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UNLABELLED: Early identification of stroke symptoms is essential. The rate of stroke identification by call-takers at emergency medical communication centres (EMCCs) varies, and patients who are found in a lying down position are often not identified as having an ongoing stroke. OBJECTIVES: this study aimed to explore signs and symptoms of stroke in patients who had fallen or were found in a lying position. DESIGN: a retrospective exploratory qualitative study design was used. METHOD: a total of 29 emergency calls to EMCCs regarding patients discharged with a stroke diagnosis from a large teaching hospital in Stockholm, Sweden, in January-June 2011, were analysed using qualitative content analysis. RESULTS: during the emergency calls, the callers described a sudden change in the patient's health status including signs such as the patient's loss of bodily control, the patient's perception of a change in sensory perception, and the callers' inability to communicate with the patient. CONCLUSIONS: The callers' descriptions of stroke in a person found in a lying position are not always as described in assessment protocols describing the onset of a stroke. Instead, the symptom descriptions are much vaguer. Therefore, to increase identification of stroke during emergency calls, there is a need for an increased understanding of how callers describe stroke symptoms and communicate with the call-takers.

Early identification of stroke symptoms is essential. The rate of stroke identification by call-takers at emergency medical communication centres (EMCCs) varies, and patients who are found in a lying down position are often not identified as having an ongoing stroke. OBJECTIVES: this study aimed to explore signs and symptoms of stroke in patients who had fallen or were found in a lying position. DESIGN: a retrospective exploratory qualitative study design was used. METHOD: a total of 29 emergency calls to EMCCs regarding patients discharged with a stroke diagnosis from a large teaching hospital in Stockholm, Sweden, in January-June 2011, were analysed using qualitative content analysis. RESULTS: during the emergency calls, the callers described a sudden change in the patient's health status including signs such as the patient's loss of bodily control, the patient's perception of a change in sensory perception, and the callers' inability to communicate with the patient. CONCLUSIONS: The callers' descriptions of stroke in a person found in a lying position are not always as described in assessment protocols describing the onset of a stroke. Instead, the symptom descriptions are much vaguer. Therefore, to increase identification of stroke during emergency calls, there is a need for an increased understanding of how callers describe stroke symptoms and communicate with the call-takers., The third author had financial support from The Swedish Stroke Association (Stroke-Riksförbundet) and Södersjukhuset, the Department of Internal Medicine. This study is a part of the Fighting Stroke Project (Uppdrag Besegra Stroke), supported by the Swedish Heart and Lung Foundation and Karolinska Institutet; the project is supported by funding from Friends of Karolinska Institutet, USA, and Johanniterorden. Financial support was provided through the Centre for Gender Medicine at Karolinska Institutet and from the regional agreement on medical training and clinical research (ALF) between Stockholm County Council and Karolinska Institutet.

Early seizures (ES) following stroke are prevalent among the elderly population, representing the most common type of acquired seizures. This study aimed to determine the incidence of ES and investigate potential associations with various clinical and radiological factors. 260 stroke patients (mean age 72±13.2, 48.5% females) were prospectively enrolled and followed. Baseline demographic data, clinical data, stroke subtype, ES occurrence, National Institutes of Health Stroke Scale (NIHSS) scores, and Alberta Stroke Program Early CT Score (ASPECT) were collected and analyzed. ES was observed in 11.6% of patients with ischemic stroke compared to 7.1% among patients with hemorrhagic stroke. ES occurred more frequently in those with posterior circulation stroke (18.5% vs. 7.1%, P=0.008) and those with NIHSS >15 (19.4% vs. 8.4%, P=0.04). In a logistic regression analysis that adjusted for vascular risk factors and NIHSS, posterior circulation stroke remained significantly associated with ES, with an odds ratio of 3.14 (95% CI 1.20 to 7.73, P=0.012). This study revealed that ES following stroke is more common in patients with posterior circulation lesions. These findings emphasize the need for further investigation into additional factors that may influence ES occurrence and its impact on stroke management and patient outcomes.

Early identification of stroke symptoms is essential. The rate of stroke identification by call-takers at emergency medical communication centres (EMCCs) varies, and patients who are found in a lying down position are often not identified as having an ongoing stroke. Objectives: this study aimed to explore signs and symptoms of stroke in patients who had fallen or were found in a lying position. Design: a retrospective exploratory qualitative study design was used. Method: a total of 29 emergency calls to EMCCs regarding patients discharged with a stroke diagnosis from a large teaching hospital in Stockholm, Sweden, in January–June 2011, were analysed using qualitative content analysis. Results: during the emergency calls, the callers described a sudden change in the patient’s health status including signs such as the patient’s loss of bodily control, the patient’s perception of a change in sensory perception, and the callers’ inability to communicate with the patient. Conclusions: The callers’ descriptions of stroke in a person found in a lying position are not always as described in assessment protocols describing the onset of a stroke. Instead, the symptom descriptions are much vaguer. Therefore, to increase identification of stroke during emergency calls, there is a need for an increased understanding of how callers describe stroke symptoms and communicate with the call-takers.

We aimed to validate the prognostic ability and assess interrater reliability of a recently suggested measurement-based definition of near-occlusion with full collapse (distal ICA diameter ≤ 2.0 mm and/or ICA ratio ≤ 0.42). 118 consecutive patients with symptomatic near-occlusion were prospectively included and assessed on computed tomography angiography by 2 blinded observers, 26 (22%) had full collapse. At 2 days after presenting event, the risk of preoperative stroke was 3% for without full collapse and 16% for with full collapse (p = 0.01). At 28 days, this risk was 16% for without full collapse and 22% for with full collapse (p = 0.22). Interrater reliability was perfect (kappa 1.0). Thus, near-occlusion with full collapse should be defined as distal ICA ≤ 2.0 mm and/or ICA ratio ≤ 0.42 in order to detect cases with very high risk of early stroke recurrence.

The objective of this thesis is to examine some challenges that may emerge when conducting time-to-event studies based on observational data. Time-to-event (also called survival) is a setting that involves analyzing how different factors may influence the length of time until an individual experiences the event of interest. This type of analysis is commonly applied in fields such as medical research and epidemiology. In this thesis, which focuses on stroke, we are interested in the time to a recurrent stroke or the death of a patient who survived a first stroke. Hazard ratios are one of the main parameters estimated in time-to-event studies. Hazard ratios involve comparing the risk of experiencing the event between two groups, usually a treated group and an untreated group. They can also involve other factors, such as different age groups. Hazard ratios can be estimated from the data by using the Cox regression model. Observational data, in contrast to experimental data, involves data collected without any intervention or random assignment of treatment to the individuals. Confounders, that is, variables that distort or obscure the true relationship between treatment and outcome, are always present and need to be controlled for in observational studies. National registers are an important source of observational data. A national registry is a centralized database or system that collects, stores, and maintains information about a specific population or group of individuals within a country. Sweden is known for its detailed and complete national registers. In this thesis, data from the Swedish Stroke Register (Riksstroke) is used to study factors related to stroke. In time-to-event studies involving observational data, several challenges may arise for the researcher during data analysis. Some individuals may not experience the event during the observation period and thus the information about their time until the event is incomplete. These individuals are considered a

AimTo investigates the financial consequences in the overall population spouses of persons with stroke in Sweden as well as for subgroups based on spouses age, sex and modified Rankin Scale (mRS) of the person with stroke.MethodsThe study population consists of spouses aged <= 60 during the year of their partner's stroke event. Each spouse was matched to four reference individuals. This longitudinal registry data covers spouses and a reference population between 2005 and 2016. We use difference-in-differences to estimate the impact on individual income from paid work, disposable individual income, and disposable family income.ResultsThe primary analysis shows a small and statistically insignificant decrease on spouses' individual income from paid work and disposable individual income. In the subgroup analysis based on mRS, the largest effect is seen in mRS 4-5, where spouses' individual income from paid work and disposable individual income increases after their partner's stroke. Further, younger female spouses' individual income from paid work decreases by 1 614 EUR (p = 0.008) on average.ConclusionThe financial consequences are small in the overall population of spouses. However, for some subgroups, younger women, and spouses of persons with stroke and mRS 4-5, the financial consequences are more prominent.

The objective of this thesis is to examine some challenges that may emerge when conducting time-to-event studies based on observational data. Time-to-event (also called survival) is a setting that involves analyzing how different factors may influence the length of time until an individual experiences the event of interest. This type of analysis is commonly applied in fields such as medical research and epidemiology. In this thesis, which focuses on stroke, we are interested in the time to a recurrent stroke or the death of a patient who survived a first stroke. Hazard ratios are one of the main parameters estimated in time-to-event studies. Hazard ratios involve comparing the risk of experiencing the event between two groups, usually a treated group and an untreated group. They can also involve other factors, such as different age groups. Hazard ratios can be estimated from the data by using the Cox regression model. Observational data, in contrast to experimental data, involves data collected without any intervention or random assignment of treatment to the individuals. Confounders, that is, variables that distort or obscure the true relationship between treatment and outcome, are always present and need to be controlled for in observational studies. National registers are an important source of observational data. A national registry is a centralized database or system that collects, stores, and maintains information about a specific population or group of individuals within a country. Sweden is known for its detailed and complete national registers. In this thesis, data from the Swedish Stroke Register (Riksstroke) is used to study factors related to stroke. In time-to-event studies involving observational data, several challenges may arise for the researcher during data analysis. Some individuals may not experience the event during the observation period and thus the information about their time until the event is incomplete. These individuals are considered a

UNLABELLED: Early identification of stroke symptoms is essential. The rate of stroke identification by call-takers at emergency medical communication centres (EMCCs) varies, and patients who are found in a lying down position are often not identified as having an ongoing stroke. OBJECTIVES: this study aimed to explore signs and symptoms of stroke in patients who had fallen or were found in a lying position. DESIGN: a retrospective exploratory qualitative study design was used. METHOD: a total of 29 emergency calls to EMCCs regarding patients discharged with a stroke diagnosis from a large teaching hospital in Stockholm, Sweden, in January-June 2011, were analysed using qualitative content analysis. RESULTS: during the emergency calls, the callers described a sudden change in the patient's health status including signs such as the patient's loss of bodily control, the patient's perception of a change in sensory perception, and the callers' inability to communicate with the patient. CONCLUSIONS: The callers' descriptions of stroke in a person found in a lying position are not always as described in assessment protocols describing the onset of a stroke. Instead, the symptom descriptions are much vaguer. Therefore, to increase identification of stroke during emergency calls, there is a need for an increased understanding of how callers describe stroke symptoms and communicate with the call-takers.

