الفهرس 
Introduction
Epidemiology of StrokeOnly 14 pages are availabe for public view
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Abstract
Stroke is classically defined as a neurological deficit attributed to an acute focal injury of the central nervous system (CNS) by a vascular cause, including cerebral infarction, intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH), and is a major cause of disability and death worldwide. (Sacco et al, 2013)
Stroke is the second most common cause of death and the leading cause of adult disability in the world. As a result of the ageing population, the burden of stroke will increase in the next 20 years (Donnan 2008).
Despite the development of stroke center designation and improved systems to recognize stroke symptoms and deliver care promptly, only a minority of patients with acute stroke receive thrombolytic therapy, and many of them remain with residual functional deficits. (Winstein et al., 2016)
Thirty, right handed, patients with ischemic stroke were recruited from the Inpatient and Outpatient Service of the Neurology Department at Assiut University Hospital during the period from the 21st of June, 2015 till 31st of May, 2016.
All patients fulfilled the inclusion criteria:(1) The age was to range from 18 to 80 years, (2) First ever ischemic stroke, (3) Patients had criteria of middle cerebral artery occlusion or one of its branches, (4) Onset of stroke symptoms was from 2 days up to 1 month, (5) Initial NIHSS score indicated mild to moderate stroke severity (i.e. <15), and Exclusions criteria: (1) Comatosed patients, (2) Hemodynamically unstable patients, (3) Decompensated heart failure or COPD & (4) Patients with absolute contraindications to TMS.
Patients were randomly classified into three groups at 1:1:1 ratio, i.e. 10 patients in each group. One group received five sessions of ipsilesional HF rTMS, the second group received five sessions of high frequency median and ulnar nerves’ electrical stimulation of the paretic hand and the third group received five sessions of ipsilesional HF rTMS and high frequency PNS starting at the same time. All patients received physiotherapy and exercise training tailored to their level of disability.
The present study aimed to assess the efficacy of combined ipsilesional high frequency rTMS and high frequency peripheral nerves (median and ulnar nerves) electrical stimulation on improvement of post stroke motor disability.
Each patient was subjected to the following assessment scales: the National Institutes of Health Stroke Scale (NIHSS), the Scandinavian Stroke Scale (SSS), Barthel index of activities of daily living (BI) and the Medical Research Council Scale for assessment of hand grip strength. The assessment was done before, immediately after and one month after treatment. At baseline assessment, there was no significant difference between the three groups regarding any of the scales.
The main results of our study showed that after the end of treatment, there was significant improvement in each group compared to baseline and this improvement was significantly maintained after one month.
Also, at the end of treatment, compared to the group which received PNS only, the group which received both interventions showed significant improvement in the National Institutes of Health Stroke Scale (p=0.19),the Scandinavian Stoke Scale (p=0.003), Barthel activities of daily living (p=0.020) and hand grip strength according to the Medical Research Council scale for muscle strength (p=0.013). And this improvement difference was still significant after one month regarding all assessment scales, i.e NIHSS (p=0.003), SSS (p=0.002), BI (p=0.019) and MRC for hand grip strength (p=0.010)
There was no significant difference in improvement between the rTMS only group and the PNS only group. Also, at the end of treatment sessions, there was no significant difference in improvement between the rTMS only group and the group which received both interventions.
The results of our study can provide additional support for the use of combined neuromodulatory interventions to help improve the motor function in the subacute stage of stroke.