Wieslaw Oczkowski

The functional independence measure: Its use to identify rehabilitation needs in stroke survivors

To explore the potential of the Functional Independence Measure (FIM) as a prognostic indicator of outcome in stroke survivors, 113 consecutive patients were observed from admission until discharge. Patients received assessment and treatment by a multidisciplinary team in a regional tertiary care stroke-specific rehabilitation program. The FIM, Chedoke-McMaster Stroke Assessment, and discharge location were used as the main outcome measures. The results suggested that; (1) impairment variables alone are insufficient as prognostic indicators of outcome; (2) the absolute admission FIM score, not the change in the FIM score, is the best predictor of outcome disability and place of discharge; and (3) subgroups of stroke survivors with differing rehabilitation needs can be identified. The FIM allows us to classify stroke survivors according to their needs; therefore, attention should be redirected to the development of prognostic indicators for groups of stroke survivors.

Neural network modeling accurately predicts the functional outcome of stroke survivors with moderate disabilities

OBJECTIVE To predict the place of discharge or discharge Functional Independence Measure (FIM) score for stroke survivors with moderate disability using neural network modeling. Our previous work demonstrated that the FIM predicts the level of recovery for stroke survivors with either severe or mild disabilities. DESIGN Neural network analysis. SETTING Tertiary care rehabilitation program. PATIENTS One hundred forty-seven consecutive stroke survivors admitted for rehabilitation with admission FIM scores between 37 and 96 were used as the training and internal test set. Seventeen other randomly selected stroke survivors were used as the external test set. INTERVENTION A neural network model was developed using a small set of clinical variables and the admission FIM score. MAIN OUTCOME MEASURE Neural network model predicting place of discharge or discharge FIM score. RESULTS A working and accurate model was developed to predict the discharge FIM score. The model was able to predict the 17 external test cases with an accuracy = 88%, sensitivity = 83%, specificity = 91%, positive predictive value = 83%, and negative predictive value = 91%. CONCLUSION Neural network modeling is useful in the prediction of functional recovery and helps in discharge planning and allocation of rehabilitation resources.

A prospective cohort study of patients with transient ischemic attack to identify high-risk clinical characteristics.

Background and Purpose— The occurrence of a transient ischemic attack (TIA) increases an individual’s risk for subsequent stroke. The objectives of this study were to determine clinical features of patients with TIA associated with impending (⩽7 days) stroke and to develop a clinical prediction score for impending stroke. Methods— We conducted a prospective cohort study at 8 Canadian emergency departments for 5 years. We enrolled patients with a new TIA. Our outcome was subsequent stroke within 7 days of TIA diagnosis. Results— We prospectively enrolled 3906 patients, of which 86 (2.2%) experienced a stroke within 7 days. Clinical features strongly correlated with having an impending stroke included first-ever TIA, language disturbance, longer duration, weakness, gait disturbance, elevated blood pressure, atrial fibrillation on ECG, infarction on computed tomography, and elevated blood glucose. Variables less associated with having an impending stroke included vertigo, lightheadedness, and visual loss. From this cohort, we derived the Canadian TIA Score which identifies the risk of subsequent stroke ⩽7 days and consists of 13 variables. This model has good discrimination with a c-statistic of 0.77 (95% confidence interval, 0.73–0.82). Conclusions— Patients with TIA with their first TIA, language disturbance, duration of symptoms ≥10 minutes, gait disturbance, atrial fibrillation, infarction on computed tomography, elevated platelets or glucose, unilateral weakness, history of carotid stenosis, and elevated diastolic blood pressure are at higher risk for an impending stroke. Patients with vertigo and no high-risk features are at low risk. The Canadian TIA Score quantifies the impending stroke risk following TIA.

Risk factors for posterior compared to anterior ischemic stroke: an observational study of the Registry of the Canadian Stroke Network.

Background: Traditional vascular risk factors appear to exert varying magnitudes of risk for different major vascular events. For example, hypercholesterolemia is a much stronger risk factor for myocardial infarction than ischemic stroke. Limited evidence also suggests that vascular risk factors may exert differing magnitudes of risk for ischemic stroke within different cerebral arterial territories. We sought to determine the association between traditional vascular risk factors and the location of ischemic stroke (posterior versus anterior). Methods: Consecutive patients with acute ischemic stroke who were admitted to 11 regional stroke centers within the Registry of the Canadian Stroke Network were included in the study sample. The Oxfordshire Community Stroke Project classification was used to distinguish posterior from anterior circulation ischemic stroke. Multivariable logistic regression was applied to determine the association between risk factors (age, gender, diabetes mellitus, hypercholesterolemia, hypertension, atrial fibrillation and smoking history) and posterior (compared to anterior) circulation ischemic stroke. Results: In total, 8,489 patients with acute ischemic stroke were included. On multivariable analysis, diabetes mellitus (OR = 1.14; 95% CI = 1.02–1.27) was associated with an increased odds of posterior circulation ischemic stroke, whereas age (OR = 0.86; 95% CI = 0.83–0.90), female sex (OR = 0.84; 95% CI = 0.76–0.93), atrial fibrillation (OR = 0.83; 95% CI = 0.74–0.94) and pulmonary edema (OR = 0.74; 95% CI = 0.62–0.88) were related to a reduced odds of posterior compared with anterior circulation ischemic stroke. Conclusions: Some traditional vascular risk factors for ischemic stroke appear to exert different magnitudes of risk for posterior compared to anterior circulation ischemic stroke.

