Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241111EnglishN2019January10HealthcareA Three and a Half Years Histopathological Study of Fibroepithelial Breast Lesions in a Tertiary Care Hospital English0105Rohi WaniEnglish Sheema SheikhEnglish Abdul Maajed JehangeerEnglish Salma BhatEnglish Isma NiyazEnglish Bilques KhursheedEnglishBreast specimens are one of the most frequent entries in our department of pathology. Out of these surgical specimens, fibroepithelial lesions are received almost every day. Aim: To study and provide an overview of fibroepithelial lesions of breast. Further to stratify and classify various fibroepithelial lesions into fibroadenomas and phyllodes tumor. Methodology: All the 386 cases of fibroepithelial lesions received over a period of 3 1/2 years from Jan 2015-June 2018 were retrieved and studied in detail. All the associated histological changes as also the clinical details were noted down. Results: Out of the total 386 fibroepithelial lesions, there were 372 fibroadenomas and 14 phyllodes tumors. Among all phyllodes tumors there was a single case each of borderline phyllodes tumor and malignant phyllodes tumor. Conclusion: Fibroepithelial lesions show a wide range of morphology. A strict histopathological assessment with classification leads to proper diagnosis and thus proper treatment in such cases. EnglishFibroepithelial lesions, Fibroadenoma, Phyllodes tumorIntroduction Fibroepithelial lesions are the common lesions of breast. They are morphologically and behaviourally heterogeneous tumor with different clinical behaviours and treatment protocols. These constitute the commoner fibroadenomas and the rarer phyllodes tumor1. Fibroadenomas are the commonest benign biphasic fibroepithelial neoplasms occurring in 2nd and 3rd decade of life2. Phyllodes tumor occurs in an older age group usually around 45-49 years of age3. Almost all of the phyllodes tumor are reported as fibroadenomas on Fine needle aspiration cytology (FNAC) since the clinical presentation, as also the cytology findings of these overlap.  Although higher grade phyllodes tumors are rare neoplasms but need urgent attention. Accurate diagnosis and grading of phyllodes tumors are important for patient management and prognosis, as grade broadly correlates with increasing local recurrence risk, and metastasis occurs only  in malignant tumors4. Materials and Methods This study is a descriptive, retrospective type of study done on the breast specimens received in our Histopathology department over a period of 3½ years (from Jan 2015- June 2018).  All the breast cases which included lumpectomy, exci­sion biopsies, tru cut biopsies, mastectomy specimens and blocks for review were included in the study irrespective of age and sex. Specimens were received in 10% formalin and were subjected to routine haematoxylin and eosin stains. Fibroepithelial lesions were segregated and studied in detail.  Clinical data of patients was retrieved from medical records. All the sections were studied in detail, clinical history was noted down and morphological diagnosis was made. Cases were clustered as fibroadenomas and phyllodes tumors. Necessary details and variations in histopathology were noted down.  All these lesions were classified according to the WHO classification of tumors5 of breast and tabulated as such.  Results A total of 759 specimens of breast were received over this period of three and a half years. Out of these fibroepithelial lesions, fibroadenomas constituted the major portion constituting almost half of the total number of breast specimens. Thus the most common breast lesion diagnosed was a fibroadenoma  accounting for 372 cases whereas phyllodes tumor  was diagnosed in 14 constituting of one malignant phyllodes, one borderline phyllodes  and 12 benign phyllodes tumors. A  total of 386 cases of fibroepithelial lesions were encountered in this period. Discussion Fibroepithelial lesions of breast are neoplastic proliferations of specialised stroma which secondarily distorts lobules and ducts, incorporating these within a well defined mass. Although the resulting lesions do contain epithelial components, but it is only the stromal component which is neoplastic. These lesions encompass a variety of benign and malignant lesions ranging from fibroadenoma to malignant phyllodes tumor6. They encompass a heterogeneous group of lesions that range from benign to malignant, each exhibiting