Tamara Tse

Measuring participation after stroke: a review of frequently used tools

OBJECTIVE To identify and critique the measures currently used to assess participation in clinical stroke studies. DATA SOURCES Relevant articles published between January 2001 and April 2012 identified through Medline, CINAHL, and ProQuest Central databases. STUDY SELECTION Published articles involving poststroke assessment of participation. Case studies, cohort studies, and randomized controlled trials were included. DATA EXTRACTION The most frequently used measures were identified and the psychometric properties evaluated. Three raters independently evaluated each measure relative to the first and second coding levels of the International Classification of Functioning, Disability and Health (ICF) Activities and Participation domain categories. DATA SYNTHESIS Thirty-six measures were identified. The Stroke Impact Scale (SIS), London Handicap Scale, Assessment of Life Habits (LIFE-H), Frenchay Activities Index, and Activity Card Sort (ACS) were used most frequently. No single measure met criteria across all psychometric indices, and not one covered all 9 of the ICF Activities and Participation domains. The SIS, LIFE-H, and ACS covered the widest range. The domains covered most frequently were Community, Social and Civic Life, Domestic Life, and Mobility. Learning and Applying Knowledge, General Tasks and Demands, and Communication were the domains less frequently covered. CONCLUSIONS This review identified and evaluated the most frequently used participation measures in clinical stroke studies. The SIS, LIFE-H, and ACS covered the ICF Activities and Participation domain categories most comprehensively. However, none of the measures covered all the ICF Activities and Participation domain categories. The information provided in this systematic review can be used to guide the selection of participation measures to meet specific clinical and research purposes.

Mild impairment of cognition impacts on activity participation after stroke in a community-dwelling Australian cohort.

Ongoing disability following stroke can severely impact activity participation and quality of life. The authors investigated the association between cognition and mood and activity participation in 30 survivors of stroke living in the community, using quantitative assessment tools. Non-parametric correlation analyses quantified the presence and strength of association between variables. Differences for those with cognitive impairment or with depressive symptoms were investigated. Survivors of stroke with cognitive impairment of even mild severity had significantly reduced participation in all activity domains. Significant differences in activity participation were not found with mood, although relatively few were identified as being depressed. The findings suggest that mild cognitive impairment after stroke is associated with participation limitations that are important for occupational therapists to consider when planning intervention.

STroke imAging pRevention and treatment (START): A longitudinal stroke cohort study: Clinical trials protocol

Rationale Stroke and poststroke depression are common and have a profound and ongoing impact on an individuals quality of life. However, reliable biological correlates of poststroke depression and functional outcome have not been well established in humans. Aims Our aim is to identify biological factors, molecular and imaging, associated with poststroke depression and recovery that may be used to guide more targeted interventions. Design In a longitudinal cohort study of 200 stroke survivors, the START – STroke imAging pRevention and Treatment cohort, we will examine the relationship between gene expression, regulator proteins, depression, and functional outcome. Stroke survivors will be investigated at baseline, 24 h, three-days, three-months, and 12 months poststroke for blood-based biological associates and at days 3–7, three-months, and 12 months for depression and functional outcomes. A sub-group (n = 100), the PrePARE: Prediction and Prevention to Achieve optimal Recovery Endpoints after stroke cohort, will also be investigated for functional and structural changes in putative depression-related brain networks and for additional cognition and activity participation outcomes. Stroke severity, diet, and lifestyle factors that may influence depression will be monitored. The impact of depression on stroke outcomes and participation in previous life activities will be quantified. Study Outcomes Clinical significance lies in the identification of biological factors associated with functional outcome to guide prevention and inform personalized and targeted treatments. Evidence of associations between depression, gene expression and regulator proteins, functional and structural brain changes, lifestyle and functional outcome will provide new insights for mechanism-based models of poststroke depression.

