Category: Stroke

A study of stroke patients from Southern Ontario found those who smoke have more difficulty with problem-solving and decision-making than non-smokers.

The study, presented October 2 at the Canadian Stroke Congress, tested mental abilities of 76 patients, including 12 smokers, with an average age of 67.5 years, using the Montreal Cognitive Assessment (MoCA) tool. The MoCA exam tests patients with memory and problem solving questions and gives them a score out of 30.

Smokers had a median MoCA score two points lower than non-smokers — 22 out of 30 compared to 24 out of 30. Patients who had previously quit smoking achieved the same scores as lifetime non-smokers, says Gail MacKenzie, a clinical nurse specialist at Hamilton General Hospital.

"This research emphasizes the importance of smoking cessation for people with stroke or TIA," says MacKenzie. TIA, or transient ischemic attack, is a mini stroke and often serves as a warning sign that a bigger stroke is imminent. "Smoking is a risk factor for cognitive impairment for people who continue to smoke and this ability to problem-solve and make decisions has implications for patients' health and self-management of care."

Low MoCA scores can reflect problems in memory, language, attention, visual-spatial or problem-solving skills.

The 10-minute MoCA test was administered to patients attending stroke prevention clinics in Barrie, Oshawa and Hamilton.

Almost 37,000 Canadians will die prematurely each year due to tobacco use, and almost one-third of these deaths will be from cardiovascular disease. Smoking contributes to the build up of plaque in the arteries, increases the risk of blood clots, reduces the oxygen in the blood, increases blood pressure and makes the heart work harder. Smoking also nearly doubles the risk of ischemic stroke. If a person stops smoking, their risk for stroke or heart disease decreases. Within 18 months to two years of quitting, the risks of stroke are about the same as for non-smokers.

"All Canadians should be smoke-free," says Ian Joiner, director of stroke for the Heart and Stroke Foundation. "Not only does it improve the length and quality of your life — but also the lives of those around you."

Joiner says this study reinforces the importance of tobacco-control legislation, prevention programs and education.

"There needs to be more effort to help people stop smoking to protect their brain both from stroke and from mental decline after stroke," says Dr. Mark Bayley, Congress Co-Chair.

The Canadian Stroke Congress is a joint initiative of the Canadian Stroke Network, Heart and Stroke Foundation of Canada and the Canadian Stroke Consortium.

It gathers more than 1,000 stroke professionals to discuss the latest breakthroughs in stroke research and care.

 Among patients with either coronary artery disease (CAD) risk factors only, known prior heart attack, or known CAD without heart attack, the use of beta-blockers was not associated with a lower risk of a composite of cardiovascular events that included cardiovascular death, nonfatal heart attack or nonfatal stroke, according to a study in the October 3 issue of JAMA.

"Treatment with beta-blockers remains the standard of care for patients with coronary artery disease, especially when they have had a myocardial infarction [MI; heart attack]. The evidence is derived from relatively old post-MI studies, most of which antedate modern reperfusion or medical therapy, and from heart failure trials, but has been widely extrapolated to patients with CAD and even to patients at high risk for but without established CAD. It is not known if these extrapolations are justified. Moreover, the long-term efficacy of these agents in patients treated with contemporary medical therapies is not known, even in patients with prior MI," according to background information in the article.

Sripal Bangalore, M.D., M.H.A., of the NYU School of Medicine, New York, and colleagues conducted a study to evaluate the association between beta-blocker use and long-term cardiovascular outcomes. The observational study included data from patients in the Reduction of Atherothrombosis for Continued Health (REACH) registry. From this registry, 44,708 patients met the study inclusion criteria of whom 14,043 patients (31 percent) had prior MI, 12,012 patients (27 percent) had documented CAD but without MI, and 18,653 patients (42 percent) had CAD risk factors only. The last follow-up data collection was April 2009. The primary outcome for this study was a composite of cardiovascular death, nonfatal MI, or nonfatal stroke. The secondary outcome was the primary outcome plus hospitalization for atherothrombotic events or a revascularization procedure. The overall median (midpoint) follow-up was 44 months. Among the 44,708 patients in the study, 21,860 were included in the propensity score-matched analysis.

