Stroke Current Awareness Bulletin September 2019

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Cochrane Systematic Reviews

New Reviews – June 2019

Marine‐derived n‐3 fatty acids therapy for stroke

Journal Articles:

Title: Action observation therapy for improving arm function, walking ability, and daily activity performance after stroke: a systematic review and meta-analysis.

Citation: Clinical rehabilitation; Aug 2019; vol. 33 (no. 8); p. 1277-1285 Author(s): Peng, Tzu-Hsuan; Zhu, Jun-Ding; Chen, Chih-Chi; Tai, Ruei-Yi; Lee, Chia-Yi; Hsieh, Yu-Wei

Objective: This study was to investigate the effectiveness of action observation therapy on arm and hand motor function, walking ability, gait performance, and activities of daily living in stroke patients.

Design: Systematic review and meta-analysis of randomized controlled trials.

Data Sources: Searches were completed in January 2019 from electronic databases, including PubMed, Scopus, the Cochrane Library, and OTseeker.

Review Methods: Two independent reviewers performed data extraction and evaluated the study quality by the PEDro scale. The pooled effect sizes on different aspects of outcome measures were calculated. Subgroup analyses were performed to examine the impact of stroke phases on treatment efficacy.

Results: Included were 17 articles with 600 patients. Compared with control treatments, the action observation therapy had a moderate effect size on arm and hand motor outcomes (Hedge's g = 0.564; P 

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acute IE as the causative mechanism. We then performed a systematic review of reports of acute ischemic reperfusion therapy in IE since 1995 for their success rates in terms of neurological outcome, and mortality, and their risk of hemorrhagic complication.

Results: In the retrospective portion, 8 participants met criteria, of whom 4 received IVT and 4 received EVT. Through systematic review, 24 publications of 32 participants met criteria. Combined, a total of 40 participants were analyzed: 18 received IVT alone, 1 received combined IVT plus EVT, and 21 received EVT alone. IVT compared to EVT were similar in rates of good neurologic outcomes (58% versus 76%, P= .22) and mortality (21% versus 19%, P= .87), but had higher post-therapy intracranial hemorrhage (63% versus 18% [P=.006]).

Conclusion: IV thrombolysis has a higher rate of post-therapy intracranial hemorrhage compared to EVT. EVT should be considered as first-line AIS therapy for patients with known, or suspected, IE who present with a large vessel occlusion.

Title: Assessment of Condition and Medication Knowledge Gaps Among Atrial Fibrillation Patients: A Systematic Review and Meta-analysis.

Citation: The Annals of pharmacotherapy; Aug 2019; vol. 53 (no. 8); p. 773-785 Author(s): Salmasi, Shahrzad; De Vera, Mary A; Barry, Arden; Bansback, Nick; Harrison, Mark; Lynd, Larry D; Loewen, Peter S Background: Patient education facilitates construction of a correct illness representation, improves beliefs about medications, and improves knowledge, factors that have been associated with better adherence.

Objective: Our objective was to characterize the published literature about atrial fibrillation (AF) patients' disease and medication knowledge to identify knowledge gaps and misconceptions to inform AF patient education strategies.

Methods: Following PRISMA guidelines, we searched PubMed, EMBASE, CINAHL, and PsychINFO from inception to May 2018 for studies that assessed AF patients' knowledge about their condition and medications. For quantitative studies, we extracted the proportion of participants who provided correct answers to the questions asked about their condition, medications, or risk of stroke. We classified data for related questions into knowledge domains. A random-effects meta-analysis was conducted for each knowledge domain. A domain was considered a knowledge gap if the pooled mean proportion of participants who demonstrated knowledge of it was ≤50%, regardless of CI. Qualitative data were summarized narratively.

Results: A total of 21 studies were included. AF- and stroke-related knowledge gaps and misconceptions included the following: AF can be asymptomatic, AF can predispose to heart failure, women are at a higher risk of stroke, the definition of ischemic stroke, and patients' awareness of their diagnosis. Medication-related knowledge gaps were antithrombotic-drug interactions, antithrombotic-food interactions, vitamin K content of foods, the term INR (international normalized ratio) and its interpretation, and the required actions in case of a missed dose.

Conclusion and Relevance: This systematic review identified several AF patient knowledge gaps about their condition and its treatment that can inform the development of AF patient education programs.

Title: Association Between Cystatin C and the Risk of Ischemic Stroke: a Systematic Review and Meta-analysis.

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Citation: Journal of molecular neuroscience : MN; Jul 2019 Author(s): Wang, Yan; Li, Wei; Yang, Jun; Zhang, Mijuan; Tian, Chun'e; Ma, Minjiang; Zhang, Qian Abstract: Ischemic stroke is a disease that affects people's health and quality of life. Cystatin C has been found as a new biomarker of cardiovascular disease. We performed this meta-analysis to assess the relationship between cystatin C and the risk of ischemic stroke. The studies on looking at the association between cystatin C and ischemic stroke were identified from inception to November 18, 2018. We performed a random-effects meta-analysis using mean difference. Nine studies with a total of 3773 ischemic stroke patients were included into the meta-analysis. Our results showed that patients with ischemic stroke had significantly higher serum cystatin C concentrations compared with the participants without ischemic stroke (pooled mean difference, 0.11; 95% confidence interval (CI), 0.00-0.22; P = 0.04), in particular acute ischemic stroke and subclinical cerebral infarction (mean difference, 0.23; 95% CI, 0.11-0.36; P = 0.0003 and mean difference, 0.07; 95% CI, 0.05-0.09; P < 0.00001, respectively). Cystatin C was associated with ischemic stroke, and it could be considered a predictor for the risk of ischemic stroke, especially in acute ischemic stroke and subclinical cerebral infarction.

