The study evaluated whether the activity of the indoleamine 2,3 dioxygenase (IDO) enzyme is increased post-stroke and contributes to the development of post-stroke depression (PSD) via tryptophan (TRP) depletion and neurotoxic kynurenine (KYN) metabolite production. The activity of IDO was measured using the KYN/TRP ratio. Participants were assessed for depression severity using the Center for Epidemiological Studies Depression Scale (CES-D). Blood TRP, KYN, large neutral amino acids and cytokines were measured and compared. Fifty-four (mean age=69.9±15.2, male=52.7%, mean NIHSS=7.3±4.6) patients within 28.9±40.3 days of stroke were separated into two groups: non-depressed (n=38, CES-D=6.1±4.9) and those with significant depressive symptoms (n=16, CES-D=26.8±10.8). Higher mean KYN/TRP ratios were demonstrated in stroke patients with depressive symptoms (non-depressed=69.3±36.9 vs. depressive symptoms=78.3±42.0, F3,50=4.61, p=0.006) after controlling for LNAA (p=0.026) and hypertension (p=0.039). As the KYN/TRP ratio reflects decreased TRP and increased neurotoxic KYN metabolites, both mechanisms may play an etiological role in PSD.

Stroke är den näst vanligaste orsaken till funktionsnedsättning och död i världen. Vid en stroke kan livet förändras plötsligt och medför ofta en stor omställning för individen. Syftet med litteraturstudien var att undersöka patienters upplevelse av att ha drabbats av en stroke, upplevelse av tiden på sjukhus i direkt anslutning till stroke. Litteraturstudien genererade elva vetenskapliga artiklar och vars resultat resulterade i fyra teman: Den oförutsägbara kroppen, Förlusten av identitet, I vårdarens händer och Viljan och hoppet om livet. Patienters upplevelser visar att god omvårdnad är anpassad utefter varje individ. Att drabbas av en stroke upplevdes som att mista sin självständighet, genom förlust av förmågor som medförde att patienter blev beroende av andra. Att bli beroende upplevdes som en svår situation och det skapade en känsla av att förlora sin kropp och identitet, då förmågor som tagits för givet var förlorade. Upplevelserna och behoven var individuella och bör utgå från varje enskild person. Genom att ta reda på hur patienter upplever att drabbas av en stroke kan det bidra till en ökad förståelse för enskilde individen och dess behov, vilket resulterar i en bättre omvårdnadskvalitet. / Stroke is worldwide the second common cause to disabilities and death. At a stroke life can sudden change and is often a great conversion for the individual. The purpose with this literature review was to investigate patients experiences of suffering a stroke, in directly connection to hospitalization. The literature review generated in eleven scientific articles that resulted in four themes: The unpredictable body, Loss of identity, In the hands of the caregiver and The will and hope of life. Patients´ experiences show that they consider the care as good when the care is custom along each individual. Suffering a stroke was experienced as a loss of independency, thru loss of abilities that resulted in that patients became dependent of others. To become dependent of others was experienced as difficult and it created a feeling of losing its body and identity, when abilities that were taken for granted was lost. The experiences and the needs from individuals should arise from each person. By investigating how patients experience the suffering of a stroke it could contribute to an increased understanding for the individual and its needs, which results in a better quality of nursing.

ABSTRACT   Aim: The aim of this retrospective study was to identify which indications prompted an MRI examination using the protocol ”Brain screening/Stroke” and whether the screening revealed recent infarcts and their localisation.   Method: The data, which was subtracted from RIS (Röntgeninformationssystem), covered all consultation responses from stroke-rounds performed during 2015 at Akademiska Hospital in Uppsala (UAS).  A total of 235 patients underwent an MRI-examination using the protocol ”Brain screening/Stroke”. Of this total population, 9 patients with a suspected or confirmed tumour were excluded. The information was collected at UAS during the period 11-22 April, 2016.   Results: No indications were reported from the material collected. Hence, the method was insufficient to give an answer to the question at hand. In the final selection of 226 patients, no stroke could be detected in 42 % of the cases, 23 % had recent infarcts, 21 % had both recent and old infarcts and 14 % had only old infarcts. By gender the results were as follows: Of the total population, 85 patients were female. In 48% of these cases no stroke was detected, 21 % had recent infarcts, 20 % had old infarcts and 11 % had both recent and old infarcts. The remaining 142 patients were male. In 38% of these no stroke was detected, in 27% of the cases both an old an a recent stroke were detected , in 24% of the cases a recent stroke was detected and 11% had only old infarcts. Looking again at the total population, the consultation responses mentioned only recent infarcts and where these were located. The majority of the recent infarcts detected, 23 % were located in the Lobes of the brain, followed by 16% in the Cortex of the brain, 16% in the Brainstem,  13% in the Cerebellum, 10 % were locaded in ”Other parts of the brain”, 8 % were in the Talamus, 7 % were in White matter and the final 6 % in the Basala ganglia. The total number of recent infarcts detected was 189. Conclusion: The main question for this study was to see if it was possible to discover acute infarcts, using diffusion weighted MRI, and the localisation of those discovered. The method chosen worked well, but to get a better overview, more studies should be done, examining infarcts in greater detail. This knowledge may, in turn, be used as a basis for stroke diagnosis. It might also be of interest to complete this study, with a more in-depth analysis of the connection between different kinds of infarcts and the patient’s gender and age.