A Pathway Proteomic Profile of Ischemic Stroke Survivors Reveals Innate Immune Dysfunction in Association with Mild Symptoms of Depression – A Pilot Study

Depression after stroke is a common occurrence, raising questions as to whether depression could be a long-term biological and immunological sequela of stroke. Early explanations for post-stroke depression (PSD) focused on the neuropsychological/psychosocial effects of stroke on mobility and quality of life. However, recent investigations have revealed imbalances of inflammatory cytokine levels in association with PSD, though to date, there is only one published proteomic pathway analysis testing this hypothesis. Thus, we examined the serum proteome of stroke patients (n = 44, mean age = 63.62 years) and correlated these with the Montgomery–Åsberg Depression Rating Scale (MADRS) scores at 3 months post-stroke. Overall, the patients presented with mild depression symptoms on the MADRS, M = 6.40 (SD = 7.42). A discovery approach utilizing label-free relative quantification was employed utilizing an LC-ESI–MS/MS coupled to a LTQ-Orbitrap Elite (Thermo-Scientific). Identified peptides were analyzed using the gene set enrichment approach on several different genomic databases that all indicated significant downregulation of the complement and coagulation systems with increasing MADRS scores. Complement and coagulation systems are traditionally thought to play a key role in the innate immune system and are established precursors to the adaptive immune system through pro-inflammatory cytokine signaling. Both systems are known to be globally affected after ischemic or hemorrhagic stroke. Thus, our results suggest that lowered complement expression in the periphery in conjunction with depressive symptoms post-stroke may be a biomarker for incomplete recovery of brain metabolic needs, homeostasis, and inflammation following ischemic stroke damage. Further proteomic investigations are now required to construct the temporal profile, leading from acute lesion damage to manifestation of depressive symptoms. Overall, the findings provide support for the involvement of inflammatory and immune mechanisms in PSD symptoms and further demonstrate the value and feasibility of the proteomic approach in stroke research.

Reduction in retained activity participation is associated with depressive symptoms 3 months after mild stroke: An observational cohort study.

OBJECTIVE To quantify the association of depressive symptoms with retained activity participation 3 months post-stroke, after adjusting for neurological stroke severity and age. DESIGN A cross-sectional observational study of retained activity participation and depressive symptoms in stroke survivors with ischaemic stroke. PARTICIPANTS One hundred stroke survivors with mild neurological stroke severity. METHODS One hundred stroke survivors were recruited from 5 metropolitan hospitals and reviewed at 3 months post-stroke using measures of activity participation, Activity Card Sort-Australia, and depressive symptoms, Montgomery-Asberg Depression Rating Scale Structured Interview Guide (MADRS-SIGMA). RESULTS The median percentage of retained overall activity participation was 97%, (interquartile range 79-100%). Using multiple median regression, 1 point increase in the MADRS-SIGMA was associated with a median decrease of 0.7% (95% CI -1.4 to -0.1, p=0.02) of retained overall activity participation, assuming similar neurological stroke severity and age. CONCLUSION The findings of this study establish the association of depressive symptoms with retained activity participation 3 months post-stroke in stroke survivors with mild neurological stroke severity. Clinical rehabilitation recommendations to enhance activity participation need to account for those with even mild depressive symptoms post-stroke.

Increased work and social engagement is associated with increased stroke specific quality of life in stroke survivors at 3 months and 12 months post-stroke: a longitudinal study of an Australian stroke cohort

Abstract Background: There is a relative lack of longitudinal studies investigating stroke-specific outcomes and quality of life (QOL). This study aimed to identify which factors (level of disability, cognitive functioning, depressive symptoms, physical activity, and work and social engagement) were independently associated with each stroke-specific domain of QOL, adjusting for age and gender, at 3 months and 12 months post-stroke in an Australian cohort. Method: Survivors of ischemic stroke were recruited from 18 sites of the STroke imAging pRevention and Treatment (START) longitudinal cohort study. Survivors were assessed at 3 months (n = 185) and 12 months (n = 170) post-stroke using the Stroke Impact Scale (SIS), modified Rankin Scale (mRS), Montreal Cognitive Assessment (MoCA), Montgomery-Asberg Depression Rating Scale, Rapid Assessment of Physical Activity, and Work and Social Adjustment Scale (WSAS). Results: WSAS was independently associated with the SIS domains of: Physical Composite function; Participation; and Perceived Recovery at 3 months and 12 months and SIS domain of Emotion at 12 months post-stroke. The presence of depressive symptoms was independently associated with the SIS domains of: Memory and Thinking; and Emotion at 3 months. At 12 months post-stroke, mRS was independently associated with SIS domain of Physical Composite function and MoCA with SIS domain of Communication. Conclusion: Engaging in work and social activities is an important factor associated with stroke-specific domains of QOL over time. It is recommended that services focus on improving work and social engagement given their importance related to QOL in the first year of recovery post-stroke. Identifying and treating those with depressive symptoms may enhance QOL in the early months post-stroke. Trial registration: START-PrePARE Australian New Zealand Clinical Trials, www.anzctr.org.au, Registry number: ACTRN12610000987066. EXTEND ClinicalTrial.gov identifier: NCT00887328.