Rapid Assessment and Treatment of Transient Ischemic Attacks and Minor Stroke in Canadian Emergency Departments: Time for a Paradigm Shift.

A majority of acute cerebrovascular syndromes are transient ischemic attacks (TIA) or minor ischemic strokes. They are often thought of and managed as though benign, but are in fact a warning of impending disabling stroke. The risk of stroke progression or recurrence is highest in the first hours to days from initial symptom onset, with a 6.7% risk at 48 hours and a 10% risk by 7 days after a TIA.1,2 The highest risk period is early, with a median time to a recurrence or progression event of 1 day; many events occur overnight after the initial ictus.3 Many strokes are preventable after a TIA. Rapid diagnosis and treatment reduces the risk of stroke by as much as 80%4,5 and significantly reduces mortality, long-term disability, and costs.6,7 The estimated annual cost avoidance in Canada from the rapid assessment and treatment of TIA is

Screening for cognitive impairment in a stroke prevention clinic using the MoCA.

313.8 million (of which

Atraumatic versus conventional lumbar puncture needles: a systematic review and meta-analysis

269.2 million are indirect costs).8 To be most effective, the diagnosis and treatment of all TIAs and minor strokes must recognize the natural biology of the condition and should ideally occur on the same day as the event. Currently, this is not consistently achieved in Canada. There are several overlapping challenges with TIA/minor stroke management, including (1) establishing an accurate diagnosis of brain ischemia quickly; (2) establishing accurate triage approaches to risk-stratify patients; and (3) establishing systems of care that expedite both the diagnostic evaluation and initiation of treatment. Rapid access to both brain and vascular imaging is a unifying component of the solution to all these challenges. The clinical diagnosis of TIA/minor stroke is not always straightforward because a …

Computed Tomography Identifies Patients at High Risk for Stroke After Transient Ischemic Attack/Nondisabling Stroke Prospective, Multicenter Cohort Study

BACKGROUND Screening for cognitive impairment is recommended in patients with cerebrovascular disease. We sought to establish the incidence of cognitive impairment using the Montreal Cognitive Assessment (MoCA) in a cohort of consecutive patients attending our stroke prevention clinic (SPC), and to determine whether a subset of the MoCA could be derived for use in this busy clinical setting. METHODS The MoCA was administered to 102 patients. Incidence of cognitive impairment was compared to presenting complaint and final diagnosis. extent of cerebral white matter changes (WMC) was rated using the Age Related White Matter Changes (ARWMC) scale in 80 patients who underwent neuroimaging. A subset of the three most predictive test elements of the MoCA was derived using regression analysis. RESULTS 63.7% of patients scored <26/30 on the MoCA, in keeping with cognitive impairment. This was unrelated to the final diagnosis or extent of WMC, although a trend for lower MoCA scores was observed in older patients. A mini-MoCA subscore combining the clock drawing test, five-word delayed recall, and abstraction was highly correlated with the final MoCA score (R=0.901). A score of <7/10 using this 10-point mini-MoCA identified cognitive impairment as defined by the MoCA with a sensitivity of 98.5%, and a specificity of 77.6%. CONCLUSIONS Two-thirds of SPC patients demonstrated evidence for cognitive impairment, irrespective of their final diagnosis or the presence of WMC. A mini-MoCA comprised of the clock drawing test, five-word delayed recall, and abstraction represents a potential alternative to the full MoCA in this population.

