Background And Aims

The therapeutic benefits of repetitive transcranial magnetic stimulation along with physical therapy to study the neuroplasticity and neurogenesis in ischemic stroke patients has not been fully elucidated.Therefore, we determined the neuroplasticity using serum growth factors as a surrogate marker, using 1Hz rTMS with conventional physiotherapy in patients with sub acute ischemic stroke.

Methods

In this randomized, double blind, sham controlled study, participants with first ever ischemic stroke (N = 96), onset within 15 days were randomized after a run-in period of 75 ± 7 days along with a standard physical therapy to receive 10 sessions of real 1Hz rTMS (N = 47) or to sham stimulation (N = 49) on contralesional premotor cortex for 2 weeks. Participants, investigators and outcome assessors were blinded. The primary efficacy outcome was change in the level of peripheral serum growth factors VEGF & BDNF at third month. The secondary outcome was measurement of neurophysiological parameters and their correlation with growth factors levels

Results

Modified intention to treat analysis showed significant up regulation in the mean level of serum VEGF & BDNF from pre to post rTMS in Real rTMS Group. Trend of decrease in Resting Motor Threshold and increase in Motor Evoked Potential in the affected hand was seen. Statistically significant negative correlation between motor evoked potential and mean VEGF (rho = -1.000, P<0.001) in the affected hand in Real rTMS Group was seen.

Conclusions

Total ten sessions of 1Hz rTMS with physical therapy on contralateral hemisphere resulted in up regulation of serum growth factors possible reflecting improved neuroplasticity

Trial Registration Number

CTRI/2016/02/006620

Group Name

on behalf of the B-STARS Investigators

Background And Aims

Despite therapies in the acute phase of stroke, many patients are left with long-term impairment of upper limb function. We assessed whether early subacute contralesional transcranial magnetic stimulation (TMS) treatment improves upper limb motor recovery.

Methods

We randomly assigned patients with acute stroke and persistent weakness in the upper limb to ten daily sessions of contralesional continuous theta-burst stimulation (cTBS), a TMS variant, or sham cTBS, in addition to standard rehabilitation therapy. Treatment was started within three weeks after stroke onset. Patients and the assessor of the primary outcome at 90 days were blinded to treatment allocation. Target sample size was 60 patients. Primary outcome is improvement on the action research arm test (ARAT) at 90 (± 14) days with respect to baseline. Improvement on the modified Rankin Scale (MRS) is one of the secondary outcomes. Outcomes will be analyzed using paired t-tests. The trial protocol has been previously published (van Lieshout et al., BMJ Open, 2017).

Results

60 stroke patients were included. One patient withdrew before study interventions, leaving 59 patients for analysis. A participant flow diagram is shown in figure 1. Baseline characteristics are presented in table 1. Follow-up of the last patient at 90 days is planned in May 2021. Main results of the trial will be presented at the Conference.

Conclusions

Results of this largest randomized clinical trial of early subacute contralesional cTBS treatment will provide information on usefulness of this treatment for recovering hemiparetic stroke patients in addition to standard rehabilitation therapy.

Trial Registration Number

NTR6133

Background And Aims

Despite being common and often associated with a poorer outcome, very few successful treatments are available for post-stroke cognitive impairment (PSCI). Using Virtual Reality (VR) to provide cognitive therapy is a relatively new concept. In this trial, we aimed to explore the feasibility and acceptability of VR-based cognitive rehabilitation amongst the patients and staff in the subacute phase after a stroke.

Methods

Adult patients with a Montreal Cognitive Assessment (MoCA) score below 25 following a stroke, were randomised to receive VR (Fig1: a custom-made software was created) or sham-VR based cognitive rehabilitation therapy along with usual care. Their outcome was assessed at the end of the treatment and at three months using MoCA by a blinded assessor. The three months assessment of the last few participants is still continuing until June 2021. Participants were interviewed at the end of their treatment for acceptability using a structured questionnaire.

Fig 1: A snapshot of VIRTUE kitchen module

Results

Forty patients with a MoCA score of 11+8 (mean+SD) were randomised within 10+7 days from their stroke onset. Compared to the controls, those with a severe cognitive impairment (MoCA<15) had a significant improvement in their MoCA score at the end of the treatment, with the VR based cognitive rehabilitation (fig 2). The VR-based treatment was acceptable to the participants, with only a few adverse reactions reported.

Fig 2: Change in the MoCA score

Conclusions

VR-based cognitive rehabilitation is feasible and acceptable in PSCI. It also tends to have a positive effect on those with severe cognitive impairment.

Trial Registration Number

ISRCTN16608742

Group Name

On behalf of the James Lind Alliance Priority Setting Partnership for Stroke Steering Group

Background And Aims

We currently do not have research priorities, as identified by people affected by stroke and healthcare workers. The Stroke Association (UK) led a Priority Setting Partnership using the James Lind Alliance methodology. Here we announce the novel priorities for rehabilitation and long-term care.

Methods

A Steering Group comprising of people affected by stroke and representatives from UK stroke healthcare professional bodies and charities developed the protocol. A first survey collected researchable questions from people affected by stroke and professionals. Unique unanswered questions were developed through de-duplicating, combining and checking against existing evidence. Questions were then categorised according to the stroke care pathway into second prioritisation surveys. Workshops with professionals and people affected by stroke will develop the final research priorities.

Results

Almost 4000 questions were collected from over 1400 respondents (41% from professionals; 46% people affected). 47 unique unanswered questions were included in the rehabilitation and long-term care prioritisation survey, which had 960 responses, resulting in 18 questions for the final workshop. The prioritised Top 10 questions will be presented. The process had good representation from professional and people affected, however we had fewer responses from some Black and Asian ethnic communities.