Title: Effect of Standard vs Intensive Blood Pressure Control on the Risk of Recurrent Stroke: A Randomized Clinical Trial and Meta-analysis.

Citation: JAMA neurology; Jul 2019 Author(s): Kitagawa, Kazuo; Yamamoto, Yasumasa; Arima, Hisatomi; Maeda, Toshiki; Sunami, Norio; Kanzawa, Takao; Eguchi, Kazuo; Kamiyama, Kenji; Minematsu, Kazuo; Ueda, Shinichiro; Rakugi, Hiromi; Ohya, Yusuke; Kohro, Takahide; Yonemoto, Koji; Okada, Yasushi; Higaki, Jitsuo; Tanahashi, Norio; Kimura, Genjiro; Umemura, Satoshi; Matsumoto, Masayasu; Shimamoto, Kazuaki; Ito, Sadayoshi; Saruta, Takao; Shimada, Kazuyuki; Recurrent Stroke Prevention Clinical Outcome (RESPECT) Study Group Abstract: Importance The Systolic Blood Pressure Intervention Trial (SPRINT) demonstrated that a systolic blood pressure (BP) target less than 120 mm Hg was superior to less than 140 mm Hg for preventing vascular events. This trial excluded patients with prior stroke; therefore, the ideal BP target for secondary stroke prevention remains unknown.

Objective: To assess whether intensive BP control would achieve fewer recurrent strokes vs standard BP control.

Design, Setting, and Participants: Randomized clinical trial (RCT) of standard vs intensive BP control in an intent-to-treat population of patients who had a history of stroke. Patients were enrolled between October 20, 2010, and December 7, 2016. For an updated meta-analysis, PubMed and the Cochrane Central Library database were searched through September 30, 2018, using the Medical Subject Headings and relevant search terms for cerebrovascular disease and for intensive BP lowering. This was a multicenter trial that included 140 hospitals in Japan; 1514 patients who had a history of stroke within the previous 3 years were approached, but 234 refused to give informed consent. InterventionsIn total, 1280 patients were randomized 1:1 to BP control to less than 140/90 mm Hg (standard treatment) (n = 640) or to less than 120/80 mm Hg (intensive treatment) (n = 640). However, 17 patients never received intervention; therefore, 1263 patients assigned to standard treatment (n = 630) or intensive treatment (n = 633) were analyzed.

Main Outcomes and Measures: The primary outcome was stroke recurrence.

Results: The trial was stopped early. Among 1263 analyzed patients (mean [SD] age, 67.2 [8.8] years; 69.4% male), 1257 of 1263 (99.5%) completed a mean (SD) of 3.9 (1.5) years of follow-up. The mean BP at baseline was 145.4/83.6 mm Hg. Throughout the overall follow-

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up period, the mean BP was 133.2/77.7 (95% CI, 132.5-133.8/77.1-78.4) mm Hg in the standard group and 126.7/77.4 (95% CI, 125.9-127.2/73.8-75.0) mm Hg in the intensive group. Ninety-one first recurrent strokes occurred. Nonsignificant rate reductions were seen for recurrent stroke in the intensive group compared with the standard group (hazard ratio [HR], 0.73; 95% CI, 0.49-1.11; P = .15). When this finding was pooled in 3 previous relevant RCTs in a meta-analysis, the risk ratio favored intensive BP control (relative risk, 0.78; 95% CI, 0.64-0.96; P = .02; absolute risk difference, -1.5%; 95% CI, -2.6% to -0.4%; number needed to treat, 67; 95% CI, 39-250).

Conclusions and Relevance: Intensive BP lowering tended to reduce stroke recurrence. The updated meta-analysis supports a target BP less than 130/80 mm Hg in secondary stroke prevention.Trial RegistrationClinicalTrials.gov identifier: NCT01198496.

Title: Effectiveness of Botulinum Toxin Treatment for Upper Limb Spasticity Poststroke Over Different ICF Domains: A Systematic Review and Meta-Analysis.

Citation: Archives of Physical Medicine & Rehabilitation; Sep 2019; vol. 100 (no. 9); p. 1703-1725 Author(s): Andringa, Aukje; van de Port, Ingrid; van Wegen, Erwin; Ket, Johannes; Meskers, Carel; Kwakkel, Gert Abstract: To provide a comprehensive overview of reported effects and scientific robustness of botulinum toxin (BoNT) treatment regarding the main clinical goals related to poststroke upper limb spasticity, using the International Classification of Functioning, Disability and Health. Embase, PubMed, Wiley/Cochrane Library, and Ebsco/CINAHL were searched from inception up to May 16, 2018. We included randomized controlled trials comparing upper limb BoNT injections with a control intervention in patients with a history of stroke. A total of 1212 unique records were screened by 2 independent reviewers. Forty trials were identified, including 2718 patients with history of stroke. Outcome data were pooled according to assessment timing (ie, 4-8wk and 12wk after injection), and categorized into 6 main clinical goals (ie, spasticity-related pain, involuntary movements, passive joint motion, care ability, arm and hand use, and standing and walking performance). Sensitivity analyses were performed for the influence of study and intervention characteristics, involvement of pharmaceutical industry, and publication bias. Robust evidence is shown for the effectiveness of BoNT in reducing resistance to passive movement, as measured with the (Modified) Ashworth Score, and improving self-care ability for the affected hand and arm after intervention (P

