XIX. European Stroke Conference
  Barcelona, Spain
  25 - 28 May 2010

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Topic: Rehabilitation and reorganisation after stroke
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Palau Level I Foyer

 
An inter-rater reliability study of the Nottingham Stroke Dressing Assessment (NSDA).
Background Dressing problems after stroke are common. In our quest to develop the most effective interventions to treat such difficulties there is first a need to establish the psychometric properties of appropriate dressing outcome measures for use in both clinical practice and research. The Nottingham Stroke Dressing Assessment (NSDA) is a validated assessment of post stroke dressing ability1. This study investigated the inter-rater reliability of the NSDA and accompanying Dressing Error Analysis form. Methods Twenty patients (14 females, 6 males) with persistent dressing difficulties at two weeks post stroke were recruited to participate in the study. Two stroke research occupational therapists and one clinical occupational therapist acted as raters. All three therapists observed the 20 patients during the dressing process and independently completed the NSDA and error analysis form, whilst prohibited from discussion. The demographic data and descriptive statistics for the sample were analysed using the SPSS programme. The NSDA data was transposed into the STATA computer package and a kappa test was performed to assess the level of agreement between the three raters on each of the measures (individual components of the NSDA) assessed. Results Of the 47 items that could be tested, there was excellent agreement (k >0.75) on 31 items, good agreement (k >0.6) on 8 items, fair agreement (k >0.4) on 6 items, and poor agreement (k <0.4) on 2 items. The intraclass correlation coefficient between the three raters’ final percentage score was 0.988, representing excellent agreement between raters. The error analysis form also proved to have high inter-rater agreement between the three raters’ scoring. Conclusion The NSDA and error analysis form can be considered to have psychometrically proven inter-rater reliability. References 1. Walker, MF & Lincoln, NB (1990) Reacquisition of dressing skills after stroke. International Disability Studies. 12: 41-3.
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J.C.Fletcher-Smith, The University of Nottingham, Nottingham, UNITED KINGDOM
M.F.Walker   The University of Nottingham  Nottingham  UNITED KINGDOM
A.Sunderland  The University of Nottingham  Nottingham  UNITED KINGDOM
K.Garvey  The University of Nottingham  Nottingham  UNITED KINGDOM
A.Wan  Nottingham University Hospitals NHS Trust  Nottingham  UNITED KINGDOM
H.Turner  Nottingham University Hospitals NHS Trust  Nottingham  UNITED KINGDOM
         
         
         
         
         
         
         
         
         

Topic: Epidemiology of stroke
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Exhibition Hall

 
19-Year Trends in Risk Factors, Clinical Characteristics and Prognosis in Lacunar Infarcts Data from the Sagrat Cor Hospital of Barcelona Stroke Registry
Background: Cardiovascular risk factors, clinical features and early outcome of first-ever cerebral lacunar infarcts from 1986 to 2004 using the Sagrat Cor Hospital of Barcelona Stroke Registry were assessed and compared with data from patients with non-lacunar infarction. Methods: The study population consisted of 566 patients with lacunar infarct and 1,516 patients with non-lacunar infarct, included in the stroke registry up to December 31, 2004. Temporal trends for the periods 1986−1992, 1993−1998 and 1999−2004 were analyzed. Results: Age increased significantly (p < 0.001) throughout time. Dysarthria-clumsy hand and atypical lacunar syndrome increased in the 1999−2004 period. A significant increase in the use of MRI was observed since 1993. Hypertension, diabetes, obesity and hyperlipidemia were significantly more frequent in lacunar infarct patients, whereas valvular heart disease, atrial fibrillation and heart failure were significantly more frequent in the non-lacunar cohort. A significantly lower frequency of complications as compared to patients with non-lacunar infarction, as well as a higher frequency of symptom-free patients at hospital discharge was observed. The in-hospital mortality rate was 0.3% in patients with lacunar infarction and 16.3% in patients with non-lacunar infarction (p < 0.001). The percentage of patients with long hospital stay (> 12 days) was lower in the lacunar group than in the non-lacunar group (30.7% vs 53.2%, p < 0.001). Conclusion: This study shows demographic changes and variations in cardiovascular risk factors, prognosis and in-hospital mortality rate of patients with lacunar infarction over a 19-year period, which in part reflects improvements in the management and care of this condition during this span of years.
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A.Arboix, Cerebrovascular Division. Sagrat Cor Hospital , Barcelona, SPAIN
M.Grau-Olivares   Cerebrovascular Division. Sagrat Cor Hospital   Barcelona  SPAIN
L.Blanco  Cerebrovascular Division. Sagrat Cor Hospital   Barcelona  SPAIN
J.Massons  Cerebrovascular Division. Sagrat Cor Hospital   Barcelona  SPAIN
L.García-Eroles  Cerebrovascular Division. Sagrat Cor Hospital  Barcelona  SPAIN
O.Parra  Sagrat Cor Hospital   Barcelona  SPAIN
M.Oliveres  Cerebrovascular Division. Sagrat Cor Hospital   Barcelona  SPAIN
         