Stroke prevention care delivery: Predictors of risk factor management outcomes

BACKGROUND Atraumatic needles have been proposed to lower complication rates after lumbar puncture. However, several surveys indicate that clinical adoption of these needles remains poor. We did a systematic review and meta-analysis to compare patient outcomes after lumbar puncture with atraumatic needles and conventional needles. METHODS In this systematic review and meta-analysis, we independently searched 13 databases with no language restrictions from inception to Aug 15, 2017, for randomised controlled trials comparing the use of atraumatic needles and conventional needles for any lumbar puncture indication. Randomised trials comparing atraumatic and conventional needles in which no dural puncture was done (epidural injections) or without a conventional needle control group were excluded. We screened studies and extracted data from published reports independently. The primary outcome of postdural-puncture headache incidence and additional safety and efficacy outcomes were assessed by random-effects and fixed-effects meta-analysis. This study is registered with the International Prospective Register of Systematic Reviews, number CRD42016047546. FINDINGS We identified 20 241 reports; after exclusions, 110 trials done between 1989 and 2017 from 29 countries, including a total of 31 412 participants, were eligible for analysis. The incidence of postdural-puncture headache was significantly reduced from 11·0% (95% CI 9·1-13·3) in the conventional needle group to 4·2% (3·3-5·2) in the atraumatic group (relative risk 0·40, 95% CI 0·34-0·47, p<0·0001; I2=45·4%). Atraumatic needles were also associated with significant reductions in the need for intravenous fluid or controlled analgesia (0·44, 95% CI 0·29-0·64; p<0·0001), need for epidural blood patch (0·50, 0·33-0·75; p=0·001), any headache (0·50, 0·43-0·57; p<0·0001), mild headache (0·52, 0·38-0·70; p<0·0001), severe headache (0·41, 0·28-0·59; p<0·0001), nerve root irritation (0·71, 0·54-0·92; p=0·011), and hearing disturbance (0·25, 0·11-0·60; p=0·002). Success of lumbar puncture on first attempt, failure rate, mean number of attempts, and the incidence of traumatic tap and backache did not differ significantly between the two needle groups. Prespecified subgroup analyses of postdural-puncture headache revealed no interactions between needle type and patient age, sex, use of prophylactic intravenous fluid, needle gauge, patient position, indication for lumbar puncture, bed rest after puncture, or clinician specialty. These results were rated high-quality evidence as examined using the grading of recommendations assessment, development, and evaluation. INTERPRETATION Among patients who had lumbar puncture, atraumatic needles were associated with a decrease in the incidence of postdural-puncture headache and in the need for patients to return to hospital for additional therapy, and had similar efficacy to conventional needles. These findings offer clinicians and stakeholders a comprehensive assessment and high-quality evidence for the safety and efficacy of atraumatic needles as a superior option for patients who require lumbar puncture. FUNDING None.

Acute Isolated Dysarthria Is Associated with a High Risk of Stroke

Background and Purpose— Ischemia on computed tomography (CT) is associated with subsequent stroke after transient ischemic attack. This study assessed CT findings of acute ischemia, chronic ischemia, or microangiopathy for predicting subsequent stroke after transient ischemic attack. Methods— This prospective cohort study enrolled patients with transient ischemic attack or nondisabling stroke that had CT scanning within 24 hours. Primary outcome was subsequent stroke within 90 days. Secondary outcomes were stroke at ⩽2 or >2 days. CT findings were classified as ischemia present or absent and acute or chronic or microangiopathy. Analysis used Fisher exact test and multivariate logistic regression. Results— A total of 2028 patients were included; 814 had ischemic changes on CT. Subsequent stroke rate was 3.4% at 90 days and 1.5% at ⩽2 days. Stroke risk was greater if baseline CT showed acute ischemia alone (10.6%; P=0.002), acute+chronic ischemia (17.4%; P=0.007), acute ischemia+microangiopathy (17.6%; P=0.019), or acute+chronic ischemia+microangiopathy (25.0%; P=0.029). Logistic regression found acute ischemia alone (odds ratio [OR], 2.61; 95% confidence interval [CI[, 1.22–5.57), acute+chronic ischemia (OR, 5.35; 95% CI, 1.71–16.70), acute ischemia+microangiopathy (OR, 4.90; 95% CI, 1.33–18.07), or acute+chronic ischemia+microangiopathy (OR, 8.04; 95% CI, 1.52–42.63) was associated with a greater risk at 90 days, whereas acute+chronic ischemia (OR, 10.78; 95% CI, 2.93–36.68), acute ischemia+microangiopathy (OR, 8.90; 95% CI, 1.90–41.60), and acute+chronic ischemia+microangiopathy (OR, 23.66; 95% CI, 4.34–129.03) had greater risk at ⩽2 days. Only acute ischemia (OR, 2.70; 95% CI, 1.01–7.18; P=0.047) was associated with a greater risk at >2 days. Conclusions— In patients with transient ischemic attack/nondisabling stroke, CT evidence of acute ischemia alone or acute ischemia with chronic ischemia or microangiopathy was associated with increased subsequent stroke risk within 90 days.