Purpose: eHealth-based exercise therapies were developed to increase stroke patients’ adherence to home-based motor rehabilitation. However, these eHealth tools face a rapid decrease in use after a couple of weeks. This study investigates stroke patients’ motivation for home-based upper extremity rehabilitation with eHealth tools and their relation with Basic Psychological Needs. Materials and methods: This is a qualitative study using thematic analysis. We conducted semi-structured interviews with stroke patients with upper extremity motor impairments, who were discharged home from a rehabilitation centre, after they interacted with a novel eHealth coach demonstrator in their homes for five consecutive days. Results: We included ten stroke patients. Thematic analysis resulted in eight themes for home-based rehabilitation motivation: Curiosity, Rationale, Choice, Optimal challenge, Reference, Encouragement, Social Support and Trustworthiness. Those themes are embedded into three Basic Psychological Needs: “Autonomy”, “Competence”, and “Relatedness”. Conclusion: Eight motivational themes related to the three Basic Psychological Needs describe stroke patients’ motivation for home-based upper extremity rehabilitation. We recommend considering those themes when developing a home-based eHealth intervention for stroke patients to increase the alignment of eHealth tools to the patient’s needs and reduce motivational decreases in home-based rehabilitation., Design Aesthetics, Human Information Communication Design

Background: After stroke, many patients experience problems with participation in daily activities. Improving participation is the main goal in stroke rehabilitation. However, the longitudinal relationship between participation and health-related quality of life (HRQoL) remains unclear.Objectives: This study aimed to examine (1) the predictive value of participation at two months on long-term HRQoL and (2) the longitudinal relationship between participation and HRQoL.Methods: In this multicenter, prospective cohort study, patients were assessed at two and 12 months after stroke. Participation was measured with the Restriction subscale of the Utrecht Scale for Evaluation of Rehabilitation - Participation. HRQoL was assessed with the three-level version of the EuroQoL five dimensions questionnaire index score.Results: This study included 291 patients. Mean age was 66.6 +/- 12.4 years, 64.3% were male and mean National Institutes of Health Stroke Scale (NIHSS) was 2.5 +/- 2.9. Multivariable linear regression, adjusted for demographic characteristics, stroke characteristics, physical and cognitive impairment, showed that a higher level of participation at two months correlated with a higher HRQoL at one year (B = .004; 95% CI =.002-.005). Patients whose participation improved had a greater increase in HRQoL, compared to patients without improvement (0.080 +/- .21 versus -.054 +/- .21; p < .001).Conclusions: The level of participation at two months post-stroke predicts HRQoL at one year. Improvement in participation during the first year after stroke is associated with improvement in HRQoL. We recommend including the assessment of participation in daily activities at follow-up visits.

Purpose: The Nordic Nutrition Recommendations (NNR) are developed to prevent diet-related diseases. This study aimed to examine adherence to the NNR and risk of myocardial infarction (MI) and stroke among women and men in Sweden. Methods: We followed 34,898 adults from 1997 to 2016. Dietary intake was assessed once at baseline using a food frequency questionnaire. Adherence scores corresponding to NNR-editions from 2023, 2012, 2004 and 1996 were calculated. Scores were categorized into low (reference category), moderate and high adherence. Cox proportional hazards regression models adjusted for potential confounders were used to estimate hazards ratios (HR) with 95% confidence intervals (CI). Results: We identified 1649 incident cases of MI and 2071 incident cases of stroke during follow-up (mean 17.9 years). For each 1-point increase in the NNR2023-score (range 0–9), the rate of MI decreased by 14% (HR: 0.86; 95% CI 0.78–0.95). High adherence was associated with a lower rate of MI (HR: 0.72; 95% CI 0.59–0.87) (p-trend = 0.01). Moderate adherence was associated with a lower rate of stroke (HR: 0.88; 95% CI 0.78–0.99) (p-trend = 0.31). Among women, a 23% lower rate of MI (HR: 0.77; 95% CI 0.67–0.89) was observed for each 1-point increase, and high adherence was associated with a lower rate of MI (HR: 0.59; 95% CI 0.45–0.78). No associations were found in men. The results were similar, though attenuated, for earlier NNR-editions. Conclusion: Adherence to the NNR was associated with a reduced risk of MI. This association was more pronounced among women than among men and in more recent NNR-editions. The findings for stroke need further investigation.

Purpose: The use of arterial partial pressure of carbon dioxide (PaCO2) as a target intervention to manage elevated intracranial pressure (ICP) and its effect on clinical outcomes remain unclear. We aimed to describe targets for PaCO2 in acute brain injured (ABI) patients and assess the occurrence of abnormal PaCO2 values during the first week in the intensive care unit (ICU). The secondary aim was to assess the association of PaCO2 with in-hospital mortality. Methods: We carried out a secondary analysis of a multicenter prospective observational study involving adult invasively ventilated patients with traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), intracranial hemorrhage (ICH), or ischemic stroke (IS). PaCO2 was collected on day 1, 3, and 7 from ICU admission. Normocapnia was defined as PaCO2 > 35 and to 45 mmHg; mild hypocapnia as 32–35 mmHg; severe hypocapnia as 26–31 mmHg, forced hypocapnia as < 26 mmHg, and hypercapnia as > 45 mmHg. Results: 1476 patients (65.9% male, mean age 52 ± 18 years) were included. On ICU admission, 804 (54.5%) patients were normocapnic (incidence 1.37 episodes per person/day during ICU stay), and 125 (8.5%) and 334 (22.6%) were mild or severe hypocapnic (0.52 and 0.25 episodes/day). Forced hypocapnia and hypercapnia were used in 40 (2.7%) and 173 (11.7%) patients. PaCO2 had a U-shape relationship with in-hospital mortality with only severe hypocapnia and hypercapnia being associated with increased probability of in-hospital mortality (omnibus p value = 0.0009). Important differences were observed across different subgroups of ABI patients. Conclusions: Normocapnia and mild hypocapnia are common in ABI patients and do not affect patients' outcome. Extreme derangements of PaCO2 values were significantly associated with increased in-hospital mortality.

Aims: The regional and temporal differences in the associations between cardiovascular disease (CVD) and its classic risk factors are unknown. The current study examined these associations in different European regions over a 30-year period. Methods and results: The study sample comprised 553 818 individuals from 49 cohorts in 11 European countries (baseline: 1982-2012) who were followed up for a maximum of 10 years. Risk factors [sex, smoking, diabetes, non-HDL cholesterol, systolic blood pressure (BP), and body mass index (BMI)] and CVD events (coronary heart disease or stroke) were harmonized across cohorts. Risk factor-outcome associations were analysed using multivariable-adjusted Cox regression models, and differences in associations were assessed using meta-regression. The differences in the risk factor-CVD associations between central Europe, northern Europe, southern Europe, and the UK were generally small. Men had a slightly higher hazard ratio (HR) in southern Europe (P = 0.043 for overall difference), and those with diabetes had a slightly lower HR in central Europe (P = 0.022 for overall difference) compared with the other regions. Of the six CVD risk factors, minor HR decreases per decade were observed for non-HDL cholesterol [7% per mmol/L; 95% confidence interval (CI), 3-10%] and systolic BP (4% per 20 mmHg; 95% CI, 1-8%), while a minor HR increase per decade was observed for BMI (7% per 10 kg/m2; 95% CI, 1-13%). Conclusion: The results demonstrate that all classic CVD risk factors are still relevant in Europe, irrespective of regional area. Preventive strategies should focus on risk factors with the greatest population attributable risk.

