Magnus von Arbin

Spasticity After Stroke Its Occurrence and Association With Motor Impairments and Activity Limitations

Background and Purpose— There is no consensus concerning the number of patients developing spasticity or the relationship between spasticity and disabilities after acute stroke. The aim of the present study was to describe the extent to which spasticity occurs and is associated with disabilities (motor impairments and activity limitations). Methods— Ninety-five patients with first-ever stroke were examined initially (mean, 5.4 days) and 3 months after stroke with the Modified Ashworth Scale for spasticity; self-reported muscle stiffness; tendon reflexes; Birgitta Lindmark motor performance; Nine Hole Peg Test for manual dexterity; Rivermead Mobility Index; Get-Up and Go test; and Barthel Index. Results— Of the 95 patients studied, 64 were hemiparetic, 18 were spastic, 6 reported muscle stiffness, and 18 had increased tendon reflexes 3 months after stroke. Patients who were nonspastic (n=77) had statistically significantly better motor and activity scores than spastic patients (n=18). However, the correlations between muscle tone and disability scores were low, and severe disabilities were seen in almost the same number of nonspastic as spastic patients. Conclusions— Although spasticity seems to contribute to disabilities after stroke, spasticity was present in only 19% of the patients investigated 3 months after stroke. Severe disabilities were seen in almost the same number of nonspastic as spastic patients. These findings indicate that the focus on spasticity in stroke rehabilitation is out of step with its clinical importance. Careful and continual evaluation to establish the cause of the patient’s disabilities is essential before a decision is made on the most proper rehabilitation approach.

Spasticity and Its Association with Functioning and Health-Related Quality of Life 18 Months after Stroke

Background: There is no consensus concerning the presence of spasticity or the relationship between spasticity and functioning and spasticity and health-related quality of life (HRQL) in the stable phase after stroke. Objective: The aim of the present study was to describe, 18 months after stroke, the frequency of spasticity and its association with functioning and HRQL. Methods: In a cohort of 66 consecutive patients with first-ever stroke, studied prospectively, the following parameters were assessed 18 months after stroke: spasticity, by the Modified Ashworth Scale (0–4 points with 1+ as the modification), muscle stiffness, by self-report, abnormal tendon reflexes, by physical examination, motor performance, by the Lindmark Motor Assessment Scale, mobility, by the Rivermead Mobility Index, activities of daily living, by the Barthel Index, and HRQL, by the Swedish Short Form 36 Health Survey Questionnaire (SF-36). Results: Of 66 patients studied, 38 were hemiparetic; of these, 13 displayed spasticity, 12 had increased tendon reflexes, and 7 reported muscle stiffness 18 months after stroke. Weak (r < 0.5) to moderate (r = 0.5–0.75) correlations were seen between spasticity and functioning scores. Correlations between spasticity and HRQL were generally weak (r < 0.5). Hemiparetic patients without spasticity had significantly better functioning scores and significantly better HRQL on 1 of the 8 SF-36 health scales (physical functioning) than patients with spasticity. Conclusions: Few patients displayed spasticity 18 months after stroke. Spasticity might contribute to impairment of movement function and to limitation of activity, but seems to have a less pronounced effect on HRQL.

Improved screening for silent atrial fibrillation after ischaemic stroke

OBJECTIVES To what extent silent paroxysmal atrial fibrillation (AF) is present in ischaemic stroke patients has not been established. We hypothesized that brief intermittent long-term electrocardiogram (ECG) recordings at regular time intervals are more effective than short-term continuous ECG monitoring in detecting silent AF episodes. METHODS AND RESULTS Consecutive patients who had suffered an ischaemic stroke/transient ischaemic attack (TIA) and were without known AF underwent a 24 h continuous ECG recording and performed 10 s rhythm registrations using a hand-held ECG recorder twice daily for 30 days and when arrhythmia symptoms occured. Two hundred and forty-nine stroke patients were included. Mean National Institute of Health Stroke Scale (NIHSS) score was 0.9 (0-10). In total, 17 patients were diagnosed with AF. One hundred and eight AF episodes were diagnosed in 15 patients using intermittent recording, out of which 22% where unscheduled symptom triggered episodes. In three patients AF was diagnosed with both methods and in two patients AF was detected exclusively with 24 h Holter monitoring. A significant difference in favour of the hand-held ECG was shown between the two methods (P = 0.013). The total prevalence of AF was 6.8% and increased to 11.8% in patients ≥75 years. No AF was found in patients <65 years. CONCLUSIONS Prolonged brief intermittent arrhythmia screening substantially improves the detection of silent paroxysmal AF in patients with a recent ischaemic stroke/TIA, and thus facilitates the detection of patients who should receive oral anticoagulant treatment.

