled cross-over animal study in the animal laboratory of university physiology institute. SUBJECTS: Six merino cross-ewes. INTERVENTIONS: Chronic implantation of flow probes around aorta, coronary, renal and mesenteric arteries. Intravenous administration of live Escherichia coli. Random allocation to normal saline resuscitation (20[Symbol: see text]ml/kg over 15[Symbol: see text]min) or observation (control) for 210[Symbol: see text]min. Continuous measurement of central haemodynamics, organ blood flow and renal function. RESULTS: Live E. coli induced hyperdynamic sepsis with oliguria (28.3[Symbol: see text]+/-[Symbol: see text]12.6 to 16.7[Symbol: see text]+/-[Symbol: see text]11.9[Symbol: see text]ml/30min) and reduced creatinine clearance (87.9[Symbol: see text]+/-[Symbol: see text]24.5 to 44.3[Symbol: see text]+/-[Symbol: see text]34.5[Symbol: see text]ml/min). During this septic state mesenteric, coronary and renal blood flow increased. During the first hour (early effect) after saline resuscitation, central venous pressure, cardiac output, stroke volume, coronary blood flow, mesenteric blood flow, urine output and creatinine clearance increased, but there was no change in renal blood flow. In the following 2[Symbol: see text]h these increments were significantly attenuated, but urine output and creatinine clearance remained greater than controls; renal blood flow decreased slightly and the fractional excretion of sodium increased significantly. CONCLUSION: In hyperdynamic sepsis resuscitation with normal saline increases central venous pressure, cardiac output, mesenteric blood flow, urine output, creatinine clearance, and fractional excretion of sodium despite a lack of effect on renal blood flow. These effects, however, are transient.

PMID: 16775719 [PubMed - as supplied by publisher]

Related Articles

Strategies to enhance chronic disease self-management: How can we apply this to stroke?

Disabil Rehabil. 2006 Jul 6;28(13):841-7

Authors: Jones F

Purpose. Social Cognition Theory and the cognitive construct of self-efficacy often form the theoretical basis for many chronic disease self-management programmes. Self-efficacy can be influenced through these programmes and has been shown to be predictive of greater levels of functioning and psychological well-being. Stroke is regarded as a complex chronic disability, and individuals may share many of the same concerns as those living with other chronic diseases such as arthritis and chronic pulmonary disease. However there has been minimal reported research on the utility of self-management programmes following stroke.Search strategy. To comprehend the composition of chronic disease self-management programmes which could be applied to stroke, this paper examined the theoretical basis of self-management and particularly the evidence relating to interventions which have utilized self-efficacy enhancing strategies. Selected papers were retrieved from an extensive search of literature using Medline, Cinahl, PsychInfo and Web of Science databases and the Cochrane Collaboration. The search request focused on literature that specifically related to chronic disease, self-management and self-efficacy that had been published since 1995. However, seminal literature on self-efficacy produced prior to this date was also included.Discussion and conclusions. There is strong evidence to support the use of self-management programmes and their effect on self-efficacy and associated health outcomes. While there are differences in the nature of each chronic condition, there are similarities in the core skills required for self-management. Many effective strategies could be incorporated into current stroke rehabilitation programmes or used to develop targeted self-management interventions. Future research which informs stroke rehabilitation should utilize the evidence relating to other chronic conditions. This could be used to develop the most effective methods of equipping individuals following stroke to cope confidently with the transition from being discharged from therapy towards effective self-management in the longer term.

PMID: 16777771 [PubMed - in process]

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Extrinsic feedback for motor learning after stroke: What is the evidence?

