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Introduction. Rivaroxaban is a new anticoagulant providing benefits for the treatment of patients with atrial fibrillation (AF). This study is aimed at evaluating the cost-effectiveness of rivaroxaban compared to warfarin in patients with AF. Method. This economic evaluation study was conducted among 144 selected nonrandomly patients who were treated with rivaroxaban or warfarin and suffered from AF leading to stroke, in the stroke ward of Shiraz Nemazee Hospital in 2019. The final and clinical (intermediate) outcomes were QALYs and no bleeding and prevention of ischemic stroke, respectively. The study was performed from the social perspective, and a deterministic one-way sensitivity analysis was conducted to identify the effects of uncertainty. The analysis of the collected data was carried out using SPSS18 and TreeAge software. Results. Patients who received rivaroxaban had lower costs ($ 25275 vs. $ 26554) and higher QALYs (0.5 vs. 0.33) compared to those taking warfarin. Bleeding and stroke occurred in (9 vs. 40) and (1 vs. 3) patients in the rivaroxaban and warfarin groups, respectively, and there was a significant decrease in the incidence of bleeding in the rivaroxaban group (81.9% vs 44.4%). Thus, rivaroxaban in all the outcomes was cheaper and more effective than warfarin. The one-way sensitivity analysis confirmed the robustness of the results. Conclusions. Considering the incremental cost-effectiveness ratio, rivaroxaban is more cost-effective and can be a dominant alternative. Therefore, it is suggested to use rivaroxaban as the first priority in AF patients because rivaroxaban reduces costs and increases clinical outcomes compared with warfarin. [ABSTRACT FROM AUTHOR]

Swallowing impairment (dysphagia) post-stroke results in poorer outcomes. Pharyngeal electrical stimulation (PES) is a potential treatment for post-stroke dysphagia. In a post hoc analysis, we investigated PES using videofluoroscopy swallow studies (VFSS) from the STEPS trial incorporating multiple measures of safety (penetration aspiration scale-PAS), speed and duration (timing), and efficiency (clearance), as opposed to the original trial which only measured PAS scores. 81 randomised participants (PES (N = 43) versus sham (N = 38)) were analysed at baseline and 2 weeks. Participants swallowed up to 6 × 5 ml and 1 × 50 ml of thin liquid barium at 40% w / v , images at ≥25 fps. Based on PAS, the 5 ml mode bolus (most frequently occurring PAS from 6 × 5 ml) and the worst 50 ml bolus were chosen for further analysis. Eight timing measures were performed, including stage transition duration (STD) and pharyngeal transit time (PTT). Clearance measures comprised oral and pharyngeal residue and swallows to clear. Comparisons of change of scoring outcomes between PES and sham were done at 2 weeks. Wilcoxon Signed Ranks Test was also used to evaluate longitudinal changes from both groups' combined results at two weeks. Between-group analysis showed no statistically significant differences. Issues with suboptimal image quality and frame rate acquisition affected final numbers. At two weeks, both groups demonstrated a significant improvement in most safety scores (PAS) and STD, possibly due to spontaneous recovery or a combination of spontaneous recovery and swallowing treatment and usual care. A nonsignificant trend for improvement was seen in other timing measures, including PTT. This study, which conducted additional measurements of kinematic and residue analysis on the STEPS data did not detect "missed" improvements in swallowing function that the PAS is not designed to measure. However, more studies with greater numbers are required. [ABSTRACT FROM AUTHOR]

Background. Frequency and impact of medical complications on short-term mortality in young patients with intracerebral hemorrhage (ICH) have gone unstudied. Methods. We reviewed data of all first-ever nontraumatic ICH patients between 16 and 49 years of age treated in our hospital between January 2000 and March 2010 to identify medical complications suffered. Logistic regression adjusted for known ICH prognosticators was used to identify medical complications associated with mortality. Results. Among the 325 eligible patients (59% males, median age 42 [interquartile range 34–47] years), infections were discovered in 90 (28%), venous thrombotic events in 13 (4%), cardiac complications in 4 (1%), renal failure in 59 (18%), hypoglycemia in 15 (5%), hyperglycemia in 165 (51%), hyponatremia in 146 (45%), hypernatremia in 91 (28%), hypopotassemia in 104 (32%), and hyperpotassemia in 27 (8%). Adjusted for known ICH prognosticators and diabetes, the only independent complication associated with 3-month mortality was hyperglycemia (plasma glucose >8.0 mmol/L) (odds ratio: 5.90, 95% confidence interval: 2.25–15.48, P<0.001). Three or more separate complications suffered also associated with increased mortality (7.76, 1.42–42.49, P=0.018). Conclusions. Hyperglycemia is a frequent complication of ICH in young adults and is independently associated with increased mortality. However, multiple separate complications increase mortality even further. [ABSTRACT FROM AUTHOR]

