An article By Todd Neale, Senior Staff Writer for MedPage Today
Published: May 16, 2013
Reviewed by F. Perry Wilson, MD, MSCE; Instructor of Medicine, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner

Depression appears to be a risk factor for stroke among middle-age women, even after accounting for other variables, an Australian study showed.

Among women in their late 40s and early 50s who were followed for up to 12 years, meeting criteria for depression was associated with more than double the likelihood of having a stroke (OR 2.41, 95% CI 1.78-3.27), according to Caroline Jackson, PhD, and Gita Mishra, PhD, of the University of Queensland in Australia.

The relationship was partly explained by age, socioeconomic status, lifestyle, and physiological factors, but remained statistically significant after adjustment for those variables (OR 1.94, 95% CI 1.37- 2.74), they reported online in Stroke: Journal of the American Heart Association.

“Our findings contribute to the currently limited evidence on potential age differences in the association between depression and stroke, and suggest that the effect of depression may be even stronger in younger women,” they wrote.

“Further research investigating age differences within the same cohort is needed, since the identification of such differences will have important implications for policy and practice,” they continued. “In particular, this will inform the development of effective targeted prevention and intervention approaches.”

Depression has been associated with a greater stroke risk in prior studies, but there is some evidence pointing to differences by age.

To explore the issue in middle-age women, the researchers turned to the Australian Longitudinal Study on Women’s Health. The analysis included 10,547 stroke-free women ages 47 to 52 who were surveyed every 3 years from 1998 to 2010.

At each survey, depression was assessed using the Center for Epidemiological Studies Depression scale shortened version and an inquiry about whether the women were using antidepressants. The researchers classified women as having depression if they reported taking an antidepressant in the previous 4 weeks or they scored 10 or higher on the depression scale.

At each time point, roughly one-quarter of the women had depression. During follow-up, 177 had a first stroke.

The association between depression and stroke remained significant after adjustment for several factors, including age, socioeconomic status, hypertension, diabetes, heart disease, hysterectomy/oophorectomy, smoking, alcohol use, physical activity, and body mass index, and in sensitivity analyses using different definitions of depression.

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MRIs Reveal Signs of Brain Injuries Not Seen in CT Scans, Posted on: May 7, 2013 by Advance

Hospital MRIs may be better at predicting long-term outcomes for people with mild traumatic brain injuries than CT scans, the standard technique for evaluating such injuries in the emergency room, according to a clinical trial led by researchers at the University of California, San Francisco (UCSF) and the San Francisco General Hospital and Trauma Center (SFGH).

Published in the journal Annals of Neurology, the study was led by UCSF neuroradiologist Esther Yuh, MD, PhD and followed 135 people treated for mild traumatic brain injuries over the past two years at one of three urban hospitals with level-one trauma centers: SFGH, the University of Pittsburgh Medical Center and University Medical Center Brackenridge in Austin, Texas as part of a study called NIH-funded TRACK-TBI (Transforming Research and Clinical Knowledge in Traumatic Brain Injury).

All 135 patients with mild traumatic brain injuries received CT scans when they were first admitted, and all were given MRIs about a week later. Most of them (99) had no detectable signs of injury on a CT scan, but more than a quarter (27/99) who had a “normal” CT scans also had detectable spots on their MRI scans called “focal lesions,” which are signs of microscopic bleeding in the brain.

Spotting these focal lesions helped the doctors predict whether the patients were likely to suffer persistent neurological problems. About 15% of people who have mild traumatic brain injuries do suffer long-term neurological consequences, but doctors currently have no definitive way of predicting whether any one patient will or not.

“This work raises questions of how we’re currently managing patients via CT scan,” said senior author on the study Geoff Manley, MD, PhD, the chief of neurosurgery at SFGH and vice-chair of the Department of Neurological Surgery at UCSF. “Having a normal CT scan doesn’t, in fact, say you’re normal,” he added.

The problem, Manley said, is that there is no way to tell which patients are going to have the poor long-term outcomes. Some socioeconomic indicators can help predict prolonged disability, but until now there have been no proven imaging features, or blood tests for predicting how well or how fast a patient will recover. Nor is there a consensus on how to treat mild traumatic brain injuries.

