Cognitive and psychoemotional impairment dynamics in patients with hemorrhagic hemispheric stroke at the early rehabilitation stage

The aim of the study was to establish the dynamics of cognitive and psychoemotional disorders under comprehensive rehabilitation in patients with hemorrhagic hemispheric stroke (HHS) during the recovery period of the disease. 46 patients with HHS during the recovery period (31 males and 15 females) were examined on the 30th, 90th, and 180th day. For this purpose, the following modern clinical scales and tests were used: National Institutes of Health Stroke Scale (NIHSS), Modified Rankin Scale (mRS), Barthel Index (BI), Montreal Cognitive Assessment (MoCA), Mini-Mental State Examination (MMSE), “10 words remembering” test (by Luriya A.), memory self-evaluation scale, State-Trait Anxiety Inventory scale (STAI) and Beck's Depression Inventor (BDI). It was found that 89,13 % of patients with HHS had cognitive impairment. It was also determined signifi‑cant cognitive improvement during the recovery period of the disease. Additionally, the correlation analysis of values on the 30th day of the condition showed the credible impact of the neurological deficit severity by NIHSS on the MMSE, MoCA, and memory self-evaluation scale rates (p < 0.05). As well correlation between neurological impairment and Beck's somatic sings subscale was established (p < 0.05). It was additionally evaluated the impact of neurology deficit level on the BDI overall score (both subscales) on the 180th day of the disease (p < 0.05). It was estimated the age influenced on both the situational anxiety and patient gender on the personal anxiety level (p < 0.05). In addition, it was revealed the impact of lesion location on the presence and severity of depressive disorders (p < 0.05).

Electric myocardial inhomogeneity and stroke: connection and specifics

Funding Acknowledgements Type of funding sources: None. Background. The inconsistency of the literature data on the influence of different hemispheric localization of Cerebrovascular accident (CVA) on the development of cardiac arrhythmias suggests the expediency of further study of the so-called "zones" of the cerebral cortex associated with electrical instability of the myocardium. It is known that dispersion of QT interval and fragmented myocardial activity belong to the markers of electrical instability of the heart and are associated with arrhythmogenesis. The aim of the study. To study the severity of abnormalities of the parameters of electrical instability of myocardium in right and left hemispheric stroke localization in patients with hypertension. Material and methods. 111 patients with left hemispheric localization of ischemic stroke and 75 patients with right hemispheric stroke were examined. Hemorrhagic stroke was observed in 17 patients in the left hemisphere and in 13 patients in the right hemisphere. The average age was 58,2 ± 7,48 years. For all strokes, men prevailed (64% vs. 36%). For the first day of the stroke, all patients were evaluated for QT dispersion and fragmented myocardial activity on the device "Polyspectro-8EX" (Russia). Research results. Evaluation of the parameters of electrical instability of myocardium in patients with stroke revealed more pronounced disorders in hemorrhagic stroke of left hemispheric localization (Table 1). In ischemic stroke, the severity of electrophysiological parameters, reflecting the instability of the myocardium depending on the hemispheric localization, indicates the absence of differences. Conclusions. 1.The most pronounced disturbances in the parameters of electrical stability of the myocardium is observed in hemorrhagic stroke. 2.The severity of myocardial electrical instability in ischemic stroke is not associated with the localization of the focus.

Hemispheric CSF volume ratio quantifies progression and severity of cerebral edema after acute hemispheric stroke

As swelling occurs, CSF is preferentially displaced from the ischemic hemisphere. The ratio of CSF volume in the stroke-affected hemisphere to that in the contralateral hemisphere may quantify the progression of cerebral edema. We automatically segmented CSF from 1,875 routine CTs performed within 96 hours of stroke onset in 924 participants of a stroke cohort study. In 737 subjects with follow-up imaging beyond 24-hours, edema severity was classified as affecting less than one-third of the hemisphere (CED-1), large hemispheric infarction (LHI, over one-third the hemisphere), without midline shift (CED-2) or with midline shift (CED-3). Malignant edema was LHI resulting in deterioration, requiring osmotic therapy, surgery, or resulting in death. Hemispheric CSF ratio was lower on baseline CT in those with LHI (0.91 vs. 0.97, p < 0.0001) and decreased more rapidly in those with LHI who developed midline shift (0.01 per hour for CED-3 vs. 0.004/hour CED-2). The ratio at 24-hours was lower in those with midline shift (0.41, IQR 0.30–0.57 vs. 0.66, 0.56–0.81 for CED-2). A ratio below 0.50 provided 90% sensitivity, 82% specificity for predicting malignant edema among those with LHI (AUC 0.91, 0.85–0.96). This suggests that the hemispheric CSF ratio may provide an accessible early biomarker of edema severity.