         
         
         
         
         
         
         

Topic: Acute stroke: emergency management, stroke units and complications
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Palau Level I

 
Evaluation of Early Seizures in Acute Cerebrovascular Accident (CVA)
Background: Cerebrovascular accidents are one of the common causes of disability of human population all over the world. Regarding incidence of post- CVA Seizures and its effect on morbidity and mortality in these patients and few studies have been done in our country we decided to study incidence of post- CVA early seizure and epilepsy and its effects on out-come of CVA Patients hospitalized in Valiasr hospital of Zanjan city. Method: This descriptive and case control study was conducted on 404 CVA patient's files who were hospitalized in Valiasr- Zanjan hospital from Mar to Oct 2007. The data such as Gender, age, type of CVA, form of seizures, damaged brain zone, occurrence of seizure in first week, mortality day (if patient had expired) was collected through questionnaire and then analyzed. Results: Out of 404 cases with mean age of 70.3 including 227 (56/2%) men and 177 (43/8%) women.362 cases (89/6%) with ischemic CVA and 42 cases (10/4%) with hemorrhagic CVA were admitted. 388 cases (96%) had no seizure in first week after CVA (7.5%),and 16 cases (4%) had at least one early- seizure. Fifteen cases (4.1%) with ischemic CVA and 1 case (2.4%) of hemorrhagic CVA patients had at least one episode of early seizure in the first week (P= 0.579). In hemorrhagic type only one case of early seizure occurred with hemorrhage in frontal lobe. Conclusion: A survey of present data showing that early seizure after CVA more common in ischemic type of CVA especially in embolic form, and the risk of these seizures was higher at the first day after CVA. In addition, early seizure was related to higher mortality rate in CVA patients. The incidence of early seizures was higher in men. So prescribing of prophylactic anti- seizure drugs may reduce the incidence of seizure and it's complications in these patients.
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F.Golipour, Dept .of Neurology, Vali-e-Asr Hospital , Zanjan University of Medical Sciences, Zanjan, Iran , ZANJAN, IRAN
H.ARABZADEH   Zanjan University of Medical Sciences, Zanjan, Iran  ZANJAN  IRAN
A.ZAMANI  Zanjan University of Medical Sciences, Zanjan, Iran  ZANJAN  IRAN
         
         
         
         
         
         
         
         
         
         
         
         

Topic: Epidemiology of stroke
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Exhibition Hall

 
Allelic association analysis of single nucleotide polymorphisms regarding effect on ischemic stroke risk may be improved by an adequate statistical method
Background: Analyses of allelic variations in single nucleotide polymorphisms have enhanced the understanding of genetic influence on ischemic stroke risk in the last decade. However, logistic regression (LR) models including individual-based characteristics (one sampling unit per individual) in combination with allele-based genotype data (two units per individual) may diminish the statistical adequacy. Weighted LR might be an approach to handle this problem. Methods: A previously published study, including 395 ischemic stroke patients and 929 control subjects in southern Sweden regarding SNP45 (rs12188950) in the 5’ region of the phosphodiesterase 4D gene on chromosome 5, was revised. We also performed 1000 data simulations with corresponding data characteristics to examine how occasional (randomly occurring) deviations from a perfect state of Hardy-Weinberg equilibrium (HWE) would influence our estimates. Allelic-based odds ratios (OR) were calculated and compared with individual-based ORs from LR with or without weights considering HWE deviations. Results: Our previously published study exhibited only a minor departure from perfect HWE, conferring a bias of 0.6% (i.e. OR[unadjusted individual-based] = 0.728; p=0.0061 against OR[allele-based] = 0.724; p=0.0054). By weighted simple LR we obtained OR[HWE-adjusted individual-based] = 0.723; p=0.0055, conferring negligible bias. Our simulations showed almost 4% probability to obtain a bias of >2%, or 10% probability for a bias of >1.4%. This bias became negligible (<0.05%) when performing weighted simple LR. Simulations using half sample size (198 cases and 464 control subjects) conferred a probability of 10% to obtain >2.1% bias when applying unweighted simple LR. Conclusion: Occasional deviations from perfect HWE will generate systematic errors when assessing individual-based data using LR. Weighted simple LR may be used to adjust for these errors; further studies are needed regarding performing multiple LR similarly.
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H.Lövkvist, Department of Clinical Sciences, Lund, Neurology, Lund University, Lund, SWEDEN
A.G.Lindgren   Department of Clinical Sciences, Lund, Neurology, Lund University  Lund  SWEDEN
P.Höglund  Department of Laboratory Medicine, Lund, Clinical Pharmacology, Lund University  Lund  SWEDEN
         