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Findings Published in Restorative Neurology and Neuroscience
In a study designed to differentiate why some stroke patients recover from aphasia and others do not, investigators have found that a compensatory reorganization of language function to right hemispheric brain regions bodes poorly for language recovery. Patients who recovered from aphasia showed a return to normal left-hemispheric language activation patterns. These results, which may open up new rehabilitation strategies, are available in the current issue of Restorative Neurology and Neuroscience.

“Overall, approximately 30% of patients with stroke suffer from various types of aphasia, with this deficit most common in stroke with left middle cerebral artery territory damage. Some of the affected patients recover to a certain degree in the months and years following the stroke. The recovery process is modulated by several known factors, but the degree of the contribution of brain areas unaffected by stroke to the recovery process is less clear,” says lead investigator Jerzy P. Szaflarski, MD, PhD, of the Departments of Neurology at the University of Alabama and University of Cincinnati Academic Health Center.

For the study, 27 right-handed adults who suffered from a left middle cerebral artery infarction at least one year prior to study enrollment were recruited. After language testing, 9 subjects were considered to have normal language ability while 18 were considered aphasic. Patients underwent a battery of language tests as well as a semantic decision/tone decision cognitive task during functional MRI (fMRI) in order to map language function. MRI scans were used to determine stroke volume.

The authors found that linguistic performance was better in those who had stronger left-hemispheric fMRI signals while performance was worse in those who had stronger signal-shifts to the right hemisphere. As expected, they also found a negative association between the size of the stroke and performance on some linguistic tests. Right cerebellar activation was also linked to better post-stroke language ability.

The authors say that while a shift to the non-dominant right hemisphere can restore language function in children who have experienced left-hemispheric injury or stroke, for adults such a shift may impede recovery. For adults, it is the left hemisphere that is necessary for language function preservation and/or recovery.

Read, print or email the complete article by clicking on Aphasia .

Temple researchers are creating a virtual therapist for people with aphasia.

Temple researchers are developing a virtual speech therapist that could someday help people with aphasia by providing a more accessible and cost-effective tool for the repetition and practice exercises that are crucial to recovery.

The two-year study, which is being conducted by Temple’s Nadine Martin, professor of communication sciences; Emily Keshner, professor and chair of physical therapy; and Justin Shi, associate professor of computer science; along with Alex Rudnicky, professor of computer science at Carnegie Mellon University, is supported by a new $275,000 R21 NIH grant.

Currently, economics and the structure of the health care system limit the number of speech therapy sessions people with aphasia can undergo. After the sessions expire, they’re sent home with scripts to practice on their own or with a family member. While therapy doesn’t cure aphasia, it does improve language abilities — generally, those who stay stimulated through practice, therapy and feedback will continue to improve.

It’s the last part — feedback — that’s missing from simply practicing at home on one’s own, says Keshner. Without it, people with aphasia are likely to continue to make the same mistakes over and over again. A speech therapist, and someday a virtual clinician, can help the person catch and correct the mistakes.

Feedback has also not yet been perfected in the virtual world. Current computer-based speech therapy programs are built on rigid scripts. They’re unable to respond to patient mistakes, and there’s no allowance for disordered speech. If a patient uses the wrong word or makes an unfamiliar sound, the computer gets confused.

“That’s the real stumbling block — speech recognition,” said Martin. “We want to develop a virtual clinician that can be more flexible. We are developing scripts, but we’re incorporating possible utterances that the system will have to recognize. How far can we take that? That’s the big challenge for us.”

Another goal of the project is to determine how people with aphasia will respond to a virtual vs. a real therapist. This is where Shi and graduate assistant Greg Teodoro come in. They are creating different versions of the avatar for the virtual therapist — according to gender, ethnicity and even voice texture — that they will test using what is called the “Wizard of Oz” technique. As in the movie, a real person will be stationed behind a curtain and will respond to, in this case, a patient, who is interacting with the avatar of the virtual therapist.

“Ultimately, we’ll be able to program a virtual therapist to creatively respond to almost anything a patient says,” said Keshner. More specifically, she explains, the computer will be able to select content from what the patient says, restructure it and bring it back to the client who can then figure out what to say next.

