Stroke

Motor recovery after stroke is associated with changes in corticospinal integrity, intracortical excitability, and interhemispheric interactions. Transcranial magnetic stimulation (TMS) provides neurophysiological measures of these processes, but their relationship with motor recovery across randomized controlled trials remains uncertain. This systematic review synthesized evidence from randomized controlled trials investigating TMS-derived neurophysiological measures associated with motor recovery following TMS-based neuromodulation after stroke. PubMed/MEDLINE, Scopus, and Embase were searched for studies published between January 1, 2016, and July 10, 2026. Eligible trials enrolled adults with ischemic or hemorrhagic stroke, assessed at least one TMS-derived neurophysiological measure, and reported a motor or functional outcome. Study selection followed PRISMA 2020, risk of bias was assessed using Cochrane RoB 2, and certainty of evidence was evaluated using GRADE. Owing to methodological heterogeneity, findings were synthesized narratively. The search identified 1441 records; after removal of 519 duplicates, 922 records were screened, 55 full-text reports were assessed, and 16 randomized controlled trials were included. Motor evoked potential (MEP) amplitude, MEP status, and resting motor threshold were the most frequently reported measures. Several trials found that changes in corticospinal excitability accompanied improvements in upper-limb function, activities of daily living, gait, or balance. One trial found greater motor gains among participants with preserved baseline MEPs; however, the contemporary randomized-trial evidence is insufficient to establish MEP status as a predictor of differential response to neuromodulation. In contrast, short-interval intracortical inhibition, cortical silent period, and interhemispheric inhibition were assessed in very few trials, whereas intracortical facilitation was not directly evaluated in any eligible RCT. Most studies raised some risk-of-bias concerns, and one study had high overall risk. Certainty was moderate for clinical motor recovery, low for MEP- and motor-threshold-based measures, and very low for intracortical and interhemispheric measures. Overall, MEP-derived measures and resting motor threshold were the most frequently reported neurophysiological domains, whereas baseline MEP status was evaluated in only one stratified trial. Standardized TMS protocols are needed to clarify their monitoring, prognostic, and treatment-response value.

IntroductionOccupational therapists play a key role in assessing and treating somatosensory impairments post stroke including proprioception (limb position sense), touch, and temperature discrimination. Although research evidence and clinical guidelines offer strategies for assessing and treating this condition, there is limited information on how well these strategies are being implemented in routine practice. We aimed to describe the current practice of occupational therapists in somatosensory assessment and treatment of the upper limb of stroke survivors and to understand barriers and enablers to evidence-based care.MethodsThis observational study encompassed (1) a cross-sectional survey measuring self-reported use of somatosensory assessment and treatment strategies and perceived barriers to implementation and (2) a medical file audit to report on the use of somatosensory assessment and treatment with stroke patients. Data were analyzed descriptively, with enablers and barriers to evidence use classified using the three domains of the Capability, Opportunity, Motivation-Behavior (COM-B) change model.ResultsOf 50 files audited, 26 patients had documented upper limb impairment. Of these, 54% had sensation assessed. Treatment strategies were documented for 7 out of 12 patients with identified impairment. These findings aligned with therapist self-report, indicating that most clinicians used sensory assessment and treatment strategies less than once per month. Therapists reported capability (lack of skills and skill confidence) and opportunity (lack of time and opportunity to practice skills) as barriers to evidence-based practice. Occupational therapists expressed motivation to change and improve their skills in evidence-based sensory assessment and treatment.ConclusionOur findings highlight ongoing gaps between evidence and practice. Therapists report being motivated to provide evidence-based care but require support to overcome barriers, such as training and access to resources. Medical record audits aligned with survey findings; however, there were differences between reported and documented use and scope of sensory assessment and treatment in practice.

For decades, ischemic neuronal death was understood largely as a story about glutamate. Acid-sensing ion channels (ASICs) have revised that account. When cerebral blood flow stops, the penumbra can develop prolonged extracellular acidosis, and experimental studies implicate ASIC1a in mediating sufficient Ca²⁺ entry to injure neurons even when glutamate receptors are blocked, a contribution shaped by channel expression, subunit composition, and the intracellular signaling context. However, sustained acidosis does not necessarily imply sustained channel opening, given ASIC1a desensitization. Besides acidosis, glutamate, polyamines, a paradoxical intracellular alkalization, and oxidative stress can enhance ASIC1a activity or expression, and the channel also signals through a non-conducting route, recruiting RIPK1 to trigger necroptosis independently of ion flux. The relative contributions of these conducting and non-conducting mechanisms in vivo remain incompletely defined. Endogenous mechanisms may constrain injury by internalizing the channel, altering subunit expression, including conditioning-associated ASIC2a upregulation, and degrading ASIC1a through estrogen signaling. We argue that these responses are better understood as constraints on injury than as a genuine survival program, a distinction with mechanistic and therapeutic consequences. Critically, the contribution of these mechanisms may vary over time. The same channel acts as a target of homeostatic regulation before stroke, a driver of death during ischemia, a potential target at reperfusion when acidosis persists but restored flow finally permits drug delivery, and an impediment to repair for weeks afterward. The question in ASIC-targeted neuroprotection is not only whether to inhibit the channel, but also when and for how long.

As a major component of air pollution, ambient particulate matter pollution has rarely been studied with respect to its global stroke burden. This study aims to evaluate the global stroke incidence, mortality, and health inequalities related to ambient particulate matter pollution from 1990 to 2021. Utilizing the Global Burden of Disease Study 2021, we analyzed global stroke-related mortality, disability-adjusted life years, and their age-standardized rates. The estimated annual percentage change was calculated using a linear regression model. Health inequalities were measured using the concentration index and slope index of inequality. Between 1990 and 2021, global ambient particulate matter pollution-related stroke deaths and disability-adjusted life years increased by 107% and 101% respectively, yet age-standardized rates declined. China experienced the largest increases in deaths and disability-adjusted life years, Vietnam had the fastest rise in age-standardized mortality rates, the Russian Federation saw the steepest declines in deaths and disability-adjusted life years, and Estonia had the most rapid drop in age-standardized mortality rate. Middle socio-demographic index locations accounted for 46% of the global stroke burden, with age-standardized mortality rates and age-standardized disability-adjusted life years surpassing those in high socio-demographic index locations. From 1990 to 2021, age-standardized disability-adjusted life years rose in low-middle socio-demographic index locations but fell in high socio-demographic index locations. While the concentration index signaled an improvement in global inequality, the slope index of inequality in 2021 worsened compared with that in 1990. Between 1990 and 2021, the global burden of ambient particulate matter pollution-related stroke declined. However, substantial disparities persisted across different regions, sexes, and nations. For ongoing and future research efforts, priority should be given to high-risk populations and regions, while also developing innovative interventions to further reduce the incidence of ambient particulate matter pollution-related stroke and enhance patient outcomes.