European Stroke Conference

VIENNA – Measuring cognitive function might help determine if an elderly patient is at risk for developing a host of vascular diseases, including stroke and transient ischemic attack, research presented at the annual European Stroke Conference suggested.

The research, which has been accepted for publication in the Journal of Neurology, showed that lower performance in a measure of global cognitive function was associated with a 57% increase in the risk of stroke and a 69% increase in the risk of coronary heart disease (CHD).

“If a person has a poor performance or clinical impairment in cognitive function, it means that the clinician should perhaps be careful because the patient might be at risk of developing diseases such as stroke, [transient ischemic attack], myocardial infarction, and so on,” Somayeh Rostamian, a nurse scientist at Leiden (the Netherlands) University Medical Center, said in an interview.

During her presentation, she explained that it was well known that cardiovascular risk factors and diseases were associated with mild cognitive impairment. Data also have shown that mild cognitive impairment might signal the onset of common age-related neurologic diseases such as dementia.

“We hypothesized that mild cognitive impairment might be an early manifestation of vascular diseases in subjects without clinically recognized disease,” Ms. Rostamian explained, suggesting it could be “the tip of the iceberg.”

To test their hypothesis, the research team first performed a systematic review and meta-analysis (Stroke 2014;45:1342-8) to look at the available evidence on the association between cognitive impairment and stroke risk. The results showed that stroke risk was increased by 15% overall, although individual study estimates ranged from 1% up to 49%.

“We then decided to look at the association between cognitive function, stroke, and coronary heart disease, and to evaluate the association between cognitive function domains and the risk of such diseases,” Ms. Rostamian said.

Data on the cognitive function of 3,926 men and women aged 70-82 years were obtained from the randomized controlled Prospective Study of Pravastatin in the Elderly at Risk (PROSPER). This trial looked at the role of statin therapy in an elderly cohort that had or were at high risk of developing cardiovascular disease and stroke (Lancet 2002;360:1623-30). Results of the trial suggested that statin therapy might reduce the incidence of transient ischemic attacks by up to 25% (P = .051), but it did not reduce the risk for stroke or have an effect on cognitive function.

Nevertheless, the trial provided information on cognitive function that was assessed at enrollment and then annually, which could be used for the current study. Ms. Rostamian noted that the team used data from the Stroop Color and Word test, the Letter Digit Substitution Test, and the picture-word learning test, which evaluate selective attention, processing speed, and immediate and delayed memory, respectively. A composite score for executive function was obtained by combining the results of the Stroop and the Letter Digit Substitution tests, and a composite score for memory was obtained from the picture-word learning test results.

Over a follow-up period of just over 3 years, there were 155 stroke and 375 coronary events, giving incidences of 12.4 and 30.5 per 1,000 person-years, respectively.

After adjusting for multiple confounding factors, patients in the low tertile of cognitive function had the higher risk of both stroke (relative risk, 1.57; P = .010) and CHD (RR, 1.69; P < .001), compared with those in the high-cognitive function tertile who were used as a reference (RR, 1). Patients in the middle tertile also had an increased risk for both diseases (RR, 1.25 and 1.21, respectively).

The results also suggested that deficits in executive function, rather than memory, were predictive of stroke and CHD. So, it might be more important to assess patients’ ability to perform tasks that involve their ability to pay attention or process information.

Indeed, comparing patients in the low-cognitive and high-cognitive tertiles, the risk for stroke was 51% higher (RR, 1.51; P = .042) and the risk for CHD was 85% higher (RR, 1.85; P < .001). In contrast, there was no increased risk linked to memory deficits, with a RR of 0.87 for stroke and 0.99 when comparing patients in the low- and high-cognitive tertiles.

“Impaired executive function, but not memory, was associated with increased risk of cardiovascular diseases and can be considered as an indicator of cardiovascular events. Lower performance in global cognitive function was associated with a higher risk of stroke and coronary heart disease,” Ms. Rostamian summarized.

“Cognitive assessment might provide a tool for clinicians to identify older subjects at an extra risk for future cardiovascular events,” she concluded.

The original trial was supported by an investigator-initiated grant from Bristol-Myers Squibb, USA. Ms. Rostamian had no conflicts.

VIENNA – Measuring cognitive function might help determine if an elderly patient is at risk for developing a host of vascular diseases, including stroke and transient ischemic attack, research presented at the annual European Stroke Conference suggested.

The research, which has been accepted for publication in the Journal of Neurology, showed that lower performance in a measure of global cognitive function was associated with a 57% increase in the risk of stroke and a 69% increase in the risk of coronary heart disease (CHD).

“If a person has a poor performance or clinical impairment in cognitive function, it means that the clinician should perhaps be careful because the patient might be at risk of developing diseases such as stroke, [transient ischemic attack], myocardial infarction, and so on,” Somayeh Rostamian, a nurse scientist at Leiden (the Netherlands) University Medical Center, said in an interview.

During her presentation, she explained that it was well known that cardiovascular risk factors and diseases were associated with mild cognitive impairment. Data also have shown that mild cognitive impairment might signal the onset of common age-related neurologic diseases such as dementia.

“We hypothesized that mild cognitive impairment might be an early manifestation of vascular diseases in subjects without clinically recognized disease,” Ms. Rostamian explained, suggesting it could be “the tip of the iceberg.”

To test their hypothesis, the research team first performed a systematic review and meta-analysis (Stroke 2014;45:1342-8) to look at the available evidence on the association between cognitive impairment and stroke risk. The results showed that stroke risk was increased by 15% overall, although individual study estimates ranged from 1% up to 49%.

“We then decided to look at the association between cognitive function, stroke, and coronary heart disease, and to evaluate the association between cognitive function domains and the risk of such diseases,” Ms. Rostamian said.

Data on the cognitive function of 3,926 men and women aged 70-82 years were obtained from the randomized controlled Prospective Study of Pravastatin in the Elderly at Risk (PROSPER). This trial looked at the role of statin therapy in an elderly cohort that had or were at high risk of developing cardiovascular disease and stroke (Lancet 2002;360:1623-30). Results of the trial suggested that statin therapy might reduce the incidence of transient ischemic attacks by up to 25% (P = .051), but it did not reduce the risk for stroke or have an effect on cognitive function.

Nevertheless, the trial provided information on cognitive function that was assessed at enrollment and then annually, which could be used for the current study. Ms. Rostamian noted that the team used data from the Stroop Color and Word test, the Letter Digit Substitution Test, and the picture-word learning test, which evaluate selective attention, processing speed, and immediate and delayed memory, respectively. A composite score for executive function was obtained by combining the results of the Stroop and the Letter Digit Substitution tests, and a composite score for memory was obtained from the picture-word learning test results.

Over a follow-up period of just over 3 years, there were 155 stroke and 375 coronary events, giving incidences of 12.4 and 30.5 per 1,000 person-years, respectively.

After adjusting for multiple confounding factors, patients in the low tertile of cognitive function had the higher risk of both stroke (relative risk, 1.57; P = .010) and CHD (RR, 1.69; P < .001), compared with those in the high-cognitive function tertile who were used as a reference (RR, 1). Patients in the middle tertile also had an increased risk for both diseases (RR, 1.25 and 1.21, respectively).

The results also suggested that deficits in executive function, rather than memory, were predictive of stroke and CHD. So, it might be more important to assess patients’ ability to perform tasks that involve their ability to pay attention or process information.