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Stroke survivors struggle with emotional impact, report finds – Social care professionals play a crucial role in ensuring that people get support
Article by Emma Nye for Guardian Professional, on May 1st,2013 05.25 EDT

New study from the Stroke Association found that a large proportion of stroke survivors suffer feelings of depression.

Anyone who works with stroke survivors will know that, while the physical effects are obvious, they’re not the whole story. Feeling overwhelmed, the latest research report for the Stroke Assoication, surveyed more than 2,700 survivors. It found that the emotional impact of stroke can be just as devastating as the physical effects.

The full emotional impact often only becomes clear when people return home from hospital: stroke survivors often don’t know where to turn. One told us: “Many of the emotional issues arrive not at the time of stroke, when all you are doing is trying to get well again physically. But it’s months later, at home, when the reality hits you that you’ll never be the person you once were.”

Information, practical advice and emotional support is vital to helping stroke survivors and carers manage their everyday lives better. People who responded to our survey reported high rates of anxiety (67%) and feelings of depression (59%). Almost three-quarters said they felt less confident after their stroke and 40% felt abandoned to cope with their feelings and fears alone after leaving hospital.

Without early identification and solution, emotional issues can develop into more serious psychological problems. Depression increases the risk of cardiovascular disease by one and a half times compared with the general population. So stroke survivors with depression are more likely to have another stroke. Yet the majority of post-discharge care concentrates on physical rehabilitation.

This is not just an issue for stroke survivors; there are huge implications for carers too. More than half people caring for stroke victims are stressed, and it gets harder the longer they are caring. When the stroke survivor’s condition changes, they may be facing their own health problems, but by that time health and social care services have tailed off. Carers are both physically and mentally exhausted, with six in ten not getting enough sleep. We found that levels of anxiety and feelings of depression are as high for carers as they are for stroke survivors.

Stroke can also destabilise relationships. A third of survivors said they had broken up with their partner or considered doing so. Some carers tell us they feel they have brought a different person home than the one they took to hospital.

So what needs to change? Many of the tools to address this are already in place, they just aren’t being used. The National Stroke Strategy recommends all stroke survivors should have regular reviews of their health and social care needs, and that this should include an assessment of their emotional wellbeing. But the Stroke Association’s Struggling to Recover report last year showed only 39% of survivors in England were offered it. Carers are also entitled to a needs assessment that covers their psychological wellbeing, but many are unaware of this; only a quarter knew where to get an assessment.

Social care professionals play a crucial role ensuring people don’t have to struggle alone. The Stroke Association provides services to stroke survivors and in some parts of the country we are in regular contact with those back in the community, but better co-ordination between health and social care partners to meet emotional needs will make a real difference.

We can signpost those in need to key sources of support such as stroke services, clubs and groups. We have a UK-wide stroke helpline which is resourced to provide information to professionals as well as stroke survivors and carers.

Some brilliant work is being done to support survivors and carers with the emotional impact of a stroke. One great example is the multi-disciplinary team in the north-west, where clinical psychologists work alongside stroke co-ordinators in a stepped care model. Together they identify and solve emotional and psychological problems, both in the hospital and out in the community.

The emotional needs of stroke survivors must be acknowledged and addressed and adequate support put in place. Working together we can enable many more survivors and carers achieve a better life.

Read, print or share this article by going to theGUARDIAN

An implantable loop recorder established new diagnoses of atrial fibrillation in 25% of patients with cryptogenic stroke.
(Definition: A stroke which cannot be attributed to any specific cause after an extensive search for the most common causes, such as cardiac and other emboli, large or small artery thrombi or atherosclerosis.)

One third of ischemic strokes remain cryptogenic even after thorough inpatient evaluation. Numerous studies suggest that some of these patients may have paroxysmal atrial fibrillation (AF) that remains undiagnosed during their stroke hospitalization. Failing to detect these cases of AF may result in suboptimal antithrombotic therapy. However, what type and duration of cardiac monitoring should be used to rule out subclinical AF remain unclear.