The researchers found that in the prior MI group, the event rates were not significantly different among those with beta-blocker use (489 [16.93 percent]) vs. those without beta-blocker use (532 [18.60 percent]) for the primary outcome, or the secondary outcome (30.96 percent vs. 33.12 percent, respectively). In the CAD without MI cohort, the event rates were not different in those with beta-blocker use (391 [12.94 percent]) vs. those without p-blocker use (405 [13.55 percent]) for the primary outcome, for cardiovascular death, for stroke, and for MI. The event rates were higher in those with beta-blocker use (1,101 [30.59 percent] vs. those without beta-blocker use (1,002 [27.84 percent]) for the secondary outcome and for hospitalization in the propensity score-matched model.

In the risk factors alone group, the event rates were higher in those with beta-blocker use (467 [14.22 percent] vs. those without beta-blocker use (403 [12.11 percent]) for the primary outcome, for the secondary outcome (870 [22.01 percent] vs. 797 [20.17 percent], respectively) but not for MI or stroke. In the propensity score-matched model, there were similar event rates for cardiovascular death and for hospitalization.

The researchers also found that among patients with recent MI (one year or less), beta-blocker use was associated with a lower incidence of the secondary outcome.

"Among patients enrolled in the international REACH registry, beta-blocker use was not associated with a lower event rate of cardiovascular events at 44-month follow-up, even among patients with prior history of MI. Further research is warranted to identify subgroups that benefit from beta-blocker therapy and the optimal duration of beta-blocker therapy," the authors conclude.

Researchers from the Department of Biomedical Engineering at Stony Brook University have developed a high-resolution, 3D optical Doppler imaging tomography technique that captures the effects of cocaine restricting the blood supply in vessels — including small capillaries — of the brain. The study, reported in Molecular Psychiatry, and with images on the journal's October 2012 cover, illustrates the first use of the novel neuroimaging technique and provides evidence of cocaine-induced cerebral microischemia, which can cause stroke.

Stroke is one of the most serious medical risks of cocaine abuse. Cerebral blood flow (CBF) is disrupted due to the vasoactive effects of cocaine, and research has shown that the process contributes to stroke in cocaine abusers. An effective treatment has yet to be discovered because of minimal knowledge on the underlying mechanisms that cause cerebrovascular changes resulting from cocaine abuse. Current neuroimaging methods that could reveal clues to underlying mechanisms that cause cocaine-induced restricted CBF, such as magnetic resonance imaging and computed tomography angiography, are limited in scope. The Stony Brook team's neuroimaging technique offers a promising method to investigate structural changes in the small neurovascular networks of the brain that may be implicated in stroke.

In "Cocaine-induced cortical microischemia in the rodent brain: clinical implications," the researchers discovered that cocaine administered in doses equivalent to those normally taken by abusers caused constriction in blood vessels that inhibited CBF for varying lengths of time. Brain arteries, veins, and even capillaries, the smallest vessels, were affected by the doses. CBF was markedly decreased within just two-to-three minutes after drug administration. In some vessels, a decrease in CBF reached 70 percent. Recovery time for the vessels varied. Cocaine interrupted CBF in some arteriolar branches for more than 45 minutes. This effect became more pronounced after repeated cocaine administration.

"Our study revealed evidence of cocaine-induced cerebral microischemic changes in multiple experimental models, and we were able to clearly image the process and vasoactive effects at a microvascular level," said study Principal Investigator Yingtian Pan, PhD, Professor, Department of Biomedical Engineering, Stony Brook University. "These clinical changes jeopardize oxygen delivery to cerebral tissue making it vulnerable to ischemia and neuronal death."

The study reflects the collaborative research of Dr. Pan and Co-Principal Investigator Dr. Congwu Du, Associate Professor, Department of Biomedical Engineering at Stony Brook University, and Dr. Nora D. Volkow, M.D., Director of the National Institutes of Health's (NIH) National Institute on Drug Abuse. They point out that the types of cocaine-induced microischemic changes that occurred in the brain model are likely a contributor to neurotoxic effects, and they could underlie some of the neurological complications commonly experienced by cocaine abusers. These include various sensory changes, facial paralysis, numbness, and partial to full and irreversible paralysis.