         
         
         
         
         
         
         
         
         
         
         

Topic: Experimental studies
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Salon Azur

 
Computational modelling of Circle of Willis and Leptomeningeal Anastomoses: Application in studying Cerebrovascular Occlusion Syndromes
Background: The role of the Circle of Willis (CoW) in salvaging ischemic brain tissue has been emphasized above that of the leptomeningeal anastomoses (LA). We developed a computational model of the cerebral circulation to evaluate the roles of the CoW and LA in intracranial artery occlusion. We used this model to estimate the effective size of the LA under simulated Middle Cerebral Artery (MCA) occlusion. Methods: Cerebral vasculature was modelled as a network of junctions connected by cylindrical pipes and represented as a connectivity matrix. A series of experiments were simulated in which successive branches of the intracranial arteries were occluded. The diameters of intra-territorial LA between arteries within the same arterial territory were varied to estimate the size of the LA to maintain adequate flow (while keeping inter-territorial LA between arteries from different territories constant at 2mm). Results: The computational model shows zero flow in the territory of the occluded artery when there is no intra-territorial and no inter-territorial LA. The region of reduced flow became smaller and smaller as the site of occlusion was moved from the proximal large to the smaller distal intracranial artery. The presence of inter-territorial LA changes flow in the territory of the occluded artery with the greatest preservation (>65% of baseline) occurring in the arteries connected by inter-territorial LA compared to those that do not have inter-territorial LA (<20% of baseline). The CoW and LA work in tandem to provide flow to the MCA territory following MCA occlusion. The simulated conditions suggest no added benefit to flow when the intra-territorial LA increased beyond 0.25 mm. Discussion: We have provided an estimate of the anatomical extent of the LA required to function effectively as a salvaging reservoir in MCA occlusion. Computational modelling provides the ability to experimentally understand the effect of cerebral arterial occlusion on regional blood flow.
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T.G.Phan, STAR, Clayton, AUSTRALIA
J.Hilton   CSIRO  Clayton  AUSTRALIA
R.Beare  CSIRO  Clayton  AUSTRALIA
V.Srikanth  STAR  Clayton  AUSTRALIA
M.Sinnott  CSIRO  Clayton  AUSTRALIA
         
         
         
         
         
         
         
         
         
         

Topic: Vascular biology
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Salon Azur