To address this question, investigators placed implantable loop recorders (ILRs) in 51 patients who had received standard stroke evaluations, including vascular imaging, echocardiography (transthoracic in all patients and transesophageal in 30), and at least 24 hours of Holter monitoring without evidence of AF. The ILR software automatically detected AF episodes 2 minutes in duration. Two cardiologists independently reviewed any AF episodes detected by ILRs.

ILRs were implanted an average of 174 days after stroke. In 13 patients (25.5%), AF was detected after a median 48 (range, 0–154) days of monitoring. The other patients remained AF-free throughout an average 229 days of monitoring. AF was associated with older age, more-frequent premature atrial contractions during baseline Holter monitoring, and larger left atrial size.

Comment: In the recently completed EMBRACE trial, 15% of cryptogenic stroke patients assigned to 30-day external loop recorder monitoring received new diagnoses of atrial fibrillation, versus 3% of patients assigned to 24-hour outpatient Holter monitoring. It is possible but unlikely that some of these poststroke episodes of AF are incidental, because subclinical AF lasting only a few minutes has recently been shown to increase stroke risk, and the majority of cryptogenic strokes appear radiographically to have resulted from cardiac embolism. On these bases, several weeks of noninvasive cardiac monitoring should usually be performed in patients with cryptogenic stroke. The current study results suggest that longer periods of monitoring might detect even more cases of AF. However, relatively invasive and expensive implantable loop recorders cannot be routinely recommended until we see the results of the ongoing CRYSTAL-AF trial, which is comparing use of ILRs to routine clinical follow-up in patients with cryptogenic stroke.

— Hooman Kamel, MD

Read more about these Embrace – Clinical Trial and
Crystal – Clinical Trial

Dr. Brian Levine, CSR Baycrest Site Leader, describes how Baycrest has pioneered Goal Management Training (GMT), a very effective way to help people with white matter disease or covert stroke to improve decision making and planning skills. Deirdre Breton, a survivor of covert stroke, talks about how GMT helps her remain active and focused. Click Here

Read Moreabout GMT.

MINNEAPOLIS – The teenage years may be a key period of vulnerability related to living in the “stroke belt” when it comes to future stroke risk, according to a new study published in the April 24, 2013, online issue of Neurology®, the medical journal of the American Academy of Neurology.

More people have strokes and die of strokes in the southeastern area known as the stroke belt than in the rest of the United States. So far, research has shown that only part of the difference can be explained by traditional risk factors such as diabetes and high blood pressure. Previous studies have shown that people who are born in the stroke belt but no longer lived there in adulthood continue to have a higher risk of stroke, along with people who were born outside the stroke belt but lived there in adulthood.

The current study looked at how long people lived in the stroke belt and their ages when they lived there throughout life to see if any age period was most critical in influencing future stroke risk.

Data came from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study, a national random sample of the general population with more people selected from the stroke belt. The study involved 24,544 people with an average age of 65 who had never had a stroke at the start of the study, with 57 percent currently living in the stroke belt and 43 percent from the rest of the country. The study tracked each person’s moves from birth to present, with some people moving into or out of the stroke belt. The participants were then followed for an average of 5.8 years. During that time, 615 people had a first stroke.

After adjusting for stroke risk factors, only living in the stroke belt during the teenage years was associated with a higher risk of stroke. People who spent their teenage years in the stroke belt were 17 percent more likely to have a stroke in later years than people who did not spend their teenage years in the stroke belt. Across all age periods, living in the stroke belt increased the risk about two-fold for African-Americans compared to Caucasians.

“This study suggests that strategies to prevent stroke need to start early in life,” said study author Virginia J. Howard, PhD, of the School of Public Health, University of Alabama at Birmingham and a member of the American Academy of Neurology. “Many social and behavioral risk factors, such as smoking, are set in place during the teenage years, and teens are more exposed to external influences and gain the knowledge to challenge or reaffirm their childhood habits and lifestyle.”

The study was supported by the National Institute of Neurological Disorders and Stroke and the National Institute on Aging. Read More

New Device Can Quickly Spot A Stroke, An Article posted on MARCH 7, 2013 BY CHRIS | for Stroke Foundation

A pair of goggles that measures eye movement has been used in a recent study to correctly diagnose a stroke in under one minute. The study will be published in April’s issue of the journal ‘Stroke’.