Stroke is the third leading cause of death in the developed world and is the leading neurological cause of disability with a massive impact on personal life and society. Large artery atherosclerosis is one of the main causes of ischaemic stroke. However, in several aspects of this condition there is still a significant amount of uncertainty about its prevalence, appropriate investigation and possible treatment. Reliable data on epidemiology are therefore necessary to provide clinicians and researchers with crucial information to guide diagnostic and therapeutic management as well as further research. With this thesis I aimed to provide useful information about the prevalence of large artery disease in certain groups of patients, and to contribute to investigation- and managementstrategies using data from a large population based study, the Oxford Vascular Study (OXVASC). OXVASC is a prospective, population-based incidence study of vascular disease in Oxfordshire, UK, which started in 2002 and is ongoing. The study population comprises all 91,106 individuals registered with nine general practices and uses multiple methods of case ascertainment to identify all patients with vascular events. Firstly, I have shown that the prevalence of ≥50% vertebral or basilar artery stenosis in posterior circulation TIA or minor stroke is more than twice as high as the prevalence of ≥50% carotid stenosis in patients with carotid territory events, and is associated with a very high early risk of stroke of 22% and TIA of 46%. Furthermore, severe vertebral and/or basilar artery stenosis is associated with multiple TIAs at first presentation. Secondly, I have shown that early risk of stroke was higher after posterior circulation TIA, with a 1-year risk of 16%, than after carotid territory TIA, with a 1-year risk of 9%. In addition, I was able to show for the first time, that the ABCD2 score was predictive of early stroke not only in patients with carotid circulation TIA but also in patients with vertebrobasilar TIA. Thirdly, in a pilot feasibility study about arterial spin labelling magnetic resonance imaging in patients with large artery disease in the vertebrobasilar circulation I have shown that patients with severe large artery disease have significantly impaired occipital brain perfusion. My results suggest that this new technique might be a useful tool to identify suitable patients for interventional treatment of vertebrobasilar large artery disease. Fourthly, I was able to show that the risk of ipsilateral stroke and TIA in patients with an asymptomatic carotid stenosis is very low with contemporary best medical treatment alone, suggesting that routine carotid endarterectomy for asymptomatic carotid stenosis might not longer be feasible. Finally, I have clarified that lower rates of intervention for moderate to severe symptomatic carotid stenosis in women than in men can be explained by sex-differences in the populationbased incidence of carotid large artery disease and not due to under-investigation or reluctance amongst women to undergo investigation or treatment.