 
Expressions of platelet CD40L and CD62p correlate with clinical outcome in acute phase of ischemic stroke
Background: The expressions of CD62p and CD40L are a sensitive marker of platelet activation and platelet-related inflammatory processes. CD62p binding leukocytes engages the white blood cells into thrombosis. CD40L expressed on the platelets forms a receptor-ligand pair (CD40-CD40L). CD40-CD40L signalling induces release of a wide range of cytokines and growth factors that exert pro-inflammatory effects. The white blood count measured within 24 hours of clinical onset is related to the early in-hospital death or prolonged hospitalization in acute stroke patients. Then we hypothesized that platelet expressions of CD62 and CD40L correlate with clinical outcome assessed during acute phase of ischemic stroke. Methods: We assessed the percentage of platelets expressing CD40L and CD62p using flow cytometry (FACSCanto, Becton Dickinson) in 93 (48M/45F) subjects with ischemic stroke at day 10. of event. The clinical condition of stroke patients was measured on the Scandinavian Stroke Scale (SSS) and on the National Institute of Health Stroke Scale (NIHSS) at the same time as flow cytometry study. The Kendall tau correlation coefficient was used to correlate studied parameters. The null hypothesis stating no relation between variables was rejected for significance P<0.01. Results: We confirmed significant negative correlations between the SSS scoring and CD40L expression (t = - 0.33, p=0.007) and between SSS scoring and CD62p expression (t = - 0.46, p=0.002). We revealed the positive correlations between the NIHSS scoring and CD40L expression (t = 0.2, p=0.004) and between the NIHSS scoring and CD62p expression (t = 0.38, p= 0.009). Conclusions: An increased percentage of platelets expressing CD40L or CD62p correlates with lower scoring in SSS and with higher scoring in NIHSS in acute stroke subjects.
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M.Lukasik, Poznan University of Medical Sciences, Poznan, POLAND
G.Dworacki   Poznan University of Medical Sciences  Poznan  POLAND
J.Kufel  Poznan University of Medical Sciences  Poznan  POLAND
B.Brzezicha  Poznan University of Medical Sciences  Poznan  POLAND
W.Kozubski  Poznan University of Medical Sciences  Poznan  POLAND
         
         
         
         
         
         
         
         
         
         

Topic: Brain imaging
Oral Session :   
Poster Session: Poster Session Red
Date: Wednesday 26 May 2010
Time: 12:30 - 14:00
Room: Palau Level I

 
Correlation between penumbra and infarct topography in MCA stroke
Background: The correlation and difference between penumbra and regional risk of infarction in MCA stroke has been described only in terms of volume but not at a voxel level. In this study we investigate the differences between maps of penumbral region and infarcts in the MCA territory. Method: 64 multirow detector CT scan was used to acquire 8 cm coverage of the brain in the vertical dimension. Twelve patients, with middle cerebral artery (MCA) occlusion, were studied within 6 hours of stroke onset. Penumbra voxels were defined as voxels > 4 sec on mean transit time (MTT) map and <2.5 ml/100 g on cerebral blood volume (CBV) map. MCA infarct was defined on FLAIR images in patients with MCA occlusion. The difference between the Penumbra and the Infarct map at a voxel level was calculated using the Fisher exact test and Z score. The Fisher exact map provides an index of probability of the difference between the two maps at a voxel level. The Z score map provides a normalised distance between the Penumbral and Infarct maps at a given voxel Results: Perfusion abnormalities within the MCA territory were heterogenous, reflecting the different regions at higher risk of ischaemia. The Penumbral and Infarct maps provide complementary information on the differences between Penumbra and Infarct maps. These maps show that deep compartment of the MCA territory has lowest probability (<0.0001on Fisher exact test) of being penumbra tissue and that certain parts of the superficial compartment has high normalised distance (Z score > 2) between penumbra tissue and the risk of infarction. Discussion: The Fisher exact probability map and the Z score map may be useful in determining the significance of Penumbra voxel.
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T.G.Phan, STAR, Clayton, AUSTRALIA
H.Ma   STAR  Clayton  AUSTRALIA
J.Ly  STAR  Clayton  AUSTRALIA
M.Holt  Monash Medical Centre  Clayton  AUSTRALIA
W.Chong  Monash Medical Centre  Clayton  AUSTRALIA
V.Sriknath  STAR  Clayton  AUSTRALIA
         
         
         
         
         
         
         
         
         

Topic: Rehabilitation and reorganisation after stroke
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Palau Level I Foyer