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Author(s): Yang, Jheng-Dao; Liao, Chun-De; Huang, Shih-Wei; Tam, Ka-Wai; Liou, Tsan-Hon; Lee, Yu-Hao; Lin, Chia-Yun; Chen, Hung-Chou Objective: The aim of this study is to investigate the effectiveness of electrical stimulation in arm function recovery after stroke.

Methods: Data were obtained from the PubMed, Cochrane Library, Embase, and Scopus databases from their inception until 12 January 2019. Only randomized controlled trials (RCTs) reporting the effects of electrical stimulation on the recovery of arm function after stroke were selected.

Results: Forty-eight RCTs with a total of 1712 patients were included in the analysis. The body function assessment, Upper-Extremity Fugl-Meyer Assessment, indicated more favorable outcomes in the electrical stimulation group than in the placebo group immediately after treatment (23 RCTs (n = 794): standard mean difference (SMD) = 0.67, 95% confidence interval (CI) = 0.51-0.84) and at follow-up (12 RCTs (n = 391): SMD = 0.66, 95% CI = 0.35-0.97). The activity assessment, Action Research Arm Test, revealed superior outcomes in the electrical stimulation group than those in the placebo group immediately after treatment (10 RCTs (n = 411): SMD = 0.70, 95% CI = 0.39-1.02) and at follow-up (8 RCTs (n = 289): SMD = 0.93, 95% CI = 0.34-1.52). Other activity assessments, including Wolf Motor Function Test, Box and Block Test, and Motor Activity Log, also revealed superior outcomes in the electrical stimulation group than those in the placebo group. Comparisons between three types of electrical stimulation (sensory, cyclic, and electromyography-triggered electrical stimulation) groups revealed no significant differences in the body function and activity.

Conclusion: Electrical stimulation therapy can effectively improve the arm function in stroke patients.

Title: Effectiveness of High-Intensity Interval Training for Fitness and Mobility Post Stroke: A Systematic Review.

Citation: PM & R : the journal of injury, function, and rehabilitation; Aug 2019; vol. 11 (no. 8); p. 868-878 Author(s): Wiener, Joshua; McIntyre, Amanda; Janssen, Scott; Chow, Jeffrey Ty; Batey, Cristina; Teasell, Robert Objective: To evaluate the evidence on the effectiveness of high-intensity interval training (HIIT) in improving fitness and mobility post stroke. TYPE: Systematic review.

Literature Survey: Medline, Embase, CINAHL, PsycINFO, and Scopus were searched for articles published in English up to January 2018.

Methodology: Studies were included if the sample was adult human participants with stroke, the sample size was ≥3, and participants received >1 session of HIIT. Study and participant characteristics, treatment protocols, and results were extracted.

Synthesis: Six studies with a total of 140 participants met inclusion criteria: three randomized controlled trials and three pre-post studies. HIIT protocols ranged 20 to 30 minutes per session, 2 to 5 times per week, and 2 to 8 weeks in total. HIIT was delivered on a treadmill in five studies and a stationary bicycle in one study. Regarding fitness measures, HIIT produced significant improvements in peak oxygen consumption compared to baseline, but the effect was not significant compared to moderate intensity continuous exercise (MICE). Regarding mobility measures, HIIT produced significant improvements on the 10-Meter Walk Test (10MWT), 6-Minute Walk Test (6MWT), Berg Balance Scale (BBS), Functional Ambulation Categories (FAC), Timed Up and Go Test, and Rivermead Motor Assessment compared to baseline. The effect of HIIT was significant compared to MICE on the 10MWT and FAC but not on the 6MWT or BBS.

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Conclusions: There is preliminary evidence that HIIT may be an effective rehabilitation intervention for improving some aspects of cardiorespiratory fitness and mobility post stroke.

Title: Exercise programs delivered according to guidelines improve mobility in people with stroke: A Systematic Review and meta-analysis.

Citation: Archives of physical medicine and rehabilitation; Aug 2019 Author(s): Pogrebnoy, Dina; Dennett, Amy Objective: To determine if prescribing a combined aerobic and resistance training exercise program in accordance with American Stroke Association physical activity guidelines improves mobility and physical activity levels of people after stroke.

Data Sources: Online database search from earliest available date to August 27, 2018.

Study Selection: Randomized controlled trials evaluating the effectiveness of exercise programs prescribed in accordance with guidelines for improving mobility and physical activity levels in adults with sub-acute or chronic stroke.

Data Extraction: Two independent reviewers completed data extraction. Risk of bias was assessed using the Physiotherapy Evidence Database Scale and overall quality of evidence was assessed using the Grades of Research, Assessment, Development and Evaluation approach.