Longitudinal changes in activity participation in the first year post-stroke and association with depressive symptoms

Abstract Research question: 1. Does activity participation improve over time in the first year after stroke? 2. What is the association of depressive symptoms on retained activity participation 12-months post-stroke adjusting for neurological stroke severity and age? 3. Is an improvement in activity participation associated with a decrease in depressive symptoms between 3- and 12-months post-stroke? Design: Longitudinal observational study of activity participation and depressive symptoms in ischemic stroke survivors. Participants: A total of 100 stroke survivors with mild neurological stroke severity. Methods: A total of 100 stroke survivors were recruited from five metropolitan hospitals and assessed at 3- and 12-months post-stroke using measures of activity participation (Activity Card Sort-Australia (ACS-Aus)) and depressive symptoms (Montgomery–Asberg Depression Rating Scale Structured Interview Guide (MADRS-SIGMA)). Results: There was a significant association between time (pre-stroke to 3-months post-stroke) and current activity participation (−5.2 activities 95% CI −6.8 to −3.5, p < 0.01) and time (pre-stroke to 12-months) and current activity participation (−2.1 activities 95% CI −3.7 to −0.5, p = 0.01). At 12-months post-stroke, a one-point increase in depressive symptoms was associated with a median decrease of 0.3% (95% CI −1.4% to −0.1%, p = 0.02) of retained overall activity participation, assuming similar neurological stroke severity and age. A decrease in depressive symptoms between 3- and 12-months post-stroke was associated with an improvement of 0.31 (95% CI −0.5 to −0.1, p = 0.01) in current activity participation. Conclusions: Activity participation improves during the first year of recovery post-stroke in stroke survivors with mild neurological stroke severity and is associated with depressive symptoms over time and at 12-months post-stroke. Implications for rehabilitation Improvements in participation occur in the first 3-months post-stroke and continue to a lesser degree in the first year after stroke. Depressive symptoms are associated with lower participation at 12-months. A multidimensional approach targeting depressive symptoms and increasing participation in the early months post-stroke and throughout the first-year after stroke is recommended to increase overall recovery following stroke. A focus on increasing leisure activity participation is recommended to improve depressive symptoms. Trial registration: Australian New Zealand Clinical Trials Registry identifier: ACTRN12610000987066.

Scoping Review: The Trajectory of Recovery of Participation Outcomes following Stroke

Participation is a central concept in health and well-being and healthcare, yet operationalizing this concept has been difficult. Its definition, uses in healthcare, and impacts on recovery require ongoing research. Our review question goes like this: from the longitudinal evidence investigating participation among stroke survivors, what are the patterns of participation recovery in stroke survivors over time, and what interventions are used to improve participation? To fully understand these questions, we also ask, how is participation defined in the stroke literature, and what are the measures of participation used in the stroke literature? A systematic scoping review was undertaken using the search terms “stroke,” “longitudinal,” “participation,” and “outcome” in seven databases. Articles included were published until April 2017, written in English, and had at least two longitudinal assessments of participation. Fifty-nine articles met the inclusion criteria. The International Classification of Functioning, Disability and Health was the most frequent definition of participation used (34%). There were 22 different measures of participation. Eight of ten studies demonstrated significant improvements in participation up to 12 months poststroke. Efficacy of interventions and their impact on participation varied. The various definitions, measures, and intervention efficacies of participation highlight the need for further research worldwide into achieving meaningful participation and quality of life among stroke survivors. Future practice should include participation as a main outcome measure.

Application of the world stroke organization health system indicators and performance in Australia, Singapore, and the USA.

