Transcript www1.mans.edu.eg

Stroke is a common cause of death in the
world and it may lead to severe activity
limitations in the survivors.
The clinical presentation varies from minor
neurological symptoms to severe deficits,
depending on the location and the size of
the brain lesion.
 Hemiparesis, one of the most striking
features in the acute phase, occur in 80-90%
of all stroke patients.
All persistent neurological deficits, in
combination with the secondary medical
and psychological complications, may cause
more or less severe activity limitations in
several domains of human functioning.
The term recovery may refer to various
pathophysiological and clinical processes
that occur in stroke patients.
According to the International Classification
of Human Functioning of WHO, the current
study generally discriminates between
Recovery of the primary neurological deficits
(restoration of body functions)
Functional recovery (improved performance of
activities).
Apparently, the restoration of neurological
deficits will result in functional recovery.
However, functional recovery may also
occur in patients who do experience no or
only partial neurological recovery.
 In these cases, functional recovery is the
result of the development of novel adaptive
strategies following therapy and learning
Processes mediating motor recovery
 Restitution theory (Resolution of pathology)
Resolution of pathological changes may allow for recovery at
the cellular level
 Substitution theory (Behavioral Compensation)
Development of compensatory movement strategies may
enable ‘recovery’ of certain motor functions
 Brain plasticity
Undamaged regions in the sensori-motor network take over
the function of damaged areas
Potential mechanisms of brain plasticity
 Removal of inhibition
 Sprouting of new connections
 Altered synaptic strength in existing local networks
 Altered recruitment of existing pathways
 Functional recovery after stroke is influenced by
many factors and recovery profiles are
characterized by high interindividual variability.
Prediction of functional outcome for
individuals immediately after stroke onset is
difficult but become somewhat easier and
more relevant, once it is clear that the
patient is likely to survive (at about 2 weeks
post stroke).
However the quality of motor recovery after
stroke is difficult to predict on the basis of
only clinical data and radiological finding
A valid prognosis for the individual stroke
patient is required as early as possible after
stroke onset in order to:
 Inform the patients and his relatives adequately
Initiate optimal rehabilitation based on realistic
goal
Facilitate discharge planning(including necessary
home adjustment and support)
Extensive prognostic studies have been
performed to address the prediction of stroke
outcome. Many prediction models have been
proposed ,but their predictive validity
appeared to be rather poor.
Moreover, It is also difficult to give a precise
time window for motor recovery in individual
patient .
 Several clinical and demographic variables
may be valid predictors of general
functional recovery, including
 Consciousness at the onset
 Orientation in time and place
 Age
 Sitting balance
 Severity of paresis
 Disability on admission
 Urinary incontinence
 Previous stroke
 The initial grade of paresis is an important
predictor for motor recovery and
subsequent functional recovery.
 However, particularly in non cooperative
patients or severely cognitively impaired
patients clinical neurological examination
may be invalid and thus inconclusive with
respect to diagnosis.
 Moreover, in case of initial paralysis clinical
examination alone lacks the possibility to
detect the potential for motor recovery.
Motor evoked potentials (MEPs), obtained
at various times after stroke, have also been
studied as valid predictors.
 These motor potentials are evoked by
means of noninvasive magnetic stimulation
of the motor cortex, and they assess
objectively and quantitively the integrity of
the motor pathways.
 Until now, the use of motor evoked
potentials (MEPs) in predicting motor and
functional outcome is still equivocal and
studies seems to be contradictory.