differing degrees of stromal proliferation in relation to the epithelial compartment 7. These lesions comprise a morphologically and biologically spectrum of biphasic tumors with epithelial and stromal components that demonstrate widely variable clinical behaviour. Fibroadenomas are common benign tumors with a number of histologic variants, most of which pose no diagnostic challenge. Cellular and juvenile fibroadenomas can have overlapping features with phyllodes tumors and should be recognized. Phyllodes tumors constitute a spectrum of lesions with varying clinical behaviour and are graded as benign, borderline or malignant based on a set of histologic features according to recommendations by the World Health Organization (WHO)4. Fibroadenomas are benign tumor masses arising from both the epithelium and stroma of breast consecutively. They constitute the most common breast lesions especially in young age groups. It arises from terminal duct lobular unit from the intralobular stromal mesenchymal cells (Fig 1), along with the hyperplasia of intralobular ductal and acinar epithelium2. All the cases of fibroepithelial lesions in our study were fibroadenomas except the 14 phyllodes tumor cases. There was a wide age range of 13 to 50 years in our cases. Size varied from as small as less than 1cm to as big as 10 cm. There were three cases of fibroadenomatosis in which more than two fibroadenomas were resected from a single patient at one point of time from the same breast or contralateral breasts. Grossly all the fibroadenomas  were round, nodular, discrete firm swellings with cut surface showing homogenous firm greyish white surface with slit like spaces.  Bilateral breast adenoma was seen in 10 (2.6%) of cases. A wide variety of proliferative changes can be seen in the epithelial components of fibroadenoma2,8. A lot of the common microscopic variations of fibroadenoma were encountered in our study also. Out of these simple fibroadenoma, which had no  other pathological association was seen in 76%  of cases. The most common pathological association was fibrocystic change seen in about 16% followed by adenosis which was seen in 13 of fibroadenomas (Table 1). The most frequent association of fibroadenoma with fibrocystic disease was similar to studies as that of Geethamala K et al2. Epithelial hyperplasia was present in a total of 7 cases with mild hyperplasia in 4 and moderate hyperplasia in 3 cases. This is much less (47/372) than was seen in a study by Geethamala K, et al2 and Kuijper et al (43.9%)8. There were 2 cases each of complex fibroadenoma, fibroadenoma with apocrine metaplasia and Juvenile fibroadenoma. A single case of myxoid fibroadenoma, giant fibroadenoma and fibroadenoma with stromal hyalinisation was also seen All these histological variants usually do not pose any problem with the diagnosis, however cellular and Juvenile fibroadenoma (Fig 2) have some overlapping features with benign phyllodes tumor and thus should be recognised since the course of disease and treatment is quite different from one another4,6,9. Although there are no clear cut boundaries but strict histologic assessment of features with classification ultimately reveal the correct diagnosis and thus provide useful clinical information10. Phyllodes tumor is a rare fibroepithelial lesion as compared to fibroadenoma, with wide spectrum of morphology. It has risk of local recurrence and uncommon metastasis. Although microscopic distinction between fibroadenoma and phyllodes tumor especially benign phyllodes tumor is difficult, strict histologic assessment of a combination of histologic features with classification help to achieve the correct diagnosis and provide useful clinical information10. Phyllodes tumors were classified according to three tier grading system of WHO classification into benign, borderline and malignant4 (Table2). Out of the total cases of 14 phyllodes tumor, 1 (7%) was borderline, 1 (7%) was malignant and the rest (12=86%) were all benign (Fig 3 &4). There was another case of breast sarcoma but it was a primary case of Fibrosarcoma without any evidence of it arising from or any association with phyllodes tumor. The value of FNAC in the diagnosis of phyllodes tumor has always remained controversial3. In all our cases of phyllodes tumor FNAC was done as a first line investigation and it was reported as fibroadenoma in 11 out of the 12 benign phyllodes tumors. Only in a single case of