The availability of proper tests for gait evaluation following cerebral ischemia in rats has been limited. The automated, quantitative CatWalk system, which was initially designed to measure gait in models of spinal cord injury, neuropathic pain, and peripheral nerve injury, is said to be a useful tool for the study of motor impairment in stroke animals. Here we report our experiences of using CatWalk XT with rats subjected to transient middle cerebral artery occlusion (MCAO), during their six-week followup. Large corticostriatal infarct was confirmed by MRI in all MCAO rats, which was associated with severe sensorimotor impairment. In contrast, the gait impairment was at most mild, which is consistent with seemingly normal locomotion of MCAO rats. Many of the gait parameters were affected by body weight, walking speed, and motivation despite the use of a goal box. In addition, MCAO rats showed bilateral compensation, which was developed to stabilize proper locomotion. All of these interferences may confound the data interpretation. Taken together, the translational applicability of CatWalk XT in evaluating motor impairment and treatment efficacy remains to be limited at least in rats with severe corticostriatal infarct and loss of body weight. [ABSTRACT FROM AUTHOR]

Background. Stroke frequently leaves survivors with hemiparesis. To prevent persistent deficits, rehabilitation may be more effective if started early. Early training is often limited because of orthostatic reactions. Tilt-table stepping robots and functional electrical stimulation (FES) may prevent these reactions. Objective. This controlled convenience sample study compares safety and feasibility of robotic tilt-table training plus FES (ROBO-FES) and robotic tilt-table training (ROBO) against tilt-table training alone (control). A preliminary assessment of efficacy is performed. Methods. Hemiparetic ischemic stroke survivors (age 58.3 ± 1.2 years, 4.6 ± 1.2 days after stroke) were assigned to 30 days of ROBO-FES (n = 38), ROBO (n = 35), or control (n = 31) in addition to conventional physical therapy. Impedance cardiography and transcranial doppler sonography were performed before, during, and after training. Hemiparesis was assessed using the British Medical Research Council (MRC) strength scale. Results. No serious adverse events occurred; 8 patients in the tilt-table group prematurely quit the study because of orthostatic reactions. Blood pressure and CBFV dipped < 10% during robot training. In 52% of controls mean arterial pressure decreased by ≥ 20%. ROBO-FES increased leg strength by 1.97 ± 0.88 points, ROBO by 1.50 ± 0.85 more than control (1.03 ± 0.61, P < 0.05). CBFV increased in both robotic groups more than in controls (P < 0.05). Conclusions. Robotic tilt-table exercise with or without FES is safe and may be more effective in improving leg strength and cerebral blood flow than tilt table alone. [ABSTRACT FROM AUTHOR]

Background. Depression after stroke may have great burden on the likelihood of functional recovery and long-term outcomes. Objective. To estimate the association between depression after stroke and subsequent mortality. Methods. A systematic search of articles using PubMed and Web of Science databases was performed. Odds ratios (ORs) and hazard ratios (HRs) were used as association measures for pooled analyses, based on random-effects models. Results. Thirteen studies, involving 59,598 subjects suffering from stroke (6,052 with and 53,546 without depression), had data suitable for meta-analysis. The pooled OR for mortality at followup in people suffering from depression after stroke was 1.22 (1.02-1.47). Subgroups analyses highlighted that only studies with medium-term followup (2-5 years) showed a statistically significant association between depression and risk of death. Four studies had data suitable for further analysis of pooled HR. The meta-analysis revealed a HR for mortality of 1.52 (1.02-2.26) among people with depression after stroke. Conclusions. Despite some limitations, this paper confirms the potential role of depression on post stroke mortality. The relationship between depression and mortality after stroke seems to be related to the followup duration. Further research is needed to clarify the nature of the association between depression after stroke and mortality. [ABSTRACT FROM AUTHOR]

Objective. To assess the prevalence, clinical and laboratory characteristics, and short-term outcomes of poststroke hip fracture (HF). Methods. A cross-sectional study of 761 consecutive patients aged ≥60 years (82.3 ± 8.8 years; 75% females) with osteoporotic HF. Results. The prevalence of poststroke HF was 13.1% occurring on average 2.4 years after the stroke. The poststroke group compared to the rest of the cohort had a higher proportion of women, subjects with dementia, history of TIA, hypertension, coronary artery disease, secondary hyperparathyroidism, higher serum vitamin B12 levels (>350 pmol/L), walking aid users, and living in residential care facilities. The majority of poststroke HF patients had vitamin D insufficiency (68%) and excess bone resorption (90%).This group had a 3-fold higher incidence of postoperative myocardial injury and need for institutionalisation. In multivariate analysis, independent indicators of poststroke HF were female sex (OR 3.6), history of TIA (OR 5.2), dementia (OR 4.1), hypertension (OR 3.2), use of walking aid (OR 2.5), and higher vitamin B12 level (OR 2.3). Only 15% of poststroke patients received antiosteoporotic therapy prior to HF. Conclusions. Approximately one in seven HFs occurs in older stroke survivors and are associated with poorer outcomes. Early implementation of fracture prevention strategies is needed. [ABSTRACT FROM AUTHOR]

