Karl Matz

Dysphagia Bedside Screening for Acute-Stroke Patients. The Gugging Swallowing Screen

Background and Purpose— Acute-onset dysphagia after stroke is frequently associated with an increased risk of aspiration pneumonia. Because most screening tools are complex and biased toward fluid swallowing, we developed a simple, stepwise bedside screen that allows a graded rating with separate evaluations for nonfluid and fluid nutrition starting with nonfluid textures. The Gugging Swallowing Screen (GUSS) aims at reducing the risk of aspiration during the test to a minimum; it assesses the severity of aspiration risk and recommends a special diet accordingly. Methods— Fifty acute-stroke patients were assessed prospectively. The validity of the GUSS was established by fiberoptic endoscopic evaluation of swallowing. For interrater reliability, 2 independent therapists evaluated 20 patients within a 2-hour period. For external validity, another group of 30 patients was tested by stroke nurses. For content validity, the liquid score of the fiberoptic endoscopic evaluation of swallowing was compared with the semisolid score. Results— Interrater reliability yielded excellent agreement between both raters (&kgr;=0.835, P<0.001). In both groups, GUSS predicted aspiration risk well (area under the curve=0.77; 95% CI, 0.53 to 1.02 in the 20-patient sample; area under the curve=0.933; 95% CI, 0.833 to 1.033 in the 30-patient sample). The cutoff value of 14 points resulted in 100% sensitivity, 50% specificity, and a negative predictive value of 100% in the 20-patient sample and of 100%, 69%, and 100%, respectively, in the 30-patient sample. Content validity showed a significantly higher aspiration risk with liquids compared with semisolid textures (P=0.001), therefore confirming the subtest sequence of GUSS. Conclusions— The GUSS offers a quick and reliable method to identify stroke patients with dysphagia and aspiration risk. Such a graded assessment considers the pathophysiology of voluntary swallowing in a more differentiated fashion and provides less discomfort for those patients who can continue with their oral feeding routine for semisolid food while refraining from drinking fluids.

Insular Involvement Is Associated with QT Prolongation: ECG Abnormalities in Patients with Acute Stroke

Purpose: Aim was to assess the frequencies of electrocardiographic (ECG) abnormalities, including QT prolongation, in acute stroke patients and their association with stroke severity, stroke subtype and location, and cardiovascular risk factors. Methods: Prospectively, admission 12-lead ECG findings, stroke characteristics, cardiovascular risk factors, and potential QT-prolonging factors were collected in 122 consecutive patients with acute stroke. Results: Eighty-four patients (69%) had ECG abnormalities, most frequently ST changes in 34%, QT prolongation in 31%, and atrial fibrillation in 27% of them. Insular involvement and prior stroke independently predicted QT prolongation in small infarcts (insular involvement OR 0.12, 95% CI 0.02–0.74, p = 0.022; prior stroke OR 0.20, 95% CI 0.06–0.70, p = 0.012). Conclusion: Continuous ECG monitoring and assessment of the QT interval should be mandatory in patients with acute stroke.

Helicopter Transport of Stroke Patients and Its Influence on Thrombolysis Rates: Data From the Austrian Stroke Unit Registry

Background and Purpose— Acute stroke management requires minimization of prehospital time. This study addresses the value of helicopter transport compared with other means of transportation to a stroke unit and compares their rates of thrombolysis on a nationwide basis. Methods— Prospective data collection and prespecified evaluation of data from 32 stroke units between 2003 and 2009 were used. We distinguished between patients transported either directly to a stroke unit or transferred indirectly via a peripheral hospital. Thus, there were 6 transport groups: helicopter emergency service (HEMS) direct and indirect, ambulance accompanied by an emergency physician direct and indirect, and ambulance without physician direct and indirect. Demographic and clinical factors, time delays, and rates of thrombolysis of patients transported by helicopter were compared with factors of patients transported otherwise. Results— Of 21 712 ischemic stroke patients, 905 patients (4.1%) were transported by helicopter. Of these, 752 patients (3.4%) were transported by direct HEMS, and 153 patients (0.7%) were transported by indirect HEMS. Thrombolysis rates were highest for HEMS (24% direct, 29% indirect) transport, followed by ambulance accompanied by an emergency physician (18% direct, 15% indirect). The probability of receiving thrombolysis was highest for indirect HEMS transport (OR 3.6, 2.2–6.0), followed by indirect ambulance accompanied by an emergency physician transport (OR 1.5, 1.1–1.9). The shortest times, 90 minutes or less from stroke onset to hospital arrival, were achieved with direct AMBP and direct HEMS transport. Conclusions— The shortest hospital arrival times and highest thrombolysis rates were seen in ischemic stroke patients transported by helicopter.