Indeed, comparing patients in the low-cognitive and high-cognitive tertiles, the risk for stroke was 51% higher (RR, 1.51; P = .042) and the risk for CHD was 85% higher (RR, 1.85; P < .001). In contrast, there was no increased risk linked to memory deficits, with a RR of 0.87 for stroke and 0.99 when comparing patients in the low- and high-cognitive tertiles.

“Impaired executive function, but not memory, was associated with increased risk of cardiovascular diseases and can be considered as an indicator of cardiovascular events. Lower performance in global cognitive function was associated with a higher risk of stroke and coronary heart disease,” Ms. Rostamian summarized.

“Cognitive assessment might provide a tool for clinicians to identify older subjects at an extra risk for future cardiovascular events,” she concluded.

The original trial was supported by an investigator-initiated grant from Bristol-Myers Squibb, USA. Ms. Rostamian had no conflicts.

VIENNA – Measuring cognitive function might help determine if an elderly patient is at risk for developing a host of vascular diseases, including stroke and transient ischemic attack, research presented at the annual European Stroke Conference suggested.

The research, which has been accepted for publication in the Journal of Neurology, showed that lower performance in a measure of global cognitive function was associated with a 57% increase in the risk of stroke and a 69% increase in the risk of coronary heart disease (CHD).

“If a person has a poor performance or clinical impairment in cognitive function, it means that the clinician should perhaps be careful because the patient might be at risk of developing diseases such as stroke, [transient ischemic attack], myocardial infarction, and so on,” Somayeh Rostamian, a nurse scientist at Leiden (the Netherlands) University Medical Center, said in an interview.

During her presentation, she explained that it was well known that cardiovascular risk factors and diseases were associated with mild cognitive impairment. Data also have shown that mild cognitive impairment might signal the onset of common age-related neurologic diseases such as dementia.

“We hypothesized that mild cognitive impairment might be an early manifestation of vascular diseases in subjects without clinically recognized disease,” Ms. Rostamian explained, suggesting it could be “the tip of the iceberg.”

To test their hypothesis, the research team first performed a systematic review and meta-analysis (Stroke 2014;45:1342-8) to look at the available evidence on the association between cognitive impairment and stroke risk. The results showed that stroke risk was increased by 15% overall, although individual study estimates ranged from 1% up to 49%.

“We then decided to look at the association between cognitive function, stroke, and coronary heart disease, and to evaluate the association between cognitive function domains and the risk of such diseases,” Ms. Rostamian said.

Data on the cognitive function of 3,926 men and women aged 70-82 years were obtained from the randomized controlled Prospective Study of Pravastatin in the Elderly at Risk (PROSPER). This trial looked at the role of statin therapy in an elderly cohort that had or were at high risk of developing cardiovascular disease and stroke (Lancet 2002;360:1623-30). Results of the trial suggested that statin therapy might reduce the incidence of transient ischemic attacks by up to 25% (P = .051), but it did not reduce the risk for stroke or have an effect on cognitive function.

Nevertheless, the trial provided information on cognitive function that was assessed at enrollment and then annually, which could be used for the current study. Ms. Rostamian noted that the team used data from the Stroop Color and Word test, the Letter Digit Substitution Test, and the picture-word learning test, which evaluate selective attention, processing speed, and immediate and delayed memory, respectively. A composite score for executive function was obtained by combining the results of the Stroop and the Letter Digit Substitution tests, and a composite score for memory was obtained from the picture-word learning test results.

Over a follow-up period of just over 3 years, there were 155 stroke and 375 coronary events, giving incidences of 12.4 and 30.5 per 1,000 person-years, respectively.

After adjusting for multiple confounding factors, patients in the low tertile of cognitive function had the higher risk of both stroke (relative risk, 1.57; P = .010) and CHD (RR, 1.69; P < .001), compared with those in the high-cognitive function tertile who were used as a reference (RR, 1). Patients in the middle tertile also had an increased risk for both diseases (RR, 1.25 and 1.21, respectively).

The results also suggested that deficits in executive function, rather than memory, were predictive of stroke and CHD. So, it might be more important to assess patients’ ability to perform tasks that involve their ability to pay attention or process information.

Indeed, comparing patients in the low-cognitive and high-cognitive tertiles, the risk for stroke was 51% higher (RR, 1.51; P = .042) and the risk for CHD was 85% higher (RR, 1.85; P < .001). In contrast, there was no increased risk linked to memory deficits, with a RR of 0.87 for stroke and 0.99 when comparing patients in the low- and high-cognitive tertiles.

“Impaired executive function, but not memory, was associated with increased risk of cardiovascular diseases and can be considered as an indicator of cardiovascular events. Lower performance in global cognitive function was associated with a higher risk of stroke and coronary heart disease,” Ms. Rostamian summarized.

“Cognitive assessment might provide a tool for clinicians to identify older subjects at an extra risk for future cardiovascular events,” she concluded.

The original trial was supported by an investigator-initiated grant from Bristol-Myers Squibb, USA. Ms. Rostamian had no conflicts.

VIENNA – Reperfusion within 6 hours of a stroke proved to be a better predictor of both imaging and clinical outcomes than recanalization in an analysis of patients included in a multicenter, prospective, longitudinal study.

Indeed, when reperfusion was achieved, penumbra salvage was more likely (P < .0001), there was less lesion growth (P = .0002), and a smaller overall infarct size (P < .0001).

“Early revascularization is the main therapeutic goal in ischemic stroke as it can reduce infarct growth and improve clinical recovery,” said Tae-Hee Cho, Ph.D., who presented the research at the annual European Stroke Conference.

Dr. Cho of Hôpital Neurologique Pierre Wertheimer in Lyon, France, noted that reperfusion and recanalization are often closely related but can be disassociated with one occurring without the other. Although prior studies have looked at which might be a better marker for poststroke outcomes, later time windows were involved, so the aim of the present research was to look at an earlier point in time.

The I-KNOW European consortium database was used to identify patients with acute ischemia in the anterior circulation who had a confirmed occlusion on magnetic resonance angiography (MRA) and in whom reperfusion and recanalization had been assessed on a repeat scan, either within 6 hours of symptom onset if intravenous tissue plasminogen activator (tPA) was used or within 12 hours if no tPA was given.

Of 168 patients included in the database, 46 had the necessary data and were analyzed. The median age of the included patients was 69 years (range, 64-74). The majority was male (61%), with a median lesion size of 18.9 mL measured using diffusion-weighted magnetic resonance imaging.

At admission, the middle cerebral artery was occluded at M1 in 15 patients, 22 had M2 occlusion, 9 had M3 occlusion, and 1 patient had A1 occlusion. The median penumbra volume was 13.3 mL.

“Reperfusion and recanalization were assessed within 6 hours in all patients,” Dr. Cho observed. The median delay was 302 minutes, he added.

Results showed that reperfusion occurred in 27 (59%) patients and recanalization in 19 (41%) patients. Around 30% achieved reperfusion without recanalization, but the latter didn’t occur if reperfusion was not present.

“All imaging events were significantly improved by reperfusion,” Dr. Cho reported. This was not seen with recanalization, he observed. A similar pattern was seen for favorable clinical responses, which was defined as a fall of 8 points or a score of 0-1 on the National Institutes of Health Stroke Scale.

Dr. Cho noted that the research, which was published in Stroke just before the conference, showed that reperfusion within 6 hours of symptom onset was better than recanalization at predicting imaging outcomes and that it might be a reliable surrogate for clinical outcome.