 
Analysis of patient selected goals from the Botulinum Toxin for the Upper Limb after Stroke (BoTULS) trial
Background Assessment tools to capture patient selected goals are increasingly used in rehabilitation research and it has been suggested that they should be utilised in the evaluation of botulinum toxin treatment. Methods 333 participants with upper limb spasticity took part in the BoTULS trial. The intervention group received botulinum toxin injections plus a four week upper limb therapy programme. The control group received the upper limb therapy programme alone. As a secondary outcome measure, the Canadian Occupational Performance Measure (COPM) was used to select and score individual participant goals. Up to five goals were chosen after examining performance limitations in three occupational areas (self care, productivity and leisure). A simple coding framework was developed to analyse goal choices. The Mann Whitney U test was used to compare change in goal performance and satisfaction scores between the randomisation groups at one month. Results Selection of goals was completed by 311/333 (93.4%) participants (control group, 150/163 (92.0%), intervention group 161/170 (94.7%)). The median number of goals chosen in both groups was 4 [IQR 3-5]. The commonest goal choices were about personal care. These included washing, dressing, grooming and feeding. Goals related to household management included performance of household chores, food preparation, use of cutlery/crockery and use of kitchenware. Median change in performance was 2.3 [IQR 1.3-4.0] in the control group and 2.3 [IQR 1.2-3.8] in the intervention group (p=0.535). Median change in satisfaction was 2.4 [IQR 1.0-4.4] and 2.3 [IQR 1.0-4.0] in the groups respectively (p=0.342). Conclusion Personal care and household management goals are common rehabilitation choices in patients with upper limb spasticity after stroke. Treatment with botulinum toxin did not enhance attainment of participant selected goals.
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L.C.Shaw, Newcastle University, Newcastle upon Tyne, UNITED KINGDOM
F.M.J.van Wijck   Queen Margaret University  Edinburgh  UNITED KINGDOM
C.I.MPrice  Northumbria Healthcare NHS Foundation Trust  Newcasle upon Tyne  UNITED KINGDOM
PShackley  University of Sheffield  Sheffield  UNITED KINGDOM
NSteen  Newcastle University  Newcastle upon Tyne  UNITED KINGDOM
M.P.Barnes  International Centre for Neurorehabilitation  Newcastle upon Tyne  UNITED KINGDOM
G.A.Ford  Newcastle University  Newcastle upon Tyne  UNITED KINGDOM
L.A.Graham  International Centre for Neurorehabilitation  Newcastle upon Tyne  UNITED KINGDOM
HRodgers  Newcastle University  Newcastle upon Tyne  UNITED KINGDOM
         
         
         
         
         
         

Topic: Etiology of stroke and risk factors
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Exhibition Hall

 
Prevalence of significant internal carotid stenosis remains high in those 80 years and over.
Progressive severity of Internal Carotid artery stenosis is associated with increasing stroke risk. Although there is good evidence that surgery is of benefit in symptomatic disease, especially in older subjects, there is little data on carotid disease prevalence in the 80+ age group and much of the data there is relates to a time when this population would have had little lifetime exposure to prevention therapy. We studied a large recent population of subjects 80+ years to determine if they have a higher prevalence of significant carotid disease than younger populations and if severity of disease at presentation for scanning increases with age. Methods: Data on all initial carotid duplex ultrasounds on subjects 80+ years performed in a large University Hospital over a 40 month period 2006-2009 were examined. The vascular department provides a non age limited service for investigation of subjects with suspected carotid disease. Ultrasounds are graded according to NASCET criteria. Results were compared with control populations of consecutive subjects 60-69 years and 70-79 years performed in the same time period. Results: Data on 3367 subjects were reviewed (80+years: 989 subjects (1965 arteries), 70-79 years: 1111 subjects (2203 arteries), 60-69 years 1267 subjects (2517 arteries)). A smaller proportion of those 60-69 years had >50% stenosis than in the other groups(80+ yrs: 83.4%, 70-79 yrs: 82.3%, 60-69 yrs: 87.8%. Chi Sq 31.7, p<0.0001) but there was little difference between those 70-79 years and 80+ (Chi sq 0.82, p=0.36). There was however no difference between groups in proportion of those with severe stenosis (>80%) or occlusion 80+ yrs: 4.9%, 70-79 yrs: 6.0%, 60-69 yrs: 5.2%. Chi Sq 2.5, p=0.28). Conclusion: In this selected hospital population incidence of significant carotid disease (>50% stenosis) at presentation increased slightly between peoples 60s and 70s but not thereafter. Incidence of severe disease (>80% stenosis) did not increase.
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S.O'Sullivan, St James's Hospital, Dublin, IRELAND
M.P.Colgan   St James's Harbison  Dublin  IRELAND
BNiBhuachalla  St James's Hospital  Dublin  IRELAND
D.M.Moore  St James's Hospital  Dublin  IRELAND
PMadhavan  St James's Hospital  Dublin  IRELAND
S.M.O'Neill  St James's Hospital  Dublin  IRELAND
J.A.Harbison  Trinity College Institute for Neurosciences.  Dublin  IRELAND
         
         
         
         
         
         
         
         

Topic: Rehabilitation and reorganisation after stroke
Oral Session :  A
Poster Session:  
Date: Thursday 27 May 2010
Time: 14:10 - 14:20
Room: H2