Background. Assessing poststroke cognitive impairment is complex. A subscale of the NIHSS, the Cog-4, has been proposed as a quick test of "cognitive impairment." but a study of its properties in a larger dataset is lacking. Methods. Data from 9,147 patients with acute stroke from the VISTA archive was used to generate Cog-4 scores. The statistical properties of Cog-4, its relationship with baseline clinical characteristics, and other functional outcome measures at day 90 were assessed. Results. Mean age of patients was 69.2 years and 45.8%, were females. Day-90 Cog-4 was highly positively skewed (skewness 0.926). Patients with left hemispheric stroke had higher day-90 Cog-4 score (P < 0.001). Age, stroke severity, and previous stroke were significant predictors of Cog-4. Cog-4 was significantly correlated with dependency (modified Rankin Scale, rs = 0.512), and disability (Barthel Index, rs = −0.493). Conclusions. The Cog-4 scale at day 90 cannot be considered a useful test of cognition since it only superficially measures cognition. It is heavily dependent on the side of stroke, is inevitably associated with functional outcome (being a subset of the NIHSS), and suffers from a profound "floor" effect. Specific and validated measures are more appropriate for the assessment of poststroke cognition than Cog-4 [ABSTRACT FROM AUTHOR]

Background. Frontal lobe atrophy (FLA) is associated with late life depression. However, the role that FLA plays in the development of depression after stroke (DAS) remains unknown. This study thus examined the association between FLA and DAS. Methods. A convenience sample of 705 Chinese patients with acute ischemic stroke admitted to the acute stroke unit of a university-affiliated regional hospital in Hong Kong participated in the study. A psychiatrist administered the Structural Clinical Interview for DSMIV to all patients and made a diagnosis of DAS three months after the index stroke. Results. Eighty-five (12.1%) patients were diagnosed with DAS. In univariate analysis, the DAS patients were more likely to have severe FLA (14.1% versus 5.6%). Severe FLA remained an independent predictor of DAS in multivariate analysis, with an odds ratio of 2.6 (95% confidence intervals = 1.2-5.9). Conclusions. The results suggest that FLA may play a role in the pathogenesis of DAS, which supports the hypothesis that cumulative vascular burden may be important in predicting DAS. Further investigations are needed to clarify the impact of FLA on the clinical presentation, treatment response, and outcome of DAS in stroke survivors. [ABSTRACT FROM AUTHOR]

Objective. Survivors of perinatal stroke may be at risk for behavioral problems. Perinatal risk factors that might increase the likelihood of later behavior problems have not been identified. The goal of this study was to explore whether perinatal factors might contribute to behavior problems after perinatal stroke. Methods. 79 children with unilateral perinatal stroke were studied. Perinatal factors included gender, gestational age, neonatal seizures, instrumented delivery, fetal distress, acute birth problems, birth weight, and time of diagnosis. Subjects with evidence of hypoxic ischemic encephalopathy were excluded. Parents completed the Achenbach Child Behavior Checklist (CBCL) (Achenbach 1985). The CBCL yields T-scores in several symptom scales. We focused on Social, Thought, and Attention Problems scates. Results. Gestational age and the presence of uteroplacental insufficiency were associated with significant differences on the Thought Problems scale; Attention Problems scores approached significance for these variables. Fetal distress, neonatal seizures, or neonatal diagnosis was associated with 25-30% incidence of clinically significant T-scores on Social, Thought, and Attention Problems scales. Conclusions. Several perinatal factors were associated with a high incidence of social, thought, and behavior problems in children with perinatal stroke. These findings may be useful in anticipatory guidance to parents and physicians caring for these children. [ABSTRACT FROM AUTHOR]

Studies from a single laboratory have shown that in rodent models of permanent stroke, administration of the sulfonylurea glibenclamide (Glib) is highly effective in reducing edema, mortality, and lesion volume. The Stroke Therapy Academic Industry Roundtable (STAIR) recommends that new acute treatments for ischemic stroke to be replicated across different laboratories. Accordingly, we examined the effect of low-dose Glib in a permanent suture occlusion model of stroke. Male Sprague-Dawley rats underwent permanent middle cerebral artery occlusion (pMCAO) followed by an initial intraperitoneal injection of Glib (10 µg/kg) and the start of a constant infusion (200 ng/h) via miniosmotic pump at the onset of ischemia. Functional deficits were assessed by Neurological Severity Score (NSS) and grip-strength meter at 24 and 48 h after pMCAO. Glib-treated rats showed a significant reduction in infarct volume, lower NSS, and less hemispheric swelling compared to vehicle. Grip strength was decreased significantly in pMCAO rats compared to shams and significantly improved by treatment with Glib. Taken together, these data indicate that Glib has strong neuroprotective effects following ischemic stroke and may warrant further testing in future clinical trials for human stroke. [ABSTRACT FROM AUTHOR]