TMS is a non-invasive and
effective methodology with
potential diagnostic and
therapeutic uses. Studies to
date have not provided
enough data to establish
the clinical indication for a
systematic application of
TMS as a diagnostic or
therapeutic tool in any
neurological or psychiatric
disease
The data from TMS
studies in stroke patients
have specifically been
used to
 Assess the motor impairment
 Predict motor & functional
recovery
 Study cortical reorganization
for clinical recovery
 Study inhibitory phenomenon
induced by stimulation
A prospective hospital-based clinical study
Ischemic cerebral stroke
188
115
Day 1
Day 7
102
Day 30
78
Day 90
66 healthy normal subjects matched with
age and gender of the selected patient
provided a normative database of
neurophysiologic measurement
Inclusion & Exclusion Criteria
Best current knowledge in clinical routine
NIHSS
Add your text
MRC
Barthel index
Routine
Add your text
Laboratory
Parameters
CT
Add your text
Head Scan
Motor Evoked
Potential
Add
your text
Study
NIHSS categorized into 3 groups
poor outcome
Borderline outcome
Favorable outcome
NIHSS≤8
Minor Disability
NIHSS from 8-14
Moderate Disability
NIHSS > 14
Sever Disability
BI categorized into 3 groups
Severe Dependence
Moderate Dependence
Functional Independence
BI > 95
BI from 70-90
BI ≤70
For Dichotomization of the results
BI
NIHSS
Favorable
Poor
Favorable
Poor
If ≤8
If > 8
If ≥ 95
If < 95
Site
Size
Normal (N)
Normal (N)
Small (<2cm)
Cortical (C)
Moderate (2-5cm)
Large (5-10cm)
CT Brain
Subcortical (S)
Cortico-subcortical (CS)
Basal ganglia (BG)
Cortical, subcortical and
basal ganglion (CSBG).
Mag Pro R30 magnetic stimulator
model 2003 featuring Biphasic
wave form with circular coil C-100.
Group 1
Normal response
Delayed CCT >2.5 SD
MEPs
Group 2
Significant interside latency difference of 50%.
Left – right difference in amplitude of 50%
or more
Group 3
No potential could be obtained.




Day 1
Day 7
188
115
Day 90
Day 30
102
78
Refusal 30
Refusal 3
Refusal 2
Recurrence 18
Recurrence 5
Recurrence 8
Improved 5
Improved 3
Improved 7
Death 20
Death 2
Death 7
Age distribution
62.74
59.93
Day1
Day7
61.76
61.48
Day 30
Day 90
Sex distribution
100%
90%
80%
46.31
51.3
50
46.2
39.4
70%
60%
Female
50%
Male
40%
30%
60.6
53.7
48.7
50
53.8
20%
10%
0%
Day 1
Day 7
Day 30
Day 90
Control
Side of hemiparesis
100
90
80
44.1
45.2
40.2
41
70
60
Left
Right
50
40
30
55.9
54.8
59.8
59
20
10
0
Day1
Day7
Day30
Day90
Risk factors
100%
DM
Hypertension
Smoking
AF
IHD
RHD
Hepatic
Renal
Dyslipedemia
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
AF
Smoking
DM
Hypertension
IHD
RHD
Hepatic
RenalDyslipedemia
CT Brain findings (Size of lesion)
Day 1
Day 7
45
40.9
40
35
41
30
25
28.7
23.5
20
15
20.7
10
3
20.2
5
18
0
Normal
Small
Moderate
Large
CT Brain findings (Site of lesion)
Day 1
Day 7
50
45
45.27
40
43.1
35
30
25
20
15
20.7
10
18.3
13.1
16
7
15.7
5
13
12.8
0
N
6.4
C
S
CS
1.1
BG
CSBG
Mean values of NIHSS
12
11.28
10
Mean
9.71
8
6.78
5.49
6
4
2
0
NIH1
NIH7
NIH30
NIH90
Mean values of Barthel Index
80
70
71.47
60
61.08
50
47.74
40
30
Mean
20
10
0
Barthel 7
Barthel 30
Barthel 90
Mean values of MRC score
2.5
Mean
1.99
2
1.83
1.5
1.14
1.1
1
0.71
0.5
0.6
0.43
0.32
0
Umscor1
Umscor7
Umscor30
Umscor90
Lmscor1
Lmscor7
Lmscor30
Lmscor90
Mean values of MEPs amplitude