Bakgrund: Att drabbas av stroke i unga år innebär en stor livsförändring. Försämrad livskvalitét, nedsatt välbefinnande och påverkade relationer är några konsekvenser av att insjukna. Många får dessutom bestående funktionsnedsättningar som påverkar vardagen, såväl i hemmet som på arbetet. En stroke innebär ett trauma som är svårt att hantera för de drabbade individerna, sjukdomen ses som något som bara drabbar äldre. Tidigare studier visar att professionellt stöd till unga individer som drabbas av stroke är begränsat. Syfte: Syftet med studien var att beskriva unga kvinnors upplevelser av livet efter att ha drabbats av stroke. Metod: Analysmetoden som användes var en kvalitativ innebördsanalys av narrativa texter från sex bloggar, skrivna på svenska av kvinnor i åldrarna 26-45 år, bosatta i Sverige. Resultat: Unga kvinnor som drabbats av stroke upplevde att livet efter insjuknandet bestod av ett ständigt sökande efter mening och sammanhang. De fick genomleva mycket oförståelse och kände skuld och skam över att inte längre passa in. Kvinnorna upplevde brist på professionellt stöd och fick därmed stödja sig på sina anhöriga. Slutsats: Unga kvinnor som drabbats av stroke är i behov av stöd och rehabilitering. Omvårdnaden behöver bli mer person- och familjecentrerad för att minska lidande hos kvinnor som lever med konsekvenserna av stroke. / Background: Suffering a stroke at a young age is life-changing. Reduced quality of life and well-being, and impact on relationships are some of the consequences following the disease. Some people get permanent disabilities that affects everyday life, both at home and at work. A stroke often means a trauma that is hard to handle for the individuals, and the disease is seen as something that only affects older people. Previous studies show that professional support to young individuals suffering a stroke is limited. Aim: The aim of this study was to describe young women's experiences of life after having suffered a stroke. Method: This study was made with a qualitative meaning analysis of narrative texts from six blogs, written in Swedish by women, age 26-45, living in Sweden. Results: Young women experienced life following a stroke as a constant search for meaning and coherence. They had lived through a lot of misunderstandings and they felt guilty and ashamed because they no longer fit in. The women experienced lack of professional support and therefore had to rely on their relatives for support. Conclusion: Young women who have suffered a stroke are in need of support and rehabilitation. Nursing care needs to be more person- and family centered to minimize suffering in women living with the consequences of stroke.

Bakgrund: Fatigue (hjärntrötthet) är ett tillstånd som kan uppkomma till följd av exempelvis en stroke och förklaras som en extrem trötthet som inte går att vila bort. Detta är ett tillstånd som många gånger kan upplevas som ett problem efter en stroke. Syfte: Att belysa hur det är att leva med fatigue till följd av stroke. Metod: En litteraturstudie bestående av nio vetenskapliga artiklar med kvalitativ ansats genomfördes för att besvara syftet. Artiklarna kvalitetsgranskades och en innehållsanalys av artiklarnas resultat utfördes. Resultat: Post-stroke fatigue kunde upplevas påfrestande och inverkade negativt på livet. Sömn och vila tog upp mycket tid och nya rutiner krävdes för att orka med det vardagliga livet. Det blev svårare att upprätthålla samma sociala liv som tidigare. Informationen som gavs till patienterna upplevdes som bristfällig och vårdpersonalen kunde uppfattas okunniga om fatigue till följd av stroke. De personer som hade en ökad kunskap om fatigue kunde lättare hantera och anpassa sig till situationen. Slutsats: Att arbeta personcentrerat kan underlätta för att upptäcka vårdbehovet av fatigue. För att upptäcka vårdbehovet kan en större kunskap hos sjuksköterskorna behövas än vad patienterna upplever att de har. Kunskapen om post-stroke fatigue kan utökas genom att implementera det i sjuksköterskeutbildningen.

Stroke is the third leading cause of mortality in the United States, and so far, no clinical interventions have been shown completely effective in stroke treatment. Stroke may result in hypoxia, glutamate release and oxidative stress. One approach for protecting neurons from excitotoxic damage in stroke is to attenuate receptor activity with specific antagonists. Disulfiram requires bio-activation to S-methyl N, N-diethylthiolcarbamate sulfoxide (DETC-MeSO). In vivo, DETC-MeSO is further oxidized to the sulfone which is carbamoylated forming Carbamathione, a glutathione adducts. Carbamathione proved to be useful as a pharmacological agent in the treatment of cocaine dependence with the advantage that it lacks ALDH2 inhibitory activity. Carbamathione is a partial NMDA glutamate antagonist. The purpose of this dissertation study is to evaluate the neuroprotective effects of Carbamathione drug on PC-12 cell line and to understand the protective mechanisms underlying in three stroke-related models: excessive glutamate, hypoxia/reoxygenation and bilateral carotid artery occlusion (BCAO). Carbamathione was administered 14 mg/kg subcutaneously for 4 days with the first injection occurring 30 min after occlusion in the mouse BCAO stroke model. Mice were subjected to the locomotor test, and the brain was analyzed for infarct size. Heat shock proteins, key proteins involved in apoptosis and endoplasmic reticulum (ER) stress, were analyzed by immunoblotting. Carbamathione reduced both cell death following hypoxia/reoxygenation and brain infarct size. It improved performance on the locomotor test. The level of pro-apoptotic proteins declined, and anti-apoptotic, P-AKT and HSP27 protein expressions were markedly increased. We found that Carbamathione suppresses the up- regulation of Caspase-12, Caspase-3 and significantly declined ER stress protein markers GRP 78, ATF4, XBP-1, and CHOP. Carbamathione can down- regulate ATF 4 and XBP1 expression, indicating that Carbamathione inhibits the ER stress induced by hypoxia/reoxygenation through suppressing PERK and IRE1 pathways. Carbamathione elicits neuroprotection through the preservation of ER resulting in reduction of apoptosis by increase of anti-apoptotic proteins and decrease of pro-apoptotic proteins. Carbamathione can suppress the activation of both PERK and IRE1 pathways in PC-12 cell cultures and has no inhibitory effect on ATF6 pathway. These findings provide promising and rational strategies for stroke therapy. / Includes bibliography. / Dissertation (Ph.D.)--Florida Atlantic University, 2017. / FAU Electronic Theses and Dissertations Collection