Other study co-authors include Stony Brook Biomedical Engineering graduate students H. Ren, Z. Yuan, and research staff K. Park.

The research was supported, in part, by NIH grants and the National Institute on Alcohol Abuse and Alcoholism Intramural Research Program.

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Journal Reference:

1. H Ren, C Du, Z Yuan, K Park, N D Volkow, Y Pan. Cocaine-induced cortical microischemia in the rodent brain: clinical implications. Molecular Psychiatry, 2011; 17 (10): 1017 DOI: 10.1038/mp.2011.160

NewsPsychology (Oct. 8, 2012) — Eating tomatoes and tomato-based foods is associated with a lower risk of stroke, according to new research published in the October 9, 2012, print issue of Neurology®, the medical journal of the American Academy of Neurology. Tomatoes are high in the antioxidant lycopene.

The study found that people with the highest amounts of lycopene in their blood were 55 percent less likely to have a stroke than people with the lowest amounts of lycopene in their blood.

The study involved 1,031 men in Finland between the ages of 46 and 65. The level of lycopene in their blood was tested at the start of the study and they were followed for an average of 12 years. During that time, 67 men had a stroke.

Among the men with the lowest levels of lycopene, 25 of 258 men had a stroke. Among those with the highest levels of lycopene, 11 of 259 men had a stroke. When researchers looked at just strokes due to blood clots, the results were even stronger. Those with the highest levels of lycopene were 59 percent less likely to have a stroke than those with the lowest levels.

"This study adds to the evidence that a diet high in fruits and vegetables is associated with a lower risk of stroke," said study author Jouni Karppi, PhD, of the University of Eastern Finland in Kuopio. "The results support the recommendation that people get more than five servings of fruits and vegetables a day, which would likely lead to a major reduction in the number of strokes worldwide, according to previous research."

The study also looked at blood levels of the antioxidants alpha-carotene, beta-carotene, alpha-tocopherol and retinol, but found no association between the blood levels and risk of stroke.

The study was supported by Lapland Central Hospital.

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Journal Reference:

1. J. Karppi, J. A. Laukkanen, J. Sivenius, K. Ronkainen, S. Kurl. Serum lycopene decreases the risk of stroke in men: A population-based follow-up study. Neurology, 2012; 79 (15): 1540 DOI: 10.1212/WNL.0b013e31826e26a6

A hospital stroke team used auto industry "lean" manufacturing principles to accelerate treatment times, according to new research in the American Heart Association's journal Stroke.

In a prospective observational study, the average time between patients arriving at Barnes-Jewish Hospital in St. Louis, Mo., and receiving the clot-busting agent tissue plasminogen activator (tPA), decreased 21 minutes using process improvement techniques adapted from auto manufacturing. Data from more than 200 patients was included in the study analysis, ranging over 3 years.

The shorter the time between patients arriving at the hospital and receiving tPA, the greater the chance to reduce brain injury after stroke, researchers said.

Using lean techniques, the hospital's stroke team identified unnecessary or inefficient steps such as inefficient patient transportation, tasks performed one at a time rather than simultaneously, and time-consuming traditional lab-based tests. Protocols were formulated to eliminate wasteful steps, keeping only crucial steps that added "value" to patient care, in keeping with auto-manufacturers' lean methods which eliminates inefficiencies in automobile production.

The team streamlined the process by having EMS route patients directly to the CT scanner for immediate brain imaging, enlisted the help of more team members each with fewer tasks to complete, and instituted bedside tests which provide laboratory results within minutes. These modifications ensured that rapid diagnosis and treatment would be available for patients as soon as they arrived at the Emergency Department.

As a result, 78 percent of stroke patients received tPA within one hour of arrival. The "Get with the Guidelines" national database indicates that currently only about 30 percent of patients in the United States are treated within one hour. The overall treatment time was reduced from 60 minutes to 39 minutes — sustained for a year after implementation.

The protocol changes didn't alter patient safety or clinical outcomes, researchers said.