3
2.85
Mean
2.5
2.3
2.1
2
1.5
1.47
1.41
1.21
1.11
1
0.86
0.5
0
ULAmp1
ULAmp7
ULAmp30
ULAmp90
LLAmp1
LLAmp7
LLAmp30
LLAmp90
McNemar crosstabulation for binomial values of NIHSS
NIH 90
NIH 1
Favorable
poor
total
Exact Sig. (2-tailed) .000
Favorable
poor
total
Count
20
0
20
% of total
25.60%
0%
25.60%
count
29
29
58
% of total
37.20%
37.20%
74.40%
count
49
29
78
% of total
62.80%
37.20%
100%
McNemar crosstabulation for binomial values of Barthel index
Barthel 90
Independent
Barthel 7
dependent
total
Exact Sig. (2-tailed) .001
Independent
Dependent
total
Count
0
1
1
% of total
0%
1.30%
1.30%
count
15
62
77
% of total
19.20%
79.50%
98.70%
count
15
63
78
% of total
19.20%
80.80%
100%
Backward stepwise regression test of NIH 1 with Many Variables
Variables
Partial
R
S.E of
partial R
Wald X²
P value
Odds Ratio
Value
95% CI for value
Lower
Upper
Hypertension
-.861
.402
4.591
.032
.423
.192
.929
Smoking
-.763
.390
3.831
.049
.466
.217
1.001
Constant
2.246
.385
33.981
.000
9.451
Backward stepwise regression test of NIH 7 with Many Variables
Variables
Triglycerides
Constant
Partial
R
S.E of
partial R
Wald X²
P value
Odds Ratio
Value
.020
.007
9.234
.002
1.020
-1.838
.827
4.933
.026
.159
95% CI for value
Lower
Upper
1.007
1.033
Backward stepwise regression test of NIH 30 with Many Variables
Partial R
Variables
S.E of
partial R
Wald X²
P value
Odds Ratio
Value
95% CI for value
Lower
Upper
Age
.470
.218
4.670
.031
1.600
1.045
2.451
SS
-1.582
.709
4975
.026
.205
.051
.825
SS7
1.369
.708
3.736
.053
3.933
9.81
15.766
Constant
-2.929
1.374
4.542
.033
.053
SS 1: subcortical stroke of initial CTexamination
SS7: subcortical stroke of CTexamination after one week.
Backward stepwise regression test of NIH 90 with Many Variables
Partial R
Variables
Age
Constant
S.E of
partial R
Wald X²
P value
Odds Ratio
Value
.673
.265
6.451
.011
1.960
-4.805
1.724
7.770
.005
.008
95% CI for value
Lower
Upper
1.166
3.295
Backward stepwise regression test of UMRC score 90 with Many Variables
Variables
Partial
R
S.E of
partial
R
Wald X²
Odds Ratio
P value
Value
95% CI for value
Lower
Upper
Hypertension
-1.883
.865
4.741
.029
.152
.028
.829
CS 1
2.321
1.373
2.859
.091
10.190
.691
150.249
SS 1
3.167
1.353
5.476
.019
23.744
1.673
337.013
CS 7
-2.609
1.122
5.406
.020
.074
.008
.664
SS 7
-4.197
1.559
7.248
.007
.015
.001
.319
Constant
3.643
1.076
11.466
.001
38.204
SS 1: subcortical stroke of initial CTexamination CS1: cortical stroke of initial CT examination
SS7: subcortical stroke of CTexamination after one week. CS7: cortical stroke of CT examination after one week
Backward stepwise regression test of LMRC score 90 with Many Variables
Variables
Partial
R
S.E of
partial
R
Wald X²
P value
Odds Ratio
Value
95% CI for value
Lower
Upper
Hypertension
-2.401
1.092
4.833
.028
.091
.011
.771
SS 1
3.445
1.853
3.456
.063
31.346
.829
1184.519
SS 7
-4.167
1.923
4.697
.030
.016
.000
.671
Cholesterol
-.031
.011
7.955
.005*
.970
.950
.991
10.389
3.035
11.716
.001
32487.135
Constant
SS 1: subcortical stroke of initial CTexamination
SS7: subcortical stroke of CTexamination after one week
* P value significant if <.05
Standardized and Unstandardized discriminant function coefficient predicting motor recovery (NIH 90)
Variables
St Function
Unst Function
NIH 1
.928