Update on the third international stroke trial (IST-3) of thrombolysis for acute ischaemic stroke and baseline features of the 3035 patients recruited

BackgroundIntravenous recombinant tissue plasminogen activator (rtPA) is approved in Europe for use in patients with acute ischaemic stroke who meet strictly defined criteria. IST-3 sought to improve the external validity and precision of the estimates of the overall treatment effects (efficacy and safety) of rtPA in acute ischaemic stroke, and to determine whether a wider range of patients might benefit.DesignInternational, multi-centre, prospective, randomized, open, blinded endpoint (PROBE) trial of intravenous rtPA in acute ischaemic stroke. Suitable patients had to be assessed and able to start treatment within 6 hours of developing symptoms, and brain imaging must have excluded intracranial haemorrhage and stroke mimics.ResultsThe initial pilot phase was double blind and then, on 01/08/2003, changed to an open design. Recruitment began on 05/05/2000 and closed on 31/07/2011, by which time 3035 patients had been included, only 61 (2%) of whom met the criteria for the 2003 European approval for thrombolysis. 1617 patients were aged over 80 years at trial entry. The analysis plan will be finalised, without reference to the unblinded data, and published before the trial data are unblinded in early 2012. The main trial results will be presented at the European Stroke Conference in Lisbon in May 2012 with the aim to publish simultaneously in a peer-reviewed journal. The trial result will be presented in the context of an updated Cochrane systematic review. We also intend to include the trial data in an individual patient data meta-analysis of all the relevant randomised trials.ConclusionThe data from the trial will: improve the external validity and precision of the estimates of the overall treatment effects (efficacy and safety) of iv rtPA in acute ischaemic stroke; provide: new evidence on the balance of risk and benefit of intravenous rtPA among types of patients who do not clearly meet the terms of the current EU approval; and, provide the first large-scale randomised evidence on effects in patients over 80, an age group which had largely been excluded from previous acute stroke trials.Trial registrationISRCTN25765518

Post-stroke dementia – a comprehensive review

Post-stroke dementia (PSD) or post-stroke cognitive impairment (PSCI) may affect up to one third of stroke survivors. Various definitions of PSCI and PSD have been described. We propose PSD as a label for any dementia following stroke in temporal relation. Various tools are available to screen and assess cognition, with few PSD-specific instruments. Choice will depend on purpose of assessment, with differing instruments needed for brief screening (e.g., Montreal Cognitive Assessment) or diagnostic formulation (e.g., NINDS VCI battery). A comprehensive evaluation should include assessment of pre-stroke cognition (e.g., using Informant Questionnaire for Cognitive Decline in the Elderly), mood (e.g., using Hospital Anxiety and Depression Scale), and functional consequences of cognitive impairments (e.g., using modified Rankin Scale). A large number of biomarkers for PSD, including indicators for genetic polymorphisms, biomarkers in the cerebrospinal fluid and in the serum, inflammatory mediators, and peripheral microRNA profiles have been proposed. Currently, no specific biomarkers have been proven to robustly discriminate vulnerable patients (‘at risk brains’) from those with better prognosis or to discriminate Alzheimer’s disease dementia from PSD. Further, neuroimaging is an important diagnostic tool in PSD. The role of computerized tomography is limited to demonstrating type and location of the underlying primary lesion and indicating atrophy and severe white matter changes. Magnetic resonance imaging is the key neuroimaging modality and has high sensitivity and specificity for detecting pathological changes, including small vessel disease. Advanced multi-modal imaging includes diffusion tensor imaging for fiber tracking, by which changes in networks can be detected. Quantitative imaging of cerebral blood flow and metabolism by positron emission tomography can differentiate between vascular dementia and degenerative dementia and show the interaction between vascular and metabolic changes. Additionally, inflammatory changes after ischemia in the brain can be detected, which may play a role together with amyloid deposition in the development of PSD. Prevention of PSD can be achieved by prevention of stroke. As treatment strategies to inhibit the development and mitigate the course of PSD, lowering of blood pressure, statins, neuroprotective drugs, and anti-inflammatory agents have all been studied without convincing evidence of efficacy. Lifestyle interventions, physical activity, and cognitive training have been recently tested, but large controlled trials are still missing.