Higher Prehospital Priority Level of Stroke Improves Thrombolysis Frequency and Time to Stroke Unit The Hyper Acute STroke Alarm (HASTA) Study

Background and Purpose— Early initiated treatment of stroke increases the chances of a good recovery. This randomized controlled study evaluates how an increased priority level for patients with stroke, from level 2 to 1, from the Emergency Medical Communication Center influences thrombolysis frequency, time to stroke unit, and whether other medical emergencies reported negative consequences. Methods— Patients aged 18 to 85 years in Stockholm, Sweden, with symptoms of stroke within 6 hours were randomized from the Emergency Medical Communication Center or emergency medical services to an intervention group, priority level 1, immediate call of an ambulance, or to a control group with standard priority level, that is, priority level 2 (within 30 minutes). Before study start, an educational program on identification of stroke and importance of early initiated treatment was directed to all medical dispatchers and ambulance and emergency department personnel. Results— During 2008, 942 patients were randomized of which 53% (n=496) had a final stroke/transient ischemic attack diagnosis. Patients in the Emergency Medical Communication Center randomized intervention group reached the stroke unit 26 minutes earlier than the control group (P<0.001) after the emergency call. Thrombolysis was given to 24% of the patients in the intervention group compared with 10% of the control subjects (P<0.001). The higher priority level showed no negative effect on other critical ill patients requiring priority level 1 prehospital attention. Conclusion— This randomized study shows negligible harm to other medical emergencies, a significant increase in thrombolysis frequency, and a shorter time to the stroke unit for patients with stroke upgraded to priority level 1 from the Emergency Medical Communication Center and through the acute chain of stroke care.

The impact of somatosensory function on activity performance and length of hospital stay in geriatric patients with stroke

Objective: To investigate in geriatric patients with stroke the relationship between somatosensory function, activity performance and the length of stay (LOS) in either hospital or nursing home. Design: Survey. Setting: Stroke unit and geriatric rehabilitation unit. Subjects: One hundred and fifteen consecutive patients with acute stroke ≥65 years old. Main outcome measures: Clinically assessed somatosensory function, activity of daily living according to the Barthel Index (BI) (0–100 points), mobility according to the Rivermead Mobility Index (RMI) (0–15 points) and LOS. Results: Ten days after stroke onset, the patients with normal (n = 46), impaired (n = 31) and nonassessable (n = 38) somatosensory function scored 85, 40 and 0 points respectively on the BI, and 8.5, 2 and 0 points respectively on the RMI. Forty-one of 46 patients (89%) with normal somatosensory function were discharged home within three months, compared with 10 of 31 patients (32%) with impaired somatosensory function and three of 38 patients (8%) who were nonassessable. These between-group differences were statistically significant (p < 0.001). Multiple regression, to adjust for the impact of age, social situation and bladder function on outcome still proved a statistically significant (p < 0.001) predictive value of normal somatosensory function. Conclusions: Normal somatosensory function is related to high activity levels and short LOS more often than somatosensory impairment is related to activity limitations and long LOS.

Thrombin activatable fibrinolysis inhibitor and its relationship to fibrinolysis and inflammation during the acute and convalescent phase of ischemic stroke.

To investigate thrombin activatable fibrinolysis inhibitor (TAFI) in ischemic stroke and its relationship to fibrinolysis and inflammation, we investigated 32 patients with ischemic stroke during the acute phase and after 60 days. TAFI antigen levels, global markers of hemostasis (coagulation and fibrinolysis) and inflammatory markers were measured in plasma. TAFI antigen levels were significantly elevated at admission (128%; 109–151%) and at day 1 (129%; 109–152%) compared with day 60 (108%; 91–127%; both P < 0.01) and with healthy control individuals (99%; 76–122%; P < 0.05). In parallel, fibrinolysis assessed as the overall fibrinolysis potential (OFP), part of the overall hemostatic potential assay (OHP), was decreased at all time points compared with control individuals (P < 0.01 for all) and was found to be inversely related to TAFI (r = −0.40; P = 0.0008; n = 20). The OFP and the overall coagulation potential (another part of the OHP assay), and to a lesser degree TAFI, showed significant relationships to C-reactive protein and fibrinogen. In conclusion, elevated TAFI antigen levels may be a consequence of an acute phase reaction, and together with a depressed OFP suggest impaired fibrinolysis in patients with acute ischemic stroke. The OHP method may be useful as a complement to standard hemostatic variables in evaluating hemostasis in stroke patients.

NETosis promotes cancer-associated arterial microthrombosis presenting as ischemic stroke with troponin elevation.