benign phyllodes tumor, it was reported as phyllodes tumor on cytology. There is a significant overlap of phyllodes tumor with fibroadenoma in cytological diagnosis and it’s always difficult to diagnose phyllodes tumor on FNAC alone11. The sensitivity for diagnosing phyllodes tumors by FNAC is only 40%, although increased sensitivity can be achieved by combining cytohistological and radiological results12. Clinical presentation of a patient giving a diagnostic clue towards phyllodes tumors rather than fibroadenoma should always be investigated through radiology and core needle biopsy which has high sensitivity since the surgical management is the mainstay and moreover local recurrence has been associated with inadequate local excision3. In a study done by Karim et al, the clinical and pathological features of a large single institutional series of ethnically diverse patients with phyllodes tumours was done to determine which characteristics were predictive of outcome. Sixty five phyllodes tumors were analysed; 34 were benign, 23 borderline and eight malignant (34 low grade and 31 high grade PTs on a two tiered grading system). Out of these Nine patients (15%) had local recurrences. A greater percentage of higher grade tumours recurred and women of Asian origin had a higher recurrence rate than those of non-Asian origin. The 5 year disease-free survival was 81% as also the time to recurrence was significantly lower in the high grade group. There were no metastases or deaths from disease. The mean age at diagnosis and the mean tumour volume, both significantly increased with grade. Thus tumour grade was the only parameter related significantly to outcome of these patients13. In the benign phyllodes tumor, the size varied from smallest 4cm to largest measuring 15cms. The age varied from 17 to 45 years. One of the benign phyllodes tumors showed areas of tubular adenosis with foci of hyalinisation and fibrocystic changes in the adjacent areas. Another phyllodes tumor was seen in a 30 years old female who presented with a huge swelling in her left breast. She had noticed it four months back as small swelling, with a history of recent rapid increase in size and had reached the present diameter of 10x10 cm. In the meanwhile patient had seeked medical help in which FNAC of the swelling was done and reported as diagnostic possibilities of either a ductal carcinoma with osteoclast type giant cells or ductal carcinoma with increased stromal cellularity. Ultrasonography was reported as Fibroadenoma- BIRADS II. Trucut biopsy was done and reported descriptively as Malignancy with fibromyxoid stroma. Radical mastectomy was performed and we received a huge mastectomy specimen measuring 20x16x7 cms with axillary tail measuring 14x7x4 cms. On cut section a huge growth measuring 10x10x6 cms was occupying all quadrants sparing just the portion of upper inner quadrant. Cut surface of growth was variegated having friable, necrotic and haemorrhagic areas. On microscopic examination it came out to be stromal cell tumor with pleomorphic cells showing moderate to marked atypia (Fig 3&4). The mitotic rate of >5/10hpf was counted, although such high mitotic count was present in focal areas only. All the lymphnodes were free from tumor. Benign phyllodes tumor was identified in 70-80 %of the serial sections. So the final diagnosis of borderline phyllodes tumor was given. In our study a single case of malignant phyllodes tumor (Fig5) was seen. A young 25 years old female presented with swelling right breast. The duration of swelling was a few days only and tru cut biopsy was done straightway on the basis of clinical features and radiological suspicion of malignancy. It was reported as malignant phyllodes on biopsy and surgery (partial mastectomy was performed within days of diagnosis). Grossly we received a partial mastectomy specimen with a globular , greyish white, well circumscribed firm area measuring 7x4x3 cc. On cut section it was variegated with areas of hemmorhage. Microscopy revealed a pleomorphic cell population with mitotic rate of >15/hpf. There was also an area of malignant smooth muscle differentiation (Fig 5). The diagnosis of Malignant phyllodes tumor with Leiomyosarcomatous element was rendered. IHC was advised for confirmation and it came out positive for desmin and smooth muscle actin. Conclusion Fibroepithelial lesions of breast are one of the most common lesions especially in young