The mirror world of motor inhibition: The alien hand syndrome in chronic stroke

Alien hand syndrome (AHS) is rare, but important due to its disabling impact on everyday life. The determining characteristic of AHS is intermanual conflict, a type of inhibitory motor behaviour that occurs against willed action. Its components have previously been described as single case reports, but not as a systematic study. This review includes eight chronic cases, all of which are due to infarcts of the anterior cerebral artery. Clinical investigation included testing of motor behaviour related to everyday activities, such as tying shoelaces, lighting a candle and other bimanual tasks. Video-analysis showed that conflicting behaviour occurs in two distinct forms. One consists of interfering, rudimentary, hesitant and repetitive movements of the (alien) hand, often initiated by movements of the other hand. In some instances, disturbance of ongoing action is seen as spacious, ballistic-like extensions of the whole arm. This was most prevalent in three of the eight cases. In one patient, it was also seen as conflict with both feet (eg, when putting on slippers) or as a conflict of intentions (eg, when planning to enter a room). The other form consisted of massive groping and grasping behaviour as the most dominant features, such as a “tug of war between hands”, and was seen in five patients. Avoidance behaviour included sitting on the affected arm, holding it under the table or keeping objects out of reach. Enforcement of such strategies was used for rehabilitation and—although beneficial in the training sessions—carried over very little to everyday life. All cases had two distinct brain lesions, one in the genu or anterior rostrum of the corpus callosum and one in the contralateral frontomedial cortical and subcortical region. Chronic AHS is the only clinical syndrome that shows complex inhibitory motor behaviour in a more or less pure form because it has become detached from the control of motor planning and execution. It can best be understood as sequences of complex inhibitory motor programmes that have become isolated from normal motor planning, which usually suppresses them via the contralateral cortico-subcortical prefrontal circuits and the corpus callosum. Thus, the mirror world of complex motor inhibition becomes clinically visible in such patients.

Multidomain Lifestyle Interventions for the Prevention of Cognitive Decline After Ischemic Stroke: Randomized Trial

Background and Purpose— Cognitive impairment occurs in ⩽30% of all stroke survivors. However, effective therapies aimed at preventing poststroke cognitive decline are lacking. We assessed the efficacy of a multidomain intervention on preventing cognitive decline after stroke. Methods— In this randomized, observer-blind trial patients were recruited within 3 months after an acute stroke in 5 Austrian neurological centers. Patients were assigned to a 24-month lifestyle-based multidomain intervention or standard stroke care. Primary outcomes were the cognitive subscale of the Alzheimer Disease Assessment Scale (ADAS-cog) and occurrence of cognitive decline in the composite scores of at least 2 of 5 cognitive domains at 24 months. Results— A total of 101 patients were randomized into multi-intervention and 101 into standard care during June 2010 and November 2012. Of them, 76 patients in the intervention group and 83 in the control group were included in the final intention-to-treat analysis. At 24 months, 8 of 76 (10.5%) patients in the intervention group and 10 of 83 (12.0%) patients in the control group showed cognitive decline corresponding to a relative risk reduction of 0.874 (95% confidence interval, 0.364–2.098). The change in ADAS-cog from baseline to 24 months was not different either (median 0 [IQR, −1 to 2] in both groups; P=0.808). Conclusions— This trial found no benefit of 24-month multidomain intervention with focus on improvement in lifestyle and vascular risk factors on the incidence of poststroke cognitive decline in comparison with standard stroke care. Studies with a larger sample size are needed. Clinical Trial Registration— URL: http://clinicaltrials.gov. Unique identifier: NCT01109836.