.293
Age
-.458
- .467
WBCs
-.353
- .112
Classification resultsª of motor recovery predicted from discriminant function
Predict group membership
NIH 90
Count
Favorable
poor
41
8
83.7%
16.3%
4
25
13.8%
86.2%
45
33
57.7%
42.3%
Favorable
%
Count
Poor
%
Total
Count
%
ª . 84.6% of original grouped cases correctly classified
Total
49
100%
29
100%
78
100%
Standardized and Unstandardized discriminant function coefficient predicting Functional recovery
( Barthel 90)
Variables
St Function
Unst Function
NIH 1
.842
.258
PT
.416
.233
Smoking
-.341
-.729
LDL
-.374
-.010
Pt: prothrombin time
LDL: low density lipoprotein
Classification resultsª of motor recovery predicted from discriminant function
Predict group membership
Independent
Barthel 90
Count
Total
Dependent
13
2
15
86.7%
13.3%
100%
9
54
63
14.3%
85.7%
100%
22
56
78
28.2%
71.8%
100%
Independent
%
Count
Dependent
%
Total
Count
%
ª . 85.9% of original grouped cases correctly classified
Standardized and Unstandardized discriminant function coefficient predicting motor recovery
(UMRCScore 90)
Variables
St Function
Unst Function
UMRCScore 1
1.023
1.559
NIH 1
-.438
-.110
PT
-.505
-.271
Classification resultsª of motor recovery predicted from discriminant function
Predict group membership
UMRC score 90
Count
Total
Favorable
poor
14
2
16
87.5%
12.5%
100%
8
54
62
12.9%
87.1%
100%
22
56
78
28.2%
71.8%
100%
Favorable
%
Count
Poor
%
Total
Count
%
ª . 87.2% of original grouped cases correctly classified
Standardized and Unstandardized discriminant function coefficient predicting motor recovery
(LMRC score 90)
Variables
St Function
Unst Function
UMRC score 1
.822
1.460
NIH 1
-.637
-.166
Classification resultsª of motor recovery predicted from discriminant function
Predict group membership
LMRC score 90
Count
Total
Favorable
poor
9
2
11
81.8%
18.2%
100%
10
57
67
14.9%
85.1%
100%
19
24.4%
59
75.6%
78
100%
Favorable
%
Count
Poor
%
Total
Count
%
ª . 84.6% of original grouped cases correctly classified
Functional recovery using Barthel index versus NIH recovery
Recovery NIH
F. recovery
(BI)
No
Yes
Total
Exact Sig. (2-sided) .039
No
Yes
Total
Count
40
18
58
% of Total
51.3%
23.1%
74.4%
Count
1
19
20
% of Total
1.3%
24.4%
25.6%
Count
41
37
78
% of Total
52.6%
47.4%
100.0%
Functional recovery using Barthel index versus UMRC score recovery
Recovery UMRC score
F. recovery
(BI)
No
Yes
Total
No
Yes
Total
Count
43
15
58
% of Total
55.1%
19.2%
74.4%
Count
9
11
20
% of Total
11.5%
14.1%
25.6%
Count
52
26
78
% of Total
66.7%
33.3%
100.0%
Exact Sig. (2-sided) .307
Functional recovery using Barthel index versus LMRC score recovery
Recovery LMRC score
F. recovery
(BI)
No
Yes
Total
Exact Sig. (2-sided) .405
No
Yes
Total
Count
44
14
58
% of Total
56.4%
17.9%
74.4%
Count
9
11
20
% of Total
11.5%
14.1%
25.6%
Count
53
25
78
% of Total
67.9%
32.1%
100.0%
Recovery using NIH versus UMRC score recovery
Recovery UMRC score
Recovery NIH
No
Yes
Total
No
Yes
Total
Count
28
13
41
% of Total
35.9%
16..7%
52.6%
Count
24
13
37
% of Total
30.8%
16.7%
47.4%
Count
52
26
78
% of Total
66.7%
33.3%
100.0%
Exact Sig. (2-sided) 1.000
Recovery using NIH versus LMRC score recovery
Recovery LMRC score
Recovery NIH
No
Yes
Total
Exact Sig. (2-sided) .851
No
Yes
Total
Count
30
11
41
% of Total
38.5%
14.1%
52.6%
Count
23
14
37
% of Total