BACKGROUND: While most European Regions perform well in global comparisons, large discrepancies within stroke epidemiological parameters exist across Europe. The objective of this analysis was to evaluate the stroke burden across European regions and countries in 2019 and its difference to 2010. METHODS: The GBD 2019 analytical tools were used to evaluate regional and country-specific estimates of incidence, prevalence, deaths, and disability-adjusted life years of stroke for the European Region as defined by the World Health Organization, with its 53 member countries (EU-53) and for European Union as defined in 2019, with its 28 member countries (EU-28), between 2010 and 2019. Results were analyzed at a regional, subregional, and country level. RESULTS: In EU-53, the absolute number of incident and prevalent strokes increased by 2% (uncertainty interval [UI], 0%-4%), from 1 767 280 to 1 802 559 new cases, and by 4% (UI, 3%-5%) between 2010 and 2019, respectively. In EU-28, the absolute number of prevalent strokes and stroke-related deaths increased by 4% (UI, 2%-5%) and by 6% (UI, 1%-10%), respectively. All-stroke age-standardized mortality rates, however, decreased by 18% (UI, -22% to -14%), from 82 to 67 per 100 000 people in the EU-53, and by 15% (UI, -18% to -11%), from 49.3 to 42.0 per 100 000 people in EU-28. Despite most countries presenting reductions in age-adjusted incidence, prevalence, mortality, and disability-adjusted life year rates, these rates remained 1.4×, 1.2×, 1.6×, and 1.7× higher in EU-53 in comparison to the EU-28. CONCLUSIONS: EU-53 showed a 2% increase in incident strokes, while they remained stable in EU-28. Age-standardized rates were consistently lower for all-stroke burden parameters in EU-28 in comparison to EU-53, and huge discrepancies in incidence, prevalence, mortality, and disability-adjusted life-year rates were observed between individual countries.

A quarter of ischaemic strokes are lacunar subtype, typically neurologically mild, usually resulting from intrinsic cerebral small vessel pathology, with risk factor profiles and outcome rates differing from other stroke subtypes. This European Stroke Organisation (ESO) guideline provides evidence-based recommendations to assist with clinical decisions about management of lacunar ischaemic stroke to prevent adverse clinical outcomes. The guideline was developed according to ESO standard operating procedures and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. We addressed acute treatment (including progressive lacunar stroke) and secondary prevention in lacunar ischaemic stroke, and prioritised the interventions of thrombolysis, antiplatelet drugs, blood pressure lowering, lipid lowering, lifestyle, and other interventions and their potential effects on the clinical outcomes recurrent stroke, dependency, major adverse cardiovascular events, death, cognitive decline, mobility, gait, or mood disorders. We systematically reviewed the literature, assessed the evidence and where feasible formulated evidence-based recommendations, and expert concensus statements. We found little direct evidence, mostly of low quality. We recommend that patients with suspected acute lacunar ischaemic stroke receive intravenous alteplase, antiplatelet drugs and avoid blood pressure lowering according to current acute ischaemic stroke guidelines. For secondary prevention, we recommend single antiplatelet treatment long-term, blood pressure control, and lipid lowering according to current guidelines. We recommend smoking cessation, regular exercise, other healthy lifestyle modifications, and avoid obesity for general health benefits. We cannot make any recommendation concerning progressive stroke or other drugs. Large randomised controlled trials with clinically important endpoints, including cognitive endpoints, are a priority for lacunar ischaemic str

Background: Few certainties exist regarding optimal management of Blood Pressure (BP) in the very first hours after an ischemic stroke and many questions remain still unanswered. Our work aimed to evaluate the role of BP and its trend as possible determinants of in-hospital mortality (primary outcome), discharge disabilities and hospitalization length (secondary outcomes) in ischemic stroke patients presented with Hypertensive Emergencies (HE). Methods: We retrospectively evaluated patients presented to Niguarda Hospital, Emergency Department (ED), from 2015 to 2017 with a neurological ischemic HE. BP at ED presentation (T0), its management in ED (T1) and its values at the stroke unit admission (T2) were evaluated. Results: 267 patients were included (0.13 % of all ED accesses and 17.9 % of all ischemic strokes). In the whole population, BP values were not associated with in-hospital mortality while T0 and T2 SBP result were associated to discharge disability and hospitalization length. In pre-specified subgroup analysis these associations were confirmed only in untreated subjects (not anti-hypertensive nor thrombolysis). In fact, no significant relationship can be found between BP values and any secondary outcome in thrombolysis and anti-hypertensive treated patients. Conclusions: BP values and its management can not be related to in-hospital mortality in stroke patients, presented with HE, while they are associated to discharge disability and hospitalization length. In subgroup analysis, results were confirmed only in untreated (not anti-hypertensive therapies nor thrombolytic).

Stroke ranks among the prevalent factors contributing to child mortality. Cryptogenic stroke has been linked with patent foramen ovale (PFO), which has been suggested as a possible route for thrombus, gas bubble, or another particulate that comes through systemic venous circulation to the brain artery. Yet, the most effective approach for managing cryptogenic stroke involving a PFO remains uncertain. This case aims to report a PFO patient with complications of stroke. A 5-year-old girl was admitted to the emergency department at Dr. Zainoel Abidin Hospital, Banda Aceh, Indonesia, after experiencing numbness and weakness on her right side and a sudden onset of slurred speech three days before admission. Laboratory findings only showed leukocytosis, while coagulation tests were normal. Non-contrast brain CT revealed an occurrence of cerebral infarction in the left hemisphere. Transcranial Doppler showed no atherosclerosis in cerebral arteries, and carotid Doppler ultrasound results were reported normal. Transthoracic echocardiography showed a PFO with the right-to-left shunt. The patient was treated with an intravenous infusion of citicoline 250 mg twice daily, oral aspirin 80 mg daily, and oral mecobalamin 250 mg daily and was planned to undergo a PFO closure procedure. However, the patient’s parents rejected the plan to perform a PFO closure procedure. PFO has the potential to be a contributing factor to cryptogenic stroke among children. PFO closure followed by antiplatelet therapy for a couple of months has been shown to outperform medical therapy alone. However, additional evaluation should be done to cautiously consider the PFO closure procedure in children.

Wie geht es nach der stationären Rehabilitation nach einem Schlaganfall weiter? Wird die betroffene Person in ihrem häuslichen Umfeld zurechtkommen? Hausbesuche vor Austritt geben Ergotherapeut*innen einen Einblick in die physische und soziale Umgebung und wie sich diese auf die Betätigungsperformanz der betroffenen Person auswirkt. Klient*innenzentrierte Massnahmen können im Hinblick auf den Austritt ergriffen werden. Was spricht aus Sicht von Ergotherapeut*innen für oder gegen Hausbesuche und was heisst das für die Praxis?

[Resumo] A idade é un factor de risco do accidente cerebrovascular, as persoas maiores de 80 anos teñen unha probabilidade do 2,5% de sufrir un ictus. A aparición de secuelas, aumenta en función da idade da persoa. Sufrir un ictus pode repercutir directamente na calidade de vida das persoas, sendo susceptibles de intervención dende Terapia Ocupacional. Obxectivo: O obxectivo principal é investigar o impacto do ictus na calidade de vida e as ocupacións das persoas maiores institucionalizadas en centros xerontolóxicos. Metodoloxía: Tratase dun estudo mixto, cun deseño secuencial exploratorio, empregando metodoloxía cualitativa e cuantitativa. A mostra seleccionada está formada por 7 participantes. Na parte cualitativa, empregarase unha entrevista semi-estructurada para a recollida da información, a parte cuantitativa, será avaliada coa escala CAVIDACE. Resultados: Das entrevistas xurdiron diversas categorías que dan resposta aos obxectivos marcados: principais cambios a raíz do ictus, repercusión do ictus no desempeño ocupacional e a CV dende a mirada de persoas maiores con ictus. Todos os participantes do estudo sufriron algunha secuela derivada do ictus, que provocou unha perda de independencia, e en consecuencia, tivo efecto na súa Calidade de Vida e nas súas ocupacións. Na Escala CAVIDACE a media dos Índices de Calidade de Vida é de 97,8 puntos. Conclusións: O ictus ten un impacto directo na perda de independencia das persoas que o sofren, repercutindo no seu desempeño ocupacional e na súa vida diaria, e producindo unha percepción negativa da Calidade de Vida., [Resumen] Las personas mayores de 80 años tienen una probabilidad del 2,5% de sufrir un ictus. La aparición de secuelas aumenta en función de la edad de la persona. Sufrir un ictus puede repercutir directamente en la Calidad de Vida de la persona, siendo susceptible de intervención desde Terapia Ocupacional. Objetivo: El objetivo principal es investigar el impacto del ictus en la calidad de vida y las ocupaciones de las personas mayores institucionalizadas en centros gerontológicos. Metodología: Es un estudio mixto, con un diseño secuencial exploratorio, empleando metodología cualitativa y cuantitativa. La muestra seleccionada está formada por 7 participantes. En la parte cualitativa, se empleará una entrevista semi-estructurada para la recogida de información, la cuantitativa será evaluada con la escala CAVIDACE. Resultados: De las entrevistas surgieron diversas categorías que dan respuesta a los objetivos marcados: principales cambios a raíz del ictus, repercusión del ictus en el desempeño ocupacional y CV desde la mirada de personas mayores. Todos los participantes del estudio sufrieron alguna secuela derivada del ictus, que provocó una pérdida de independencia y, en consecuencia, una alteración en su Calidad de Vida. En la Escala CAVIDACE la media de los Índices de Calidad de Vida es de 97,8 puntos. Conclusiones: El ictus tiene un impacto directo en la pérdida de independencia de las personas que lo sufren, repercutiendo en su desempeño ocupacional y en su vida diaria, y produciendo una percepción negativa de la Calidad de Vida., [Abstract] People over 80 years of age have a 2.5% probability of suffering a stroke. The appearance of sequelae increases depending on the age of the person. Suffering a stroke can have a direct impact on the person's Quality of Life, being susceptible to intervention from Occupational Therapy. Objective: The main objective is to investigate the impact of stroke on the quality of life and occupations of older people institutionalized in gerontological centers. Methodology: It is a combined study, with an exploratory sequential design, using qualitative and quantitative methodology. The selected sample includes 7 participants. In the qualitative part of the study, a semi-structured interview will be used to collect information, the quantitative part will be evaluated with the CAVIDACE scale. Results: Various categories emerged from the interviews that respond to the marked objectives: main changes resulting from the stroke, impact of the stroke on occupational performance and QoL from the perspective of older people. All study participants suffered some sequelae from the stroke, which caused a loss of independence and, consequently, an alteration in their Quality of Life. In the CAVIDACE Scale the average of the Quality-of-Life Indices is 97.8 points. Conclusions: Suffering a stroke has a direct impact on the loss of independence of people who suffer it, modifying their occupational performance and daily life, and producing a loss in the perception of Quality of Life.