Data Synthesis: Data was pulled from a total of 499 participants for meta-analysis. There was high-level evidence that exercise programs adhering to guidelines improve habitual walking speed (Mean Difference 0.07m/s, 95% CI -0.01 to 0.16) and walking endurance (Mean Difference 39.2 meters, 95% CI 17.2 to 61.2). A sensitivity analysis demonstrated high level evidence of improvements in walking endurance (Mean Difference 51.1 meters, 95% CI 19.96 to 82.24) and moderate-level evidence of improvements on the timed up and go test (Standardized Mean Difference 0.57, 95% CI 0.16 to 0.99). No differences were detected for other mobility outcome measures or physical activity levels. Adherence was high and few adverse events were reported.

Conclusion: A combined exercise program comprising aerobic and resistance training that adheres to the American Stroke Association guidelines, is safe, and should be prescribed in addition to usual care to improve mobility. Further research is needed to understand the relationship between exercise programs and behavior change requirements to improve long term physical activity levels.

Title: Factors associated with delayed presentation at the emergency department in patients with acute ischemic stroke. Citation: Brain Injury; Aug 2019; vol. 33 (no. 9); p. 1257-1261 Author(s): Dimitriou, Panagiotis; Tziomalos, Konstantinos; Christou, Konstantinos; Kostaki, Stavroula; Angelopoulou, Stella-Maria; Papagianni, Marianthi; Ztriva, Eleftheria; Chatzopoulos, Georgios; Savopoulos, Christos; Hatzitolios, Apostolos I.

Background and Aims: Pre-hospital delay is a crucial factor that determines the eligibility for intravenous thrombolysis in patients with acute ischemic stroke. We aimed to evaluate the time to presentation at the emergency department (ED) and the factors that affect this time.

Patients and Methods: We prospectively studied 682 patients who were admitted with acute ischemic stroke (43.3% men, age 79.9 ± 6.6 years).

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Results: The median time to presentation at the ED was 2.1 h (range 0.15 to 168 h); 68.8% of the patients arrived within 4.5 h and 56.5% arrived within 3 h from the onset of symptoms. Independent predictors of presentation within 4.5 h were the use of emergency medical services (EMS) for transportation to the hospital (OR 2.61, 95% CI 1.38–4.94, p =.003), family history of cardiovascular disease (CVD)(OR 4.0 0,95%CI 1.61–12.23, p =.006) and the absence of history of smoking (OR 2.49, 95% CI 1.13–5.42, p =.021). Independent predictors of presentation within 3 h were the use of EMS for transportation to the hospital (OR 6.24, 95% CI 2.52–16.63, p =.0001), family history of CVD (OR 3.07, 95% CI 1.14–9.43, p =.03), and a moderately severe stroke at admission (OR vs. minor stroke 0.38, 95% CI 0.16–0.87, p =.02).

Conclusions: A considerable proportion of patients with acute ischemic stroke arrives at the ED after the 4.5-h threshold for performing intravenous thrombolysis. Non-smokers, patients with a family history of CVD, with moderately severe stroke and those who use the EMS are more likely to arrive on time.

Title: How to perform mirror therapy after stroke? Evidence from a meta-analysis.

Citation: Restorative neurology and neuroscience; Aug 2019 Author(s): Morkisch, Nadine; Thieme, Holm; Dohle, Christian

Background: A recently updated Cochrane review for mirror therapy (MT) showed a high level of evidence in the treatment of hemiparesis after stroke. However, the therapeutic protocols used in the individual studies showed significant variability.

Objective: A secondary meta-analysis was performed to detect which parameters of these protocols may influence the effect of MT for upper limb paresis after stroke.

Methods: Trials included in the Cochrane review, which published data for motor function / impairment of the upper limb, were subjected to this analysis. Trials or trial arms that used MT as group therapy or combined it with electrical or magnetic stimulation were excluded. The analysis focused on the parameters mirror size, uni- or bilateral movement execution, and type of exercise. Data were pooled by calculating the total weighted standardized mean difference and the 95% confidence interval.

Results: Overall, 32 trials were included. The use of a large mirror compared to a small mirror showed a higher effect on motor function. Movements executed unilaterally showed a higher effect on motor function than a bilateral execution. MT exercises including manipulation of objects showed a minor effect on motor function compared to movements excluding the manipulation of objects. None of the subgroup differences reached statistical significance.

Conclusions: The results of this analysis suggest that the effects on both motor function and impairment of the affected upper limb depend on the therapy protocol. They furthermore indicate that a large mirror, unilateral movement execution and exercises without objects may be parameters that enhance the effects of MT for improving motor function after stroke.

Title: Hyponatremia Is Associated With Increased The Mortality In Patients With Acute Stroke: A Systematic Review And Meta-Analysis

Citation: Atherosclerosis; Aug 2019; vol. 287 Author(s): Barkas F.; Klouras E.; Liontos A.; Megapanou E.; Liamis G.; Milionis H.

Background and Aims: Hyponatremia is a common electrolyte abnormality which is associated with increased mortality both in hospitalized patients and in the community. Low serum sodium levels are frequently found in patients with acute stroke and could adversely

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affect their prognosis. We aimed to assess available data regarding the mortality risk associated with hypontatremia in patients with acute stroke

Methods: We conducted a meta-analysis of prospective and retrospective trials investigating the impact of hyponatremia on the mortality of patients diagnosed with acute ischemic or hemorrhagic stroke.