Dr. Jenny Tsai and Dr. Gregory Albers of the Stanford Stroke Center in Palo Alto, Calif., commented on the data independently in an editorial accompanying the published paper, noting, “Optimal stroke therapy should result in both recanalization and reperfusion.”

They suggested that the higher rate of reperfusion than recanalization in the study is perhaps not unexpected “because recruitment of collateral circulation can occur rapidly in the setting of an acute vessel obstruction.”

They also observed that, while the findings suggest that reperfusion is of greater physiologic importance, these are not discrete or static entities. Imaging provides “a snapshot of an evolving process” and “an occluded vessel at a moment in time does not imply that beneficial recanalization did not occur subsequently.”

However, the editorialists concluded that, “if you must choose one, we agree with Cho et al.: the Oscar goes to reperfusion.”

Dr. Cho and Dr. Tsai had no disclosures. Dr. Albers is an equity shareholder in iSchemaView.

VIENNA – Reperfusion within 6 hours of a stroke proved to be a better predictor of both imaging and clinical outcomes than recanalization in an analysis of patients included in a multicenter, prospective, longitudinal study.

Indeed, when reperfusion was achieved, penumbra salvage was more likely (P < .0001), there was less lesion growth (P = .0002), and a smaller overall infarct size (P < .0001).

“Early revascularization is the main therapeutic goal in ischemic stroke as it can reduce infarct growth and improve clinical recovery,” said Tae-Hee Cho, Ph.D., who presented the research at the annual European Stroke Conference.

Dr. Cho of Hôpital Neurologique Pierre Wertheimer in Lyon, France, noted that reperfusion and recanalization are often closely related but can be disassociated with one occurring without the other. Although prior studies have looked at which might be a better marker for poststroke outcomes, later time windows were involved, so the aim of the present research was to look at an earlier point in time.

The I-KNOW European consortium database was used to identify patients with acute ischemia in the anterior circulation who had a confirmed occlusion on magnetic resonance angiography (MRA) and in whom reperfusion and recanalization had been assessed on a repeat scan, either within 6 hours of symptom onset if intravenous tissue plasminogen activator (tPA) was used or within 12 hours if no tPA was given.

Of 168 patients included in the database, 46 had the necessary data and were analyzed. The median age of the included patients was 69 years (range, 64-74). The majority was male (61%), with a median lesion size of 18.9 mL measured using diffusion-weighted magnetic resonance imaging.

At admission, the middle cerebral artery was occluded at M1 in 15 patients, 22 had M2 occlusion, 9 had M3 occlusion, and 1 patient had A1 occlusion. The median penumbra volume was 13.3 mL.

“Reperfusion and recanalization were assessed within 6 hours in all patients,” Dr. Cho observed. The median delay was 302 minutes, he added.

Results showed that reperfusion occurred in 27 (59%) patients and recanalization in 19 (41%) patients. Around 30% achieved reperfusion without recanalization, but the latter didn’t occur if reperfusion was not present.

“All imaging events were significantly improved by reperfusion,” Dr. Cho reported. This was not seen with recanalization, he observed. A similar pattern was seen for favorable clinical responses, which was defined as a fall of 8 points or a score of 0-1 on the National Institutes of Health Stroke Scale.

Dr. Cho noted that the research, which was published in Stroke just before the conference, showed that reperfusion within 6 hours of symptom onset was better than recanalization at predicting imaging outcomes and that it might be a reliable surrogate for clinical outcome.

Dr. Jenny Tsai and Dr. Gregory Albers of the Stanford Stroke Center in Palo Alto, Calif., commented on the data independently in an editorial accompanying the published paper, noting, “Optimal stroke therapy should result in both recanalization and reperfusion.”

They suggested that the higher rate of reperfusion than recanalization in the study is perhaps not unexpected “because recruitment of collateral circulation can occur rapidly in the setting of an acute vessel obstruction.”

They also observed that, while the findings suggest that reperfusion is of greater physiologic importance, these are not discrete or static entities. Imaging provides “a snapshot of an evolving process” and “an occluded vessel at a moment in time does not imply that beneficial recanalization did not occur subsequently.”

However, the editorialists concluded that, “if you must choose one, we agree with Cho et al.: the Oscar goes to reperfusion.”

Dr. Cho and Dr. Tsai had no disclosures. Dr. Albers is an equity shareholder in iSchemaView.

VIENNA – Reperfusion within 6 hours of a stroke proved to be a better predictor of both imaging and clinical outcomes than recanalization in an analysis of patients included in a multicenter, prospective, longitudinal study.

Indeed, when reperfusion was achieved, penumbra salvage was more likely (P < .0001), there was less lesion growth (P = .0002), and a smaller overall infarct size (P < .0001).

“Early revascularization is the main therapeutic goal in ischemic stroke as it can reduce infarct growth and improve clinical recovery,” said Tae-Hee Cho, Ph.D., who presented the research at the annual European Stroke Conference.

Dr. Cho of Hôpital Neurologique Pierre Wertheimer in Lyon, France, noted that reperfusion and recanalization are often closely related but can be disassociated with one occurring without the other. Although prior studies have looked at which might be a better marker for poststroke outcomes, later time windows were involved, so the aim of the present research was to look at an earlier point in time.

The I-KNOW European consortium database was used to identify patients with acute ischemia in the anterior circulation who had a confirmed occlusion on magnetic resonance angiography (MRA) and in whom reperfusion and recanalization had been assessed on a repeat scan, either within 6 hours of symptom onset if intravenous tissue plasminogen activator (tPA) was used or within 12 hours if no tPA was given.

Of 168 patients included in the database, 46 had the necessary data and were analyzed. The median age of the included patients was 69 years (range, 64-74). The majority was male (61%), with a median lesion size of 18.9 mL measured using diffusion-weighted magnetic resonance imaging.

At admission, the middle cerebral artery was occluded at M1 in 15 patients, 22 had M2 occlusion, 9 had M3 occlusion, and 1 patient had A1 occlusion. The median penumbra volume was 13.3 mL.

“Reperfusion and recanalization were assessed within 6 hours in all patients,” Dr. Cho observed. The median delay was 302 minutes, he added.

Results showed that reperfusion occurred in 27 (59%) patients and recanalization in 19 (41%) patients. Around 30% achieved reperfusion without recanalization, but the latter didn’t occur if reperfusion was not present.

“All imaging events were significantly improved by reperfusion,” Dr. Cho reported. This was not seen with recanalization, he observed. A similar pattern was seen for favorable clinical responses, which was defined as a fall of 8 points or a score of 0-1 on the National Institutes of Health Stroke Scale.

Dr. Cho noted that the research, which was published in Stroke just before the conference, showed that reperfusion within 6 hours of symptom onset was better than recanalization at predicting imaging outcomes and that it might be a reliable surrogate for clinical outcome.

Dr. Jenny Tsai and Dr. Gregory Albers of the Stanford Stroke Center in Palo Alto, Calif., commented on the data independently in an editorial accompanying the published paper, noting, “Optimal stroke therapy should result in both recanalization and reperfusion.”

They suggested that the higher rate of reperfusion than recanalization in the study is perhaps not unexpected “because recruitment of collateral circulation can occur rapidly in the setting of an acute vessel obstruction.”

They also observed that, while the findings suggest that reperfusion is of greater physiologic importance, these are not discrete or static entities. Imaging provides “a snapshot of an evolving process” and “an occluded vessel at a moment in time does not imply that beneficial recanalization did not occur subsequently.”

However, the editorialists concluded that, “if you must choose one, we agree with Cho et al.: the Oscar goes to reperfusion.”