The lead author of the study stated that this is the first study to accurately diagnose if a patient has a stroke or not.
Misdiagnosis of stroke is a huge issue worldwide. Around 100,000 strokes are misdiagnosed every year in U.S., which results over 20,000 deaths or severe physical and speech impairments.

Speed is the key to treating stroke and could be the difference between life and death. Magnetic resonance imaging (MRI) is currently the best procedure to assess stroke, but this can take up to 6 hours with costs over $1,000.

Sometimes patients are sent home without an MRI to assess if they have had a stroke. The patient could of had a mini stroke which is then followed by a life threatening stroke. Around 4% of dizziness cases in the emergency room are caused by stroke.

The study only involved 12 patients, so it is impossible for a small study to prove 100% accurate. The device has been in use for a year in Europe, but has not yet been approved in U.S. for diagnosing a stroke. The U.S. Food and Drug Administration has only approved it for use in assessing balance.

The device which is known as a video-oculography machine, is a modification of a “head impulse test” which is used for patients with constant chronic dizziness and other inner ear-balance disorders.

This device would be a huge boost for otolaryngologists as they are unable see everybody due to the large amount of patients and emergency room physicians can’t be easily trained to develop expertise in eye movement interpretation. This would mean more patients getting diagnosed correctly and much faster.

The test involves the patient wearing a pair of goggles which has a webcam and is processed with special software. The patient is asked to focus on one particular spot on the wall while the doctor moves the patient’s head from side to side.
Normally our balance system in our ears keeps our eyes stable when our head is moving. For patients with vertigo, the test is nearly always abnormal. Stroke patients, even though they have the same dizziness symptoms, don’t have this impairment.

The test in the study was 100% accurate when compared with MRI, which assessed 6 patients with a stroke and 6 who didn’t.

The lead author of the study suggests the test could be also incorporated into a smartphone application.

Read original article by clicking on Stroke Foundation.

An article posted in Science Daily

Jan. 31, 2013 — A study led by King’s College London has identified a new genetic variant associated with stroke. By exploring the genetic variants linked with blood clotting — a process that can lead to a stroke — scientists have discovered a gene which is associated with large vessel and cardioembolic stroke but has no connection to small vessel stroke.

Published in the journal Annals of Neurology, the study provides a potential new target for treatment and highlights genetic differences between different types of stroke, demonstrating the need for tailored treatments.

Approximately 152,000 people in Britain have a stroke each year, costing the UK over £8.2 billion. While there are thought to be 1.2 million stroke survivors in the UK, more than half have been left with disabilities that affect their daily lives.

A stroke occurs when the blood supply to the brain is cut off, often due to a blood clot blocking an artery that carries blood to the brain, which then leads to brain cell damage. Coagulation (blood clotting) abnormalities, particularly easy clotting of the blood, are therefore common contributing factors in the development of stroke.

Dr Frances Williams, Senior Lecturer from the Department of Twin Research and Genetic Epidemiology at King’s and lead author of the paper, said: ‘Previous studies have demonstrated the influence of genetic factors on the components of coagulation. The goal of this study was to extend these observations to determine if they were further associated with different types of stroke.’

The research was carried out in three stages. The first consisted of a genome-wide association study (GWAS) in 2100 healthy volunteers which identified 23 independent genetic variants that were involved in coagulation. The second stage examined the 23 variants in 4200 stroke and non-stroke cases from centres across Europe (Wellcome Trust Case Control Consortium 2 and MORGAM collections) and found that a particular mutation on the ABO gene was significantly associated with stroke.

Stage three of the study used the MetaStroke cohort, a project of the International Stroke Genetics Consortium which comprises 8900 stroke cases recruited from centres in the Europe, USA and Australia, whose DNA has been collected and undergone GWA scan. It was confirmed that a variant in the ABO blood type gene was associated with stroke, a finding specific to large vessel and cardioembolic stroke.

Dr Williams said: ‘The discovery of the association between this genetic variant and stroke identifies a new target for potential treatments, which could help to reduce the risk of stroke in the future. It is also significant that no association was found with small vessel disease, as this suggests that stroke subtypes involve different genetic mechanisms which emphasises the need for individualised treatment.’ Read, print and email this original article by clicking on Science Daily.