29.5%
17.9%
47.4%
Count
53
25
78
% of Total
67.9%
32.1%
100.0%
Change of Amplitude at different time sets
23.1
38.2
59.1
76.9
61.8
LLAmp90
LLAmp30
66.1
P = 0.000
24.4
46.1
64.3
69.6
40.9
LLAmp7
33.9
75.6
LLAmp1
ULAmp30
53.9
35.7
30.4
No response
ULAmp90
Normal
ULAmp7
ULAmp1
Change of CMCT at different time sets
25.6
52.65
LLCMCT90
LLCMCT1
ULCMCT90
ULCMCT1
21.8
64.15
43.6
P = 0.000
52.65
17.9
47.4
44.9
3.8
17.9
7.7
No response
Delayed
Normal
Upper Limbs
54.1
Sensitivity &
Specificity of
MEPs
specificity
Motor
Recovery
Sensitivity
45
60
Recovery
Sensitivity
Functional
specificity
46.6
Lower Limbs
54.1
Sensitivity &
Specificity of
MEPs
specificity
Motor
Recovery
Sensitivity
42.5
65
Recovery
Sensitivity
Functional
specificity
46.6
Amplitude of patients versus control
6
5
4.81
4.81
4.81
4.76
4.76
4.76
4.76
4.76
P = 0.000
4
3.31
3
2.44
2
2.89
2.95
2.33
2.36
2.76
2.38
3.3
2.45
2.24
2.46
2.76
2.34
1.62
Patients Right
1.59
Patients Left
1
control Right
control Left
0
UL amp1
UL amp7
UL amp 30
UL amp90
LL amp1
LL amp7
LL amp 30
LL amp90
CMCT of patients versus control
20
18.83
18
18.63
18.3
18.36
16
17.09
16.66
17.19
14
P = 0.000
12
11.01
10
10.26
P = 0.003
10.21
10.37
10.22
9.63
14.66
14.66
14.66
15.62
14.66
P = 0.003
10.22
8
8.99
Patients Right
6
Patients Left
5.74
4
5.74
5.74
5.74
control Right
control Left
2
0
UL CMCT 1 UL CMCT 7 UL CMCT 30 UL CMCT 90 LL CMCT 1 LL CMCT 7 LL CMCT 30 LL CMCT 90
Upper Limbs
Comparison between MEPs (CMCT) values of the affected and unaffected sides
Paired Differences
95% Confidence
Interval of the
Difference
Mean
Std.
Deviation
Std.
Error
Mean
Upper
Lower
Sig. (2tailed)
ULCMCT1 - UULCMCT
3.55455
2.85124
0.38446
2.78375
4.32534
0.000
ULCMCT7 - UULCMCT
3.75455
2.73497
0.47610
2.78477
4.72432
0.000
ULCMCT30 - UULCMCT
3.75789
2.69009
0.43639
2.87369
4.64210
0.000
ULCMCT90 - UULCMCT
2.76923
2.75013
0.44037
1.87774
3.66072
0.000
ULCMCT: Upper limb central motor conduction time
UULCMCT: Unaffected upperr limb central motor conduction time
Upper Limbs
Comparison between MEPs (Amplitude) values of the affected and unaffected sides
Paired Differences
95% Confidence
Interval of the
Difference
Mean
Std.
Deviation
Std.
Error
Mean
Upper
Lower
Sig. (2tailed)
ULAmp1 - UULAmp
-1.91091
2.46859
0.33287
-2.57826
-1.24355
0.000
ULAmp7 - UULAmp
-0.79697
2.44521
0.42566
-1.66400
0.07006
0.070
ULAmp30 - UULAmp
-0.97895
1.99908
0.32429
-1.63603
-0.32187
0.005
-0.20769
1.87412
0.30010
-0.81521
0.39983
0.493
ULAmp90 - UULAmp
ULAmp: Upper limb amplitude
UULAmp: Unaffected Upper limb amplitude
Lower Limbs
Comparison between MEPs (CMCT) values of the affected and unaffected sides
Paired Differences
95% Confidence
Interval of the
Difference
Mean
Std.
Deviation
Std.
Error
Mean
Upper
Lower
Sig. (2tailed)
LLCMCT1 - ULLCMCT
3.80714
2.47400
0.33060
3.14460
4.46968
0.000
LLCMCT7 - ULLCMCT
3.47297
2.67485
0.43974
2.58113
4.36481
0.000
LLCMCT30 - ULLCMCT
2.39767
2.35690
0.35942
1.67233
3.12302
0.000
LLCMCT90 - ULLCMCT
2.08108
2.33117
0.38324
1.30383
2.85833
0.000
LLCMCT: lower limb central motor conduction time
ULLCMCT: Unaffected lower limb central motor conduction time
Lower Limbs
Comparison between MEPs (Amplitude) values of the affected and unaffected sides
Paired Differences
95% Confidence
Interval of the
Difference
Mean
Std.