Disabil Rehabil. 2006 Jul 6;28(13):831-40

Authors: van Vliet PM, Wulf G

Purpose. There is little guidance on using extrinsic feedback to enhance motor learning after stroke. This narrative review synthesises research findings and identifies questions remaining to be answered.Method. A summary is given relating to the use of extrinsic feedback in healthy subjects. Then, research concerning content of feedback, feedback scheduling, and attentional focus is discussed in relation to patients with stroke.Results. Though research is scarce, preliminary key findings were as follows: Patients’ balance performance can improve from receiving visual feedback about weight distribution during practice; auditory feedback of force production may improve performance of sit-to-stand; providing feedback on less than 100% of trials, and giving summary or average feedback may enhance learning; instructions or feedback inducing an external focus may be more effective than those with an internal focus. Further research is needed concerning the relative benefits of verbal, visual, video and kinematic feedback; reduced feedback frequencies and summary feedback schedules; feedback delays, error estimation, and self-controlled feedback; and attentional focus of feedback.Conclusions. Although there are some indications that feedback might enhance motor learning after stroke, there are many areas as yet not examined and there is clearly a need for considerable research in this area.

PMID: 16777770 [PubMed - in process]

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Interference between balance, gait and cognitive task performance among people with stroke living in the community.

Disabil Rehabil. 2006 Jul 6;28(13):849-56

Authors: Hyndman D, Ashburn A, Yardley L, Stack E

Purpose. To explore differences in cognitive-motor interference between people with stroke and controls when performing functional tasks and to compare dual task performance of stroke fallers and non-fallers.Method. Thirty-six people with stroke (mean age 66.5, SD 11.8, mean time since onset 16 months, range 7 - 56) and 24 controls (mean age 62.3, SD 11.61) performed balance and gait tasks in isolation and in conjunction with a cognitive task (remembering a seven item-shopping list). Three-dimensional movement analysis was used to assess anterior posterior (AP) and lateral (ML) sway; 5 m walk time, stride length and velocity.Results. In the single task condition, people with stroke had greater AP sway, reduced velocity and stride length and a longer 5 m walk time than controls (p < 0.01). In the dual task condition, sway reduced and gait slowed in both groups (p < 0.01 for AP sway, stride length, velocity, walk time); only the increase in walk time was greater in people with stroke than in the controls (F = 4.2, p = 0.046). Cognitive performance was maintained during the balance trials but deteriorated during the dual task gait trials in people with stroke (p = 0.017). Similar trends were noted for fallers and non-fallers with stroke: Only group effects for stride length and velocity reached significance (p < 0.05) and only the reduction in stride length was significantly greater among fallers than non-fallers (F = 12.3, p = 0.001).Conclusions. People with stroke and controls employed similar strategies during the simultaneous performance of simple functional and silent cognitive tasks and maintained postural stability. Increased walk time and decreased cognitive recall were greater for people with stroke and reduced stride length distinguished fallers from non-fallers.

PMID: 16777772 [PubMed - in process]

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Gait outcome following outpatient physiotherapy based on the Bobath concept in people post stroke.

Disabil Rehabil. 2006 Jul 6;28(13):873-81

Authors: Lennon S, Ashburn A, Baxter D

Purpose. The purpose of this study was to characterize the gait cycle of patients with hemiplegia before and after a period of outpatient physiotherapy based on the Bobath concept.Methods. Nine patients, at least 6 weeks post stroke and recently discharged from a stroke unit, were measured before and after a period of outpatient physiotherapy (mean duration = 17.4 weeks). Therapy was documented using a treatment checklist for each patient. The primary outcome measures were a number of gait variables related to the therapists’ treatment hypothesis, recorded during the gait cycle using the CODA motion analysis system. Other secondary outcome measures were the Motor Assessment Scale, Modified Ashworth Scale, subtests of the Sodring Motor Evaluation Scale, the Step test, a 10-m walk test, the Barthel Index and the London Handicap Score.Results. Recovery of more normal gait patterns in the gait cycle (using motion analysis) did not occur. Significant changes in temporal parameters (loading response, single support time) for both legs, in one kinematic (dorsiflexion during stance) and one kinetic variable on the unaffected side (hip flexor moment), and most of the clinical measures of impairment, activity and participation (with the exception of the Modified Ashworth Scale and the 10-m walk) were noted.Conclusions. Study findings did not support the hypothesis that the Bobath approach restored more normal movement patterns to the gait cycle. Further research is required to investigate the treatment techniques that are effective at improving walking ability in people after stroke.

PMID: 16777775 [PubMed - in process]

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A content analysis of physiotherapy for postural control in people with stroke: An observational study.