Dr. Cho and Dr. Tsai had no disclosures. Dr. Albers is an equity shareholder in iSchemaView.

VIENNA – Handheld ECG monitors offered a practical, noninvasive solution to detecting atrial fibrillation in patients who had been diagnosed with ischemic stroke or transient ischemic attack in a retrospective hospital-based study.

The results presented at the annual European Stroke Conference showed an overall detection rate of 7.6%, which is in the same range seen in previous studies of handheld ECG monitors but was higher than in most studies that used 24-hour Holter monitoring, said study investigator Dr. Ann-Sofie Olsson of Hallands Hospital Halmstead (Sweden).

The retrospective study included data on 356 patients who had been seen at the hospital for ischemic stroke or transient ischemic attack (TIA) and who had undergone intermittent handheld ECG testing to monitor for atrial fibrillation (AF). The mean age of patients was 66 years, 53% were male, and 46% were diagnosed with ischemic stroke and 56% with TIA. The mean baseline CHA₂DS₂-VASc score was 4.2, suggesting patients were at reasonably moderate risk of subsequent AF-related stroke.

The ECG monitor used consisted of a small, lightweight plastic box that patients held by two thumb sensors for 10, 20, or 30 seconds, with measurements taken twice a day (morning and evening) for 14 days. The sensors, which provided lead I of a standard ECG, provided information on atrial movement that was transmitted to a data server and was viewed via a web browser.

“We defined a positive investigation as either atrial fibrillation for a minimum of 10 seconds or a short, irregular supraventricular arrhythmia, Dr. Olsson explained.

Overall, 27 (7.6%) of the 356 patients evaluated had a positive result, with a 95% confidence interval ranging from 5.1% to 10.1%. While there was no statistically significant difference in AF detection rates between men (8.5%) and women (6.5%), detection rates were higher if patients had had an ischemic stroke rather than a TIA (11% vs. 5%, P = .032). There was also a trend (P = .051) for better detection rates in older (≥65 years) than younger (<65 years) patients, at 8.8% vs. 4.2%, respectively.

“It is natural to ask ourselves whether we can improve the detection rates by selecting higher-risk patients,” Dr. Olsson said, commenting on the lower detection rate seen in TIA patients despite there being more TIA cases in the study cohort.

“We saw high adherence to the monitoring; only six (1.5%) patients did not complete the investigation,” said Dr. Olsson, noting that older age did not seem to be an obstacle to performing the ECG with the handheld monitor as the oldest patient in the study was 90 years.

Dr. Olsson noted that the monitor used in the study had a sensitivity of 96% and a specificity of 92%.

Dr. Olsson reported having no relevant financial disclosures.

VIENNA – Handheld ECG monitors offered a practical, noninvasive solution to detecting atrial fibrillation in patients who had been diagnosed with ischemic stroke or transient ischemic attack in a retrospective hospital-based study.

The results presented at the annual European Stroke Conference showed an overall detection rate of 7.6%, which is in the same range seen in previous studies of handheld ECG monitors but was higher than in most studies that used 24-hour Holter monitoring, said study investigator Dr. Ann-Sofie Olsson of Hallands Hospital Halmstead (Sweden).

The retrospective study included data on 356 patients who had been seen at the hospital for ischemic stroke or transient ischemic attack (TIA) and who had undergone intermittent handheld ECG testing to monitor for atrial fibrillation (AF). The mean age of patients was 66 years, 53% were male, and 46% were diagnosed with ischemic stroke and 56% with TIA. The mean baseline CHA₂DS₂-VASc score was 4.2, suggesting patients were at reasonably moderate risk of subsequent AF-related stroke.

The ECG monitor used consisted of a small, lightweight plastic box that patients held by two thumb sensors for 10, 20, or 30 seconds, with measurements taken twice a day (morning and evening) for 14 days. The sensors, which provided lead I of a standard ECG, provided information on atrial movement that was transmitted to a data server and was viewed via a web browser.

“We defined a positive investigation as either atrial fibrillation for a minimum of 10 seconds or a short, irregular supraventricular arrhythmia, Dr. Olsson explained.

Overall, 27 (7.6%) of the 356 patients evaluated had a positive result, with a 95% confidence interval ranging from 5.1% to 10.1%. While there was no statistically significant difference in AF detection rates between men (8.5%) and women (6.5%), detection rates were higher if patients had had an ischemic stroke rather than a TIA (11% vs. 5%, P = .032). There was also a trend (P = .051) for better detection rates in older (≥65 years) than younger (<65 years) patients, at 8.8% vs. 4.2%, respectively.

“It is natural to ask ourselves whether we can improve the detection rates by selecting higher-risk patients,” Dr. Olsson said, commenting on the lower detection rate seen in TIA patients despite there being more TIA cases in the study cohort.

“We saw high adherence to the monitoring; only six (1.5%) patients did not complete the investigation,” said Dr. Olsson, noting that older age did not seem to be an obstacle to performing the ECG with the handheld monitor as the oldest patient in the study was 90 years.

Dr. Olsson noted that the monitor used in the study had a sensitivity of 96% and a specificity of 92%.

Dr. Olsson reported having no relevant financial disclosures.

VIENNA – Handheld ECG monitors offered a practical, noninvasive solution to detecting atrial fibrillation in patients who had been diagnosed with ischemic stroke or transient ischemic attack in a retrospective hospital-based study.

The results presented at the annual European Stroke Conference showed an overall detection rate of 7.6%, which is in the same range seen in previous studies of handheld ECG monitors but was higher than in most studies that used 24-hour Holter monitoring, said study investigator Dr. Ann-Sofie Olsson of Hallands Hospital Halmstead (Sweden).

The retrospective study included data on 356 patients who had been seen at the hospital for ischemic stroke or transient ischemic attack (TIA) and who had undergone intermittent handheld ECG testing to monitor for atrial fibrillation (AF). The mean age of patients was 66 years, 53% were male, and 46% were diagnosed with ischemic stroke and 56% with TIA. The mean baseline CHA₂DS₂-VASc score was 4.2, suggesting patients were at reasonably moderate risk of subsequent AF-related stroke.

The ECG monitor used consisted of a small, lightweight plastic box that patients held by two thumb sensors for 10, 20, or 30 seconds, with measurements taken twice a day (morning and evening) for 14 days. The sensors, which provided lead I of a standard ECG, provided information on atrial movement that was transmitted to a data server and was viewed via a web browser.

“We defined a positive investigation as either atrial fibrillation for a minimum of 10 seconds or a short, irregular supraventricular arrhythmia, Dr. Olsson explained.

Overall, 27 (7.6%) of the 356 patients evaluated had a positive result, with a 95% confidence interval ranging from 5.1% to 10.1%. While there was no statistically significant difference in AF detection rates between men (8.5%) and women (6.5%), detection rates were higher if patients had had an ischemic stroke rather than a TIA (11% vs. 5%, P = .032). There was also a trend (P = .051) for better detection rates in older (≥65 years) than younger (<65 years) patients, at 8.8% vs. 4.2%, respectively.

“It is natural to ask ourselves whether we can improve the detection rates by selecting higher-risk patients,” Dr. Olsson said, commenting on the lower detection rate seen in TIA patients despite there being more TIA cases in the study cohort.

“We saw high adherence to the monitoring; only six (1.5%) patients did not complete the investigation,” said Dr. Olsson, noting that older age did not seem to be an obstacle to performing the ECG with the handheld monitor as the oldest patient in the study was 90 years.

Dr. Olsson noted that the monitor used in the study had a sensitivity of 96% and a specificity of 92%.