"There is growing awareness that fast and efficient treatment is important for improving the effectiveness of tPA. National guidelines suggest that door-to-needles times should be under 60 minutes, yet these guidelines do not state how this can be achieved. Lean process improvements methodology can be effectively applied towards achieving this and other process improvement goals," said Jin-Moo Lee, M.D., Ph.D., lead author of the study and Director of the Cerebrovascular Disease Section in the Department of Neurology at Washington University School of Medicine in St. Louis.

A larger study is needed to validate results, researchers said.

Other co-authors are Andria L. Ford, M.D.; Peter Panagos, M.D.; Jennifer A. Williams, R.N.; Mary Spencer, R.N., M.S.N.; Craig McCammon, Pharm.D.; Naim Khoury, M.D.; and Tomoko Sampson, M.D. Author disclosures are on the manuscript.

NIH Specialized Programs of Translational Research in Acute Stroke (SPOTRIAS) and the Institute of Clinical and Translational Sciences at Washington University-St. Louis funded the study.

New research reveals that stroke may be affecting people at a younger age. The study is published in the October 10, 2012, online issue of Neurology®, the medical journal of the American Academy of Neurology.

"The reasons for this trend could be a rise in risk factors such as diabetes, obesity and high cholesterol," said study author Brett Kissela, MD, MS, with the University of Cincinnati College of Medicine in Ohio and a Fellow of the American Academy of Neurology. "Other factors, such as improved diagnosis through the increased use of MRI imaging may also be contributing. Regardless, the rising trend found in our study is of great concern for public health because strokes in younger people translate to greater lifetime disability."

For the study, researchers looked at occurrences of strokes in people between the ages 20 and 54 in the Greater Cincinnati/Northern Kentucky area during three separate, one year-long periods between July of 1993 and June of 1994, and the calendar years of 1999 and 2005. Only first ever strokes were included in the analysis.

The study found that the average age of people who experienced stroke fell from 71 years in 1993 and 1994 to 69 years in 2005. In addition, the study found that strokes among people under 55 made up a greater percentage of all strokes over time, growing from about 13 percent in 1993-94 to 19 percent in 2005. The stroke rate in young people increased in both African-Americans and Caucasians, from 83 strokes per 100,000 people in 1993-94 in African-Americans to 128 per 100,000 in 2005 and in Caucasians from 26 strokes per 100,000 people in 1993-94 to 48 per 100,000 in 2005.

"The good news is that some of the possible contributing factors to these strokes can be modified with lifestyle changes, such as diet and exercise," said Kissela. "However, given the increase in stroke among those younger than 55, younger adults should see a doctor regularly to monitor their overall health and risk for stroke and heart disease."

Research shows that use of popular antidepressants is linked to an increased risk of some strokes caused by bleeding in the brain, but that the risk is low, according to a multi-study analysis published in the October 17, 2012, online issue of Neurology®, the medical journal of the American Academy of Neurology.

For the research, scientists analyzed all of the studies that have looked at antidepressant use and stroke, which included 16 studies with more than 500,000 total participants. They found that people taking selective serotonin reuptake inhibitors (SSRIs), which are the most commonly used antidepressants, were 50 percent more likely to have an intracranial hemorrhage than those not taking the antidepressants and about 40 percent more likely to have an intracerebral hemorrhage.

But study author Daniel G. Hackam, MD, PhD, FRCPC, of Western University in London, Ontario, said the findings should be viewed with caution. "Because these types of strokes are very rare, the actual increased risk for the average person is very low," he said.

An estimated 24.6 of these strokes occur per 100,000 people per year. According to the research, the use of SSRIs would increase the risk by one additional stroke per 10,000 people per year.

"Overall, these results should not deter anyone from taking an SSRI when it is needed," Hackam said. "In general these drugs are safe, and obviously there are risks to having depression go untreated. But doctors might consider other types of antidepressants for people who already have risk factors for these types of strokes, such as those taking blood thinners, people who have had similar strokes already or those with severe alcohol abuse."

New research links motor skills and perception, specifically as it relates to a second finding — a new understanding of what the left and right brain hemispheres "hear." Georgetown University Medical Center researchers say these findings may eventually point to strategies to help stroke patients recover their language abilities, and to improve speech recognition in children with dyslexia.

The study, presented at Neuroscience 2012, the annual meeting of the Society for Neuroscience, is the first to match human behavior with left brain/right brain auditory processing tasks. Before this research, neuroimaging tests had hinted at differences in such processing.