females. Out of these fibroadenomas are quite common and the rarer phyllodes tumor can cause a lot of clinical concern. Moreover the need to differentiate fibroadenomas from phyllodes tumor due to the different surgical procedures required for these tumors and the tendency of malignancy in phyllodes needs to be considered seriously. Acknowledgement Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. Source of Funding: Nil Conflict of interest: Nil Englishhttp://ijcrr.com/abstract.php?article_id=2551http://ijcrr.com/article_html.php?did=25511.Daramola AO, Oguntunde OA, Awolola NA. Audit of fibroepithelial tumors of the breast in a Nigerian tertiary institution. Niger. J Clin Pract 2016; 19:645-8 2.Geethamala K, Vani BR, Murthy VS, Rhada M. Fibroadenoma: A harbour for various histopathological changes. Clin Cancer Investig  J 2015; 4:183-7 3.Mishra SP, Tiwary SK, Mishra M, Khanna AK. Phyllodes  Tumor of Breast: A Review Article. Hindawi Publishing Corporation. ISRN Surgery. Volume 2013, Article ID 361469, 10 pageshttp://dx.doi.org/10.1155/2013/361469 4.Krings G, Bean GR, Chen YY. Fibroepithelial lesions; The WHO spectrum.  Semin Diagn Pathol 2017 Sep; 34(5):438-452 5.Lakhani S, Ellis I, Schnitt S, et al.: WHO Classification of Tumours of the Breast, 4th ed. Lyon, IARC, Press, 2012 6.Giri D. Fibroepithelial Lesions; Arch Pathol Lab Med. 2009; 133:713–721 7. Tan BY, Tan PH. A Diagnostic Approach to Fibroepithelial Breast Lesions. Surg Pathol Clin. 2018 Mar; 11(1):17-42 8. Kuijper A, Mommers ECM, Wall E, van Diest PJ. Histopathology of fibroadenoma of the breast. Am J Clin Pathol 2001; 115:736-42 9. Yasir S, Nassar A, Jimenez RE, Jenkins SM, Hartmann LC, Degnim AC, Frost M, Visscher DW. Cellular fibroepithelial lesions of the breast: A long term follow up study. Ann Diagn Pathol. 2018 Aug; 35:85-91 10. Zhang Y, Kleer CG. Phyllodes Tumor of the Breast. Histopathologic Features, Differential Diagnosis, and Molecular/Genetic Updates. Arch Pathol Lab Med. 2016; 140:665–671 11. Tse GM, Ma TK, Pang LM, Cheung H. Fine needle aspiration cytologic features of mammary phyllodes tumors. Acta  Cytol. 2002 Sep-Oct; 46(5):855-63 12. Ward ST, Jewkes AJ, Jones BG, Chaudhri S, Hejmadi RK, Ismail T. The sensitivity of needle core biopsy in combination with other investigations for the diagnosis of phyllodes tumours of the breast. Int J Surg. 2012; 10(9):527-31. 13. Karim RZ, Gerega SK, Yang YH, Spillane A, Carmalt H, Scolyer RA, Lee CS. Phyllodes tumours of the breast: A clinicopathological analysis of 65 cases from a single institution. Breast. 2009 Jun; 18(3):165-70.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241111EnglishN2019January10HealthcareRelationship & Comparison between Post-Stroke Motor Recovery and Functional Recovery – An Observational Study English0609Ashish KakkadEnglish Priyanshu V. RathodEnglishAims and Objectives: This study explored relationship between post-stroke motor recovery and functional recovery in Gujarat, India. Patients, Materials and Methods: This Study involved 67 (48 males and 19 females) individuals diagnosed of stroke by Neurophysician or General Physician with less than 6 months of post stroke duration. Fugl Meyer Motor Assessment Score was (total of upper extremity and lower extremity sub score) was used to assess their post-stroke motor recovery. Their functional recovery was assessed using the Modified Barthel Index. They were assessed on the same day for Fugl-Meyer Motor Assessment as well as Modified Barthel Index. Data were analyzed using the Pearson’s Moment Correlation and Students’ paired t-test at p =0.05. Results: Patients’ mean age was 57.52± 13.1 years ranging between 17 years and 80 years. Their motor recovery had direct positive relationship (r=0.791, p=0.00) with their functional recovery but there was significant difference (t=13.16, p=0.00) between motor recovery and functional recovery. Mean score of motor recovery by total of Fugl-Meyer Upper extremity & Lower extremity subscore is 54.79 (54.79%) of total 100 score. Mean score of functional recovery by Modified Barthel Index was 14.06 (70.3%) of total 20 score. Conclusion: Though Motor recovery has positive impact on the functional recovery in stroke survivors, motor recovery and functional recovery may differ significantly where functional recovery may exceed than motor recovery. EnglishStroke, Stroke rehabilitation, Recovery of functionIntroduction World Health Organization (WHO) defines