alan barber - gp cme sat 0835 barber - recovery after stroke.pdf · alan barber professor of...
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Alan BarberProfessor of Clinical NeurologyUniversity of Auckland
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9000 new strokes in NZ every year 3rd most common cause of death
1 in 5 die within first month 1 in 2 dead or dependent by 1 year
Major cause of long term adult disability
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Not restricted to the elderly 1 in 4 people with stroke are working age
Major problem in Maori/Pacific Age of onset Maori 56 y
Pacific 60 yEuropeans 73 y
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Stroke unit care Ischemic stroke aspirin stroke thrombolysis hemicraniectomy for malignant infarction
Very few phase III rehabilitation studies
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Sudden onset dysphasia & dense right sided weakness
iv thrombolysis at 3 hours 40 mins minimal improvement at 24 hours
What are her prospects for further recovery? What mechanisms underlie further recovery? What treatments available to promote
recovery?
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Most survivors show spontaneous functional improvement
Rehabilitation facilitates this improvement Occurs due to behavioural changes = adaptation &
compensation recovery = re-organisation of brain with
surviving areas taking over function of damaged brain
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Neurons contributing to complex functions distributed throughout cortex with signals routed along multiple pathways
This diffuse connectivity facilitates recovery
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Rapid unmasking of latent synapses Molecular & cellular changes peri-infarct & connected areas excitable axonal sprouting, synaptogenesis
Compensatory circuits strengthened & refined by activity
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Rapid unmasking of latent synapses Molecular & cellular changes peri-infarct & connected areas excitable axonal sprouting, synaptogenesis
Compensatory circuits strengthened & refined by activity
Brain function re-mapped from damaged to surviving connected areas
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Somatotopic shifts adjacent if small stroke
S1
M1
PMv
SMA
M1
Nudo ‘96, Frost ‘03, Plautz ‘04, Dancause ‘05, Eisner-Janowicz ‘08
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More distant if larger strokes
S1
M1
PMv
SMA
M1
Nudo ‘96, Frost ‘03, Plautz ‘04, Dancause ‘05, Eisner-Janowicz ‘08
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Sudden onset dysphasia & dense right sided weakness
iv thrombolysis at 3 hours 40 mins minimal improvement at 24 hours
What are her prospects for further recovery?
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SAFE score MRC grade for finger extn + shoulder abdn dichotomised into ≤7 or ≥8
Stinear C. Lancet Neurol 2010
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Motor evoked potentials presence/absence
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T1-WI Diffusion tensor imaging
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T1-WI Fractional anisotropy asymmetry index
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Stinear C. Lancet Neurol 2010
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Sudden onset dysphasia & dense right sided weakness
iv thrombolysis at 3 hours 40 mins minimal improvement at 24 hours
What treatments on the horizon to promote recovery?
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Currently few therapeutic options physical therapy occupational therapy speech language therapy
Wide range therapies under investigation few tested in phase III clinical studies
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www.rehabmed.emory.edu www.schlaganfalltraining.de
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Dopaminergic Cholinergic agents Amphetamines Serotonin reuptake inhibitors
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Active-Passive Bilateral Training
Stinear C. Brain 2008
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SuppressExcite
cTBSiTBS
Stroke side X
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May improve function following stroke But few cells enter the brain little/no differentiation into neural cells functional improvement within few days
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Acute stroke therapies benefit few patients Techniques are required to enhance
response to rehabilitation therapies Multiple avenues of research but few phase
III studies Unlikely there will be a one size fits all
solution
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Dr Cathy Stinear Prof Winston Byblow Funding Agencies Health Research Council of NZ Stroke Foundation of NZ Neurological Foundation of NZ Julius Brendel Trust