AimTo investigates the financial consequences in the overall population spouses of persons with stroke in Sweden as well as for subgroups based on spouses age, sex and modified Rankin Scale (mRS) of the person with stroke.MethodsThe study population consists of spouses aged <= 60 during the year of their partner's stroke event. Each spouse was matched to four reference individuals. This longitudinal registry data covers spouses and a reference population between 2005 and 2016. We use difference-in-differences to estimate the impact on individual income from paid work, disposable individual income, and disposable family income.ResultsThe primary analysis shows a small and statistically insignificant decrease on spouses' individual income from paid work and disposable individual income. In the subgroup analysis based on mRS, the largest effect is seen in mRS 4-5, where spouses' individual income from paid work and disposable individual income increases after their partner's stroke. Further, younger female spouses' individual income from paid work decreases by 1 614 EUR (p = 0.008) on average.ConclusionThe financial consequences are small in the overall population of spouses. However, for some subgroups, younger women, and spouses of persons with stroke and mRS 4-5, the financial consequences are more prominent.

AimTo investigates the financial consequences in the overall population spouses of persons with stroke in Sweden as well as for subgroups based on spouses age, sex and modified Rankin Scale (mRS) of the person with stroke.MethodsThe study population consists of spouses aged <= 60 during the year of their partner's stroke event. Each spouse was matched to four reference individuals. This longitudinal registry data covers spouses and a reference population between 2005 and 2016. We use difference-in-differences to estimate the impact on individual income from paid work, disposable individual income, and disposable family income.ResultsThe primary analysis shows a small and statistically insignificant decrease on spouses' individual income from paid work and disposable individual income. In the subgroup analysis based on mRS, the largest effect is seen in mRS 4-5, where spouses' individual income from paid work and disposable individual income increases after their partner's stroke. Further, younger female spouses' individual income from paid work decreases by 1 614 EUR (p = 0.008) on average.ConclusionThe financial consequences are small in the overall population of spouses. However, for some subgroups, younger women, and spouses of persons with stroke and mRS 4-5, the financial consequences are more prominent.

BACKGROUND AND AIMS: Patients with long atrial high-rate episodes (AHRE) ≥ 24 hours and stroke risk factors are often treated with anticoagulation for stroke prevention. Anticoagulation has never been compared to no anticoagulation in these patients. METHODS: This secondary prespecified analysis of NOAH-AFNET 6 examined interactions between AHRE duration at baseline and anticoagulation with edoxaban compared to placebo in patients with AHRE and stroke risk factors. The primary efficacy outcome was a composite of stroke, systemic embolism, or cardiovascular death. The safety outcome was a composite of major bleeding and death. Key secondary outcomes were components of these outcomes and ECG-diagnosed atrial fibrillation. RESULTS: AHRE ≥24 hours were present at baseline in 259/2389 patients enrolled in NOAH-AFNET 6 (11%, 78 ± 7 years old, 28% women, CHA2DS2-VASc score 4). Clinical characteristics were not different from patients with shorter AHRE. During a median follow-up of 1.8 years, the primary outcome occurred in 9/132 patients with AHRE ≥24 hours (4.3%/patient-year, 2 strokes) treated with anticoagulation and in 14/127 patients treated with placebo (6.9%/patient-year, 2 strokes). AHRE duration did not interact with the efficacy (p-interaction = 0.65) or safety (p-interaction = 0.98) of anticoagulation. Analyses including AHRE as a continuous parameter confirmed this. Patients with AHRE ≥24 hours developed more ECG-diagnosed atrial fibrillation (17.0%/patient-year) than patients with shorter AHRE (8.2%/patient-year; p < 0.001). CONCLUSIONS: This hypothesis-generating analysis does not find an interaction between AHRE duration and anticoagulation therapy in patients with device-detected AHRE and stroke risk factors. Further research is needed to identify patients with long AHRE at high stroke risk., NOAH-AFNET6 was partially funded by BMBF (German Ministry of Education and Research, Berlin, Germany) through the DZHK (German Center for Cardiovascular Research, Berlin, Germany, grant number FKZ 81X2800182) and by Daiichi Sankyo Europe. Further support was provided by European Union CATCH ME (grant agreement no. 633196) to P.K. and U.S. and AFNET; AFFECTEU (grant agreement no. 847770) to P.K.; MAESTRIA (grant agreement 965286) to A.G., P.K., U.S. and AFNET; British Heart Foundation (AA/18/2/34218) to P.K.; German Research Foundation (Ki 509167694) to P.K.; DZHK (grant numbers 81Z0710116 and 81Z0710110) to P.K., Leducq Foundation to P.K., and the Dutch Heart Foundation (EmbRACE, grant number 01–002-2022-0118) to U.S. P.K. was partially supported by European Union AFFECT-EU (grant agreement no. 847770), MAESTRIA (grant agreement no. 965286), and British Heart Foundation (PG/17/30/32961; PG/20/22/35093; AA/18/2/34218); German Center for Cardiovascular Research supported by the German Ministry of Education and Research (DZHK, grant numbers DZHK FKZ 81X2800182, 81Z0710116, and 81Z0710110), German Research Foundation (Ki 509167694), and Leducq Foundation. R.B.S. has received funding from the European Research Council (ERC) under the European Union’s Horizon 2020 research and innovation programme under the grant agreement no. 648131, the European Union’s Horizon 2020 research and innovation programme under the grant agreement no. 847770 (AFFECTEU); German Center for Cardiovascular Research (DZHK e.V.) (81Z1710103 and 81Z0710114); German Ministry of Research and Education (BMBF 01ZX1408A) and ERACoSysMed3 (031L0239); and Wolfgang Seefried project funding German Heart Foundation.

This chapter focuses on robotic gait training. As a basis, it summarizes the neurophysiological rationale for such training. These neurophysiological findings are mostly based on animal studies. The observations from these studies led to the development of theories such as the spinal central pattern generator (CPG). In a deductive manner, studies have then also been performed on human participants showing similar phenomena. Based on the neurophysiological mechanisms, robot-assisted locomotor training is justified even in patients with severe functional limitations. Those patients would not be able to maintain an upright posture while performing stepping movements in a conventional training condition. The clinical application of robotic gait training is, therefore, another focus of this chapter. Different robotic devices and their relevant characteristics are introduced. Not all devices are designed to purely assist locomotor training by maximally exploiting the neuroplastic potential of the central nervous system. Some devices can also be considered assistive technologies which support patients in their daily life mobility. General aspects which are relevant for robotic gait training during rehabilitation are summarized. Then the chapter takes the translation of the fundamental principles one step further and addresses the application of robotic gait training in specific neurological conditions, that is, in stroke, traumatic brain injury (TBI), spinal cord injury (SCI), multiple sclerosis (MS), and Parkinson’s disease. These parts are written by experts in their respective fields. Every section follows the same structure and informs the reader about the condition in general, specific gait limitations, and the rehabilitation thereof. If available, the latter is supported by recent high-level evidence. In the other cases, relevant primary studies are summarized. Because specific clinical guidelines for the application of robotic gait training are largely missing, the

We aimed to validate the prognostic ability and assess interrater reliability of a recently suggested measurement-based definition of near-occlusion with full collapse (distal ICA diameter ≤ 2.0 mm and/or ICA ratio ≤ 0.42). 118 consecutive patients with symptomatic near-occlusion were prospectively included and assessed on computed tomography angiography by 2 blinded observers, 26 (22%) had full collapse. At 2 days after presenting event, the risk of preoperative stroke was 3% for without full collapse and 16% for with full collapse (p = 0.01). At 28 days, this risk was 16% for without full collapse and 22% for with full collapse (p = 0.22). Interrater reliability was perfect (kappa 1.0). Thus, near-occlusion with full collapse should be defined as distal ICA ≤ 2.0 mm and/or ICA ratio ≤ 0.42 in order to detect cases with very high risk of early stroke recurrence.