Time Trends in Patient Characteristics Treated on Acute Stroke-Units Results From the Austrian Stroke Unit Registry 2003–2011

Background and Purpose— Demographic changes, increased awareness of vascular risk factors, better diagnostic, progress in medical care, and increasing primary stroke prevention influence the profile of patients admitted to stroke-units. Changes in patient population and stroke type have important consequences on outcome and management at stroke-units. Methods— Data from the national database of the Austrian Stroke Unit Registry were analyzed for time-trends in demography, risk factors, cause, and stroke severity. Results— Data of 48 038 ischemic and 5088 hemorrhagic strokes were analyzed. Between 2003 and 2011, median age increased significantly for ischemic strokes from 68 to 71 years in men and from 76 to 78 years in women, respectively. Ischemic stroke patients showed significantly increased rates of hypertension, hypercholesterolemia, and atrial fibrillation. In hemorrhagic strokes an increase for hypercholesterolemia and cardiac diseases other than atrial fibrillation and myocardial infarction were only found in men. A small but significant decrease in stroke severity was found for ischemic strokes from 4 to 3 points on the National Institutes of Health Stroke Scale in men and from 5 to 4 in women, and for hemorrhagic strokes from 9 to 6 points in men and from 9 to 7 in women. Cardioembolic strokes increased slightly, whereas macroangiopathy decreased. Conclusions— Significant time trends were seen for characteristics of ischemic and hemorrhagic stroke patients admitted to acute stroke-units in Austria. These include trends for older age and toward milder strokes with more cardioembolic causes. This signals a need for increased resources for managing multimorbidity and enabling early mobilization.

Prevention of post-stroke cognitive decline: a review focusing on lifestyle interventions.

Despite a high prevalence of post‐stroke cognitive impairment, therapeutic possibilities are still limited. Stroke and dementia share the same cluster of modifiable risk factors. Thus, lifestyle interventions and strict adherence to medication may not only decrease the risk of recurrent stroke but also the risk of post‐stroke cognitive decline.

Dyslipidemia, elevated LDL cholesterol and reduced nocturnal blood pressure dipping denote lacunar strokes occurring during nighttime

Previous studies have shown a peak occurrence of ischemic stroke in the morning but no consistent finding has been attributed to this. Focused on lacunar strokes we performed a prospective study with a detailed diagnostic protocol including parameters of recent infection, indicators of sleep apnea and cerebral vasoreactivity (CVR), aimed at defining differences in risk profiles between diurnal and nocturnal strokes. Consecutively we included 33 nocturnal and 54 diurnal strokes. Baseline characteristics, known risk factors, stroke severity and topology were not different between groups. The mean low‐density lipoprotein (LDL) cholesterol level was significantly higher amongst patients with nocturnal strokes (133.3 ± 35.2 mg/dl vs. 115.5 ± 39.8 mg/dl; P = 0.04), as well as the proportion of patients with any dyslipidemia (94% vs. 77.8%; P = 0.047). Twenty‐four‐hour blood pressure recordings showed a reduced nocturnal decrease of blood pressure in subjects with strokes that occurred between 10 pm and 6 am in comparison with those whose strokes occurred between 6 am and 2 pm (5.0 ± 7.3% vs. 11.0 ± 6.7%; P = 0.049). No significant differences were found for parameters of recent infection (including seroreactivity against Chlamydia pneumoniae and cytomegalovirus), CVR, indicators of sleep apnea and the degree of white matter disease assessed by magnetic resonance tomography. Dyslipidemia, especially elevated LDL cholesterol is more prevalent in nocturnal lacunar strokes especially when combined with a reduced nocturnal dipping of blood pressure. This risk factor profile can be regarded as an additional target for stroke prevention.