Dynamics of clinical-neurological indicators of patients with hemorrhagic hemispheric stroke in the recovering period of the disease

The aim of our study was the investigation of the dynamics of clinical-neurological indicators of patients with hemorrhagic hemispheric stroke (HHS) in the recovering period of the disease by comprehensive neurological, medical and social research. Materials and methods. 90 patients in the age from 38 to 70 years were studied, 58 men – 64.4 % and 32 women – 35.6 %. The condition of the patients was evaluated by NIHSS, mRS, BI and MSA on the 30th, 180th, 360th day of HHS. Depending on their self-care recovering level the patients were divided in two groups for analysis: the first one was formed with the patients whose self-care level completely was restored on the 360th day (ВІ = 100), and the second one was formed with the patients with BI 95 and less on the 360th day. Results. Structure of indicators according to NIHSS, mRS, ВІ and MSA on the 30th day of disease in these groups was analyzed during rehabilitation, as well as distribution of the patients based on their gender and process lateralization. Analyzing the data of the dynamics of the recovery period of HHS depending on the lateralization of the process and the sex of patients, we can notice that there was no significant difference during the recovery period of HHS depending of the lateralization of the process, for example, in patients with the damaged dominant hemisphere median score of BI was 70 points on the 30th day, patients with the lesion of subdominant hemisphere – 65, and on the 360th days in both groups it was 95 points. There was also no significant difference in the dynamics of neurological deficit and recovery of functional activity depending on the gender of patients. On the 30th day of the disease in the group of patients who fully restored their daily activity on the 360th day of HHS a significantly higher score for BI was determined than in the group with incomplete recovery (80 (70; 85) points against 55 (45; 65) points (P ˂ 0.05)). Although a significantly greater regression of functional disorders was found in the second group of patients (P ˂ 0.05). An analysis of the impact of spasticity on the recovery of self-care level showed a significant negative impact of increased muscle tone on the recovery of self-care (P ˂ 0.05) and reduction of the probability of complete recovery of independence in everyday life with increasing degree of spasticity (P ˂ 0.05). At the same time, no significant factors (sex, age, side of the lesion, etc.) were identified that would affect the development of spasticity in patients with HHS, except for the level of neurological deficit according to NIHSS. When we analyzed the distribution of patients in these two groups by sex, it was revealed that the groups didn't have any significant difference. There was also no significant difference in the study's groups depending of the lateralization of the stroke. Conclusions. It was found that on the 30th day of the disease in 35.6 % of patients the total score on NIHSS ranged from 2 to 6 points, 55.6 % of patients had mRS of 3 points and 48.9 % of patients had severe dependent of outside help in daily life by BI. Significant positive dynamics of recovery on NIHSS, mRS, BI scales on the 180th and 360th day of the disease (P ˂ 0.05) was revealed. The dependence of the indicators of the level of self-care on the 360th day of HHS, on the severity of stroke on the 30th day of the disease (P ˂ 0.01) and on the presence of manifestations of increased muscle tone was established. It was found that patients who had manifestations of spasticity on the 360th day of the disease had a significantly higher score for NIHSS at the onset of the disease, on the 30th day of the disease and on the 360th day of the disease than patients without manifestations of increased muscle tone (P ˂ 0.05). However, no interconnection was found between the indicators of the level of self-care on the 360th day of HHS and the lateralization of the process as well as the sex of patients.