The objective of this thesis is to examine some challenges that may emerge when conducting time-to-event studies based on observational data. Time-to-event (also called survival) is a setting that involves analyzing how different factors may influence the length of time until an individual experiences the event of interest. This type of analysis is commonly applied in fields such as medical research and epidemiology. In this thesis, which focuses on stroke, we are interested in the time to a recurrent stroke or the death of a patient who survived a first stroke. Hazard ratios are one of the main parameters estimated in time-to-event studies. Hazard ratios involve comparing the risk of experiencing the event between two groups, usually a treated group and an untreated group. They can also involve other factors, such as different age groups. Hazard ratios can be estimated from the data by using the Cox regression model. Observational data, in contrast to experimental data, involves data collected without any intervention or random assignment of treatment to the individuals. Confounders, that is, variables that distort or obscure the true relationship between treatment and outcome, are always present and need to be controlled for in observational studies. National registers are an important source of observational data. A national registry is a centralized database or system that collects, stores, and maintains information about a specific population or group of individuals within a country. Sweden is known for its detailed and complete national registers. In this thesis, data from the Swedish Stroke Register (Riksstroke) is used to study factors related to stroke. In time-to-event studies involving observational data, several challenges may arise for the researcher during data analysis. Some individuals may not experience the event during the observation period and thus the information about their time until the event is incomplete. These individuals are considered a

Background: The aim of the International Stroke Recovery and Rehabilitation Alliance is to create a world where worldwide collaboration brings major breakthroughs for the millions of people living with stroke. A key pillar of this work is to define globally relevant criteria for centers that aspire to deliver excellent clinical rehabilitation and generate exceptional outcomes for patients. Objectives: This paper presents consensus work conducted with an international group of expert stroke recovery and rehabilitation researchers, clinicians, and people living with stroke to identify and define criteria and measurable indicators for Centers of Clinical Excellence (CoCE) in stroke recovery and rehabilitation. These were intentionally developed to be ambitious and internationally relevant, regardless of a country’s development or income status, to drive global improvement in stroke services. Methods: Criteria and specific measurable indicators for CoCE were collaboratively developed by an international panel of stroke recovery and rehabilitation experts from 10 countries and consumer groups from 5 countries. Results: The criteria and associated indicators, ranked in order of importance, focused upon (i) optimal outcome, (ii) research culture, (iii) working collaboratively with people living with stroke, (iv) knowledge exchange, (v) leadership, (vi) education, and (vii) advocacy. Work is currently underway to user-test the criteria and indicators in 14 rehabilitation centers in 10 different countries. Conclusions: We anticipate that use of the criteria and indicators could support individual organizations to further develop their services and, more widely, provide a mechanism by which clinical excellence can be articulated and shared to generate global improvements in stroke care.

Background: Despite the proven cost effectiveness of mechanical thrombectomy (MT) in patients with acute ischemic stroke (AIS) due to large vessel occlusion, treatment within 6 hours from symptom onset remains inaccessible for many patients. We aimed to find the optimal number and location of treatment facilities with respect to the cost effectiveness of MT in patients with AIS, first by the most cost effective implementation of comprehensive stroke centers (CSCs), and second by the most cost effective addition of complementary thrombectomy capable stroke centers (TSCs). Methods: This study was based on nationwide observational data comprising 18 793 patients with suspected AIS potentially eligible for treatment with MT. The most cost effective solutions were attained by solving the p median facility location-allocation problem with the objective function of maximizing the incremental net monetary benefit (INMB) of MT compared with no MT in patients with AIS. Deterministic sensitivity analysis (DSA) was used as the basis of the results analysis. Results: The implementation strategy with seven CSCs produced the highest annual INMB per patient of all possible solutions in the base case scenario. The most cost effective implementation strategy of the extended scenario comprised seven CSCs and four TSCs. DSA revealed sensitivity to variability in MT rate and the maximum willingness to pay per quality adjusted life year gained. Conclusion: The combination of optimization modeling and cost effectiveness analysis provides a powerful tool for configuring the extent and locations of CSCs (and TSCs). The most cost effective implementation of CSCs in Sweden entails 24/7 MT services at all seven university hospitals.

Background: Despite the proven cost effectiveness of mechanical thrombectomy (MT) in patients with acute ischemic stroke (AIS) due to large vessel occlusion, treatment within 6 hours from symptom onset remains inaccessible for many patients. We aimed to find the optimal number and location of treatment facilities with respect to the cost effectiveness of MT in patients with AIS, first by the most cost effective implementation of comprehensive stroke centers (CSCs), and second by the most cost effective addition of complementary thrombectomy capable stroke centers (TSCs). Methods: This study was based on nationwide observational data comprising 18 793 patients with suspected AIS potentially eligible for treatment with MT. The most cost effective solutions were attained by solving the p median facility location-allocation problem with the objective function of maximizing the incremental net monetary benefit (INMB) of MT compared with no MT in patients with AIS. Deterministic sensitivity analysis (DSA) was used as the basis of the results analysis. Results: The implementation strategy with seven CSCs produced the highest annual INMB per patient of all possible solutions in the base case scenario. The most cost effective implementation strategy of the extended scenario comprised seven CSCs and four TSCs. DSA revealed sensitivity to variability in MT rate and the maximum willingness to pay per quality adjusted life year gained. Conclusion: The combination of optimization modeling and cost effectiveness analysis provides a powerful tool for configuring the extent and locations of CSCs (and TSCs). The most cost effective implementation of CSCs in Sweden entails 24/7 MT services at all seven university hospitals.

Purpose: Optimal systolic blood pressure (SBP) management during endovascular treatment (EVT) for acute ischemic stroke remains a topic of debate. Though BP is associated with worse functional outcome, the relationship between BP and post-procedural intracranial hemorrhage (ICH) is less well-known. We aimed to investigate the association between BP during EVT and post-procedural ICH on dual-energy CT (DECT). Methods: We included all patients who underwent EVT for an anterior circulation large vessel occlusion between 2010 and 2019, and received DECT < 3 h post-EVT. All BP measurements during the EVT procedure were used to calculate mean arterial pressure (MAP mean), mean SBP (SBP mean), and SBP max-min (highest minus lowest). ICH was assessed using virtual post-procedural unenhanced DECT reconstructions and classified as intraparenchymal or extraparenchymal. Symptomatic ICH was scored according to the Heidelberg criteria. The association between different BP parameters and ICH was assessed using multivariable logistic regression. Results: We included 478 patients. Seventy-six patients (16%) demonstrated ICH on DECT, of which 26 (34%) were intraparenchymal. Symptomatic intraparenchymal and extraparenchymal ICH occurred in 10 (38%) and 4 (8%) patients. SBP max, SBP mean, and MAP mean were associated with intraparenchymal ICH with an adjusted odds ratio of 1.19 (95%CI, 1.02–1.39), 1.22 (95%CI, 1.03–1.46), and 1.40 (95%CI, 1.09–1.81) per 10 mmHg, while BP was not significantly associated with extraparenchymal ICH. BP did not differ between asymptomatic and symptomatic ICH. Conclusion: Procedural BP is associated with intraparenchymal ICH on post-EVT DECT but not with extraparenchymal ICH. Future studies should evaluate whether individual procedural BP management reduces post-EVT ICH and improves clinical outcome. Graphical Abstract: (Figure presented.)

Sammanfattning Bakgrund:Stroke beskrivs som en utav de största folksjukdomarna. Stroke är en neurologisk sjukdom som delas in i två olika grupper, hjärninfarkt och hjärnblödning. Hjärninfarkt uppstår i 85 procent av strokefallen medan hjärnblödning sker hos 15 procent av de drabbade. Stroke förändrar livet för individen genom bland annat funktionsnedsättningar och begränsningar i vardagen. Psykisk påfrestning uppstår även då stroke kan föra med sig förändrad personlighet. Syfte: Studiens syfte var att beskriva vuxna personers upplevelser av sin livssituation efter en stroke.Metod: Studien baserade sig på en allmän litteraturöversikt och utgår ifrån en kvalitativ metod med induktiv ansats. Åtta vetenskapliga artiklar inkluderades och analysen genomfördes utifrån Dorothea Orems egenvårdsteori. Resultat: Dataanalysens resultat gav två huvudteman. (Behov av rehabilitering och återhämtning) samt (Behov av anpassning till det nya livet efter en stroke). Under behov avrehabilitering och återhämtning ingick subteman professionell hjälp och kroppsliga förändringar. Under anpassning till det nya livet efter en stroke ingick subteman som socialt stöd, Jobb och ekonomiska resurser samt rädsla för framtiden och hopp. Slutsats: Studien belyser att personer får en förändrad vardag efter en stroke på grund avsjukdomens psykiska och fysiska påverkan. Genom att få förståelse för vuxna personensupplevelse av sin livssituation efter en stroke kan sjuksköterskan erbjuda en god personcentrerad vård.

Bakgrund: Stroke är en sjukdom som drabbar 25 000 – 30 000 personer i Sverige varje åroch är den tredje vanligaste dödsorsaken. Stroke som kan vara antingen en propp i hjärnaneller en hjärnblödning kan ge skador på hjärnan som till exempel förlamning och sviktandetalförmåga, afasi. Afasi innebär språkstörning och är en vanlig komplikation eftergenomgången stroke. Att plötsligt förlora förmågan till att prata gör personer med afasiledsna och frustrerade. Kommunikation handlar om att muntligt eller skriftligt utbyta ideéroch information. En god kommunikation är det som skapar ett bra vårdmöte mellansjuksköterskan och patienten med afasi. Om det finns brister i kommunikationen i vårdmötetriskerar det att drabba patienten och den personcentrerade vården negativt. Syfte: Syftet med studien var att belysa sjuksköterskors erfarenheter av att kommunicera medpatienter med afasi efter stroke. Metod: Denna studie är en integrerande sammanställning av kvalitativ forskning inspireradav matasyntes. Studien har gjort sökningar i databaserna Cinahl och PubMed. Studien ärbaserad på artiklar med kvalitativ forskning. Resultatet från åtta vetenskapliga artiklaranalyserades med hjälp av Fribergs analysmodell. Resultat: Fyra kategorier kunde identifieras, sjuksköterskans erfarenheter av att tid interäcker till, sjuksköterskans erfarenheter av att relationen och kunskap till patienten ärvärdefulla, sjuksköterskans erfarenheter av olika strategier vid kommunikation med patientermed afasi och sjuksköterskans erfarenheter av icke-verbal kommunikation med patienter medafasi. Slutsats: Tid är något som påverkar flera olika delar av omvårdnaden. Det påverkarkommunikationen med patienter, användandet av kommunikationsstrategier ochförutsättningen för sjuksköterskan att kunna skapa en relation till patienten.