Conclusions

The Top 10 priorities in stroke rehabilitation and long-term care will reflect the needs and priorities of professionals and people affected by stroke who will benefit from future stroke research. Stroke research is underfunded so it's vital additional funds are directed towards these priorities.

We acknowledge members of the Steering group and all participants.

Trial Registration Number

Not applicable

Group Name

On behalf of ISIS-HERMES group

Background And Aims

Motor hand deficits impact autonomy in everyday life and neuroplasticity processes of motor recovery can be explored using resting-state functional MRI (rs-fMRI) connectivity. Based on the Milner and Goodale model positing that a dorsal circuit from the visual cortex via the posterior parietal to premotor and motor regions control hand movements, we explored the relationship between occipital-parietal-sensorimotor connectivity and hand recovery following stroke using rs-fMRI.

Methods

We used two datasets. Dataset-I (HERMES, CHUGA) included 23 patients (aged 53 ± 9.32 years, 17 males) with moderate-severe stroke (NIHSS ≥ 7). To validate our results, we used a second dataset from another hospital (IRMAS, Hôpital Pitié-Salpêtrière). Dataset-II included 54 patients (aged 58.59 ± 14.6 years, 32 males) with mild-severe stroke (NIHSS ≥ 1). All patients underwent 3D-T1 and resting state (14 minutes) sequences on a 3T MRI one month post-stroke, and handgrip strength assessment at one (M0) and six months (M6) post-stroke. We performed an ROI-to-ROI connectivity analysis using Conn Toolbox (https://web.conn-toolbox.org/).

Results

In dataset-I, handgrip performances at one and six month correlated with increased connectivity between occipital and sensorimotor (BA4a, BA2, BA6) and superior parietal cortices, and between contralesional and ipsilesional sensorimotor cortices (Figure). A similar pattern was found for dataset-II, with additional occipital connections to the supplementary motor area, insula, inferior parietal lobule, and parietal operculum.

Conclusions

This study revealed that hand motor recovery is associated with increased occipital-sensorimotor connectivity, supporting our hypothesis. The influence of visual inputs on motor performance could be useful in hand rehabilitation following stroke.

Trial Registration Number

Not applicable

Background And Aims

Recovery of memory function after stroke is variable. In some patients, memory impairment becomes a cornerstone of post-stroke dementia but in up to a third of patients, significant improvement occurs in the year following stroke. The factors and mechanisms that explain heterogeneity of prognosis remain poorly understood. This study investigated brain structural factors that predict change in memory scores after stroke.

Methods

A sample of 51 patients from STRATEGIC, a longitudinal study of cognition after ischaemic stroke, underwent cognitive assessment and research MRI at baseline and follow-up cognitive assessment at 1 year. Measures of white matter microstructure – across the whole white matter and in the tractography-defined fornix – hippocampal subfield grey matter volumes and volume of the cholinergic basal forebrain were extracted at baseline and correlated with change in scores for episodic and verbal working memory. Demographic, risk factors and lesion characteristics were also evaluated as predictors of change in memory scores.

Results

No associations were found with demographic, risk factor or lesion variables. In a whole brain analysis, associations with change in memory scores were found primarily in the fornix (Figure). Baseline volumes of hippocampal subfields also correlated with improvement in free recall. Interestingly, similar associations were found for measures of working memory (Digit Span backwards).

Conclusions

Recovery of memory function correlates with baseline integrity of the core hippocampal network for memory. Individual variation in these structures due to early neurodegeneration and co-morbidity is a likely factor in poor recovery in individual patients.

Trial Registration Number

NCT03982147

Group Name

On behalf of the QASC Europe Steering and Implementation Committees

Background And Aims

Assisted implementation of protocols to manage fever, hyperglycaemia (sugar) and swallowing (FeSS) following stroke significantly reduce 90-day death and disability. An international collaboration between the Nursing Research Institute, Australian Catholic University; European Stroke Organisation; Angels Initiative; and Registry of Stroke Care Quality facilitated nurse-initiated FeSS protocols into stroke units in multiple European countries. We present results on FeSS protocol compliance during the four-year QASC Europe Project.

Methods

Our multi-country, multi-centre, pre-test/post-test study was conducted between 2017-2021. Data were provided at baseline and three months after FeSS protocol implementation. Nursing clinical champions, with support from the Project team (European Liaison Officer, Angels Consultants, Country Coordinators and the Nursing Research Institute) conducted multidisciplinary workshops identifying barriers and facilitators to protocol implementation, and held education sessions. Outcomes were adjusted for clustering by country and hospital controlling for age/sex/NIHSS.

Results

Data from 76 hospitals (18 countries) were received for 4196 patients at baseline, and from 64 hospitals (17 countries) for 3348 patients’ post-implementation (Total n=7544). There were improvements in: temperature monitoring on day of admission (Pre:42.7%; Post:78.5%, p<0.00001); treatment of fever >37.5°C with paracetamol within one hour (Pre:56.8%; Post:79.0%, p<0.00001); blood glucose monitoring on day of admission (Pre:37.5%; Post:74.7%, p<0.00001); treatment of hyperglycemia >10mmol/L with insulin within one hour (Pre:59.0%; Post:75.4%, p<0.00001); and swallow screening before food or fluids (Pre:59.1%; Post:82.7%, p<0.00001).

Conclusions

We achieved successful large-scale implementation of the FeSS protocols into countries with different health care systems, many of which have no access to reperfusion therapies. This will reduce death and disability post-stroke.

Trial Registration Number

Not applicable