Result(s): Nine eligible cohorts (n=20,826) were identified up to November 2018. The pooled analysis showed a significant increase by 71% of all stroke mortality in patients with hyponatremia (risk ratio, RR 1.71, 95%CI 1.37-2.14, p

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Methods: MEDLINE and EMBASE were searched for studies that investigated the association between LA echocardiographic parameters measured by transthoracic echocardiography and cardiovascular outcomes in patients with or without AF. Data were independently abstracted by two reviewers and pooled using random-effects meta-analysis. The primary outcome was incident stroke or thromboembolic events. Secondary outcomes were heart failure, all-cause mortality and major adverse cardiac events (MACE).

Results: Twenty-three studies of patients with AF (14 939 patients) and 68 studies of patients without AF (50 720 patients) in this systematic review. Increasing LA diameter was significantly associated with stroke and thromboembolic events in patients without AF (risk ratio (RR) 1.38, 95% CI 1.02 to 1.87; p=0.03), but not in patients with AF (RR 1.02, 95% CI 0.98 to 1.07; p=0.27; p for difference=0.05). Increasing LA diameter index was significantly associated with MACE in patients with AF (RR 1.13, 95% CI 1.09 to 1.17; p

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needed to address chronic cognitive and mood symptoms affecting the quality of life of persons with stroke.

Title: Measures used to assess impact of providing care among informal caregivers of persons with stroke, spinal cord injury, or amputation: a systematic review

Citation: Disability and rehabilitation; Jul 2019 ; p. 1-27 Author(s): Scholten E.W.M.; Hillebregt C.F.; Ketelaar M.; Visser-Meily J.M.A.; Post M.W.M. Purpose: (1) To identify measures used to evaluate the impact of caregiving among caregivers of persons with stroke, spinal cord injury, and amputation; and (2) to systematically evaluate their clinimetric properties reported in validation studies.

Material(s) and Method(s): Two separate systematic reviews (Embase, PsycINFO, CINAHL, Pubmed/Medline) were conducted. COSMIN guidelines were used to assess clinimetric properties and methodological quality of studies.

Result(s): (1) 154 studies published between 2008 and May 2019 were included, in which 48 measures were used, mostly describing negative impact. Thirty measures were used only once and not further described. (2) In general, structural validity, internal consistency, and hypothesis testing were often investigated. Reliability, cross-cultural and criterion validity to a lesser extent, and scale development and content validity were rarely described. Tests of measurement error and responsiveness were exceptional. Most supporting evidence was found for the Zarit Burden Interview Short Form, Caregiver Burden Scale and Positive Aspects of Caregiving Questionnaire.

Conclusion(s): There is a wide variety of impact of caregiving measures. The present study provided a detailed overview of what is known about clinimetric characteristics of 18 different measures repeatedly used in research. The overview provides clinicians a guidance of appropriate measure selection. PROSPERO registration: CRD42018094796 IMPLICATIONS FOR REHABILITATION Clinicians should be aware that information about measure development and clinimetric properties for most measures used to assess impact of informal caregiving is incomplete. Most supporting evidence was found for the Zarit Burden Interview Short Form, Caregiver Burden Scale and Positive Aspects of Caregiving Questionnaire. This overview of clinimetric properties provides clinicians guidance for selection of an appropriate measure.

Title: Medical Mobile Applications for Stroke Survivors and Caregivers.

Citation: Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association; Aug 2019 ; p. 104318 Author(s): Piran, Pirouz; Thomas, Jinu; Kunnakkat, Saroj; Pandey, Abhishek; Gilles, Nadege; Weingast, Sarah; Burton, Dee; Balucani, Clotilde; Levine, Steven R; Mobile Applications for Stroke (MAPPS) Investigators Background: Recent studies estimate nearly half of the US population can access mobile medical applications (apps) on their smartphones. The are no systematic data available on apps focused on stroke survivors/caregivers.

Objective: To identify apps (a) designed for stroke survivors/caregivers, (b) dealing with a modifiable stroke risk factor (SRF), or (c) were developed for other purposes but could potentially be used by stroke survivors/caregivers.

Methods: A systematic review of the medical apps in the US Apple iTunes store was conducted between August 2013 and January 2016 using 18 predefined inclusion/exclusion

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criteria. SRFs considered were: diabetes, hypertension, smoking, obesity, atrial fibrillation, and dyslipidemia.

Results: Out of 30,132 medical apps available, 843 (2.7%) eligible apps were identified. Of these apps, (n = 74, 8.7%) apps were specifically designed for stroke survivors/caregivers use and provided the following services: language/speech therapy (n = 28, 37%), communication with aphasic patients (n = 19, 25%), stroke risk calculation (n = 11, 14%), assistance in spotting an acute stroke (n = 8, 10%), detection of atrial fibrillation (n = 3, 4%), direction to nearby emergency room (n = 3, 4%), physical rehabilitation (n = 3, 4%), direction to the nearest certified stroke center (n = 1, < 2%), and visual attention therapy (n = 1,

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Title: Nuanced effects of music interventions on rehabilitation outcomes after stroke: a systematic review. Citation: Topics in stroke rehabilitation; Sep 2019; vol. 26 (no. 6); p. 473-484 Author(s): Le Perf, Gaël; Donguy, Anne-Lise; Thebault, Guillaume Background: Music is affordable and easily integrated in rehabilitation exercises, and has demonstrated different effects on the brain. We hypothesized that music interventions could improve rehabilitation outcomes after stroke.