2
Effectiveness of Virtual Reality using Wii Gaming technology in STroke Rehabilitation (EVREST): A Randomized Clinical Trial and Proof of Principle
Background: Most stroke survivors experience hemiparesis, resulting in functional limitation of an upper extremity. Evidence suggests that increasing intensity of rehabilitation results in better motor recovery. Limited evidence is available on Virtual reality (VR) use for stroke rehabilitation. Objective: To evaluate the feasibility, safety and efficacy of virtual reality using Nintendo Wii© gaming technology (VRWii) to improve arm recovery in stroke patients. Design & Setting: Prospective, single-blinded, pilot, randomized, clinical trial with two parallel groups conducted in a tertiary care rehabilitation institution including patients with stroke within 2 months from onset with a motor deficit of ≥3 on the Chedoke-McMaster Scale (arm). Interventions: Participants were assigned to VRWii versus recreational therapy (RT) while receiving usual care (standard rehabilitation). Main Outcome Measures: The primary feasibility outcome was the total time receiving the intervention. The primary safety outcome was the proportion of patients experiencing intervention-related adverse events during the study period. Efficacy, a secondary outcome measure, was measured by the Wolf Motor Function Test (WMFT), Box and Block Test, and Stroke Impact Scale at 4 week post-intervention follow-up visit. Results: Overall, 22/110 (20%) of screened patients were randomized. The mean age (range) was 61.3 (41-83) years. The interventions were successfully delivered in 9 of 10 participants in the VRWii and 8 out of 10 in the RT arm (0.1; 95%CI -0.21, 0.41). Mean total session time 388 min (RT) vs. 364 min (VRWii) (-23.3; 95%CI -173.7, 127.1). There were no serious adverse events in any group. For the main secondary efficacy end-point, participants in the VRWii arm had a significant average motor function improvement of 7 seconds (WMFT -7.4 seconds; 95%CI -14.5, - 0.2) after adjustment for age, baseline functional status (WMFT) and stroke severity. Conclusions: Virtual reality using Wii gaming technology represents a safe, feasible, and potentially effective alternative to facilitate rehabilitation therapy and promote motor recovery after stroke. ClinicalTrials.gov registration # NTC692523
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on behalf of the Stroke Outcome Research Canada (SORCan) Working Group

G.Saposnik, St. Michael's Hospital, University of Toronto, Toronto, CANADA
R.Teasell   St. Michael's Hospital, University of Toronto  Toronto  CANADA
M.Mamdani  St. Michael's Hospital, University of Toronto  Toronto  CANADA
K.E.Thorpe  St. Michael's Hospital, University of Toronto  Toronto  CANADA
D.Cheung  St. Michael's Hospital, University of Toronto  Toronto  CANADA
J.Willems  St. Michael's Hospital, University of Toronto  Toronto  CANADA
J.Hall  St. Michael's Hospital, University of Toronto  Toronto 
W.McIlroy  St. Michael's Hospital, University of Toronto  Toronto  CANADA
M.Bayley  St. Michael's Hospital, University of Toronto  Toronto  CANADA
L.G.Cohen  St. Michael's Hospital, University of Toronto  Toronto  CANADA
         
         
         
         
         

Topic: Management and economics
Oral Session :   
Poster Session: Poster Session Red
Date: Wednesday 26 May 2010
Time: 12:30 - 14:00
Room: Palau Level I

 
Impact of Organized Acute Stroke Care with Telemedicine Support on Costs of Inpatient Medical Treatment and Post-Stroke Personal Care
Background: Stroke-Unit care is effective in reducing death and dependency. The wider implementation of Stroke-Units is hampered by higher costs compared to conventional care and limited evidence about effects on costs for post-discharge care. Methods: We analysed health insurance and nursing care fund data from two 21-months admission periods before and after implementation of a community intervention program based on Stroke-Unit care with telemedicine support. Medical outcomes over 30 months of follow-up and average costs of in- and outpatient care were assessed in 5 intervention and 5 matched control hospitals. Hospital costs were calculated with costs per day and costs for outpatient personal care with standardized payments depending on level-of-care and service category. The primary outcome was total costs for stroke-related care per survived year in patients not receiving paid care before index stroke. Findings: 1179 patients were analysed in the pre-implementation (609 in intervention, 570 in control hospitals) and 1277 patients in the post-implementation period (767 and 510). No differences in medical outcomes or costs per survived year were found before network implementation. While medical outcomes in control hospitals remained almost unchanged after implementation, fewer patients of intervention hospitals died or received paid care during follow-up (at 3 month: 39.2% versus 30.8%; p<0.01). Patients in intervention hospitals had higher costs for acute inpatient care (€5,309 vs. €4,901, p=0.04) but lower costs for post-stroke personal care (€3,946 vs. €5,132; p=0.04). After adjustment for relevant baseline parameters, a trend towards lower total costs for stroke-related care per survived year was seen in intervention hospitals (€18,509 vs. €21,065; p=0.098). Conclusions: When considering both health insurance and nursing care fund costs, the incremental costs for acute Stroke-Unit care in hospital are compensated by savings in outpatient care.
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The Telemedical Projekt for Integrative Stroke Care (TEMPiS)