Aim To examine how Australia, Singapore and the United States of America (USA) match to the World Stroke Organization Global Stroke Services health system monitoring indicators (HSI). Design Descriptive comparative study Participants The health systems of Australia, Singapore, the USA. Outcome measures Published data available from each country were mapped to the 10 health system monitoring indicators proposed by the World Stroke Organization. Results Most health system monitoring indicators were at least partially met in each country. Thrombolytic agents were available for use in acute stroke. Stroke guidelines and stroke registry data were available in all three countries. Stroke incidence, prevalence, and mortality rates were available but at non-uniform times post-stroke. The International Classification of Disease 9 or 10 coding systems are used in all three countries. Standardized clinical audits are routine in Australia and the USA, but not in Singapore. The use of the modified Rankin Scale is collected sub-acutely but not at one year post-stroke in all three countries. Conclusions The three developed countries are performing well against the World Stroke Organization health system monitoring indicators for acute and sub-acute stroke care. However, improvements in stroke risk assessment and at one-year post-stroke outcome measurement are needed.

Neuroimaging associates of depression in stroke

Session 1: ICH/TIA 1100–1230 Management of unruptured intracranial arteriovenous malformations in pediatric patients with stereotactic radiosurgery D Ding, Z Xu, C-P Yen, R M Starke, J P Sheehan University of Virginia, Charlottesville, Virginia, USA Background: Unruptured intracranial arteriovenous malformations (AVM) in pediatric patients (age <18 years) were excluded from A Randomized Trial of Unruptured AVMs. Therefore, the efficacy of stereotactic radiosurgery (SRS) for unruptured pediatric AVMs is poorly understood. The goal of this study is to determine the outcomes and define the predictors of obliteration following SRS for unruptured pediatric AVMs. Methods: We evaluated a prospective, institutional AVM SRS database, from 1989 to 2013. Patients with age <18 years at the time of SRS, unruptured nidi, and at least two years of radiologic follow-up or AVM obliteration were selected for analysis. Statistical analyses were performed to determine actuarial obliteration rates and identify factors associated with obliteration. Results: In the 51 unruptured pediatric AVM patients included for analysis, the median age was 13 years, and the most common presentation was seizure (53%). The median nidus volume, radiosurgical margin dose, and radiologic follow-up were 3.2 cm, 21.5 Gy, and 45 months, respectively. The actuarial AVM obliteration rates at 3, 5, and 10 years were 29%, 54%, and 72%, respectively. In the multivariate Cox regression analysis, higher margin dose (P = 0.002), fewer draining veins (P = 0.038), and lower Virginia Radiosurgery AVM Scale (P = 0.003) were independent predictors of obliteration. The incidences of radiologically evident, symptomatic, and permanent radiation-induced changes were 55%, 16%, and 2%, respectively. The annual post-radiosurgery hemorrhage rate was 1.3%. Conclusion: Radiosurgery affords a favorable risk to benefit profile for unruptured pediatric AVMs. Pediatric patients with unruptured AVMs merit further study to define an optimal management approach. 1. Al-Shahi Salman R, White PM, Counsell CE, du Plessis J, van Beijnum J, Josephson CB, Wilkinson T, Wedderburn CJ, Chandy Z, St George EJ, Sellar RJ, Warlow CP. Outcome after conservative management or intervention for unruptured brain arteriovenous malformations. JAMA 2014; 311:1661–1669. 2. Ding D, Xu Z, Yen CP, Starke RM, Sheehan JP. Radiosurgery for unruptured cerebral arteriovenous malformations in pediatric patients. Acta Neurochir (Wien) 2014. DOI: 10.1007/s00701-0142305-4. 