{2023}
Baseline Function and Rehabilitation Are as Important as Stroke Severity as Long-term Predictors of Cognitive Performance Post-stroke
Although individuals with low stroke severity tend to recover well, cognitive impairment is common independent of stroke size or location. In this study, the patterns of recovery for individual cognitive domains and factors associated with outcome were examined. A prospectively enrolled cohort of 46 patients with minor stroke (an average NIH Stroke Scale score of 2.7) was administered cognitive testing at 1, 6, and 12 mos postinfarct. Composite T scores were generated for global cognition and well as independent cognitive domains at each time point. Paired t tests compared changes in scores over time. Regression models identified factors associated with improvement.
Results
The percentage of patients scoring at or above the normative mean increases over time, indicating recovery, but varies by cognitive domain and remains low for many domains.
Patterns of recovery are distinct for individual cognitive domains for patients with minor stroke.
Stroke severity and rehabilitation influence trajectory. Premorbid baseline predicts long-term outcome.
Girgenti, Sophia G. BS; Brunson, Autumn O. BS; Marsh, Elisabeth B. MD. Baseline Function and Rehabilitation Are as Important as Stroke Severity as Long-term Predictors of Cognitive Performance Post-stroke. American Journal of Physical Medicine & Rehabilitation 102(2S):p S43-S50, February 2023. | DOI: 10.1097/PHM.0000000000002125
{2022}
Multi-Domain Cognitive Dysfunction After Minor Stroke Suggests Generalized Disruption of Cognitive Networks
Cognitive impairment across multiple domains is common at 1-month following a minor stroke, regardless of location in the brain. These results suggest there is some sort of global cognitive network that is disrupted by a minor stroke.
Elisabeth B. Marsh, Sheena Khan, Rafael H. Llinas, Keenan A. Walker, Jason Brandt. Multi-domain cognitive dysfunction after minor stroke suggests generalized disruption of cognitive networks. Brain and Behavior 2022; DOI:10.1002/brb3.2571
Bilaterally Reduced Rolandic Beta Band Activity in Minor Stroke Patients
Bilateral reduced rolandic beta band activity was found in minor stroke patients without severe weakness, further illustrating global network disruption post-stroke regardless of lesion location. Findings of global connectivity dysfunction affecting sensorimotor cortex despite small lesions far from sensorimotor areas also suggest rolandic beta band activity may be a potential biomarker and treatment target.
Kulasingham J, Brodbeck C, Khan S, Marsh EB, Simon JZ. Bilaterally reduced rolandic beta band activity in minor stroke patients. Front Neurol, 28 March 2022 | https://doi.org/10.3389/fneur.2022.819603
{2020}
Post-Stroke Acute Dysexecutive Syndrome: A Disorder Resulting from Minor Stroke due to Disruption of Network Dynamics
Cerebral activation patterns for stroke patients during a word-picture matching task one month post-stroke were compared to a group of age-matched controls and found decreased amplitude and temporal dispersion in the areas of the brain that are responsible for visual word processing. These results demonstrate that disruption of network dynamics may be responsible for difficulty with attention and concentration after stroke. These differences persisted 6 months after infarct, though clinical exams continued to improve.
Elisabeth B. Marsh, Christian Brodbeck, Rafael H. Llinas, Dania Mallick, Joshua P. Kulasingham, Jonathan Z. Simon, Rodolfo R. Llinas. Proceedings of the National Academy of Sciences Dec 2020, 202013231; DOI: 10.1073/pnas.2013231117
Identifying Delirium Early after Stroke: A New Prediction Tool for the Intensive Care Unit
Delirium is common, affecting an estimated 10-48% of patients admitted to the hospital after stroke. We found that age greater than 64 years, presence of IVH, intubation, stroke with cognitive dysfunction, aphasia, or neglect, and presence of AKI were most strongly associated, and created a tool to predict the risk of delirium following stroke. Identifying factors early can help predict the risk of delirium and improve outcomes.
Haight TN, Marsh EB. Identifying Delirium Early After Stroke: A new prediction tool for the intensive care unit. Journal of Stroke and Cerebrovascular Diseases, 2020;29(11):105219.
Early Post-stroke Cognition: In-Hospital Predictors and the Association with Functional Outcome
Post-stroke cognitive dysfunction can significantly impact transitioning back to a “normal life”, especially in the initial months of stroke recovery. The study confirmed that cognitive impairment is common, even in those with minor stroke, and is associated with follow-up functional status. Fortunately, we are able to predict patients at greatest risk using factors available during acute hospitalization. Individuals not actively working prior to their hospitalization, presenting with NIHSS scores higher than 6, and left-sided infarcts are at the highest risk for poor cognitive outcomes and should be identified for targeted rehabilitation to improve long-term outcomes.
Sharma, R., Mallick, D., Llinas, R. H., & Marsh, E. B. (2020). Early Post-stroke Cognition: In-hospital Predictors and the Association With Functional Outcome. Frontiers in neurology, 11, 613607. https://doi.org/10.3389/fneur.2020.613607
The Post-Pipeline Headache: New Headaches Following Flow Diversion For Intracranial Aneurysm
Flow diversion using devices such as the “pipeline” stent is now a common treatment for unruptured intracranial aneurysms. Symptoms can remit over time; however, two-thirds experience ongoing headaches, particularly those with associated migrainous features.