Deviatio
n
Std.
Error
Mean
Upper
Lower
Sig. (2tailed)
LLAmp1 - ULLAmp
-1.10893
2.61904
0.34998
-1.81031
-.40754
0.003
LLAmp7 - ULLAmp
-0.98919
1.88941
0.31062
-1.61915
-.35923
0.003
LLAmp30 - ULLAmp
-0.62093
1.86975
0.28513
-1.19636
-.04550
0.035
LLAmp90 - ULLAmp
-0.27838
1.94110
0.31911
-0.92557
0.36882
0.389
LLAmp: lower limb amplitude
ULLAmp: Unaffected lower limb amplitude
Risk factors according to motor recovery (NIHSS)
NIHSS No recovery
NIHSS recovery
25
25
20
22
15
23
10
13
22
12
10
20
14
18
5
0
23
3
3
1
0
3
2
2
0 3
3
14
19 17
Site of lesion according to motor recovery (NIHSS)
No recovery
recovery
25
20
21
15
19
10
4
5
8
2
3
6
0
N
6
C.S
B.G
3
0
5
1
S
B.G C.S
C
Size of lesion according to motor recovery (NIHSS)
No recovery
18
P = insignificant
17
16
recovery
14
12
12
10
15
8
13
6
4
4
2
4
11
2
0
Normal
Small
Moderate
Large
Mean NIHSS according to motor recovery (NIHSS)
16
No recovery
P = 0.000
14
13.45
12
12.55
10
9.76
8
6
recovery
7.9
7
4
4.78
2
1.93
0.93
0
NIH1
NIH7
NIH30
NIH90
Mean Barthel according to motor recovery (NIHSS)
100
No recovery
recovery
87.41
90
80
P = 0.000
73.7
70
60
56.67
50
40
63.04
52.25
40.69
30
20
10
0
Barthel7
Barthel30
Barthel90
Mean amplitude according to motor recovery (NIHSS)
4
3.65
No recovery
recovery
3.5
3.61
3.15
2.84
3
2.87
2.45
2.45
2.5
2.59
2.32
2.5
1.98
1.99
2
1.5
2.74
2.17
1.63
1.6
1
P = insignificant
0.5
0
ULamp1
ULamp7
ULamp30
ULamp90
LLamp1
LLamp7
LLamp30
LLamp90
Mean CMCT according to motor recovery (NIHSS)
25
No recovery
recovery
19.2
20
18.61
17.34
18.92
17.99
15
16.53
16.96
16.04
10.59
10.41
10.27
10.19
9.9
10.01
10
10.39
9.11
P = insignificant
5
0
ULCMCT1
ULCMCT7
ULCMCT30
ULCMCT90
LLCMCT1
LLCMCT7
LLCMCT30
LLCMCT90
Risk factors according to functional recovery
No recovery
recovery
P = insignificant
40
35
30
32
25
36
20
15
15
16
10
5
0
29
29
17
22
10
6
5 1
1 0
3 2
0
2
10
9
2
10
13
7
Site of lesion according to functional recovery
No recovery
recovery
30
P = insignificant
25
30
20
15
10
10
5
1
5
9
5
3
0
0
6
Normal
C.S
B.G
7
1
S
B.G C.S
C
1
Size of lesion according to functional recovery
No recovery
recovery
25
20
23
15
10
9
13
1
5
17
5
4
6
0
Normal
Small
Moderate
Large
Mean NIHSS according to functional recovery
14
No recovery
12
12.79
recovery
11.79
P = 0.000
10
8
8.97
7.14
6.65
6
4.25
4
1.5
2
0.7
0
NIH1
NIH7
NIH30
NIH90
Mean amplitude according to functional recovery
4.5
No recovery
recovery
4
3.91
3.53
3.5
2.91
2.79
3
2.51
3.14
3.01
2.31
2.5
2.54
2
2.41
2.43
2.03
2.23
1.71
1.97
1.5
1.57
1
P = insignificant
0.5
0
ULamp1
ULamp7
ULamp30
ULamp90
LLamp1
LLamp7
LLamp30
LLamp90
Mean CMCT according to functional recovery
25
No recovery
recovery
19.34
20
P = 0.024
18.77
P = 0.045
17.5
18.59
17.55
16.47
15
16.68
15.54
P = 0.012
10.79
10
10.39
10.63
10.23
10.15
10.14
9.84
9.36
P = insignificant
5
0
ULCMCT1
ULCMCT7
ULCMCT30
ULCMCT90
LLCMCT1
LLCMCT7
LLCMCT30
LLCMCT90
Case One
UL
LL
4.7
3.4
21.4
28.7
5.4
18.1
3.4
28
7
2.2
19.8
29.3
2.3
5
19
28.1
Day 7
UL
Case Two
LL
33.1
1.8
3.7
31.7
Day 7
Case Three
UL
LL
1.6
36
35
1.6
1.8
26.9
0.1
33
0.7
28.2
21.4
Day 7
0.4
Case Four
UL
LL
0.1
1.6
27.2
35.6
1.7
30
23.3
1.8
3.6
2.4
30.2
23.1
4.2
4.7
27.3
20.9
Day 7
The severity of neurologic deficit at entry is
the cranial parameter with statistically
significant difference between those who
experienced functional and/or motor
recovery and those who did not.
