Factors necessary for independent walking in patients with thalamic hemorrhage

Hiraoka et al. BMC Neurology (2017) 17:211 DOI 10.1186/s12883-017-0991-2 RESEARCH ARTICLE Open Access Factors necessary for independent walking in patients with thalamic hemorrhage Shigenori Hiraoka1, Shinichiro Maeshima1,2* , Hideto Okazaki1, Hirokazu Hori1, Shinichiro Tanaka1, Sayaka Okamoto1, Reisuke Funahashi1, Kei Yagihashi1, Ikuko Fuse1, Naoki Asano1 and Shigeru Sonoda1 Abstract Background: Thalamic hemorrhages cause motor paralysis, sensory impairment, and cognitive dysfunctions, all of which may significantly affect walking independence. We examined the factors related to independent walking in patients with thalamic hemorrhage who were admitted to a rehabilitation hospital. Methods: We evaluated 128 patients with thalamic hemorrhage (75 men and 53 women; age range, 40–93 years) who were admitted to our rehabilitation hospital. The mean duration from symptom onset to rehabilitation hospital admission was 27.2 ± 10.3 days, and the mean rehabilitation hospital stay was 71.0 ± 31.4 days. Patients’ neurological and cognitive functions were examined with the National Institutes of Health Stroke Scale (NIHSS) and Mini-Mental State Examination (MMSE), respectively. The relationship between patients’ scores on these scales and their walking ability at discharge from the rehabilitation hospital was analyzed. Additionally, a decision-tree analysis was used to create a model for predicting independent walking upon referral to the rehabilitation hospital. Results: Among the patients, 65 could walk independently and 63 could not. The two patient groups were significantly different in terms of age, duration from symptom onset to rehabilitation hospital admission, hematoma type, hematoma volume, neurological symptoms, and cognitive function. The decision-tree analysis revealed that the patient’s age, NIHSS score, MMSE score, hematoma volume, and presence of ventricular bleeding were factors that could predict independent walking. Conclusions: In patients with thalamic hemorrhage, the neurological symptoms, cognitive function, and neuroimaging factors at onset are useful for predicting independent walking. Keywords: Hemorrhage, Thalamus, Outcome, Rehabilitation, Ambulation Background Cerebral hemorrhage occurs in 18.5% of stroke patients and thalamic hemorrhage accounts for 26% of all cerebral hemorrhages [1]. The thalamus is a vital structure that has extensive neural connections with other structures, allowing it to send signals throughout the brain including to the cerebral cortex. As such, the thalamus is involved in sensory and motor signal relays and in the regulation of consciousness. Given its interconnectedness with other regions, thalamic hemorrhages can cause cognitive dysfunctions such as aphasia, unilateral neglect, and memory impairments, as well as motor paralysis and sensory disturbances. These deficits can * Correspondence: 1 Department of Rehabilitation Medicine II, School of Medicine, Fujita Health University, Tsu, Japan 2 Department of Rehabilitation Medicine, Fujita Health University, Nanakuri Memorial Hospital, 114-2 Oodoricho, Tsu, Mie 514-1295, Japan greatly affect a patient’s ability to perform activities of daily living (ADLs) [2]. The prognosis of patients with thalamic hemorrhage varies depending on the patient’s age, neurological severity, hematoma location and size, complications, and treatment type. In rehabilitation wards, patients undergo intensive treatment in the early stages after stroke to help decrease ADL impairments and hasten recovery. Upon returning home, the reacquisition of walking ability is a major focus for patients with stroke with disabilities. However, few reports discuss the factors related to walking in patients with thalamic hemorrhage [3]. Understanding these factors is important for predicting patient outcome and for efficiently and effectively advancing their rehabilitation program. The information available upon discharge of the patient from the acute-care hospital may be useful for © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Hiraoka et al. BMC Neurology (2017) 17:211 predicting whether a patient will be able to walk independently upon discharge from the rehabilitation hospital. Here, we analyzed the factors related to independent walking in patients with thalamic hemorrhage who were admitted to a rehabilitation hospital. Methods Patients From April 2013 to March 2016, 181 patients with thalamic hemorrhage visited the rehabilitation department of our hospital. After excluding patients with a history of previous stroke, neurodegenerative disease, and unconsciousness, as well as those who underwent surgical treatment or tracheotomy, we finally enrolled 128 patients (75 men and 53 women) in our study. The present study was conducted with the approval of the ethics committee at our university. Written informed consent was obtained from all patients or their legally acceptable representatives following a thorough explanation of the study. Evaluations We evaluated the following items in our patients with thalamic hemorrhage: age, duration from symptom onset to rehabilitation hospital admission, classification for hematoma location on computed tomography (CT) images [4], side of the stroke focus, hematoma volume, ventricular bleeding (yes/no), and neurological and cognitive function. The hematoma type was classified as follows: type I, hematoma localized in the thalamus; type II, hematoma extending into the internal capsule; and type III, hematoma extending into the midbrain (Fig. 1). The hematoma volume was calculated using the CT images that were acquired upon admission to the acute-care hospital as follows: major axis of the hematoma × minor axis × height × 1/2 (mL) [5]. Neurological severity was evaluated using the National Institutes of Health Stroke Scale (NIHSS) [6], and cognitive function was evaluated using the Mini-Mental State Examination (MMSE) [7]. At rehabilitation hospital Page 2 of 5 discharge, we assessed the patients’ functional ambulation category (FAC, Table 1) [8]. Here, patients were considered independent walkers if they had an FAC score ≥4 (i.e., they could walk independently on level ground but required assistance with stairs and slopes). We divided the patients into two groups based on the FAC at discharge, as follows: independent-walking group (FAC ≥4) and dependent-walking group (FAC <4). Statistical analysis Data were analyzed (...truncated)