The influence of nicergoline on cerebral, systemic and cardiac hemodynamics in patients who have had an ischemic stroke

The Aim of study was analysis of the effect of nicergoline on the cerebral, cardiac, systemic hemodynamics of patients after ischemic stroke, taking into account the hemispheric localization of the ischemic focus. Materials and methods. A comprehensive clinical and neurological examination was carried out in 38 elderly patients (mean age 64.3 ± 2.5 years) who had undergone atherothrombotic ischemic stroke in the carotid system (recovery period). There were 20 patients with left hemispheric stroke and 18 with right hemispheric stroke. All patients had arterial hypertension (AH). These were ACE inhibitors (enalapril 10-20 mg 1 tablet 2 times a day) and hydrochlorothiazide at a dose of 12.5 mg. Patients received nicergoline at a dose of 4 mg IV drip for 10 days. A comprehensive examination was carried out before and after treatment with nicergoline. The Results of the study allowed us to conclude that the course of nicergoline intake in patients after ischemic atherothrombotic stroke improves the subjective state and reduces the severity of neurological disorders, cerebral hemodynamics, increases linear systolic blood flow velocities (LBFVsys) and reduces peripheral resistance in individual extra- and intracranial vessels of the carotid and vertebro-basilar basins. In patients with right and left hemispheric localization of stroke under the influence of nicergoline, LBFVsys increases in the right and left ICA, PCA, and VA. In addition, LBFVsys increases in patients with right hemispheric stroke in the right MBA; in patients with left hemisphere - in two MBA and BA. In ischemic stroke patients, nicergoline affects systemic and cardiac hemodynamics: it reduces the systemic and cardiac hemodynamics, decreases the systemic vascular resistance and increases the ejection fraction, changes the structure of the relationship between systemic and cerebral hemodynamics, forming a positive relationship between blood pressure and hemodynamics in the vessels of the vertebro-basilar basin. Thus, the complex positive effect of nicergoline on various levels of cerebral, systemic and cardiac hemodynamics in ischemic stroke patients gives grounds to recommend the inclusion of this drug in the rehabilitation system of this category of patients.

Video-Oculography During Free Visual Exploration to Detect Right Spatial Neglect in Left-Hemispheric Stroke Patients With Aphasia: A Feasibility Study

Spatial neglect has been shown to occur in 17–65% of patients after acute left-hemispheric stroke. One reason for this varying incidence values might be that left-hemispheric stroke is often accompanied by aphasia, which raises difficulties in assessing attention deficits with conventional neuropsychological tests entailing verbal instructions. Video-oculography during free visual exploration (FVE) requires only little understanding of simple non-verbal instruction and has been shown to be a sensitive and reliable tool to detect spatial neglect in patients with right-hemispheric stroke. In the present study, we aimed to investigate the feasibility of FVE to detect neglect in 10 left-hemispheric stroke patients with mild to severe aphasia as assessed by means of the Token Test, Boston Naming Test and Aachener Aphasie Test. The patient’s individual deviation between eye movement calibration and validation was recorded and compared to 20 age-matched healthy controls. Furthermore, typical FVE parameters such as the landing point of the first fixation, the mean gaze position (in ° of visual angle), the number and duration of visual fixations and the mean visual exploration area were compared between groups. In addition, to evaluate for neglect, the Bells cancellation test was performed and neglect severity in daily living was measured by means of the Catherine Bergego Scale (CBS). Our results showed that the deviation between calibration and validation did not differ between aphasia patients and healthy controls highlighting its feasibility. Furthermore, FVE revealed the typical neglect pattern with a significant leftward shift in visual exploration bahaviour, which highly correlated with neglect severity as assessed with CBS. The present study provides evidence that FVE has the potential to be used as a neglect screening tool in left-hemispheric stroke patients with aphasia in which compliance with verbal test instructions may be compromised by language deficits.