Gweh, D., Khan, S., Pelletier, L., Tariq, N., Llinas, R. H., Caplan, J., & Marsh, E. B. The Post-Pipeline Headache: New Headaches Following Flow Diversion for Intracranial Aneurysm. Journal of Vascular and Interventional Neurology, 2020, 11(1), 34.
Resource Allocation: Stable Patients Remain Stable 12-24 Hours Post-tPAA
New onset of neurologic deterioration is rare 12-24 hours after treatment of acute stroke. Stable patients with low NIHSS scores and no ICU needs may not require intensive monitoring greater than 12 hours post-treatment.
Khan, S., Soto, A., & Marsh, E. B. Resource Allocation: Stable Patients Remain Stable 12–24 h Post-tPA. Neurocritical care, 2020 Oct;33(2):582-586. doi: 10.1007/s12028-019-00889-z
{2019}
A Therapeutic International Normalized Ratio Results in Smaller Infarcts And Better Outcomes For Patients With Ischemic Stroke
Stroke size and severity is significantly reduced in patients with ischemic strokes who present therapeutic on warfarin. The greater volume of brain saved may ultimately lead to better functional recovery.
Merbach, D., Lawrence, E., Mallick, D., & Marsh, E. B. A Therapeutic International Normalized Ratio Results in Smaller Infarcts and Better Outcomes for Patients with Ischemic Stroke. Journal of Stroke and Cerebrovascular Diseases, 2019, 28(10), 104278.
{2018}
Shorter Intensive Care Unit Stays? The Majority Of Post-Intravenous tPA Symptomatic Hemorrhages Occur Within 12 Hours Of Treatment
Symptomatic Intracerebral hemorrhages associated with the administration of intravenous tPA typically occurs within the first 12 hours of treatment. Longer monitoring in an intensive care unit-like setting may be unnecessary for most individuals.
Chang, A., Llinas, E. J., Chen, K., Llinas, R. H., & Marsh, E. B. Shorter intensive care unit stays? The majority of post-intravenous tPA (Tissue-Type plasminogen activator) symptomatic hemorrhages occur within 12 hours of treatment. Stroke, 2018, 49(6), 1521-1524.
Cerebral Microbleeds Shouldn’t Dictate Treatment Of Acute Stroke: A Retrospective Cohort Study Evaluating Risk of Intracerebral Hemorrhage
Intravenous tissue plasminogen activator (IV tPA) after acute ischemic stroke carries the risk of symptomatic intracerebral hemorrhage (sICH). A high cerebral microbleed burden (>10) in ischemic stroke patients treated with IV tPA are associated with a higher risk of sICH. However, the overall rate of sICH in the presence of CMB is very low, indicating that the presence of CMBs by itself should not dictate the decision to treat with thrombolytics.
Chacon-Portillo, M. A., Llinas, R. H., & Marsh, E. B. Cerebral microbleeds shouldn’t dictate treatment of acute stroke: a retrospective cohort study evaluating risk of intracerebral hemorrhage. BMC neurology, 2018, 18(1), 33.
Collaterals Predict Outcome Regardless Of Time Last Known Normal
Recent studies suggest that patients with large vessel ischemic strokes with favorable imaging may be treated outside the standard 6-hour window. When imaging is favorable, regardless of time last known well, follow-up outcomes (NIHSS and mRS) are comparable and appear to be driven most significantly by the presence of collaterals. This acts as evidence for the use of imaging to guide decision making in individuals who do not meet classic criteria for intervention.
Sharma R, Llinas R, Urrutia V, *Marsh EB. Collaterals predict outcome regardless of time last known normal. Journal of Stroke and Cerebrovascular Diseases, 2018;27(4):971-977.
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Chronic Post-Stroke Fatigue: It May No Longer Be About the Stroke Itself
Early Post-Stroke Fatigue (PSF) is shown to be linked to stroke severity (using NIHSS and mRS scores), while chronic PSF is driven by medical co-morbidities and medication use. This is clinically important as continued fatigue 6 months post-stroke may be reflective of other factors.
Chen, K., & Marsh, E. B. (2018). Chronic Post-Stroke Fatigue: It May No Longer Be About the Stroke Itself. Clinical Neurology and Neurosurgery. doi:10.1016./j.clineuro.2018.09.027.
Pre-stroke employment results in better patient-reported outcomes after minor stroke
Prior occupational status may represent an important prognostic indicator for patients with minor stroke. Individuals working at the time of their infarct report better functional outcomes irrespective of age or stroke severity.
Marsh EB, Lawrence E, Hillis AE, Chen K, Gottesman RF, Llinas RH. Pre-stroke employment results in better patient-reported outcomes after minor stroke. Clinical Neurology and Neurosurgery 2018;165:38-42.
{2016}
The NIH Stroke Scale Has Limited Utility in Accurate Daily Monitoring of Neurologic Status
The NIHSS has many advantages; however, it may miss functional changes when used in place of a comprehensive neurological examination to measure improvement post-stroke.
Marsh EB, Lawrence E, Gottesman RF, Llinas RH. The NIH stroke scale has limited utility in accurate daily monitoring of neurologic status. Neurohospitalist 2016;6(3):97-101.