Introduction: Lacunar strokes are both common and disabling; they cause up to 52 strokes per 100,000 people per year and 29-46% of survivors are disabled. Lacunar stroke is part of the spectrum of small vessel disease (SVD) which also causes cognitive impairment and gait disturbance; together these lead to dementia, falls and disability. Current evidence suggests that SVD is caused by a separate aetiology from large vessel stroke, which may be mediated by blood brain barrier (BBB) permeability and may affect organs other than the brain. We set out to establish whether SVD is a multi-system disorder of primary endothelial function, with leakage of blood-brain barrier leading to lacunar stroke, disability, and cognitive impairment. Methods: We recruited 264 patients with a lacunar or cortical stroke (118 lacunar, 146 cortical). All patients received baseline assessment of clinical features, magnetic resonance imaging (MRI), renal function, and assessment of dietary salt. At 1-3 months post-stroke we carried out cognitive testing and contrast MRI to assess blood-brain barrier integrity. We followed patients up at 12 months post-stroke with repeat cognitive testing, MRI, and assessment of disability and recurrent stroke. Results: We established that lacunar stroke has a different risk factor profile to cortical stroke, confirming findings from previous cohorts, but adding dietary salt as a risk factor for lacunar stroke and other SVD features. We confirmed that patients with a clinical stroke who did not have a lesion on diffusion-weighted MRI had the same clinical outcomes at 1 year post-stroke as those patients who did have a lesion. We established that patients who have a lacunar stroke are at as high a risk of post-stroke cognitive impairment as those with a cortical stroke. We found that blood brain barrier leakage predicted cognitive impairment at one year after lacunar and cortical stroke. We established the rates of disability and cognitive impairment at one-year post-lacunar stroke to estimate the required sample size for future trials. Conclusions: Taken together these findings confirm that lacunar stroke is part of a syndrome separate to large vessel stroke and may be mediated through blood brain barrier leakage. Dietary salt is an additional risk factor. The findings support further randomised controlled trials of treatments aimed specifically at lacunar stroke and lifestyle interventions including dietary salt reduction.