Dr. Olsson reported having no relevant financial disclosures.

VIENNA – The concept of cryptogenic stroke is outdated and should be replaced by the relatively new clinical construct of embolic stroke of undetermined source, or ESUS, Dr. Hans Christoph Diener said at the annual European Stroke Conference.

The underlying premise is that these strokes of so-called unknown cause are actually due to thromboembolic events from more minor-risk or covert cardiac sources and thus could potentially be prevented by anticoagulation with the newer non-vitamin K oral anticoagulants (NOACs). In fact, Dr. Diener noted that the concept of ESUS came about because researchers wanted to do secondary prevention trials in cryptogenic stoke but the U.S. Food and Drug Administration would not allow it as there was no way to truly diagnose it.

The paradigm of cryptogenic stroke was developed at a time when sophisticated imaging was not available, Dr. Diener of the University of Duisburg-Essen, Germany, observed, noting that it was a diagnosis of exclusion. The term could also encompass cases where incomplete diagnostic evaluation had been performed.

ESUS on the other hand was “positively defined” and required a clear set of criteria to be met as set out recently by the Cryptogenic Stroke/ESUS International Working Group (Lancet Neurol. 2014;13:429–438). These criteria relied on a minimum diagnostic work-up including brain computed tomography (CT) or magnetic resonance imagine (MRI), 12-lead ECG, precordial echocardiography, cardiac monitoring for 24 hours or longer, and imaging of both the extra- and intracranial arteries supplying the area of brain ischemia.

The criteria are:

* Stroke detected by CT or MRI that is not lacunar

* Absence of extracranial or intracranial atherosclerosis causing ≥50% luminal stenosis in the arteries supplying the area of ischemia

* No major-risk cardioembolic source of embolism

* No other specific cause of stroke identified (e.g. arteritis, dissection, migraine/vasospasm, drug misuse)

According to the established TOAST (Trial of Org 10172) Criteria (Stroke. 1993;23:35–41) there are five main categories of ischemic stroke: large vessel disease, cardio-embolic disease, small vessel disease unknown (cryptogenic), or other causes or those with conflicting etiology. “These criteria were developed to include people with a particular pathophysiology into randomized trials,” Dr. Diener noted and using this classification a quarter of all ischemic strokes are generally classified as cryptogenic. Another quarter can be due to large artery atherosclerotic stenosis, another quarter to small artery disease (lacunar stroke), a fifth due to major-risk cardio-embolic disease, and the remainder to unusual events, such as dissection or arteritis.

“These different entities have different consequences for treatment,” Dr. Diener noted. “In someone who had a significant large artery atherosclerotic stenosis most probably it would be surgery or stenting,” he said while “in someone who has an identified cardiogenic source of embolism it is clearly anticoagulation.” Patients with small vessel disease would probably be treated via risk factor management.

“And then we have this entity called cryptogenic stroke,” he said. Because this category of stroke was so heterogeneous and defined by what it is not rather than what it is, treatment options were not clearly defined and performing secondary prevention trials just not possible, until now.

ESUS could include a range of pathophysiologies, he acknowledged, although the majority were likely to be unrecognized paroxysmal atrial fibrillation (AF). Others could be atrial high rate episodes, heart failure, silent myocardial infarction, patent foramen ovale, atherosclerotic plaques in the aortic arch, or nonstenotic atherosclerotic plaques in the cervical or intracranial arteries.

There are two possible strategies for stroke prevention in patients with ESUS, Dr. Diener suggested. The first was to use more sophisticated tools to detect clinically silent AF. Methods of detecting clinically silent AF via cardiac monitoring has evolved greatly from the original Holter monitoring equipment to the ambulatory devices and implantable recorders available today. Trials such as EMBRACE (N Engl J Med. 2014;370:2467-77) and CRYSTAL-AF (N Engl J Med. 2014; 370:2478-2486) had shown the respective benefits of prolonged ambulatory and implantable device monitoring, he said. The next generation of technology could include ECG- and perhaps even biomarker monitoring via the iPhone and Apple Watch, Dr. Diener said.

The second strategy for secondary stroke prevention in ESUS was to treat irrespective of the possible etiology or to develop new and more effective anticoagulatnt therapies. Dr. Diener is co-chair of the RE-SPECT ESUS-trial, which is currently recruiting patients using the new ESUS definition and will randomize a target of 6,000 patients to treatment with dabigatran, aspirin, or matching placebos. There is also another trial, NAVIGATE ESUS, comparing the NOAC rivaroxaban to aspirin with a similar design and 7,000-patient target accrual, he said. Both trials are event driven and are expected to run for 2-3 years. Results should be available in 2018.

“The old concept of cryptogenic stroke is not very useful if you want to do randomized trials in a defined population and this is why we created the definition of ESUS,” Dr. Diener said.

“In the future, we have two ways to address this problem. One way is much more sophisticated diagnostic testing to detect silent AF and the other way is to treat and to improve the medical treatment of these patients. Hopefully, three years from now, we have evidence that we have something to offer that is superior to aspirin and has a superior side effect profile.”

Introducing the concept of ESUS has not been not without its critics, however, and in a comment published in the Lancet Neurology, Dr. Martin Dennis of the Western General Hospital in Edinburgh, Scotland, pointed out that the name selected might mislead clinicians.

“An unknown proportion of patients with ESUS will not have an embolic stroke, but a stroke due to in-situ thrombosis,” he argued. “Although one can see the advantages of the name for gaining support from funders and clinicians for a trial, and for marketing new oral anticoagulants if they prove effective, the name will mislead clinicians.”

Dr. Dennis suggested that a better name might be to refer to these strokes as “non-lacunar ischaemic stroke without a defined cause”.

Dr. Diener and his institution have received financial support from a number of German and European funding bodies, and wide range of pharmaceutical companies.

VIENNA – The concept of cryptogenic stroke is outdated and should be replaced by the relatively new clinical construct of embolic stroke of undetermined source, or ESUS, Dr. Hans Christoph Diener said at the annual European Stroke Conference.

The underlying premise is that these strokes of so-called unknown cause are actually due to thromboembolic events from more minor-risk or covert cardiac sources and thus could potentially be prevented by anticoagulation with the newer non-vitamin K oral anticoagulants (NOACs). In fact, Dr. Diener noted that the concept of ESUS came about because researchers wanted to do secondary prevention trials in cryptogenic stoke but the U.S. Food and Drug Administration would not allow it as there was no way to truly diagnose it.

The paradigm of cryptogenic stroke was developed at a time when sophisticated imaging was not available, Dr. Diener of the University of Duisburg-Essen, Germany, observed, noting that it was a diagnosis of exclusion. The term could also encompass cases where incomplete diagnostic evaluation had been performed.

ESUS on the other hand was “positively defined” and required a clear set of criteria to be met as set out recently by the Cryptogenic Stroke/ESUS International Working Group (Lancet Neurol. 2014;13:429–438). These criteria relied on a minimum diagnostic work-up including brain computed tomography (CT) or magnetic resonance imagine (MRI), 12-lead ECG, precordial echocardiography, cardiac monitoring for 24 hours or longer, and imaging of both the extra- and intracranial arteries supplying the area of brain ischemia.

