Treating the invisible: moving towards more personalized stroke care

In recent years improvements in stroke care with intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT) have led to improved clinical outcome by early opening of the occluded vessel to restore blood flow to the salvageable ischemic brain tissue that is not already infarcted. This has also contributed to a substantial decrease in recurrent stroke and vascular event rates over the past five decades. Despite these strides, secondary prevention remains crucial in reducing modifiable risk factors to prevent recurrent cardiovascular events, given the increased risk following a stroke. Recurrent stroke poses long-term risks of physical disability and dementia. However, even with improved functional independence for stroke patients leaving hospitals, those with transient ischemic attacks (TIAs) or minor strokes often face disabilities like fatigue, cognitive impairment, depression, and anxiety. Moreover, many have low levels of cardiorespiratory fitness and lead sedentary lifestyles, further compromising their quality of life and increasing the risk of recurrent cardiovascular events. This thesis aims to enhance stroke care by investigating the efficacy of lifestyle interventions for secondary prevention of cardiovascular events and exploring the interaction of physical activity and exercise in mitigating post-TIA or minor stroke challenges. Tertiary prevention efforts, which extend beyond secondary prevention to address rehabilitation and improve quality of life, are also examined. A systematic review and meta-analysis in Chapter 2 assess the effectiveness of lifestyle interventions in preventing recurrent cardiovascular events after TIA or stroke. While certain interventions, particularly those focusing on cardiovascular fitness and lasting over four months, show promise in reducing systolic blood pressure, comprehensive criteria for future research are recommended to ensure replicability and comparability. Chapter 3 presents findings from a trial investigating the safety and feasibility of a post-stroke care program with a year-long exercise intervention, demonstrating its potential in optimizing secondary prevention. Chapter 4 outlines the rationale and design of the MoveIT trial, a randomized controlled study assessing the impact of an exercise intervention on preventing cognitive decline after TIA or minor stroke. In Chapter 5, cardiorespiratory fitness in TIA and minor stroke patients is explored, revealing associations with cardiovascular and pulmonary disease and modifiable risk factors but not stroke-related factors. The MoveIT trial's results, discussed in Chapter 6, suggest a modest improvement in executive functioning with exercise intervention but no significant effects on global cognitive functioning or secondary outcomes. Further analysis in Chapter 7 indicates that exercise intervention might improve executive functioning over time, emphasizing its potential benefit in post-stroke cognitive rehabilitation. Chapter 8 delves into the association between post-stroke fatigue and cardiorespiratory fitness, highlighting the confounding role of depression and anxiety. Finally, Chapter 9 discusses the overarching findings, emphasizing the need for comprehensive assessment and intervention strategies targeting post-stroke challenges to enhance secondary and tertiary prevention efforts. Overall, this thesis underscores the importance of lifestyle interventions and exercise in mitigating post-stroke complications, while emphasizing the need for tailored rehabilitation strategies and further research to optimize stroke care.