stroke as a clinical syndrome characterized by rapidly developing clinical symptoms and/or signs of focal and at times global loss of cerebral function, with symptoms lasting more than 24 hours or leading to death, with no apparent cause other than that of vascular origin.1,2 Stroke is classified into two types. Ischemic stroke is the most common type affecting about 67-80% of individuals with stroke2,3 and results when a clot or block impairs blood flow, depriving the brain of essential oxygen and nutrients, leading to disruption of cellular metabolism, injury and death of tissues. Hemorrhagic stroke occurs when blood vessels rupture, causing leakage of blood in and around brain. It may occur due to increase in intracranial pressure or restriction of distal blood flow.1 Central Venous Sinus Thrombosis (CVST) is the presence of acute thrombosis (a blood clot) in the dural venous in sinuses, which drain blood from the brain. Symptoms may include headache, abnormal vision, any of the symptoms of stroke such as weakness of the face and limbs on the side of the body and seizures.4 Stroke is a global health problem. It is second commonest cause of death and fourth leading cause of disability worldwide.5 In developed countries, stroke is the first leading cause of disability, second leading cause of death.5 It makes an important concern not only for the physiotherapists but for the entire rehabilitation team. The incidence of stroke rises rapidly with increasing age. In India, the overall prevalence rate for stroke lies between 84 – 262 per 100,000 in rural area and between 334 – 424 per 100,000 in urban areas.6 After the age of 55 years, the risk of stroke doubles every 10 years; two thirds of all strokes occurring in people older than the age of 65 years.7 The incidence of stroke is about 1.25 times greater for males than female.8 Katherine J. Sullivan et al did a study “Fugl-Meyer Assessment of Sensorimotor Function after Stroke Standardized Training Procedure for Clinical Practice and Clinical Trials” in 2011 to find out reliability of the same score and found that intra-rater reliability for the expert rater was high for the motor and sensory scores (range, 0.95–1.0). Inter-rater agreement (intraclass correlation coefficient, 2, 1) between expert and therapist raters was high for the motor scores (total, 0.98; upper extremity, 0.99; lower extremity, 0.91) and sensory scores (total, 0.93; light touch, 0.87; proprioception, 0.96). 9 Ohura T et al in 2017, found validity and reliability for Modified Barthel Index in study on stroke patients. ICC for inter-rater reliability for first session was 0.99. For intra rater reliability, mean value of ICC was 0.99 for individual task, inter rate kw coefficients for the first session ranged from 0.77 to 0.94 with intra-rater kw coefficients from 0.85 to 0.96. They concluded with strong criterion related validity against the Barthel Index, with higher reliabilities. Scoring system is convenient tool allowing anyone to assess activity of daily life.10 Stroke- related physical disability diminishes quality of daily living, place care burden on families, and increase need for long-term institutionalization11,12 Recovery after stroke occurs in two phases: neurological or functional. Neurological recovery occurs as a result of brain repair and reorganization while functional recovery depends on many factors including extent of motor affectation and the quality of rehabilitation13. Although neurological recovery may peak within the first three months of stroke; functional recovery continues with improvement in the recoveries of specific functions like mobility and social participation.13 Neurological recovery includes motor recovery, sensory recovery and also balance recovery. Functional recovery describes dependency of individual in activity of daily life. Another dimension to be taken into consideration is Quality of life which is individual perception of his/her position in life in the context of the culture and value system in which they live and in relation to their goals, expectations, standards, and concern.14 Recent studies have shown that Stroke has negative impact on both the functional recovery and quality of life of stroke survivors. Quality of life of stroke survivors increases with improvement in functional recovery.14 Stroke has impact on both the motor recovery and functional recovery in individuals who have survived stroke