The NIH stroke scale has a predictive power
of 84.6% when considering the motor
outcomes in ischemic stroke patients in the
territory of anterior cerebral circulation .
Gathering the clinical scores together may give
a better prognostic model of recovery after
stroke.
However the only valid model for predicting
the recovery after stroke (p value =0.039) is by
gathering both Barthel index and NIHSS scores
Age affect and significantly interact (p=0.011)
with stroke motor outcome (NIH90) after 3
months i.e. the more advanced the age the
higher is NIHSS
The negative impact of age on functional
outcome is most apparent when clinical
status at discharge is being assessed.
WBCs count affected negatively the stroke
motor recovery (NIH90) after three months
i.e. the larger the WBCs count the higher is
the NIHSS score.
For that, attenuating neutrophilic response
early after ischemic stroke may be a viable
therapeutic strategy and warrants further
study.
 Smoking affects the functional recovery rather
than the motor recovery 3 months after stroke.
Moreover, smoking is associated with increase in
stroke severity at the onset.
 Infarction site (both the cortical and subcortical
ischemia ) has greater influence on motor score
of the upper limb three months after stroke.
 Also, subcortical stroke significantly affect the
stroke severity (NIH30) in the first month after
the stroke (p=0.026).
There were significant change of the MEPs
( Amp & CMCT) recorded at different time sets
after stroke . These changes towards normal
values of either the unaffected side or that of
healthy control indicate restoration of
corticopinal tract function after stroke
The higher rate of MEPs change to near normal
values occurred at 3 months post stroke.
Our findings signify the favor of amplitude rather
than conduction time in predicting recovery i.e.
MEP amplitude has a higher prognostic value rather
than the CMCT.
In the current study, the amount of variance of
the outcome explained by the neurophysiologic
measures, although is clearly higher if examined
at 3 month; it indicates the limited predictive
value of these measures alone
MEPs showed a higher specificity than sensitivity
(although both of low values) indicating that its
negative predictive value is much important than
its positive predictive value.
From the current study, It can be concluded that
in acute phase, neurophysiologic measures alone
are not helpful in predicting motor recovery in
patients with stroke and their values are limited
even at 3 months. However, clean benefit is
obtained when neurophysiologic measures are
used in combination with clinical examination.
Early prediction of stroke outcome remains
one of the most important and unresolved
issues in neurological rehabilitation.
 The already known predictors of outcome
help us to ascertain the chances of recovery
poststroke, but none of them, alone or in
combination, permits us to determine
whether a patient can recuperate from a
disability.
There should be an Egyptian model for predicting
the recovery after stroke. This model can be used
to make clinically useful predictions of the course
of functional recovery based on patient
characteristics and initial progress.
This model should also use different known and
well established prognostic variables in predicting
recovery at any time point after stroke.
Data from clinical and functional assessments,
specially the initial degree of motor weakness, and
anatomical and pathological information derived
from CT scans are taken together with the results of
TMS investigations will be more predictive than any
single method alone
There should be an effort to recruit a larger
number of patients (multicenter studies?) in a
series that
Is designed well in statistical terms,
Is truly representative of the general population
affected by stroke,
Is tested with the appropriate methodology