Background. Several studies have examined determinants related to post-stroke fatigue. However, it is unclear which determinants can predict an increase in poststroke fatigue over time. Aim. This prospective cohort study aimed to identify determinants which predict an increase in post-stroke fatigue. Methods. A total of 250 patients with stroke were examined at inpatient rehabilitation discharge (T0) and 24 weeks later (T1). Fatigue was measured using the Fatigue Severity Scale (FSS). An increase in post-stroke fatigue was defined as an increase in the FSS score beyond the 95% limits of the standard error of measurement of the FSS (i.e., 1.41 points) between T0 and T1. Candidate determinants included personal factors, stroke characteristics, physical, cognitive, and emotional functions, and activities and participation and were assessed at T0. Factors predicting an increase in fatigue were identified using forward multivariate logistic regression analysis. Results. The only independent predictor of an increase in poststroke fatigue was FSS (OR 0.50; 0.38-0.64, P < 0.001). The model including FSS at baseline correctly predicted 7.9% of the patients who showed increased fatigue at T1. Conclusion. The prognostic model to predict an increase in fatigue after stroke has limited predictive value, but baseline fatigue is the most important independent predictor. Overall, fatigue levels remained stable over time. [ABSTRACT FROM AUTHOR]

Foot drop is a quite common problem in nervous system disorders. Neuromuscular electrical stimulation (NMES) has showed to be an alternative approach to correct foot drop improving walking ability in patients with stroke. In this study, twenty patients with stroke in subacute phase were enrolled and randomly divided in two groups: one group performing the NMES (i.e. Walkaide Group,WG) and the Control Group (CG) performing conventional neuromotor rehabilitation. Both groups underwent the same amount of treatment time. Significant improvements of walking speed were recorded for WG (168±39%) than for CG (129±29%, P = 0.032) as well as in terms of locomotion (Functional Ambulation Classification score: P = 0.023). In terms of mobility and force, ameliorations were recorded, even if not significant (Rivermead Mobility Index: P = 0.057; Manual Muscle Test: P = 0.059). Similar changes between groups were observed for independence in activities of daily living, neurological assessments, and spasticity reduction. These results highlight the potential efficacy for patients affected by a droop foot of a walking training performed with a neurostimulator in subacute phase. [ABSTRACT FROM AUTHOR]

Objective. To compare participation in moderate to high intensity physical activities in persons before and after a mild stroke. Methods. We used data from the Cognitive Rehabilitation and Research Group to examine changes in moderate to high intensity physical activity participation in persons who had a mild stroke as defined by an NIH Stroke Scale score of less than 6 (N = 127). Using the Activity Card Sort, we compared the participants' high-demand leisure activity (leisure activities that are moderate to high intensity physical activities) participation at 6-months after stroke with their prestroke level. Results. We found a significant decrease in numbers of high-demand leisure activities in all participants and in each demographic group after mild stroke. Conclusion. These results suggest that persons after mild stroke are not retaining the high-demand leisure activities they were doing prior to their stroke. Health professionals must promote participation in high-demand leisure activities in patients with mild stroke as a tool to enhance health and fitness. [ABSTRACT FROM AUTHOR]

The aim of this pilot study was to analyze the effect of a strength training program on indicators of trait and state anxiety in patients with ischemic stroke. The subjects were divided into two groups: experimental group (EG) consisting of 11 subjects aged 51.7 ± 8.0 years and a control group (CG) with 13 subjects aged 52.5 ± 7.7 years. EG underwent 12 weeks of strength training, with a frequency of three times a week. For data collection, a State-Trait Anxiety Inventory (STAI) was used. Significant differences were found between pre- and posttest in EG for trait anxiety (43.2 ± 12.5 pretest 39.9 ± 7.3 posttest) and state anxiety (46.9 ± 7.6 pretest 44.9 ± 7.7 posttest) with no differences in CG for trait anxiety (42.9 ± 12.2 pretest 42.6 ± 12.1 posttest) and state anxiety (47.4 ± 8.1 pretest 47.5 ± 8.0 posttest). In the evaluation between the groups, significant differences were found for all indicators of trait anxiety (39.9 ± 7.3 EG; 42.6 ± 12.1 CG) and state anxiety (44.9 ± 7.7 EG; 47.5 ± 8.0 CG). This pilot study indicates that strength training may provide an improvement in trait and state anxiety more than one year after stroke. [ABSTRACT FROM AUTHOR]