episode but the relationship between motor recovery and functional recovery in stroke has not been clearly explained. However, the relationship between these differential shifts in neurological recovery and functional recovery among stroke survivors has not been well explored. Therefore, this study explored the relationship between post-stroke motor recovery and functional recovery in stroke survivors within first 6 months of post stroke duration. Methods This study was ethically approved by a RK University, Gujarat. This study involved 67 consecutively recruited stroke survivors diagnosed of stroke by Neurophysician or General physician as per selection criteria as follows: Inclusion criteria: 1. All stroke patients who are willing to participate 2. Both male & female stroke patients 3. Mini mental scale examination score >2415 4. Duration of stroke varies from discharge from hospital up to 6 months16 Exclusion criteria: 1. Stroke patients who are not cooperative. 2. Stroke patients who have auditory &/or visual deficits. 3. Stroke patients who do not have proper medical records. 4. Patients having another neurological deficit with stroke. Oral as well as written consent was taken by patient &/or relative from those who were willing to participate. All subjects were explained about the study and were assessed for different demographic data as well as for motor as well as functional recovery by Fugl-Meyer Motor Assessment Score and Modified Barthel Index Score respectively. Fugl-Meyer Motor Assessment scale was used to assess their post stroke motor recovery. And Modified Barthel Index was used to assess functional recovery of stroke patients. Both of these scales were assessed on the same day for particular patients. They were also interviewed for demographic characteristics (age, gender, body mass index, side of body affected), clinical variables (length of coma, length of hospitalization, hypertension, diabetes and other co-morbidities) and history (addiction history, transient ischemic attack history, family history). Data was summarized using mean and standard deviation, frequency. Data were analyzed using the Pearson’s correlation for relationship between motor recovery and functional recovery and paired t-test for comparison between motor recovery and functional recovery of participants. Results Study included 67 stroke patients. Mean age of the participants was 57.52±13.1 years with majority (92.53%) between 17 and 80 years. Total 19 (28.36%) females and 48 (71.64%) males were included in study. The left side of the body was affected in 35 (52.23%) of the participants while right side of body was affected in 32 (47.76%) patients. Out of the participants who took part in the study, 57 had ischemic stroke (85.07%) while 10 (14.93%) had hemorrhagic stroke. Positive family history of stroke was found in 5 (7.46%) patients. 13 (19.4%) patients themselves had history of transient ischemic attack or stroke in past and had stroke another time. Total 19 (28.36%) patients were diagnosed with hypertension as co-morbidity while 30 (44.75%) patients were diagnosed with diabetes. 29 (43.28%) patients had at least one of the addictions of tobacco, alcohol or smoking. Data was checked for plausibility and cleaned. The kolmogrov-smirnov test was used to analyze normal distribution assumption of outcomes measures and was found normally distributed. Pearson correlation test was applied to find out relation between Fugl-Meyer Motor Assessment Score and Modified Barthel Index Score. By this test, r value found was 0.791 (n=67, p=0.00). Paired student’s t-test was applied to compare Fugl-Meyer Motor Assessment Score and Modified Barthel Index Score. By this test, t value found was 13.161 (n=67, df=66, p=0.00) Discussion From the results, it is observed that motor recovery has positive impact on functional recovery which suggests that with motor recovery, functional performance also improves of stroke patient as the time passes. It is also found that there is significant difference between motor recovery and functional recovery suggesting that motor recovery and functional recovery may happen at different rate. From mean value, it can be observed that functional recovery exceed than motor recovery. Motor performance accounts recovery of affected side only which is limited to neurological recovery only. Functional performance may also include contribution from normal side also to compensate