H.J.Audebert, Center for Stroke Research, Charité Universitätsmedizin Berlin, Berlin, GERMANY
P.Reitmeir   Institute of Health Economics, Helmholtz Zentrum München  Munich  GERMANY
S.von Reden  Dept. of Cardiology, University of Wuerzburg  Wuerzburg  GERMANY
R.Holle  Institute of Health Economics, Helmholtz Zentrum München  Munich  GERMANY
R.L.Haberl  Dept. of Neurology, Klinikum Harlaching, Städtisches Klinikum München GmbH  Munich  GERMANY
J.Schenkel  German Chamber of Physicians  Berlin  GERMANY
         
         
         
         
         
         
         
         
         

Topic: Interesting and challenging cases
Oral Session :   
Poster Session: Poster Session Red
Date: Wednesday 26 May 2010
Time: 12:30 - 14:00
Room: Exhibition Hall

 
Amyloid angiopathy presenting as convexity SAH and heralding lobar hemorrhage: clinical, imaging and biopsy features
Background: There are sporadic case reports of amyloid angiopathy presenting as subarachnoid hemorrhage (SAH). In previous case reports with short follow up, the prognosis appears to be relatively benign. We have encountered three such cases where the prognoses are less benign. The clinical, imaging and biopsy features will be described below. Method: A retrospective of patients who presented to Monash Medical Centre with convexity SAH and no evidence of intracranial aneurysm. Results: The three patients present with multiple transient sensory symptoms that are similar to the marching symptoms in migrainous attacks. Only one of the three had accompanying headache. All patients underwent CT, MRI and MR angiography and two of the three patients had CT angiography. Patient 1 was clinically labelled as having transient ischemic attack, patient 2 as having migraine and patient 3 has having focal seizure. All patients developed lobar hemorrhage within 1 to 26 months of the initials presentation. In Patient 1 lobar hemorrhage occurred after commencement of antiplatelet drug and in Patient 2 it occurred after commencement of a Statin. Brain biopsy in patients (1 and 2) revealed typical changes of amyloid angiopathy. 11C-Pittsburgh compound B (PIB) PET study in patient (1) shows increased PIB uptake in the occipital temporal region. Patient 1 developed features of dementia 30 months after the initial presentation and was commenced on Donepezil. Conclusion: Convexity SAH may be the presenting feature of amyloid angiopathy and is likely to be followed by lobar hemorrhage. Recognition of these features can lead to avoidance of antiplatelet and anticoagulation therapy.
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T.G.Phan, STAR, Clayton, AUSTRALIA
S.Singhal   Stroke Unit, Monash Medical Centre  Clayton  AUSTRALIA
J.VLy  STAR  Clayton  AUSTRALIA
S.Bower  Stroke Unit, Monash Medical Centre  Clayton  AUSTRALIA
P.Kempster  Stroke Unit, Monash Medical Centre  Clayton  AUSTRALIA
         
         
         
         
         
         
         
         
         
         

Topic: Intracerebral/subarachnoid haemorrhage and venous diseases
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Palau Level I Foyer