The criteria are:

* Stroke detected by CT or MRI that is not lacunar

* Absence of extracranial or intracranial atherosclerosis causing ≥50% luminal stenosis in the arteries supplying the area of ischemia

* No major-risk cardioembolic source of embolism

* No other specific cause of stroke identified (e.g. arteritis, dissection, migraine/vasospasm, drug misuse)

According to the established TOAST (Trial of Org 10172) Criteria (Stroke. 1993;23:35–41) there are five main categories of ischemic stroke: large vessel disease, cardio-embolic disease, small vessel disease unknown (cryptogenic), or other causes or those with conflicting etiology. “These criteria were developed to include people with a particular pathophysiology into randomized trials,” Dr. Diener noted and using this classification a quarter of all ischemic strokes are generally classified as cryptogenic. Another quarter can be due to large artery atherosclerotic stenosis, another quarter to small artery disease (lacunar stroke), a fifth due to major-risk cardio-embolic disease, and the remainder to unusual events, such as dissection or arteritis.

“These different entities have different consequences for treatment,” Dr. Diener noted. “In someone who had a significant large artery atherosclerotic stenosis most probably it would be surgery or stenting,” he said while “in someone who has an identified cardiogenic source of embolism it is clearly anticoagulation.” Patients with small vessel disease would probably be treated via risk factor management.

“And then we have this entity called cryptogenic stroke,” he said. Because this category of stroke was so heterogeneous and defined by what it is not rather than what it is, treatment options were not clearly defined and performing secondary prevention trials just not possible, until now.

ESUS could include a range of pathophysiologies, he acknowledged, although the majority were likely to be unrecognized paroxysmal atrial fibrillation (AF). Others could be atrial high rate episodes, heart failure, silent myocardial infarction, patent foramen ovale, atherosclerotic plaques in the aortic arch, or nonstenotic atherosclerotic plaques in the cervical or intracranial arteries.

There are two possible strategies for stroke prevention in patients with ESUS, Dr. Diener suggested. The first was to use more sophisticated tools to detect clinically silent AF. Methods of detecting clinically silent AF via cardiac monitoring has evolved greatly from the original Holter monitoring equipment to the ambulatory devices and implantable recorders available today. Trials such as EMBRACE (N Engl J Med. 2014;370:2467-77) and CRYSTAL-AF (N Engl J Med. 2014; 370:2478-2486) had shown the respective benefits of prolonged ambulatory and implantable device monitoring, he said. The next generation of technology could include ECG- and perhaps even biomarker monitoring via the iPhone and Apple Watch, Dr. Diener said.

The second strategy for secondary stroke prevention in ESUS was to treat irrespective of the possible etiology or to develop new and more effective anticoagulatnt therapies. Dr. Diener is co-chair of the RE-SPECT ESUS-trial, which is currently recruiting patients using the new ESUS definition and will randomize a target of 6,000 patients to treatment with dabigatran, aspirin, or matching placebos. There is also another trial, NAVIGATE ESUS, comparing the NOAC rivaroxaban to aspirin with a similar design and 7,000-patient target accrual, he said. Both trials are event driven and are expected to run for 2-3 years. Results should be available in 2018.

“The old concept of cryptogenic stroke is not very useful if you want to do randomized trials in a defined population and this is why we created the definition of ESUS,” Dr. Diener said.

“In the future, we have two ways to address this problem. One way is much more sophisticated diagnostic testing to detect silent AF and the other way is to treat and to improve the medical treatment of these patients. Hopefully, three years from now, we have evidence that we have something to offer that is superior to aspirin and has a superior side effect profile.”

Introducing the concept of ESUS has not been not without its critics, however, and in a comment published in the Lancet Neurology, Dr. Martin Dennis of the Western General Hospital in Edinburgh, Scotland, pointed out that the name selected might mislead clinicians.

“An unknown proportion of patients with ESUS will not have an embolic stroke, but a stroke due to in-situ thrombosis,” he argued. “Although one can see the advantages of the name for gaining support from funders and clinicians for a trial, and for marketing new oral anticoagulants if they prove effective, the name will mislead clinicians.”

Dr. Dennis suggested that a better name might be to refer to these strokes as “non-lacunar ischaemic stroke without a defined cause”.

Dr. Diener and his institution have received financial support from a number of German and European funding bodies, and wide range of pharmaceutical companies.

VIENNA – The concept of cryptogenic stroke is outdated and should be replaced by the relatively new clinical construct of embolic stroke of undetermined source, or ESUS, Dr. Hans Christoph Diener said at the annual European Stroke Conference.

The underlying premise is that these strokes of so-called unknown cause are actually due to thromboembolic events from more minor-risk or covert cardiac sources and thus could potentially be prevented by anticoagulation with the newer non-vitamin K oral anticoagulants (NOACs). In fact, Dr. Diener noted that the concept of ESUS came about because researchers wanted to do secondary prevention trials in cryptogenic stoke but the U.S. Food and Drug Administration would not allow it as there was no way to truly diagnose it.

The paradigm of cryptogenic stroke was developed at a time when sophisticated imaging was not available, Dr. Diener of the University of Duisburg-Essen, Germany, observed, noting that it was a diagnosis of exclusion. The term could also encompass cases where incomplete diagnostic evaluation had been performed.

ESUS on the other hand was “positively defined” and required a clear set of criteria to be met as set out recently by the Cryptogenic Stroke/ESUS International Working Group (Lancet Neurol. 2014;13:429–438). These criteria relied on a minimum diagnostic work-up including brain computed tomography (CT) or magnetic resonance imagine (MRI), 12-lead ECG, precordial echocardiography, cardiac monitoring for 24 hours or longer, and imaging of both the extra- and intracranial arteries supplying the area of brain ischemia.

The criteria are:

* Stroke detected by CT or MRI that is not lacunar

* Absence of extracranial or intracranial atherosclerosis causing ≥50% luminal stenosis in the arteries supplying the area of ischemia

* No major-risk cardioembolic source of embolism

* No other specific cause of stroke identified (e.g. arteritis, dissection, migraine/vasospasm, drug misuse)

According to the established TOAST (Trial of Org 10172) Criteria (Stroke. 1993;23:35–41) there are five main categories of ischemic stroke: large vessel disease, cardio-embolic disease, small vessel disease unknown (cryptogenic), or other causes or those with conflicting etiology. “These criteria were developed to include people with a particular pathophysiology into randomized trials,” Dr. Diener noted and using this classification a quarter of all ischemic strokes are generally classified as cryptogenic. Another quarter can be due to large artery atherosclerotic stenosis, another quarter to small artery disease (lacunar stroke), a fifth due to major-risk cardio-embolic disease, and the remainder to unusual events, such as dissection or arteritis.

“These different entities have different consequences for treatment,” Dr. Diener noted. “In someone who had a significant large artery atherosclerotic stenosis most probably it would be surgery or stenting,” he said while “in someone who has an identified cardiogenic source of embolism it is clearly anticoagulation.” Patients with small vessel disease would probably be treated via risk factor management.

“And then we have this entity called cryptogenic stroke,” he said. Because this category of stroke was so heterogeneous and defined by what it is not rather than what it is, treatment options were not clearly defined and performing secondary prevention trials just not possible, until now.

ESUS could include a range of pathophysiologies, he acknowledged, although the majority were likely to be unrecognized paroxysmal atrial fibrillation (AF). Others could be atrial high rate episodes, heart failure, silent myocardial infarction, patent foramen ovale, atherosclerotic plaques in the aortic arch, or nonstenotic atherosclerotic plaques in the cervical or intracranial arteries.

