Disability after stroke

Recent years have seen the emergence of successful treatment strategies for ischemic stroke, but these are most effective only when initiated within several hours after stroke onset. Therefore, extremely rapid diagnosis and initiation of treatment are critical in avoiding death or severe disability. 

In the acute group, in which the hypothermia was initiated at KM-2 h after stroke, the clinical outcome varied depending on the time of hypothermia initiation. A patient who underwent the therapy beginning at 10 h after stroke became completely independent. Another patient who underwent the therapy at 24 h after stroke had a moderate right hemiparesis, but was able to walk with a cane. The remaining patient who underwent the therapy at 42 h after stroke became disabled and died in the chronic phase. Thus, it seems that the time for initiating hypothermia critically influences the clinical outcome. This supports the view that the hypothermia therapy may be best indicated for hyperacute stroke. 

Some degree of recovery occurs in the majority of patients after stroke, and complete recovery is possible although the prognosis is difficult to predict in an individual patient. Rehabilitation to aid recovery and enable the patient to develop strategies for coping with disability forms the mainstay of treatment after the acute stroke period. 

Neglect is one of the most disabling impairments for patients after stroke. Although individual studies of rehabilitation specifically for neglect have shown benefit, a review of 15 such studies showed no impact on disability or discharge home (Bowen et al 2002). Visuo-spatial-motor training, in which the affected limb is moved to increase attention to that side, has been shown to be effective in a single randomized controlled trial (Kalra et al. 1997). 

Collen EM, Wade DT (1991). Residual mobility problems after stroke. International Disability Studies 13 12-15... 

Collen FM, Wade DT, Bradsbaw CM (1990). Mobility after stroke reliability of measures of impairment and disability. International Disability Studies 12 6-9... 

Nervous system In a study of the usefulness of intrathecal baclofen in severe spastic hemi-paresis after stroke in eight patients, six had functional deterioration and weakening of the paretic side, with walking disability [44 ]. 

Alteplase initiated within 3 hours of symptom onset has been shown to reduce the ultimate disability due to ischemic stroke. A head CT scan must be obtained to rule out hemorrhage before beginning therapy. The patient must also meet specific inclusion criteria and no exclusionary criteria (Table 13-2). The dose is 0.9 mg/kg (maximum 90 mg) infused IV over 1 hour after a bolus of 10% of the total dose given over 1 minute. Anticoagulant and... 

In a much larger survey of 93,399 subjects participating in non-therapeutic research in the United States, 37 subjects were reported to be temporarily disabled and one to be permanently disabled. The latter was due to a stroke occurring 3 days after investigation, and its attributability is unknown. 

A 75 year old man was examined on a routine visit 1 month after being disabled by a stroke. He was very immobile and in bed. He complained of a painful heel, which on examination was inflamed and with a small necrotic centre. A pressure sore was diagnosed and suitable measures taken to manage this. A week later there were further lesions on the other foot but this time on the dorsum of the foot and lower leg. These were not easily explained by pressure necrosis, indeed a closer examination suggested a vasculitis. The cause for this was frusemide which had been prescribed for a mild heart failure apparent at the time of the stroke. It is very easy to accept the obvious without careful examination. 

Recombinant tissue plasminogen activator has increasingly been used for patients presenting with acute stroke symptoms. A recent outcomes study demonstrated an advantage with respect to neurologic disability at 1 year in those patients with acute ischemic stroke who received intravenous t-PA within 3 hours after onset of symptoms. 

Is impaired cerebral vasomotor reactivity a predictive factor of stroke in asymptomatic patients Stroke 27 2188-2190 HaUiday A, Mansfield A, Marro JC for the MRC Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group (2004). Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms randomised controlled trial Lancet 363 1491-1502 Hand PJ, Wardlaw JM, Rivers CS et al. (2006). MR diffusion-weighted imaging and outcome prediction after ischemic stroke. Neurology 66 1159-1163... 

Non-neurological complications after acute stroke are more frequent with increasing age, pre-stroke disability, stroke severity and poor general nursing and other care (Box 20.1). To some extent, the site of the lesion may also be relevant for instance, obstructive and central... 

The mechanisms of recovery are incompletely understood. Acute resolution of edema and recanalization of occluded vessels leading to resolution of penumbral dysfunction may contribute. In the subacute phase, changes in neuronal networks and neuronal plasticity are important (Kreisel et al. 2007 Nudo 2007). The mechanisms share similarities with those involved in learning and memory. The rate of recovery of all impairments is maximal in the first few weeks, slows down after two or three months and probably stops at about 6-12 months post-stroke (Pedersen et al. 1995 Kreisel et al. 2007). Later improvement in functional abilities, and particularly in social activities, is probably more to do with adaptation to disability and minimizing handicap rather than further recovery of physical impairments. Impaired quality of life is common even when patients appear to be Uttle disabled. 

Stroke remains the third most common cause of death in industrialized nations, after myocardial infarction and cancer, and the single most common reason for permanent disability [1], Each year about 780,000 Americans experience a new or recurrent stroke. Approximately 1 in 4 people dies within 1 year after his or her initial stroke. This means that on average, every 40 s someone in the U.S. has a stroke and every 3 min someone in the U.S. dies from a stroke [2]. Moreover, 30-50% of stroke survivors do not regain functional independence, and 15-30% of all stroke survivors are permanently disabled (i.e., not able to walk, talk clearly, or feed themselves with a favored hand). Stroke therefore results in a massive financial and personal burden on our society. Indeed, the estimated direct and indirect cost of stroke for 2008 adds up to approximately 65.5 billion dollars [2]. 

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