3. Mohr JP, Parides MK, Stapf C, Moquete E, Moy CS, Overbey JR, Al-Shahi Salman R, Vicaut E, Young WL, Houdart E, Cordonnier C, Stefani MA, Hartmann A, von Kummer R, Biondi A, Berkefeld J, Klijn CJ, Harkness K, Libman R, Barreau X, Moskowitz AJ. Medical management with or without interventional therapy for unruptured brain arteriovenous malformations (ARUBA): a multicentre, non-blinded, randomised trial. Lancet 2014; 383:614–621. Subclinical ischemic lesions in patients with intracranial haemorrhage S Singhal, J V Ly, R V Chandra, J Zhou, C Soufan, H Ma, B Clissold, V Srikanth, T G Phan Monash Health, Clayton, VIC, Australia Background and Purpose: Subclinical ischemic lesions on diffusion weighted MR imaging (MRI-DWI) have been recently described in patients with spontaneous intracerebral hemorrhage (ICH) and convexity subarachnoid hemorrhage (cSAH). Such lesions are postulated to be part of the amyloid angiopathy spectrum. We hypothesized that the frequency of these MRI-DWI lesions may differ between patients presenting with cSAH, lobar ICH and basal ganglia ICH. Methods: Retrospective study of patients presenting between 2011–2014 with cSAH and/or ICH and subsequent MRI. Patients with an aneurysm, arteriovenous malformation, or hemorrhagic infarct were excluded. ICH topography was classified as lobar or basal ganglia; MRI-DWI lesions were classified as subclinical if there were no associated symptoms; contrast enhanced scans were assessed for leptomeningeal contrast enhancement. Results: Of 115 eligible patients, 56 patients had MRI within 14 days of hemorrhage (mean age 69.4 ± 11.5 years; 48% male). Overall, 21% (n = 12/56) patients with cSAH and/or ICH had subclinical MRI-DWI lesions. MRI-DWI lesions occurred more frequently in patients with cSAH than basal ganglia ICH (n = 5/12 vs 2/30; p = 0.006) and in patients with lobar ICH than basal ganglia ICH (n = 5/18 vs 2/30; p = 0.04). There was no significant difference in MRI-DWI lesions between cSAH and lobar ICH. Patients with MRI-DWI lesions had more frequent adjacent leptomeningeal contrast enhancement (p < 0.001). Conclusion: Subclinical ischemic lesions occur more frequently in patients with cSAH and lobar ICH than basal ganglia ICH. More frequent leptomeningeal contrast enhancement in these patients may point to a common underlying amyloid-related small vessel vasculopathy. Impact of haematoma shape and density on 90-day outcome after intracerebral haemorrhage: The INTERACT2 study C Delcourt, S Zhang, H Arima, S Sato, R A-S Salman, X Wang, C Stapf, T Robinson, P Lavados, J Chalmers, E Heeley, C Anderson Neurology and Mental Health Division, The George Institute for Global Health, Sydney, NSW, Australia The University of Sydney, Sydney, NSW, Australia Neurology Department, Royal Prince Alfred Hospital, Sydney, NSW, Australia University of Edinburgh, NHS Lothian, Edinburg, United Kingdom Université Paris Diderot – Sorbonne Paris, AP-HP Hôpital Lariboisière, Paris, France Leicester Royal Infirmary, University of Leicester, Leicester, United Kingdom Departamento de Medicina, Clínica Alemana, Universidad del Desarrollo (P.M.L.), Santiago, Chile The George Institute for Global Health, Sydney, NSW, Australia Background: Irregularity of shape and heterogeneous density suggest multiple bleeding foci and different periods of bleeding, respectively, in acute intracerebral hemorrhage (ICH). These features predict hematoma expansion but with uncertain significance on patient outcome. The aim of this study was to assess the association of shape and density on outcome among participants of INTERACT2, an open-label randomized controlled trial. Method: Shape and density were measured in 2066 patients with baseline CT. The Barras scale was used to categorize the appearance of the ICH, on the largest axial slice, into ‘regular’ (1 to 2) vs ‘irregular’ (3 to 5); density variation into ‘homogeneous’ (1 to 2) vs ‘heterogeneous’ (3 to 5). Logistic regression models were used to assess hematoma parameters on the primary outcome defined as death or major disability (mRS 3–6) at 90 days. Secondary outcomes were death and major disability, separately. Results: Shape irregularity was associated with poor outcome (OR 1.64, 95%CI 1.33–2.03), and separately only on major disability (OR 1.5, 95% CI 1.24–1.83). Density heterogeneity was not associated with poor outcome (OR 1.09, 95%CI 0.87–1.36), or the separate components of death or disability. Abstracts