There are two possible strategies for stroke prevention in patients with ESUS, Dr. Diener suggested. The first was to use more sophisticated tools to detect clinically silent AF. Methods of detecting clinically silent AF via cardiac monitoring has evolved greatly from the original Holter monitoring equipment to the ambulatory devices and implantable recorders available today. Trials such as EMBRACE (N Engl J Med. 2014;370:2467-77) and CRYSTAL-AF (N Engl J Med. 2014; 370:2478-2486) had shown the respective benefits of prolonged ambulatory and implantable device monitoring, he said. The next generation of technology could include ECG- and perhaps even biomarker monitoring via the iPhone and Apple Watch, Dr. Diener said.

The second strategy for secondary stroke prevention in ESUS was to treat irrespective of the possible etiology or to develop new and more effective anticoagulatnt therapies. Dr. Diener is co-chair of the RE-SPECT ESUS-trial, which is currently recruiting patients using the new ESUS definition and will randomize a target of 6,000 patients to treatment with dabigatran, aspirin, or matching placebos. There is also another trial, NAVIGATE ESUS, comparing the NOAC rivaroxaban to aspirin with a similar design and 7,000-patient target accrual, he said. Both trials are event driven and are expected to run for 2-3 years. Results should be available in 2018.

“The old concept of cryptogenic stroke is not very useful if you want to do randomized trials in a defined population and this is why we created the definition of ESUS,” Dr. Diener said.

“In the future, we have two ways to address this problem. One way is much more sophisticated diagnostic testing to detect silent AF and the other way is to treat and to improve the medical treatment of these patients. Hopefully, three years from now, we have evidence that we have something to offer that is superior to aspirin and has a superior side effect profile.”

Introducing the concept of ESUS has not been not without its critics, however, and in a comment published in the Lancet Neurology, Dr. Martin Dennis of the Western General Hospital in Edinburgh, Scotland, pointed out that the name selected might mislead clinicians.

“An unknown proportion of patients with ESUS will not have an embolic stroke, but a stroke due to in-situ thrombosis,” he argued. “Although one can see the advantages of the name for gaining support from funders and clinicians for a trial, and for marketing new oral anticoagulants if they prove effective, the name will mislead clinicians.”

Dr. Dennis suggested that a better name might be to refer to these strokes as “non-lacunar ischaemic stroke without a defined cause”.

Dr. Diener and his institution have received financial support from a number of German and European funding bodies, and wide range of pharmaceutical companies.

VIENNA – A digital handgrip developed by U.K. researchers allowed more patients with arm weakness caused by a stroke to self-rehabilitate than did the use of standard mobile device touch screen controls in a 6-month, single-center survey.

Results showed that almost all patients (94%) could use the novel wireless controller, compared with 56%-62% of patients who could successfully use the gestures that commonly control mobile devices, such as swiping, tilting, or touching a screen.

Courtesy Paul Rinne

“Standard mobile gaming technology can be used by the majority of stroke patients with moderate and mild arm weakness” Paul Rinne said at the annual European Stroke Conference. “It could increase the amount of complementary therapy given and hopefully be more economical” than existing technology used in motor rehabilitation programs, he suggested.

The device could bring stroke rehabilitation to the patients’ bedside and allow additional self-therapy, said Mr. Rinne, who is completing his PhD in brain sciences and is a researcher at the Human Robotics Group, Imperial College London, where the handgrip was developed.

Physiotherapist-led physical therapy is one of the main components of poststroke rehabilitation programs and evidence shows that the success of such therapy is greatly influenced by how intensively, long, and often patients perform task-specific exercises (PLoS One 2014;9:e87987). The problem, of course, is having sufficient human and financial resources to maximize potential benefits, Mr. Rinne observed. According to a National Institute for Health and Care Excellence estimate, 55% of stroke patients receive less than 45 minutes of motor rehabilitation exercise per day. Other data suggest that patients do not receive therapy for very long or perform too few repetitions during a session.

Although gaming technology is already being used as an adjunct to traditional physical therapy in some centers, the cost of equipment currently used is often high and it is often geared toward patients with high motor function. It cannot be used by patients at the bedside or at home at the moment, which would help increase the “dose” of treatment. The use of mobile devices is thus gaining interest as a possible alternative means of supplementing current rehabilitation programs, making it both more accessible – around 75% of the general public have access to a mobile device, Mr. Rinne observed – and more engaging or motivating for patients.

Mr. Rinne and coinvestigators surveyed all patients presenting with arm weakness on admission to a large hyper-acute stroke unit over a 6-month period. Of 342 patients who were screened, 89 were included. Reasons for exclusion were cognitive impairment or comorbidities (130 patients), lack of communication or language barrier (36 patients), resolution of arm weakness (34 patients), preexisting arm weakness (24 patients), arm weakness not due to stroke (5 patients), or patient refusal (24 patients).

The mean age of patients who participated was 65 years and 57% were male. The baseline National Institutes of Health Stroke Scale score was 5.8 and the NIHSS Motor subscale score was 1 on a scale of 0 to 4, signifying mild impairment. Other functional measures used were the 66-item Fugl-Meyer Assessment-Upper Extremity (FMA-UE), the 12-item Short-Form Fugl-Meyer (S-FM) scale, and the 14-item Fugl-Meyer Assessment Hand Subscale (FMA-Hand).

During the assessment period, study participants were given a mobile tablet and asked to perform a variety of touch-screen hand movements with their paretic and unaffected arms to move an object on screen. The results were given a movement score, ranging from 0 (no movement) to 3 (full range of movement) and were compared against those obtained by use of a gaming joystick and the digital handgrip developed by the Imperial College London team.

The S-FM was used to divide patients into groups depending on their baseline arm weakness. Patients with severe impairment had lower movement scores in both their paretic and unaffected hands than did those with more moderate or mild impairment. Mr. Rinne noted that there was no difference in the results seen with the conventional controllers, and a similar proportion of patients could swipe, press a button, tilt, or use the joystick successfully.

However, comparing the results obtained with the digital handgrip and mobile tablet, he noted that patients who used the digital handgrip could follow the object on screen much more accurately than when they used a swiping motion on a tablet. Even patients with severe impairment could use the handgrip.

“We found that 89% of our severely weak patients could still interact with these games and perform self-rehabilitation when using our controller,” Mr. Rinne reported. In contrast, no severely impaired patient could perform the screen swipe on a tablet.

“Performance using the handgrip was very similar across patients with different severities,” he added, noting that patients found the novel controller more comfortable and easier to use for long periods of time.

Novel control devices adapted for patients can broaden the accessibility to stroke rehabilitation, he concluded, even in those with more severe impairments.

Mr. Rinne had no conflicts of interest.

VIENNA – A digital handgrip developed by U.K. researchers allowed more patients with arm weakness caused by a stroke to self-rehabilitate than did the use of standard mobile device touch screen controls in a 6-month, single-center survey.

Results showed that almost all patients (94%) could use the novel wireless controller, compared with 56%-62% of patients who could successfully use the gestures that commonly control mobile devices, such as swiping, tilting, or touching a screen.

Courtesy Paul Rinne

“Standard mobile gaming technology can be used by the majority of stroke patients with moderate and mild arm weakness” Paul Rinne said at the annual European Stroke Conference. “It could increase the amount of complementary therapy given and hopefully be more economical” than existing technology used in motor rehabilitation programs, he suggested.

The device could bring stroke rehabilitation to the patients’ bedside and allow additional self-therapy, said Mr. Rinne, who is completing his PhD in brain sciences and is a researcher at the Human Robotics Group, Imperial College London, where the handgrip was developed.