Aim: Researchers using herbs and natural products to find new drugs often prefer flavonoids because of their potential as antioxidants and anti-inflammatories. The planned review addressed baicalein research findings in detail. This manuscript provides a complete review of baicalein’s potential pharmacological effects along with several molecular targets for better understanding of its therapeutic activities. Materials and methods: We targeted the review on in vitro and in vivo studies reported on baicalein. For this, the literature is gathered from the database available on search engines like PubMed, ScienceDirect, Scopus, and Google Scholar up to 21 December 2023. The keywords “Scutellaria baicalensis”, “Oroxylum indicum”, “Neuroprotective”, “Cardioprotective”, “Toxicity studies”, and “Baicalein” were used to fetch the content. Results: Baicalein’s molecular receptor binding approach has shown anticancer, antidiabetic, antimicrobial, antiaging, neuroprotective, cardioprotective, respiratory protective, gastroprotective, hepatic protective, and renal protective effects. The synergistic effects of this drug with other selective herbs are also contributed towards significant therapeutic potential. Conclusion: This systematic review article from a contemporary and scientific perspective offers fresh insight into S. baicalensis, O. indicum, and its bioactive component baicalein as a potential complementary medicine. Baicalein may be transformed into more efficacious and acceptable evidence-based medicine. However, we recommend more clinical and mechanistic approaches to confirm safety and efficacy of baicalein.

Background: Stroke is a common and severe disease that requires prompt care. Symptom expressions as one-sidedweakness and speech difficulties are common and included in public stroke campaigns. For some patients stroke canpresent with subtle and less common symptoms, difficult to interpret. The symptom severity assessed by the NationalInstitutes of Health Stroke Scale has decreased, and symptoms at onset may have changed. Therefore, we aimed toinvestigate how patients describe their symptoms at the onset of a first-time stroke. Methods:The study used a qualitative descriptive design and conventional content analysis. Data were collectedthrough recorded interviews with 27 patients aged 18 years and older hospitalised with a first-time stroke betweenOctober 2018 and April 2020. Data were analysed on a manifest level. Results: Symptoms at stroke onset were presented in two themes: Altered Reality and Discomfort and Changed BodyFunctions and described in five categories. Various types of symptoms were found. All symptoms were perceivedas sudden, persistent, and never experienced before and this appear as a “red thread” in the result. Regardless ofsymptom expressions, no specific symptom was described as more severe than another. Conclusions: Stroke symptoms were described with a variety of expressions. Many described complex symptomsnot typical of stroke, which can make it difficult to recognise the symptoms as a stroke and delay medical care. Publicstroke campaigns should emphasize the importance of seeking medical care at the slightest suspicion of stroke andcould be designed to help achieve this., CC-BY 4.0Grants for this study were supported by the Swedish Heart and Lung Foundation (Grant 2018 − 0589), the Agneta Prytz-Folke and Gösta Folke Foundation, the Swedish Stroke Association, the Swedish National Board of Health and Medical Care, region Västra Götaland and the Swedish state according to agreement between the Swedish Government and the County Councils Concerning Economic Support of Research and Education of Doctors (Grant ALFGBG-942665).

BACKGROUND: Posttraumatic stress disorder (PTSD) has been associated with ischemic heart disease in women veterans, but evidence for associations with other cardiovascular disorders remains limited in this population. This retrospective longitudinal cohort study evaluated the association of PTSD with incident stroke/transient ischemic attack (TIA) in women veterans. METHODS AND RESULTS: Veterans Health Administration electronic health records were used to identify women veterans aged ≥18 years engaged with Veterans Health Administration health care from January 1, 2000 to December 31, 2019. We identified women veterans with and without PTSD without a history of stroke or TIA at start of follow-up. Propensity score matching was used to match groups on age, race or ethnicity, traditional cardiovascular risk factors, female-specific risk factors, a range of mental and physical health conditions, and number of prior health care visits. PTSD, stroke, TIA, and risk factors used in propensity score matching were based on diagnostic codes. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% CIs for associations of PTSD with an incident stroke/TIA composite. Subanalyses considered stroke and TIA separately, plus age- and race- or ethnicity-stratified analyses were carried out. The analytic sample included 208 092 women veterans (104 046 with and 104 046 without PTSD). PTSD was associated with a greater rate of developing stroke/TIA (HR, 1.33 [95% CI, 1.25-1.42], P<0.001). This elevated risk was especially pronounced in women <50 years old and in Hispanic/Latina women. CONCLUSIONS: Findings indicate a strong association of PTSD with incident stroke/TIA in women veterans. Research is needed to determine whether addressing PTSD and its downstream consequences can offset this risk.

BACKGROUND: The effect of transdermal glyceryl trinitrate (GTN, a nitrovasodilator) on clinical outcome when administered before hospital admission in suspected stroke patients is unclear. Here, we assess the safety and efficacy of GTN in the prespecified subgroup of patients who had an ischaemic stroke within the Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial-2 (RIGHT-2). METHODS: RIGHT-2 was an ambulance-based multicentre sham-controlled blinded-endpoint study with patients randomised within 4 hours of onset. The primary outcome was a shift in scores on the modified Rankin scale (mRS) at day 90. Secondary outcomes included death; a global analysis (Wei-Lachin test) containing Barthel Index, EuroQol-5D, mRS, telephone interview for cognitive status-modified and Zung depression scale; and neuroimaging-determined brain frailty markers. Data were reported as n (%), mean (SD), median [IQR], adjusted common OR (acOR), mean difference or Mann-Whitney difference (MWD) with 95% CI. RESULTS: 597 of 1149 (52%) patients had a final diagnosis of ischaemic stroke; age 75 (12) years, premorbid mRS>2 107 (18%), Glasgow Coma Scale 14 (2) and time from onset to randomisation 67 [45, 108] min. Neuroimaging brain frailty was common: median score 2 [2, 3] (range 0-3). At day 90, GTN did not influence the primary outcome (acOR for increased disability 1.15, 95% CI 0.85 to 1.54), death or global analysis (MWD 0.00, 95% CI -0.10 to 0.09). In subgroup analyses, there were non-significant interactions suggesting GTN may be associated with more death and dependency in participants randomised within 1 hour of symptom onset and in those with more severe stroke. CONCLUSIONS: In patients who had an ischaemic stroke, ultra-acute administration of transdermal GTN in the ambulance did not improve clinical outcomes in a population with more clinical and radiological frailty than seen in previous in-hospital trials.

Circulating levels of the soluble ligand-binding ectodomain of the LDL receptor (sLDLR) that is proteolytically cleaved from the cell surface have been shown to correlate with plasma triglycerides, but the lipid and lipoprotein effects of longitudinal changes in sLDLR have not been examined. We sought to assess associations between changes in sLDLR and detailed lipoprotein measurements between baseline and 6 months in participants in the DIETFITS (Diet Intervention Examining The Factors Interacting with Treatment Success) weight loss trial who were randomly assigned to the low-fat (n = 225) or low-carbohydrate (n = 236) diet arms. sLDLR was assayed using a proteomic procedure, lipids and apoprotein (apo) B and apoAI were measured by standard assays, and lipoprotein particle subfractions were quantified by ion mobility methodology. Changes in sLDLR were significantly positively associated with changes in plasma cholesterol, triglycerides, apoB, large-sized and medium-sized VLDL, and small and very small LDL, and inversely with changes in large LDL and HDL. The lipoprotein subfraction associations with sLDLR were independent of age, sex, diet, and BMI, but all except for large LDL were reduced to insignificance when adjusted for triglyceride change. Principal component analysis identified three independent clusters of changes in lipoprotein subfractions that accounted for 78% of their total variance. Change in sLDLR was most strongly correlated with change in the principal component that was loaded positively with large VLDL and small and very small LDL and negatively with large LDL and HDL. In conclusion, sLDLR is a component of a cluster of lipids and lipoproteins that are characteristic of atherogenic dyslipidemia.

IntroductionConsumption of fast food has been linked to psychiatric distress, violent behaviors, and impulsivity in adolescents. The relationship between eating fast food, anger, and impulsivity has not been widely investigated. The National Consortium on Alcohol and Neurodevelopment in Adolescence community-based cohort consists of 831 youth, half at elevated risk factors for substance use disorders during adolescence, followed annually.MethodsImpulsivity using Urgency, Premeditation, Perseverance, and Sensation Seeking Impulsive Behavior scale from annual assessments was examined in relation to self-reported fast-food consumption frequency and mobile application questions of anger. This study tested the hypotheses that youth anger may be predicted by fast-food consumption frequency and impulsivity using multiple regression, in addition to whether adolescent fast-food consumption frequency may be predicted by anger and impulsivity.ResultsAmong youth, higher anger levels and impulsivity predicted greater frequency of fast-food consumption, and greater fast-food consumption frequency and impulsivity predicted higher anger levels.ConclusionsThis study's longitudinal findings are consistent with those of other studies that have found fast-food consumption and anger associated with impulsivity and also reveal a bidirectional link between anger and fast-food consumption. These results may point attention to food selection considerations for those at risk of anger and poorer psychiatric outcomes.