for completion of task along with affected side of body. By this reason, functional recovery may exceed than motor recovery. Although, stroke had been shown to have negative impact on both the motor recovery and functional recovery in stroke survivors, the relationship between motor recovery and functional recovery after stroke has not been clearly delineated. The result of this study shows that improved motor recovery results in improved functional recovery in individuals who have had an episode of stroke. This means that if effort is geared towards functional recovery rather than motor activity, there will be remarkable reduction in the dependency in activity of daily living. Even with less motor recovery, by efforts patient can be given advantage of more functional recovery which is more required for patient. This is a wake-up call for clinicians involved in stroke rehabilitation to plan goals that will improve various aspects of life of stroke survivors and tailored those activities that will improve societal integration and reduce activity limitation and participation restriction.14 Anthea Rhoda et al. (2014) conducted a similar type study. In this study, total of 73 patients from the two separate studies were matched for age at stroke onset, gender, and initial motor functioning. Motor and functional recoveries were assessed at baseline, two and six months post stroke using the Rivermead Motor Assessment Scale and the Barthel Index (BI) respectively. Significant difference between motor and functional recovery was found.17 Lucca Nannetti et al. (2004) also conducted a study to compare motor and functional recovery on 170 post stroke depression patients. They found post stroke depression does not influence motor and functional recovery suggesting that depression is not affecting recovery.18 Limitations of this study include small size and only one time assessment was taken. Undiagnosed co-morbidities can also influence findings. Future studies can target on longitudinal follow-up for all stroke patients with more sample size. Conclusion The findings of this study support the fact that motor recovery had positive impact on functional outcome in stroke survivors. But functional recovery may exceed the motor recovery. Therefore, rehabilitation of stroke patient should not be only focus on the motor recovery but also on functional recovery training equally or even more. Acknowledgement Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. Funding Self Conflict of interest None Englishhttp://ijcrr.com/abstract.php?article_id=2552http://ijcrr.com/article_html.php?did=2552 Carr JH, Shepherd RB. Neurological Rehabilitation Optimizing Motor Recovery. 2nd edition. Churchill Livingstone; 2010. http://www.worldneurologyonline.com/article/implications-of-the-ahaasa updateddefinition-of-stroke-for-the-21st-century O?Sullivan SB, Schmitz TJ. Physical Rehabilitation. 5th edition. New Delhi: Jaypee Brothers; 2007. Stam J (2005). "Thrombosis of the cerebral veins and sinuses". N. Engl.                       J. Med. 352 (17):1791–8. 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A prediction Model for functional recovery in stroke. Stroke 1997; 28: 550 – 556. Gbiri CA and Akinpelu AO. Pattern of post-stroke func- tional recovery among stroke survivors in the first 12 months. Nigerian Quarterly Journal of Hospital Medi- cine. 2011; 21(3): 16-24 Teasell RW, Foley NC, Bhogal SK. Recovery post – stroke. Evidence-Based Reviewed of Stroke Rehabilita- tion. Topics in Stroke Rehabilitation 2004; 10(1):29-58 Gbiri CA and Akinpelu AO. Relationship between post-stroke functional recovery and quality of life among Nigerian stroke survivors. The Nigerian Postgraduate Medical Journal, Vol. 20, No. 1 March, 2013 Folstein MF, Folstein SE, McHugh PR: “Mini-mental state: A practical method for grading the cognitive state of patients for the clinician.” J Psychiatr Res 1975;12:189-198. Henk T. Henrich et al. Motor recovery after stroke: a systemic review of literature: Arch Physical Med Rehabil. 2012; 82:1629-38 Anthea Rhoda, Mario Smith1, Koen Putman et al. Motor and functional recovery after stroke: a comparison between rehabilitation settings in a developed versus a developing country. BMC Health Services Research 2014, 14:82 Luca Nannetti, Matteo Paci, Jacopo Pasquini et al. Motor and functional recovery in patients with post-stroke depression. Disability and Rehabilitation, 2005; 27(4): 170–175