Objective: the aim of our review is to determine the effectiveness of different types of music interventions according to the rehabilitation objectives after stroke.

Method: A systematic review of randomized controlled trials, clinical controlled trials and cross-over design performed on PubMed and PEDro in May 2018. All of these studies focus on acute, sub-acute or chronic stroke rehabilitation with music or rhythmic auditory stimulation intervention in adults during clinical outcomes. Two independent reviewers extracted the data and assessed the risk of bias before bringing it together.

Results: Twenty-seven studies were included and analyzed. Our review found positive effects on physical status (upper-limb activity; gait parameters, balance), on cognition (neglect, attention, communication) and mood. The analysis of the quality of the evidence showed that a majority of the studies had a high risk of bias.

Conclusion: Focusing on high to moderate level evidence, our review highlighted that rhythmic auditory stimulation has a positive effect on gait and balance; that receptive music therapy improves mood as well as some cognitive functions; that there is not enough evidence to determine the effectiveness of active music therapy and melodic intonation therapy. High-quality trials with large samples would be necessary to further assess and/or recommend these interventions.

Title: Nut consumption and incidence of cardiovascular diseases and cardiovascular disease mortality: a meta-analysis of prospective cohort studies

Citation: Nutrition reviews; Jul 2019 Author(s): Becerra-Tomas N.; Paz-Graniel I.; Salas-Salvado J.; W C Kendall C.; Sievenpiper J.L.; Kahleova H.; Rahelic D. Context: Previous meta-analyses evaluating the association between nut consumption and the risk of cardiovascular disease (CVD) had substantial methodological limitations and lacked recently published large prospective studies; hence, making an updated meta-analysis highly desirable.

Objective(s): To update the clinical guidelines for nutrition therapy in relation to the European Association for the Study of Diabetes (EASD), a systematic review and meta-analysis of prospective studies was conducted using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to summarize the evidence of the association between total nuts, specific types of nuts, and the incidence of, and mortality from, CVD outcomes.

Data Sources: Relevant articles were identified by searching the PubMed and Cochrane databases.

Data Extraction: Two independent researchers screened the articles to identify those that met the inclusion criteria.

Data Analysis: The inverse variance method with fixed-effect or random-effects models was used to pool data across studies (expressed as risk ratio [RR] and 95% confidence interval

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[CI]). Heterogeneity was tested and quantified using the Cochrane Q test and I2-statistic, respectively. The GRADE system was used to assess the quality of the evidence.

Result(s): Nineteen studies were included in the analyses. The results revealed an inverse association between total nut consumption (comparing highest vs lowest categories) and CVD incidence (RR, 0.85; 95%CI, 0.800.91; I2,0%), CVD mortality (RR, 0.77; 95%CI, 0.72-0.82; I2,3%), coronary heart disease (CHD) incidence (RR, 0.82; 95%CI, 0.69-0.96; I2,74%), CHD mortality (RR, 0.76; 95%CI, 0.67-0.86; I2,46%), stroke mortality (RR, 0.83; 95%CI, 0.75-0.93; I2,0%), and atrial fibrillation (RR, 0.85; 95%CI, 0.73-0.99; I2,0%). No association was observed with stroke incidence and heart failure. The certainty of the evidence ranged from moderate to very low.

Conclusion(s): This systematic review and meta-analysis revealed a beneficial role of nut consumption in reducing the incidence of, and mortality from, different CVD outcomes.Copyright © The Author(s) 2019. Published by Oxford University Press on behalf of the International Life Sciences Institute. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Title: Perfusion CT for prediction of hemorrhagic transformation in acute ischemic stroke: a systematic review and meta-analysis.

Citation: European radiology; Aug 2019; vol. 29 (no. 8); p. 4077-4087 Author(s): Suh, Chong Hyun; Jung, Seung Chai; Cho, Se Jin; Kim, Donghyun; Lee, Jung Bin; Woo, Dong-Cheol; Oh, Woo Yong; Lee, Jong Gu; Kim, Kyung Won Objective: To investigate the diagnostic performance of perfusion CT for prediction of hemorrhagic transformation in acute ischemic stroke.

Methods: A computerized literature search of Ovid MEDLINE and EMBASE was conducted up to October 29, 2018. Search terms included acute ischemic stroke, hemorrhagic transformation, and perfusion CT. Studies assessing the diagnostic performance of perfusion CT for prediction of hemorrhagic transformation in acute ischemic stroke were included. Two reviewers independently evaluated the eligibility of the studies. A bivariate random effects model was used to calculate the pooled sensitivity and pooled specificity. Multiple subgroup analyses were performed.

Results: Fifteen original articles with a total of 1134 patients were included. High blood-brain barrier permeability and hypoperfusion status derived from perfusion CT are associated with hemorrhagic transformation. The pooled sensitivity and specificity were 84% (95% CI, 71-91%) and 74% (95% CI, 67-81%), respectively. The area under the hierarchical summary receiver operating characteristic curve was 0.84 (95% CI, 0.81-0.87). The Higgins I2 statistic demonstrated that heterogeneity was present in the sensitivity (I2 = 80.21%) and specificity (I2 = 85.94%).