INTRODUCTION Large elevations of high sensitive Troponin T (hsTnT) in ischemic stroke patients is associated with a poor outcome. In a pilot study we found a high prevalence of malignancies among these patients. Since neutrophil extracellular traps (NETs) have been linked to cancer-associated thrombosis, we hypothesized that the concomitant cerebral and myocardial ischemia could be the result of a NET-induced hypercoagulable state. MATERIALS AND METHODS Clinical assessments, plasma analyses and autopsies with histopathology (in cases of in-hospital mortality) were performed on ischemic stroke patients with high elevations of hsTnT (N=12) and normal hsTnT (N=19). RESULTS Patients with hsTnT elevation had an unexpectedly higher prevalence of cancer (p=0.002), half of which were diagnosed post-mortem. Autopsies of these patients revealed widespread myocardial, cerebral and pulmonary microthrombosis with H3Cit in thrombi. A pro-coagulant state and an increase of the NET specific marker citrullinated histone H3 (H3Cit) was found in plasma of patients with elevated hsTnT compared to patients with normal levels (p<0.001). Plasma analyses in cancer patients showed even higher H3Cit levels (p<0.001), and an increase in granulocyte colony-stimulating factor, known to prime neutrophils towards NETosis. H3Cit correlated positively with thrombin-antithrombin complex (p=0.004) and soluble P-selectin (p<0.001), further linking NETosis to the pro-thrombotic state. CONCLUSIONS The high prevalence of known or occult cancer in our study suggests that cancer-associated arterial microthrombosis may be underestimated. By linking the thrombosis to NETs, we suggest markers of NETosis that could aid in revealing cancer in arterial microthrombosis as well as arterial microthrombosis in cancer.

Elderly persons' experience and management of eating situations 6 months after stroke.

Purpose. To explore the experience and management of eating situations among persons affected by stroke, 6 months after stroke onset. Method. A qualitative constant comparative approach, influenced by principles of grounded theory, was used to analyse the interviews. Thirteen participants were interviewed in the home setting 6 months after the stroke. Results. Experiences and desire to master eating situations varied, and was related to values and previous habits. Eating difficulties were experienced as disgusting, uncomfortable, strenuous, or unproblematic and not implying shame. Getting help from others could be experienced as embarrassing and undesirable. In particular, eating could be more difficult when eating in company of unfamiliar people. The participants found new ways of mastering eating situations. Some had regained former routines. Conclusions. Old values and habits and/or involvement of other people were the basis of mastering eating situations. New ways of mastering were found, some accepted, and got used to the new situation. Some regained former routines. This knowledge could contribute to health care personnels awareness of each patients individual values and previous habits during the rehabilitation process. A dialogue is needed with the person suffering from eating difficulties after stroke, to help create the best possible individual conditions for mastering eating situations.

Disability test 10 days after acute stroke to predict early discharge home in patients 65 years and older

Objective: To identify prognostic instruments for the planning of care after acute stroke. Design: Prospective study. Setting: Stroke unit and geriatric rehabilitation unit. Subjects: One hundred and fifteen consecutive acute stroke patients ≥65 years old. Main outcome measures: Univariate and multivariate survival analyses. Length of hospital stay and residential form up to three months after onset. Results: The average length of stay was significantly shorter if age <80 years, male, living with another person, normal sensory ability, Barthel Index (BI) score ≥35 and Rivermead Mobility Index (RMI) score ≥4, assessed 10 days after onset. Multivariate analysis, also including BI subtests, showed that RMI score ≥4, which corresponds to the ability to rise from a chair in less than 15 seconds and remain erect for 15 seconds with or without aid, 10 days after onset, had the greatest impact on early discharge home after acute stroke, together with normal bladder function (BI subtest six), normal sensory ability and living with another person. Conclusion: The best predictor of early discharge home, 10 days after stroke onset, was the ability to rise from a chair with or without aid. This simple and quickly conducted test requires no special equipment and in the present study had a very high predictive value.

Plasma Semicarbazide-Sensitive Amine Oxidase in Stroke

Semicarbazide-sensitive amine oxidase (SSAO) has been suggested to be involved in the development of vascular endothelial damage. The source of the soluble form of SSAO found in the blood serum is unknown. However, it has been speculated that it is secreted from cells within the vascular wall where high activity of the enzyme is found. Altered SSAO activity has been reported in atherosclerotic plaques of the human aorta. Stroke is a manifestation of long-term atherosclerotic disease, and in this study, plasma SSAO activities were estimated in 42 patients with cerebral thrombosis and 26 patients with cerebral embolism, and compared to two control groups of 45 individuals in total. No statistically significant differences were found between the patient groups and controls regarding plasma SSAO activity, suggesting that changes in the soluble form of SSAO found in the circulation do not play a major role in this type of acute cerebrovascular event. Furthermore, it does not seem likely that the involvement of vascular tissue occurring in stroke results in release of the enzyme into the circulation. Nevertheless, further studies on tissue-bound SSAO in cerebral vessels would be of great interest.