Introduction: Cerebrovascular accidents rarely occur in children; the incidence of ischemic stroke in patients <16 years of age is between 0.6–7.9/100,000. However, they are the fourth most common cause of acute neurological deficits in the pediatric population, and possible cases should be evaluated with a high index of suspicion to ensure timely intervention. Case Report: We describe a previously healthy 17-year-old male who presented to the pediatric emergency department with a left facial droop and hemiparesis consistent with a stroke. The patient’s age and lack of comorbidities made this an extremely uncommon presentation. Our patient’s neurologic symptoms were believed to have been caused by a recent traumatic clavicular injury sustained two weeks prior, which subsequently led to vascular insult. Conclusion: Cerebrovascular accidents are an important cause of morbidity and mortality in pediatric patients. Cerebrovascular accidents in children are most often secondary to congenital causes; however, care should be taken to assess for acquired causes, such as trauma to major blood vessels. While rarely implicated in traumatic injuries, arterial structures posterior to the medial clavicle can result in severe complications.

Background and purposeCerebral vasomotor reactivity (VMR) is vital for regulating brain blood flow and maintaining neurological function. Impaired cerebral VMR is linked to a higher risk of stroke and poor post-stroke outcomes. This study explores the relationship between statin treatment intensity and VMR in patients with ischemic stroke.MethodsSeventy-four consecutive patients (mean age 69.3 years, 59.4% male) with recent ischemic stroke were included. VMR levels were assessed 4 weeks after the index stroke using transcranial Doppler, measuring the breath-holding index (BHI) as an indicator of the percentage increase in middle cerebral artery blood flow (higher BHI signifies higher VMR). Multistep multivariable regression models, adjusted for demographic and cerebrovascular risk factors, were employed to examine the association between statin intensity treatment and BHI levels.ResultsForty-one patients (55%) received high-intensity statins. Patients receiving high-intensity statins exhibited a mean BHI of 0.85, whereas those on low-intensity statins had a mean BHI of 0.67 (mean difference 0.18, 95% confidence interval: 0.13-0.22, p-value<.001). This significant difference persisted in the fully adjusted model (adjusted mean values: 0.84 vs. 0.68, p-value: .008). No significant differences were observed in BHI values within patient groups on high-intensity or low-intensity statin therapy (all p-values>.05). Furthermore, no significant association was found between baseline low-density lipoprotein (LDL) levels and BHI.ConclusionsHigh-intensity statin treatment post-ischemic stroke is linked to elevated VMR independent of demographic and clinical characteristics, including baseline LDL level. Further research is needed to explore statin therapy's impact on preserving brain vascular function beyond lipid-lowering effects.

The brain bidirectionally communicates with the gut to control food intake and energy balance, which becomes dysregulated in obesity. For example, endocannabinoid (eCB) signaling in the small-intestinal epithelium (SI) is upregulated in diet-induced obese mice (DIO) and promotes overeating by a mechanism that includes inhibiting gut-brain satiation signaling. Upstream neural and molecular mechanism(s) involved in overproduction of orexigenic gut eCBs in DIO, however, are unknown. We tested the hypothesis that overactive parasympathetic signaling at muscarinic acetylcholine receptors (mAChRs) in the SI increases biosynthesis of the eCB, 2-arachidonoyl-sn-glycerol (2-AG), which drives hyperphagi-a via local CB1Rs in DIO. Male mice were maintained on a high-fat/high-sucrose western-style diet for 60 days, then administered several mAChR antagonists 30 min prior tissue harvest or a food intake test. Levels of 2-AG and activity of its metabolic enzymes in the SI were quantitated. DIO mice, when compared to those fed a low-fat/no-sucrose diet, displayed increased expression of cFos protein in the dorsal motor nucleus of the vagus, which suggests increased activity of efferent cholinergic neurotransmission. These mice exhibited elevated levels of 2-AG biosynthesis in the SI, which was reduced to control levels by mAChR antagonists. Moreover, the peripherally-restricted mAChR antagonist, methylhomatropine bromide, and the peripherally-restricted CB1R antagonist, AM6545, reduced food intake in DIO mice for up to 24 h but had no effect in mice conditionally deficient in SI CB1Rs. These results suggest that hyperactivity at mAChRs in the periphery increases formation of 2-AG in the SI and activates local CB1Rs, which drives hyperphagia in DIO.Significance Statement Gut-brain signaling controls food intake and energy homeostasis; however, it is poorly understood how gut-brain signaling becomes dysregulated in obesity. In this study, we demonstrated that brain to gut communicati

BACKGROUND: Muscle density is inversely associated with all-cause mortality, but associations with cardiovascular disease (CVD) risk are not well understood. This study evaluated the association between muscle density and muscle area and incident total CVD, coronary heart disease (CHD), and stroke in diverse men and women. METHODS AND RESULTS: Adult participants (N=1869) in the Multi-Ethnic Study of Atherosclerosis Ancillary Body Composition Study underwent computer tomography scans of the L2-L4 region of the abdomen. Muscle was quantified by density (Hounsfield units) and area in cm2. Sex-stratified Cox proportional hazard models assessed associations between incident total CVD, incident CHD, and incident stroke across sex-specific percentiles of muscle area and density, which were entered simultaneously into the model. Mean age for men and women at baseline were 64.1 and 65.1 years, respectively, and median follow-up time was 10.3 years. For men, associations between muscle density and incident CVD were inverse but not significant in fully adjusted models (P trend=0.15). However, there was an inverse association between density and CHD (P trend=0.02; HR, 0.26 for 95th versus 10th percentile), and no association with stroke (P trend=0.78). Conversely, for men, there was a strong positive association between muscle area and incident CVD (HR, 4.19 for 95th versus 10th percentile; P trend<0.001). Associations were stronger for CHD (HR, 6.18 for 95th versus 10th percentile; P trend<0.001), and null for stroke (P trend=0.67). Associations for women were mostly null. CONCLUSIONS: For men, abdominal muscle density is associated with lower CHD risk, whereas greater muscle area is associated with markedly increased risk of CHD.

OBJECTIVES: The primary objective of this study was to examine the impact of the COVID-19 pandemic on the quality of stroke care for patients with preexisting dementia, compared with patients who had only stroke. The secondary aim was to investigate how the quality of stroke care changed during the pandemic and post-pandemic periods compared with the pre-pandemic period in patients with preexisting dementia. DESIGN: A registry-based, nationwide cohort study in Sweden. SETTING AND PARTICIPANTS: We included patients with a first stroke between 2019 and 2022, both with and without dementia. The study periods were defined as follows: pre-pandemic (January 1, 2019, to February 29, 2020), COVID-19 pandemic (March 1, 2020, to February 24, 2022), and post-COVID-19 pandemic period (February 25, 2022, to September 19, 2022). The outcomes examined were the following quality indicators of stroke care, suggested by the national guideline of stroke care in Sweden: stroke admission site, performance of swallowing assessment, reperfusion treatment, assessment for rehabilitation, and early supported discharge. METHODS: The associations were studied through group comparisons and binary logistic regressions. RESULTS: Of the 21,795 stroke patients, 1357 had documented preexisting dementia, and 20,438 had stroke without a dementia diagnosis. Throughout all study periods, a significantly lower proportion of stroke patients with preexisting dementia, compared with stroke-only patients, received reperfusion treatment, assessments for rehabilitation, and early supported discharge from stroke units. In the subgroup of stroke patients with preexisting dementia, no significant associations were found regarding the quality indicators of stroke care before, during, and after the pandemic. CONCLUSIONS AND IMPLICATIONS: Disparities in quality of stroke care were observed between stroke patients with preexisting dementia and those with only stroke during the COVID-19 pandemic. However, there were n, Open access funding is provided by Karolinska Institutet. This work was supported by the Loo and Hans Osterman Foundation (#2023-01697), the Swedish Stroke Association (Strokeförbundets Stiftelser och Fonder), Karolinska Institutet's Research Foundation Grants, Emil and Wera Cornell's Foundation, and the Swedish Research Council.