Conclusion: Although various perfusion CT parameters have been used across studies, the current evidence supports the use of perfusion CT to predict hemorrhagic transformation in acute ischemic stroke.

Key Points: • High blood-brain barrier permeability and hypoperfusion status derived from perfusion CT were associated with hemorrhagic transformation. • Perfusion CT has moderate diagnostic performance for the prediction of hemorrhagic transformation in acute ischemic stroke. • The pooled sensitivity was 84%, and the pooled specificity was 74%.

mailto:journals.permissions@oup.com

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Title: Recurrence Risk in Patients with Cryptogenic Stroke, Patent Foramen Ovale, and Thrombophilia: A Systematic Review and Meta-Analysis. Citation: Thrombosis and haemostasis; Aug 2019 Author(s): Hviid, Claus V B; Simonsen, Claus Ziegler; Hvas, Anne-Mette Objective: A patent foramen ovale (PFO) is frequently associated with cryptogenic stroke in the young. Endovascular closure is superior to antithrombotic treatment in prevention of recurrence, but in the presence of a concomitant thrombophilia, the best preventive strategy is unknown. This review investigates if thrombophilia increases the risk of recurrence in patients with cryptogenic stroke and PFO and attempts to evaluate the best antithrombotic strategy after PFO closure in these patients.

Methods: Medline, Embase, and Web of Science were searched until April 2018. Study quality was assessed by the National Heart, Lung and Blood Institute Quality assessment tool. Odds ratio (OR) and hazard ratio for recurrence were pooled in a random effect model stratified by secondary preventive strategy.

Results: Eleven studies were included. Inherited or acquired thrombophilia was associated with an increased risk of recurrence (OR = 2.41, 95% confidence interval [CI]: 1.44-4.06). Looking only at patients treated with PFO closure, the risk of recurrence just lost significance (OR = 2.07, 95% CI: 0.95-4.48). The antithrombotic treatment after PFO closure was heterogeneous and recurrent events occurred in patients with both inherited and acquired thrombophilia treated by antiplatelet as well as anticoagulant therapy.

Conclusion: Thrombophilia is associated with an increased risk of recurrence in patients with PFO and cryptogenic stroke, which may persist after PFO closure. This suggests a need for antithrombotic therapy after PFO closure. Study heterogeneity precludes strong conclusions on antithrombotic treatment, but life-long antiplatelet therapy to patients without preexisting indication for anticoagulant therapy seems reasonable.

Title: Repetitive transcranial magnetic stimulation on motor recovery for patients with stroke: A PRISMA compliant systematic review and meta-analysis

Citation: American journal of physical medicine & rehabilitation; Jul 2019 Author(s): He Y.; Li K.; Chen Q.; Bai D.; Yin J. Objective: A systematic review and meta-analysis were conducted to determine the efficacy of repetitive transcranial magnetic stimulation (rTMS) in recovering motor function in patients with stroke.

Design: A comprehensive literature search was performed to identify studies published before September 20, 2018. Electronic databases were searched. Standard mean differences (SMD) and 95% confidence intervals (CI) were used to evaluate the effects of rTMS. The stability and sensitivity of the results and sources of heterogeneity were also analyzed. The Cochrane Risk of Bias Tool was used to determine the quality of the studies.

Result(s): Twenty randomized controlled trials (n=841 patients) were included. The results showed that rTMS is beneficial to patients with post-stroke hemiplegia, as demonstrated by four scales: the Fugl-Meyer Assessment (SMD=0.635, 95% CI: 0.421-0.848); grip strength (SMD=1.147; 95% CI: 0.761-1.534); Barthel Index (SMD=0.580; 95% CI: 0.377-0.783); and National Institutes of Health Stroke Scale (SMD=-0.555; 95% CI: -0.813--0.298). Few adverse events were observed.

Conclusion(s): The analysis showed that low-frequency rTMS has a positive effect on grip strength and lower limb function as assessed by FMA.

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Title: Sex Differences in Long-Term Quality of Life Among Survivors After Stroke in the INSTRUCT.

Citation: Stroke; Aug 2019 ; p. STROKEAHA118024437 Author(s): Phan, Hoang T; Blizzard, Christopher L; Reeves, Mathew J; Thrift, Amanda G; Cadilhac, Dominique A; Sturm, Jonathan; Heeley, Emma; Otahal, Petr; Rothwell, Peter; Anderson, Craig S; Parmar, Priya; Krishnamurthi, Rita; Barker-Collo, Suzanne; Feigin, Valery; Gall, Seana Background and Purpose: Women are reported to have poorer health-related quality of life (HRQoL) after stroke than men, but the underlying reasons are uncertain. We investigated factors contributing to the sex differences.

Methods: Individual participant data on 4288 first-ever strokes (1996-2013) were obtained from 4 high-quality population-based incidence studies from Australasia and Europe. HRQoL utility scores among survivors after stroke (range from negative scores=worse than death to 1=perfect health) were calculated from 3 scales including European Quality of Life-5 Dimensions, Short-Form 6-Dimension, and Assessment of Quality of Life at 1 year (3 studies; n=1210) and 5 years (3 studies; n=1057). Quantile regression was used to estimate the median differences in HRQoL for women compared to men with adjustment for covariates. Study factors included sociodemographics, prestroke dependency, stroke-related factors (eg, stroke severity), comorbidities, and poststroke depression. Study-specific median differences were combined into pooled estimates using random-effect meta-analysis.

