Post-Stroke Recovery

Cerebrovascular Aaccident (CVA) / Stroke

Stroke may be defined as a sudden neurological deficit of presumed vascular origin 1. Stroke is the second-most cause of mortality and the third leading cause for disability, worldwide 2-4. One in 6 people will have a stroke during their lifetime and one-third of those will experience recurrence  4. 

A stroke occurs when blood flow to a part of the brain is stopped either by a blockage or the rupture of a blood vessel. As a result, the brain tissue suffers from a lack of oxygen and nutrients, brain cells begin to die in minutes and additional brain regions suffer tissue damage.

Common signs and symptoms include the abrupt onset of any of the following: side or limb weakness, side or limb sensory impairments, visual loss, speech difficulties, facial droop, gait disorders, vertigo, and a decrease in the level of consciousness. In addition, up to 50% of stroke survivors suffer from cognitive impairments including memory loss, decreased attention and processing speed, and inability to reason or plan.

In general, recovery from stroke occurs mainly within the first 30 days, though moderate and severe stroke survivors continue to improve for at least 90 days 5. Rehabilitation includes a multidisciplinary approach which includes physiotherapy, speech and language therapy, cognitive rehabilitation therapy, medications, and more. However, these programs have limited success 6.

Hyperbaric Oxygen Therapy (HBOT) and Chronic Brain Damage

Hyperbaric Oxygen Therapy (HBOT) is used for chronic and urgent medical conditions associated with tissue hypoxia (lack of oxygen supply). There is growing data on the physiological effects of HBOT on different injured tissue, including the brain, using different models of preclinical as well as clinical studies. Recently, clinical studies in the Shamir Medical Center evaluated the effect of HBOT on patients suffering from neurological deficiencies. In these studies, it was found that HBOT can induce neuroplasticity in stunned/wounded brain regions (metabolic dysfunction) even years after the acute insult.  These brain regions can be visualized by metabolic imaging of the brain, performed by SPECT analysis combined with MRI. In the regions where there is SPECT/MRI mismatch, HBOT can reactivate, initiate regeneration, and induce neuroplasticity that is correlated with the related clinical symptoms[1].

[1] Boussi-Gross et al., 2013; Boussi-Gross et al., 2015; Efrati and Ben-Jacob, 2014; Efrati et al., 2013; Tal et al., 2015a, b; Tal et al., 2017.

The results are of a patient suffering from right hemiparesis due to ischemic stroke that occurred 14 months prior to HBOT. These SPECT images demonstrate significant improvement of metabolism in the left hemisphere involving the medial and posterolateral frontal area (motor cortex, red circles) and lateral inferior frontal region (Broca's area, blue circles) in comparison to the baseline SPECT. HBOT SPECT findings correlate positively with the patient's improved motor and verbal functions.

Post Stroke and HBOT Research

Recently, clinical studies in the Shamir Medical Center evaluated the effect of HBOT on patients suffering from neurological deficiencies due to stroke. In the randomized controlled study entitled “Hyperbaric Oxygen Induces Late Neuroplasticity in Post Stroke Patients – Randomized, Prospective trial”, it was found that HBOT can induce neuroplasticity and improve both motor deficits, cognitive impairments, activities of daily life and quality of life even years after the acute insult.  The HBOT treated group showed significant improvements in NIHSS (neurological motor function score), ADL (activities of daily life score), and EQ-5D (quality of life score) compared to the controlled group. Moreover, patients in the control group were later crossed to receive HBOT, gaining similar neurological and quality of life improvements.

In another study, a retrospective analysis of 91 stroke patients revealed significant memory (both immediate and delayed) improvements after HBOT. The clinical improvements were well correlated with improvement in brain metabolism, mainly in temporal areas.

In the latest research headed by Dr. Amir Hadanny and Dr. Shai Efrati the team evaluated the effects of HBOT on the world's largest cohort of stroke patients treated with HBOT– see; “Hyperbaric oxygen therapy improves neurocognitive functions of post-stroke patients – a retrospective analysis.”  A retrospective analysis was conducted on 162 patients who were treated with HBOT for chronic stroke (>3 months after the insult) between 2008-2018 at the Sagol center.

Research Results:

  • Significant improvements in all cognitive domains post HBOT even in the late chronic stage.
  • The clinical improvements were achieved regardless of the type, the location, or the side of the stroke.

Treating Stroke: Sagol Center Recommended HBOT Protocol

Phase I Medical Assessment

The process begins with a comprehensive medical, physiological, cognitive, and imaging evaluation assessment. The tests are conducted by trained medical staff including: Physicians, Neuropsychologists, Physiotherapists, Physiologists, Nurses, and more.

The evaluation also includes metabolic/functional brain imaging: brain perfusion MRI+ brain microstructure (DTI) and brain SPECT in addition to neurocognitive tests and physical therapist assessment.

Phase III HBOT Protocol

60 Daily consecutive sessions / 5 days per week / 2 ATA / 100% Oxygen for 90min  with minutes air brakes every / total session time 120min.

Throughout the treatment period, rehab training will be provided to patients by professional cognitive and physiological professionals.

Phase III Post-HBOT Assessment

 At the end of the treatment, the evaluation and tests done at baseline will be repeated for an objective evaluation by the medical team.

References

  1. Bath PM, Lees KR. ABC of arterial and venous disease. Acute stroke. Bmj. Apr 1 2000;320(7239):920-923.
  2. Murray CJ, Lopez AD. Mortality by cause for eight regions of the world: Global Burden of Disease Study. Lancet. May 3 1997;349(9061):1269-1276.
  3. Towfighi A, Saver JL. Stroke declines from third to fourth leading cause of death in the United States: historical perspective and challenges ahead. Stroke; a journal of cerebral circulation. Aug 2011;42(8):2351-2355.
  4. Bogousslavsky J, Aarli J, Kimura J, Board of Trustees WFoN. Stroke: time for a global campaign? Cerebrovascular diseases. 2003;16(2):111-113.
  5. Duncan PW, Goldstein LB, Matchar D, Divine GW, Feussner J. Measurement of motor recovery after stroke. Outcome assessment and sample size requirements. Stroke; a journal of cerebral circulation. Aug 1992;23(8):1084-1089.
  6. Hebert D, Lindsay MP, McIntyre A, et al. Canadian stroke best practice recommendations: Stroke rehabilitation practice guidelines, update 2015. International journal of stroke : official journal of the International Stroke Society. Jun 2016;11(4):459-484.