<p>Stroke är en vanlig sjukdom som årligen drabbar 30 000 personer i Sverige. Personer som insjuknar i stroke kan drabbas av fysiska och psykiska funktionsnedsättningar. Konsekvenserna av stroke drabbar även de närstående som många gånger tar på sig vårdgivarrollen till den anhöriga. Närståendevårdare till en anhörig som har insjuknat i stroke får bära ett tungt vårdansvar. Syftet med detta vetenskapliga arbete var därför att belysa närståendevårdares upplevelser av att vårda en anhörig som har insjuknat i stroke. Arbetet utfördes som en litteraturstudie där 16 vetenskapliga artiklar granskades. I resultatet framkom två teman, <em>Att vårda är betungande</em> och <em>Att</em> <em>vårda är att anpassa sig</em>. Resultatet visade att närståendevårdarna upplevde en tung börda, ensamhet och frustration. Närståendevårdarna upplevde att det var jobbigt och tidskrävande att anpassa sin vardag till den anhöriga. Det framkom att närståendevårdarna saknade stöd, information och utbildning från hälso- och sjukvårdspersonal för att kunna hantera den nya livssituationen. Sjuksköterskan, liksom all hälso- och sjukvårdspersonal, bör uppmärksamma närståendevårdares situation. Önskvärt är mer omvårdnadsforskning på närståendevårdares copingstrategier, och hur, var och när sjuksköterskan ska ge närståendevårdare stöd, information och utbildning.</p> / <p>Stroke is a common disease that annually affects 30 000 people in Sweden. Stroke survivors may suffer physical and psychological disabilities. The impact of stroke also affects the next of kin´s of the stroke survivor who often become an informal caregiver. Informal caregivers of a relative stroke survivor may experience a heavy caring responsibility. The purpose of this scientific study was therefore to illuminate informal caregivers experiences of caring for a relative who has suffered a stroke. The study was conducted as a literature review in which 16 scientific articles were reviewed. In the result two themes were found, <em>To care is burdened</em> and <em>To care is to adapt</em>. The result showed that informal caregivers experienced heavy burden, loneliness and frustration. Informal caregivers felt that it was difficult and time consuming to adjust their daily lives to the relative. It was found that informal caregivers did not get enough support, information and education from health- professionals which they would have needed to learn how to cope with their new life situation. Nurses, and all health professionals, should pay attention to the situation of the informal caregivers. Continued nursing research on informal caregivers copingstrategies, and, how, were and when the nurse will give informal caregivers support, information and education is desirable.</p>

<p><strong>Problemställning: </strong>Stroke är en världsomspännande, allvarlig och kostnadskrävande sjukdom. Sjuksköterskans omvårdnadsinsatser av patienter med stroke bör anpassas individuellt och syfta till att främja återhämtning och förhindra komplikationer. Det är därför av vikt för sjuksköterskan att ha kunskap om hur strokedrabbade patienter upplever sin sjukdom. <strong>Syftet </strong>var att belysa patienters upplevelse av att drabbas av och leva med stroke. <strong>Metod:</strong> En litteraturstudie där 11 kvalitativa och 1 kvantitativ artikel som svarade mot studiens syfte ingick. <strong>Resultat och konklusion: </strong>Att drabbas av stroke påverkar personens hela liv med förlorad kontroll över både kropp och personlighet. Oro för att drabbas av en ny stroke leder till ett liv i osäkerhet men också till förändrade levnadsvanor. Stroken påverkar den drabbades roll i familjen och förhållandet, ilska och frustration över situationen går ut över de närmaste. Den sociala relationen med familj och vänner försämras, eftersom kvarstående fysiska eller kognitiva funktionsnedsättningar gör det svårt att delta i sociala sammanhang på samma sätt som innan sjukdomen. Överdrivna känslomässiga yttranden och extrem trötthet försvårar ytterligare social samvaro. <strong>Implikation: </strong>Det är viktigt att sjuksköterskan får ökad medvetenhet om strokepatienternas upplevelser för att kunna ge en individuellt utformad omvårdnad. Det finns behov av vidare forskning kring copingstrategier samt strokepatienternas upplevelser av sjuksköterskans omvårdnad.</p> / <p><strong>Problem: </strong>Stroke is a worldwide, serious and costly disease. Nursing interventions of patients with stroke should be individualized and adapted to promote recovery and prevent complications. It is therefore important for nurses to have knowledge of how the stroke affected patients experience their illness. <strong>The purpose </strong>was to illustrate patients’ experience of suffering from and living with a stroke. <strong>Method: </strong>A literature study, where 11 qualitative and one quantitative article that met the study’s purpose, were used. <strong>Results and conclusion: </strong>To suffer a stroke, affects the patient’s whole life with loss of control over both body and personality. Worries concerning the possibility to suffer a new stroke often results in a life of uncertainty but also in changing of lifestyles. The stroke affects the patient’s role in the family and in the relationship with the spouse; anger and frustration over the situation affect the immediate family negatively. The social relationships with family and friends deteriorate, because the residual physical or cognitive disabilities make it difficult to participate in social contexts in the same way as before the illness. Exaggerated emotional expressions and extreme fatigue makes social interaction even more difficult. <strong>Implication</strong><strong>:</strong> It is important that nurses are more aware of stroke patients' experiences in order to provide individualized care. There is a need for further research on coping strategies and the stroke patients' experiences of nursing.</p>