BACKGROUND AND OBJECTIVES: Spontaneous spinal cord infarction (SCInf) is a rare condition resulting in acute neurological impairment. Consensus on diagnostic criteria is lacking, which may present a challenge for the physician. This review aims to analyse the current literature on spontaneous SCInf, focusing on epidemiology, the diagnostic process, treatment strategies and neurological outcomes. METHODS: The study was performed in accordance with a previously published protocol. PubMed, Web of Science and Embase were searched using the keywords 'spontaneous', 'spinal cord', 'infarction' and 'ischaemic'. The eligibility of studies was evaluated in two steps by multiple reviewers. Data from eligible studies were extracted and systematically analysed. RESULTS: 440 patients from 33 studies were included in this systematic review. Analysis of vascular risk factors showed that hypertension was present in 40%, followed by smoking in 30%, dyslipidaemia in 29% and diabetes in 16%. The severity of symptoms at admission according to the American Spinal Injury Association (ASIA) Impairment Scale was score A 19%, score B14%, score C36% and score D32%. The mean follow-up period was 34.8 (±12.2) months. ASIA score at follow-up showed score A 11%, score B 3%, score C 16%, score D 67% and score E 2%. The overall mortality during the follow-up period was 5%. When used, MRI with diffusion-weighted imaging (DWI) supported the diagnosis in 81% of cases. At follow-up, 71% of the patients were able to walk with or without walking aids. CONCLUSION: The findings suggest a significant role for vascular risk factors in the pathophysiology of spontaneous SCInf. In the diagnostic workup, the use of DWI along with an MRI may help in confirming the diagnosis. The findings at follow-up suggest that neurological recovery is to be expected, with the majority of patients regaining ambulation. This systematic review highlights gaps in the literature and underscores the necessity for further research t

Stroke is a leading cause of death and disability worldwide [8], underscoring the need for effective digital solutions for stroke patients, caregivers, and healthcare professionals. Given that, this thesis aims to evaluate quality aspects of usability, accessibility, and readability of stroke-related mobile health (mHealth) applications, with the primary objective of identifying strengths and weaknesses to enhance user experience and app quality. This study assessed sixteen stroke-related apps through a comprehensive methodology, including accessibility testing with the Google Accessibility Scanner, Mobile Application Rating Scale (MARS) evaluation, heuristic evaluation, and readability assessment. Key findings indicate significant issues with touch target sizes and text contrast, which are crucial for users with impaired visionand motor skills. MARS evaluations revealed that “Constant Therapy” excelled in engagement and functionality due to its interactive features and personalized schedules. At the same time, “Stroke Recovery Predictor” and “Conversation Therapy Lite” scored lower due to limited functionality and unclear interfaces. The heuristic evaluation highlighted frequent violations of the visibility of system status and insufficient error messaging. Readability assessments showed a range of reading difficulty levels, with some apps lacking privacy policies that could be found either within the application or on the developer’s website. The study provides actionable recommendations for developers, such as improving touch target sizes, improving text contrast, increasing functional variety, optimizing navigation, and ensuring privacy policy transparency. Addressing these areas can significantly improve the usability and accessibility of stroke-related mHealth apps, ultimately supporting better health outcomes and quality of life for stroke survivors. Future research should involve more evaluators, use multiple assessment tools, and focus on specific types of

BACKGROUND: Individuals with stroke rehabilitated in an enriched environment (EE) compared to a non-EE are more likely to participate in cognitive and social activities, promoting their rehabilitation and well-being. There is a need for a more comprehensive understanding of methods to implement EEs within complex health systems, particularly in stroke units. OBJECTIVE: The aim of this systematic review was to compile the concept of an EE in stroke units. METHODS: The literature was sourced from CINAHL, Embase, and Medline databases. A detailed screening and sifting process was used to identify relevant literature. Multiple reviewers independently appraised the identified literature using a Mixed-methods Appraisal Tool. After screening 336 studies, 11 were included. RESULTS: This review reveals an EE is challenging to define and almost exclusively about activities based on access to individual and communal equipment. Generally, there are no common descriptions or conceptual agreements. CONCLUSIONS: To the best of our knowledge, this is the first study to systematically review the concept of an EE in stroke units and shows that more studies on EEs are needed. The weak definitions and unclear theoretical backgrounds of an EE in the included studies could challenge operationalization. Future research should be based on more precise definitions of an EE and broader interventions that include changes to built and natural environments.

Background: Stroke is a common and severe disease that requires prompt care. Symptom expressions as one-sidedweakness and speech difficulties are common and included in public stroke campaigns. For some patients stroke canpresent with subtle and less common symptoms, difficult to interpret. The symptom severity assessed by the NationalInstitutes of Health Stroke Scale has decreased, and symptoms at onset may have changed. Therefore, we aimed toinvestigate how patients describe their symptoms at the onset of a first-time stroke. Methods:The study used a qualitative descriptive design and conventional content analysis. Data were collectedthrough recorded interviews with 27 patients aged 18 years and older hospitalised with a first-time stroke betweenOctober 2018 and April 2020. Data were analysed on a manifest level. Results: Symptoms at stroke onset were presented in two themes: Altered Reality and Discomfort and Changed BodyFunctions and described in five categories. Various types of symptoms were found. All symptoms were perceivedas sudden, persistent, and never experienced before and this appear as a “red thread” in the result. Regardless ofsymptom expressions, no specific symptom was described as more severe than another. Conclusions: Stroke symptoms were described with a variety of expressions. Many described complex symptomsnot typical of stroke, which can make it difficult to recognise the symptoms as a stroke and delay medical care. Publicstroke campaigns should emphasize the importance of seeking medical care at the slightest suspicion of stroke andcould be designed to help achieve this., CC-BY 4.0Grants for this study were supported by the Swedish Heart and Lung Foundation (Grant 2018 − 0589), the Agneta Prytz-Folke and Gösta Folke Foundation, the Swedish Stroke Association, the Swedish National Board of Health and Medical Care, region Västra Götaland and the Swedish state according to agreement between the Swedish Government and the County Councils Concerning Economic Support of Research and Education of Doctors (Grant ALFGBG-942665).

The purpose of this study was to cross-culturally validate the Swedish version of the Gugging Swallowing Screen (GUSS-S) for use in the acute phase of stroke. Further, to evaluate the inter-rater reliability between different healthcare professionals. GUSS was translated into Swedish using a forward-backward method followed by expert rating to obtain content validity. For criterion validity, the GUSS-S score was compared with Flexible Endoscopic Evaluation of Swallowing (FEES) assessed with the Penetration-Aspiration Scale (PAS) in acute stroke patients (≤ 96 h after stroke onset). Convergent validity was calculated by comparison with the Functional Oral Intake Scale (FOIS) as per the comprehensive FEES assessment, the Standardized Swallowing Assessment (SSA), and the National Institutes of Health Stroke Scale (NIHSS). To evaluate inter-rater reliability, a nurse and a speech-language pathologist (SLP) independently assessed 30 patients. In total, 80 patients (32 women, median age 77 years (range 29–93) were included, mean 1.7 ± 0.9 days after admission. With a cut-off value of 14 points, the GUSS-S identified aspiration with a sensitivity of 100% and a specificity of 73% (area under the curve: 0.87, 95% CI 0.78–0.95). Spearman rank correlation showed very strong correlation between the GUSS-S and PAS (rs=-0.718, P = < 0.001) and FOIS (rs=0.720, P = 0.001) and strong correlation between the GUSS-S and SSA (rs=0.545, P = < 0.001) and NIHSS (rs=-0.447, P = 0.001). The inter-rater agreement for GUSS-S was substantial (Kw=0.67, P = < 0.001). The results indicate that the GUSS-S is a valid and reliable tool for the assessment of dysphagia in acute stroke patients by different healthcare professionals.

Background: To assess whether retrograde cerebral perfusion reduces neurological injury and mortality in patients undergoing surgery for acute type A aortic dissection. Methods: Single-center, retrospective, observational study including all patients undergoing acute type A aortic dissection repair with deep hypothermic circulatory arrest between January 1998 and December 2022 with or without the adjunct of retrograde cerebral perfusion. 515 patients were included: 257 patients with hypothermic circulatory arrest only and 258 patients with hypothermic circulatory arrest and retrograde cerebral perfusion. The primary endpoints were clinical neurological injury, embolic lesions, and watershed lesions. Multivariable logistic regression was performed to identify independent predictors of the primary outcomes. Survival analysis was performed using Kaplan-Meier estimates. Results: Clinical neurological injury and embolic lesions were less frequent in patients with retrograde cerebral perfusion (20.2% vs. 28.4%, p = 0.041 and 13.7% vs. 23.4%, p = 0.010, respectively), but there was no significant difference in the occurrence of watershed lesions (3.0% vs. 6.1%, p = 0.156). However, after multivariable logistic regression, retrograde cerebral perfusion was associated with a significant reduction of clinical neurological injury (OR: 0.60; 95% CI 0.36–0.995, p = 0.049), embolic lesions (OR: 0.55; 95% CI 0.31–0.97, p = 0.041), and watershed lesions (OR: 0.25; 95%CI 0.07–0.80, p = 0.027). There was no significant difference in 30-day mortality (12.8% vs. 11.7%, p = ns) or long-term survival between groups. Conclusion: In this study, we showed that the addition of retrograde cerebral perfusion during hypothermic circulatory arrest in the setting of acute type A aortic dissection repair reduced the risk of clinical neurological injury, embolic lesions, and watershed lesions.

Objective: To investigate (i) to what extent physiotherapists (PTs) working in stroke rehabilitation in various parts of the stroke care chain have implemented interventions according to the national guidelines for stroke (NGS), (ii) facilita-ting and hindering factors for the implementation, and (iii) differences between various care settings. Design: A cross-sectional study. Subjects: 148 PTs working in stroke rehabilitation in various parts of the care chain in Sweden. Methods: Data were collected by a web-based survey. Results: Task-specific training for walking (80–98%), impaired motor function (64–100%) and fall prevention (73–92%) were most implemented. Factors that facilitated implementation were: important to comply with the NGS, that PTs had confidence to per-form the interventions, and that interventions were clearly described. Limited time, lack of resources, no clear goals or routines at the workplace hindered the implementation. Significant differences (p < 0.05) between the settings existed. Municipal and primary care reported most challenges in implementing the NGS and providing evidence-based interventions. Conclusion: Most interventions, with high priority according to NGS, are provided by PTs working in stroke rehabilitation, although differences in various parts of the care chain exist. Knowledge, time, education and supportive management are important factors when implementing evidence-based interventions.