Disabil Rehabil. 2006 Jul 6;28(13):865-72

Authors: Tyson S, Selley A

Purpose. The lack of information about the content of therapy packages is a frequent criticism in stroke rehabilitation research. This study aimed to describe, in detail, the content of one aspect of physiotherapy; the rehabilitation of postural control.Methods. The design was a cross-sectional survey and the setting was in 11 NHS Trusts. The participants were 35 stroke physiotherapists working in acute and rehabilitation settings who recorded the treatment of 132 patients in 644 treatment sessions using the Stroke Physiotherapy Intervention Recording Tool. Analysis was carried out by descriptive statistics, one-way ANOVAS and chi-squares which were used to describe content of interventions and effects of the aim of treatment.Results and conclusions. Physiotherapists’ clinical practice focused on therapist-led interventions, which aimed to normalize muscle tone and promote normal movement patterns. The most frequent interventions were ‘preparation for treatment’ (n = 1969, 43%), ‘practising balance and walking activities’ (n = 1583, 34%) and ‘practising functional tasks’ (n = 703, 15%). Interventions to encourage independence or activity outside the treatment session were rarely used. This pattern was seen regardless of the aim of treatment (the restoration of sitting balance, standing balance or stepping/walking).

PMID: 16777774 [PubMed - in process]

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Motor neglect: Implications for movement and rehabilitation following stroke.

Disabil Rehabil. 2006 Jul 6;28(13):857-64

Authors: Punt TD, Riddoch MJ

Purpose. The syndrome of unilateral neglect following stroke is associated with poor outcome and presents significant challenges to those providing therapy for affected individuals. In contrast to a number of reviews which have recently appeared in therapy and rehabilitation journals relating to sensory aspects of neglect, this review focuses on ‘motor neglect’.Search strategy. We searched the clinical and scientific literature for papers concerning motor neglect. The search included the databases Web of Science, Pubmed and Cinahl, primarily using the term ‘motor neglect’. There was also a large degree of secondary searching involved.Discussion. Motor neglect refers to the under-utilization of a limb opposite a brain lesion that cannot be fully explained by primary sensory and motor deficits. The paper discusses classical descriptions of motor neglect and highlights the difficulties in disentangling motor neglect from hemiparesis. The related problem of motor extinction is introduced as a useful clinical measure of neglect-related movement difficulties and a significant clinical problem in its own right.Conclusion. Motor neglect is a relatively under-recognized deficit which may have a significant impact on patient performance and recovery following stroke. We conclude with a discussion of the implications of motor neglect for rehabilitation, including the relative contributions that may be made by Constraint-induced movement therapy and Bilateral movement therapy in managing patients with neglect-related movement problems.

PMID: 16777773 [PubMed - in process]

Complement Component C3 Mediates Inflammatory Injury Following Focal Cerebral Ischemia.

Circ Res. 2006 Jun 15;

Authors: Mocco J, Mack WJ, Ducruet AF, Sosunov SA, Sughrue ME, Hassid BG, Nair MN, Laufer I, Komotar RJ, Holland MC, Pinsky DJ, Connolly ES

The complement cascade has been implicated in ischemia/reperfusion injury, and recent studies have shown that complement inhibition is a promising treatment option for acute stroke. The development of clinically useful therapies has been hindered, however, by insufficient understanding of which complement subcomponents contribute to post-ischemic injury. To address this issue, we subjected mice deficient in selected complement proteins (C1q, C3, C5) to transient focal cerebral ischemia. Of the strains investigated, only C3(-/-) mice were protected, as demonstrated by 34% reductions in both infarct volume (P<0.01) and neurological deficit score (P<0.05). C3-deficient mice also manifested decreased granulocyte infiltration (P<0.02) and reduced oxidative stress (P<0.05). Finally, administration of a C3a-receptor antagonist resulted in commensurate neurological improvement and stroke volume reduction (P<0.05). Together, these results establish C3 activation as the key constituent in complement-related inflammatory tissue injury following stroke and suggest a C3a anaphylatoxin-mediated mechanism.

PMID: 16778128 [PubMed - as supplied by publisher]