EXPRESS: DECOMPRESSIVE SURGERY IN PATIENTS WITH MALIGNANT MIDDLE CEREBRAL ARTERY INFARCTION: A RANDOMIZED, CONTROLLED TRIAL IN A TURKISH POPULATION (DEMITUR TRIAL)

Background - Decompressive surgery (hemicraniectomy) for large hemispheric stroke reduces the risk of death and increases the chance of a favorable outcome. We aim to evaluate the outcome in patients up to 80 years of age with space-occupying hemispheric infarction treated with surgical decompression compared to medical therapy alone. Methods - This trial is a prospective, randomized, controlled, clinical trial based on a stroke center. The primary end point was survival with slight or moderate disability 12 months after randomization (defined by a score of 0 to 3 on the modified Rankin scale (mRS), which ranges from 0 [no symptoms] to 6 [death]). Secondary outcomes included death, Barthel Index, National Institute of Health Stroke Scale, and Stroke Impact Scale 2.0 (SIS) at 6 months and 1-year after randomization. The variables for subgroup analysis were age, sex, presence of aphasia and neglect. Results - We randomly allocated 151 patients aged 41 years or older (median, 65 years; range, 41 to 79) with large hemispheric stroke to either conservative medical treatment or hemicraniectomy; the assignment was made within 12 to 38 hours after the onset of symptoms. A statistically significant reduction in mortality was achieved after 30 days in the surgery group compared to the medical treatment group. Fifty-five of 70 (79%) patients randomized to surgery versus 26 of 81 (32%) patients randomized to medical treatment survived (P=0.001). Of 151 patients randomized, the proportion of patients with a mRS score ≤3 at the 6-months and 1-year follow-up was 48% and 64%, respectively, in the surgery group compared to medical treatment group, 14% and 20%, respectively (P=0.001 and P=0.001, respectively). There was a 47% absolute risk reduction of death after surgery compared to medical treatment at 1-year after stroke (P=0.001). Activities of daily living (58.8+16.1 vs 50.9+15.2; P=0.04), strength (20.2+9.2 vs 15.3+7.2; P=0.020), hand function (1.2+0.7 vs 0.8+0.6; P=0.022), memory (71.9+14.9 vs 59.2+18.5; P=0.001), and communication (62+17.7 vs 51.9+17.6; P=0.019) assessed by the SIS, were better in the surgical group than in the medical treatment group 1-year after stroke. Conclusions - This study showed that surgery in 48 hours increased survival and reduced mortality in life-threatening massive cerebral infarction. Early hemicraniectomy is a beneficial procedure in patients with large hemispheric infarction up to 80 years of age regardless of hemisphere dominance and improves daily life/ instrumental activities compared to medical therapy.

Abstract P356: Wernicke’s Vertical Occipital Fasciculus in Post-Stroke Reading

Introduction: The vertical-occipital fasciculus (VOF), which was initially described by Wernicke more than a century ago but recently rediscovered, connects visual association cortices to the posterior language areas. We hypothesized that the vertical-occipital fasciculus plays a critical role in reading. Methods: Thirty-two participants with subacute to chronic left hemispheric stroke leading to varying degrees of aphasia were enrolled in the study and underwent concurrent diffusion tensor imaging (DTI) and language assessment. Assessments included the Boston Diagnostic Aphasia Examination (BDAE) to assess oral reading and reading comprehension and the Boston Naming Test to assess picture naming. Two major cortico-cortical projection pathways, VOF, connected with posterior language cortices and frontal aslant tract (FAT), connecting anterior language areas, were mapped with deterministic tractography and quantified bilaterally. We conducted partial correlations between fractional anisotropy (FA) values of the tracts and reading and picture naming scores, controlling for age, education, and total lesion load. We corrected for multiple comparisons at the false discovery rate (FDR) (p<0.05). Results: FA of left VOF was found to be significantly correlated with BDAE total reading scores (r=0.49, p=0.004), and this remained significant after FDR correction (p=0.03). Although a significant correlation was seen between picture naming and left VOF FA (r=0.41, p=0.02), and right VOF FA (r=0.37, p=0.04), these associations were not significant after FDR correction (p>0.05). FAT FA values were not significantly associated with oral reading or picture naming tests. Conclusion: This study provides preliminary evidence that left VOF plays a potential role in reading after left hemispheric stroke.