"Language is processed mainly in the left hemisphere, and some have suggested that this is because the left hemisphere specializes in analyzing very rapidly changing sounds," says the study's senior investigator, Peter E. Turkeltaub, M.D., Ph.D., a neurologist in the Center for Brain Plasticity and Recovery. This newly created center is a joint program of Georgetown University and MedStar National Rehabilitation Network.

Turkeltaub and his team hid rapidly and slowly changing sounds in background noise and asked 24 volunteers to simply indicate whether they heard the sounds by pressing a button.

"We asked the subjects to respond to sounds hidden in background noise," Turkeltaub explained. "Each subject was told to use their right hand to respond during the first 20 sounds, then their left hand for the next 20 second, then right, then left, and so on." He says when a subject was using their right hand, they heard the rapidly changing sounds more often than when they used their left hand, and vice versa for the slowly changing sounds.

"Since the left hemisphere controls the right hand and vice versa, these results demonstrate that the two hemispheres specialize in different kinds of sounds — the left hemisphere likes rapidly changing sounds, such as consonants, and the right hemisphere likes slowly changing sounds, such as syllables or intonation," Turkeltaub explains. "These results also demonstrate the interaction between motor systems and perception. It's really pretty amazing. Imagine you're waving an American flag while listening to one of the presidential candidates. The speech will actually sound slightly different to you depending on whether the flag is in your left hand or your right hand."

Ultimately, Turkeltaub hopes that understanding the basic organization of auditory systems and how they interact with motor systems will help explain why language resides in the left hemisphere of the brain, and will lead to new treatments for language disorders, like aphasia (language difficulties after stroke or brain injury) or dyslexia.

"If we can understand the basic brain organization for audition, this might ultimately lead to new treatments for people who have speech recognition problems due to stroke or other brain injury. Understanding better the specific roles of the two hemispheres in auditory processing will be a big step in that direction. If we find that people with aphasia, who typically have injuries to the left hemisphere, have difficulty recognizing speech because of problems with low-level auditory perception of rapidly changing sounds, maybe training the specific auditory processing deficits will improve their ability to recognize speech," Turkeltaub concludes.

Early results of a Phase II intra-arterial stem cell trial for ischemic stroke showed no adverse events associated with the first 10 patients, allowing investigators to expand the study to a targeted total of 100 patients.

The results were presented October 11 by Sean Savitz, M.D., professor of neurology and director of the Stroke Program at The University of Texas Health Science Center at Houston (UTHealth), at the 8^th World Stroke Congress in Brasilia, Brazil.

The trial is the only randomized, double-blind, placebo-controlled intra-arterial clinical trial in the world for ischemic stroke. It is studying the safety and efficacy of a regenerative therapy developed by Aldagen Inc., a wholly-owned subsidiary of Cytomedix, Inc., that uses a patient's own bone marrow stem cells, which can be administered between 13 and 19 days post-stroke.

The therapy, called ALD-401, consists of stem cells that are identified using Aldagen's proprietary technology to isolate cells that express high levels of an enzyme that serves as a marker of stem cells. Pre-clinical studies found that these cells enhance recovery after stroke in mice. The cells are administered into the carotid artery. Patients are followed for 12 months to monitor safety and to assess mental and physical function.

"We have been approved by the Data Safety Monitoring Board (DSMB) to move the study into the next phase, which will allow us to expand the number of sites in order to complete enrollment," said Savitz, senior investigator for the multi-center study. As per the protocol for the trial, the Food and Drug Administration required a review by the DSMB prior to advancing to the next phase.

Preclinical research, including research at the UTHealth Medical School, has suggested that stem cells can promote the repair of the brain after an ischemic stroke, which is caused by a blood clot in the brain. Stroke is a leading cause of disability and the fourth-leading cause of death in the United States, according to 2008 statistics reported by the Centers for Disease Control and Prevention.

Physicians have sharply reduced stroke treatment time by applying a process for improving efficiency originally developed by carmakers. Early treatment helps prevent or reduce brain damage, shown in white in the scan. (Credit: Jin-Moo Lee, MD, PhD, Washington University in St. Louis)

By applying the principles of Toyota's lean manufacturing process, doctors sharply reduced the average time between patient arrival and treatment, known as door-to-needle time, from 58 to 37 minutes.