Physiotherapist-led physical therapy is one of the main components of poststroke rehabilitation programs and evidence shows that the success of such therapy is greatly influenced by how intensively, long, and often patients perform task-specific exercises (PLoS One 2014;9:e87987). The problem, of course, is having sufficient human and financial resources to maximize potential benefits, Mr. Rinne observed. According to a National Institute for Health and Care Excellence estimate, 55% of stroke patients receive less than 45 minutes of motor rehabilitation exercise per day. Other data suggest that patients do not receive therapy for very long or perform too few repetitions during a session.

Although gaming technology is already being used as an adjunct to traditional physical therapy in some centers, the cost of equipment currently used is often high and it is often geared toward patients with high motor function. It cannot be used by patients at the bedside or at home at the moment, which would help increase the “dose” of treatment. The use of mobile devices is thus gaining interest as a possible alternative means of supplementing current rehabilitation programs, making it both more accessible – around 75% of the general public have access to a mobile device, Mr. Rinne observed – and more engaging or motivating for patients.

Mr. Rinne and coinvestigators surveyed all patients presenting with arm weakness on admission to a large hyper-acute stroke unit over a 6-month period. Of 342 patients who were screened, 89 were included. Reasons for exclusion were cognitive impairment or comorbidities (130 patients), lack of communication or language barrier (36 patients), resolution of arm weakness (34 patients), preexisting arm weakness (24 patients), arm weakness not due to stroke (5 patients), or patient refusal (24 patients).

The mean age of patients who participated was 65 years and 57% were male. The baseline National Institutes of Health Stroke Scale score was 5.8 and the NIHSS Motor subscale score was 1 on a scale of 0 to 4, signifying mild impairment. Other functional measures used were the 66-item Fugl-Meyer Assessment-Upper Extremity (FMA-UE), the 12-item Short-Form Fugl-Meyer (S-FM) scale, and the 14-item Fugl-Meyer Assessment Hand Subscale (FMA-Hand).

During the assessment period, study participants were given a mobile tablet and asked to perform a variety of touch-screen hand movements with their paretic and unaffected arms to move an object on screen. The results were given a movement score, ranging from 0 (no movement) to 3 (full range of movement) and were compared against those obtained by use of a gaming joystick and the digital handgrip developed by the Imperial College London team.

The S-FM was used to divide patients into groups depending on their baseline arm weakness. Patients with severe impairment had lower movement scores in both their paretic and unaffected hands than did those with more moderate or mild impairment. Mr. Rinne noted that there was no difference in the results seen with the conventional controllers, and a similar proportion of patients could swipe, press a button, tilt, or use the joystick successfully.

However, comparing the results obtained with the digital handgrip and mobile tablet, he noted that patients who used the digital handgrip could follow the object on screen much more accurately than when they used a swiping motion on a tablet. Even patients with severe impairment could use the handgrip.

“We found that 89% of our severely weak patients could still interact with these games and perform self-rehabilitation when using our controller,” Mr. Rinne reported. In contrast, no severely impaired patient could perform the screen swipe on a tablet.

“Performance using the handgrip was very similar across patients with different severities,” he added, noting that patients found the novel controller more comfortable and easier to use for long periods of time.

Novel control devices adapted for patients can broaden the accessibility to stroke rehabilitation, he concluded, even in those with more severe impairments.

Mr. Rinne had no conflicts of interest.

VIENNA – A digital handgrip developed by U.K. researchers allowed more patients with arm weakness caused by a stroke to self-rehabilitate than did the use of standard mobile device touch screen controls in a 6-month, single-center survey.

Results showed that almost all patients (94%) could use the novel wireless controller, compared with 56%-62% of patients who could successfully use the gestures that commonly control mobile devices, such as swiping, tilting, or touching a screen.

Courtesy Paul Rinne

“Standard mobile gaming technology can be used by the majority of stroke patients with moderate and mild arm weakness” Paul Rinne said at the annual European Stroke Conference. “It could increase the amount of complementary therapy given and hopefully be more economical” than existing technology used in motor rehabilitation programs, he suggested.

The device could bring stroke rehabilitation to the patients’ bedside and allow additional self-therapy, said Mr. Rinne, who is completing his PhD in brain sciences and is a researcher at the Human Robotics Group, Imperial College London, where the handgrip was developed.

Physiotherapist-led physical therapy is one of the main components of poststroke rehabilitation programs and evidence shows that the success of such therapy is greatly influenced by how intensively, long, and often patients perform task-specific exercises (PLoS One 2014;9:e87987). The problem, of course, is having sufficient human and financial resources to maximize potential benefits, Mr. Rinne observed. According to a National Institute for Health and Care Excellence estimate, 55% of stroke patients receive less than 45 minutes of motor rehabilitation exercise per day. Other data suggest that patients do not receive therapy for very long or perform too few repetitions during a session.

Although gaming technology is already being used as an adjunct to traditional physical therapy in some centers, the cost of equipment currently used is often high and it is often geared toward patients with high motor function. It cannot be used by patients at the bedside or at home at the moment, which would help increase the “dose” of treatment. The use of mobile devices is thus gaining interest as a possible alternative means of supplementing current rehabilitation programs, making it both more accessible – around 75% of the general public have access to a mobile device, Mr. Rinne observed – and more engaging or motivating for patients.

Mr. Rinne and coinvestigators surveyed all patients presenting with arm weakness on admission to a large hyper-acute stroke unit over a 6-month period. Of 342 patients who were screened, 89 were included. Reasons for exclusion were cognitive impairment or comorbidities (130 patients), lack of communication or language barrier (36 patients), resolution of arm weakness (34 patients), preexisting arm weakness (24 patients), arm weakness not due to stroke (5 patients), or patient refusal (24 patients).

The mean age of patients who participated was 65 years and 57% were male. The baseline National Institutes of Health Stroke Scale score was 5.8 and the NIHSS Motor subscale score was 1 on a scale of 0 to 4, signifying mild impairment. Other functional measures used were the 66-item Fugl-Meyer Assessment-Upper Extremity (FMA-UE), the 12-item Short-Form Fugl-Meyer (S-FM) scale, and the 14-item Fugl-Meyer Assessment Hand Subscale (FMA-Hand).

During the assessment period, study participants were given a mobile tablet and asked to perform a variety of touch-screen hand movements with their paretic and unaffected arms to move an object on screen. The results were given a movement score, ranging from 0 (no movement) to 3 (full range of movement) and were compared against those obtained by use of a gaming joystick and the digital handgrip developed by the Imperial College London team.

The S-FM was used to divide patients into groups depending on their baseline arm weakness. Patients with severe impairment had lower movement scores in both their paretic and unaffected hands than did those with more moderate or mild impairment. Mr. Rinne noted that there was no difference in the results seen with the conventional controllers, and a similar proportion of patients could swipe, press a button, tilt, or use the joystick successfully.

However, comparing the results obtained with the digital handgrip and mobile tablet, he noted that patients who used the digital handgrip could follow the object on screen much more accurately than when they used a swiping motion on a tablet. Even patients with severe impairment could use the handgrip.

“We found that 89% of our severely weak patients could still interact with these games and perform self-rehabilitation when using our controller,” Mr. Rinne reported. In contrast, no severely impaired patient could perform the screen swipe on a tablet.

“Performance using the handgrip was very similar across patients with different severities,” he added, noting that patients found the novel controller more comfortable and easier to use for long periods of time.

Novel control devices adapted for patients can broaden the accessibility to stroke rehabilitation, he concluded, even in those with more severe impairments.

Mr. Rinne had no conflicts of interest.