Results: Women had lower pooled HRQoL than men (median differenceunadjusted 1 year, - 0.147; 95% CI, -0.258 to -0.036; 5 years, -0.090; 95% CI, -0.119 to -0.062). After adjustment for age, stroke severity, prestroke dependency, and depression, these pooled median differences were attenuated, more greatly at 1 year (-0.067; 95% CI, -0.111 to -0.022) than at 5 years (-0.085; 95% CI, -0.135 to -0.034).

Conclusions: Women consistently exhibited poorer HRQoL after stroke than men. This was partly attributable to women's advanced age, more severe strokes, prestroke dependency, and poststroke depression, suggesting targets to reduce the differences. There was some evidence of residual differences in HRQoL between sexes but they were small and unlikely to be clinically significant.

Title: Sleep-disordered breathing and poststroke outcomes.

Citation: Annals of Neurology; Aug 2019; vol. 86 (no. 2); p. 241-250 Author(s): Lisabeth, Lynda D.; Sánchez, Brisa N.; Lim, David; Chervin, Ronald D.; Case, Erin; Morgenstern, Lewis B.; Tower, Susan; Brown, Devin L. Objective: To examine the association between sleep-disordered breathing and stroke outcomes, and determine the contribution of sleep-disordered breathing to outcome disparities in Mexican Americans.

Methods: Ischemic stroke patients (n = 995), identified from the population-based Brain Attack Surveillance in Corpus Christi Project (2010-2015), were offered participation in a sleep-disordered breathing study including a home sleep apnea test (ApneaLink Plus). Sleep-disordered breathing (respiratory event index ≥10) was determined soon after stroke. Neurologic, functional, cognitive, and quality of life outcomes were assessed at 90 days poststroke. Regression models were used to assess associations between sleep-disordered breathing and outcomes, adjusted for sociodemographics, prestroke function and cognition, health-risk behaviors, stroke severity, and vascular risk factors.

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Results: Median age was 67 years (interquartile range [IQR] = 59-78); 62.1% were Mexican American. Median respiratory event index was 14 (IQR = 6-25); 62.8% had sleep-disordered breathing. Sleep-disordered breathing was associated with worse functional outcome (mean difference in activities of daily living/instrumental activities of daily living score = 0.15, 95% confidence interval [CI] = 0.01-0.28) and cognitive outcome (mean difference in modified Mini-Mental State Examination = -2.66, 95% CI = -4.85 to -0.47) but not neurologic or quality of life outcomes. Sleep-disordered breathing accounted for 9 to 10% of ethnic differences in functional and cognitive outcome and was associated with cognitive outcome more strongly for Mexican Americans (β = - 3.97, 95% CI = -6.63 to -1.31) than non-Hispanic whites (β = -0.40, 95% CI = -4.18 to 3.39, p-interaction = 0.15).

Interpretation: Sleep-disordered breathing is associated with worse functional and cognitive function at 90 days poststroke. These outcomes are reasonable endpoints for future trials of sleep-disordered breathing treatment in stroke. If effective, sleep-disordered breathing treatment may somewhat lessen ethnic stroke outcome disparities. ANN NEUROL 2019;86:241-250.

Title: The experience of occupational identity disruption post stroke: a systematic review and meta-ethnography.

Citation: Disability and rehabilitation; Aug 2019 ; p. 1-12 Author(s): Martin-Saez, Maria M; James, Neil

Purpose: After a stroke, most individuals cannot participate in some of their valued occupations, disrupting their occupational identity. The aim of this interpretive synthesis is to systematically review the existing body of research to develop an understanding of the experience of occupational identity disruption post-stroke.

Methods: A systematic review of the literature that included nine electronic databases, reference lists screening and grey literature checking was completed. Ten studies published between January 2012 and October 2018 were included. Meta-ethnography was used for the interpretive synthesis.

Findings: A three-staged process model was created. Stage 1 illustrates the four factors involved in occupational identity disruption: "A fragmented and externalized body", "losing control, freedom and independence", "changed social and familial interactions", and "occupational participation loss". Stage two explains the experience of occupational identity disruption: "Occupational identity loss", "a de-valued self", and "threat to identity continuity". Stage three shows the individual's coping strategies: "protecting one's self", "social isolation", and "re-inventing one's occupational self".

Conclusions: Stroke impacts on an individual's occupational identity, compromising the continuity of a stroke survivor's sense of self. However, occupational identity is fluid; this can be used to support individuals to re-invent the occupational self. A conceptual model was developed to support the application of these results in clinical practice. Implications for rehabilitation Occupational identity disruption impacts on stroke survivors' self-value and sense of self continuity. Health care professionals' understanding of stroke survivors experience of occupational identity disruption could contribute to realign stroke survivors and clinicians' rehabilitation goals. Occupational participation and social interaction should be core aspects of stroke rehabilitation. Occupation-focus rehabilitation could provide opportunities for stroke survivors to pursue their desired occupational identity.

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