The findings are reported Oct. 18 in the journal Stroke. In an average year, the medical school's physicians treat 1,300 stroke patients at Barnes-Jewish.

Beginning stroke treatment earlier can help prevent the brain damage that causes paralysis and loss of speech after a stroke. The researchers say the drop in treatment time results from applying a key component of lean manufacturing to patient care: getting input from all members of the team to identify inefficient steps involved in the process.

"We sought suggestions from everyone involved, from the paramedics who bring in patients, to admitting clerks, radiology technologists, nurses and physicians," says senior author Jin-Moo Lee, MD, PhD, associate professor of neurology at Washington University School of Medicine in St. Louis and director of the cerebrovascular disease section in the Department of Neurology. "Once the inefficient steps were identified, we developed a completely new protocol that eliminated them. This new treatment protocol helped us achieve one of the fastest door-to-needle times in the country."

Barnes-Jewish has a dedicated stroke team capable of quickly evaluating and treating patients with tPA, which breaks up blood clots in the brain that cause strokes. The earlier it is given, the more effective tPA is at preventing permanent brain damage caused by stroke.

Because tPA can cause dangerous bleeding in the brain and throughout the body, the drug can no longer be given if too much time elapses after a stroke begins. At that point, its risk outweighs the potential benefit. Ideally, the drug must be given within 60 minutes after a stroke begins, a period known as the "golden hour."

"We already had very good door-to-needle times, but we thought that we could do better," Lee says. "So we put all of our team members in a room for two days and asked them to evaluate each step in the door-to-needle process."

Experts at Barnes-Jewish with experience using the principles of lean manufacturing in a healthcare setting helped facilitate the discussion.

"Identifying steps that are wasteful and do not add value is a primary goal of lean manufacturing," says David Jaques, MD, vice president of Surgical Services at Barnes-Jewish Hospital and a professor at the School of Medicine. "Lean has made it possible to speed the delivery of medication or blood, improve teamwork and communication and ensure that those caring for patients always have easy access to supplies and equipment."

One problem identified by the group was repeatedly moving patients from one location to another and back again. The staff decided it would be more efficient for paramedics to bring patients directly to the emergency department's CT scanner for evaluation rather than to a patient examination room.

The group also noted that some aspects of patient care performed in sequence instead could be carried out simultaneously with the addition of extra staff. With two treatment nurses per patient, for example, one nurse can put in an IV while another gets medications. A neurologist and an emergency department physician also were assigned tasks that could be performed at the same time to speed patient care.

"We also added new specialties to the treatment team," Lee says. "We asked social workers to help identify people who were with the patient when the suspected stroke began. While they are talking with family members or co-workers, we can begin the initial assessment."

Finally, lab work for the patients was taking too long.

"Where we could, we instituted lab tests that could be performed at the bedside in minutes instead of sending the blood to the lab and waiting 30 minutes or more for results," Lee says.

The new treatment procedures were implemented in February 2011. The changes not only lowered average door-to-needle times by nearly 40 percent, but they also increased the percent of patients treated within "the golden hour" from 52 — 78 percent.

After the new procedures were put in place, the researchers monitored patients for side effects of treatment, including hemorrhages, and to make sure the accelerated process did not result in more patients getting the clot-busting drug when they were later determined to be stroke free. Neither of these negative outcomes increased.

Accelerating door-to-needle times for stroke treatment is only one example of how lean principles can be applied to improve patient care. Barnes-Jewish has already used lean principles to improve the delivery of blood products to patients, enhance patient access to radiological procedures, create more efficient operating room procedures and shorten hospital stays, according to Jaques.

"Lean principles used in manufacturing can be applied to patient care to create a higher quality, safer and more efficient hospital," Jaques says.

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Journal Reference:

1. Ford AL, Williams JA, Spencer M, McCammon C, Khoury N, Sampson T, Panagos P, Lee J-M. Reducing door-to-needle times using Toyota’s lean manufacturing principles and value stream analysis. Stroke, 2012;