 
Short term evolution of patients with venous thromboembolism after recent intracerebral hemorrhage
Background: Venous Thromboembolism (VTE), covers Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE), causes 12% of deaths in Europeans and PE 5-10% inhospital. Only 40% of at-risk patients receive adequate prophylaxis. Patients with VTE after Intracerebral Hemorrhage (IH) are uncommon, but management is complicated. The actual incidence of VTE after IH is still unclear. Greater risk of symptomatic VTE with IH (1.93%) than with ischemic stroke (1.17%). With VTE patients after IH anticoagulant treatment is normally less intense and initiated later. The objective of our study is to investigate differences between patients with VTE with and without previous history of IH. Methods: RIETE includes patients with symptomatic DVT or PE confirmed by objective tests. Definitions: major bleeding, drop >2 g/dl of hemoglobin or needs transfusion, fatal hemorrhage, death in 7 days and fatal PE, death shortly after without any other cause in both cases, immobility, bed rest ≥4 days, postoperative, surgery in previous 2 months, anemia, hemoglobin level <13 g/dl men and <12 g/dl women. Demographic, clinical, laboratory testing and follow-up parameters. Statistical analysis, to study groups of IH with regard to patients without hemorrhage, a binary logistic regression model is used. Results: RIETE includes 26,888 patients, of whom 146 (0.54%) had suffered a major intracerebral hemorrhage 30 days previously. There were no significant differences in gender or age in either group. [See Tables 1, 2 and 3]. Conclusions: Patients with recent IH had less case history of underlying cancer but more frequently anemia, postoperative, and prolonged immobility as comorbility In acute phase patients received UHF and inferior vena cava filter more frequently and LMWH less frequently and with smaller doses in comparison to patients without previous hemorrhaging. In the first month of follow-up, there were less cases of major or fatal bleeding, but VTE and PE reoccurred 4 times more frequently and fatal PE 8 times more frequently in comparison to patients without previous hemorrhaging.
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RIETE Investigators

J.J.Timiraos Fernández, Department of Neurology. Txagorritxu Hospital., Vitoria, SPAIN
J.L.Lobo Beristain   Deparment of Respiratory. Txagorritxu Hospital  Vitoria  SPAIN
V.Zorrilla Lorenzo  Deparment of Respiratory. Txagorritxu Hospital  Vitoria  SPAIN
N.Ruiz Jiménez  Department of Internal Medicine. Hospital de la Princesa  Madrid  SPAIN
J.A.Nieto Rodríguez  Department of Internal Medicine. Hospital Virgen de la Luz  Cuenca  SPAIN
D.Jiménez de Castro  Deparment of Respiratory. Hospital Ramón y Cajal  Madrid  SPAIN
M.Monreal Bosch  Department of Internal Medicine. Hospital german Trias y Pujol  Badalona  SPAIN
         
         
         
         
         
         
         
         

Topic: Stroke prevention
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Salon Azur

 
Quality of Secondary Prevention after Minor Stroke and TIA in a German Stroke Unit Setting The Course of Patients with Minor Stroke and TIA Study (COPAMiSTIA)
Background: Patients after stroke or TIA are at high risk for vascular re-events. Effective secondary prevention measures comprise risk factor control, life style modifications and antithrombotic treatment. Little data exist about quality of pharmacological and non-pharmacological secondary prevention in unselected hospital cohorts. Methods: We assessed frequency of risk factors, lifestyle habits and quality of secondary prevention in consecutive patients admitted to two stroke centers in Berlin. Patients with minor stroke (mRS<2 at time of screening) or TIA (complete symptom remission <24h) and at least one modifiable risk factor were included and followed up over 6 months. Willingness of patients to participate in a support program for intensified secondary prevention was assessed before hospital discharge. Results: 303 consecutive patients were screened. 234 patients (62% male, median age 66y [24-87]) fulfilled the inclusion criteria and were included between January and September 2009. Frequencies of known risk factors were: Hypertension: 71%; diabetes: 17%; atrial fibrillation: 15%; hypercholesterolemia: 62%; smoking: 30%; overweight (BMI 25-29): 45%; obesity (BMI≥30): 19%. Only 46% reported physical activity (≥30 minutes) at least 2 times per week. 89% stated that they would like to participate in a support program. Quality of secondary prevention during follow-up regarding risk factor control, medication compliance and lifestyle will be presented at the ESC 2010. Conclusions: Most minor stroke or TIA patients admitted to acute Stroke Units have modifiable risk factors and could benefit from lifestyle changes. The vast majority of these patients are interested in a support program for intensified secondary prevention.
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S.Leistner, Center for Stroke Research, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, GERMANY
C.H.Nolte   Center for Stroke Research, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin  Berlin  GERMANY
A.Ziegler  Center for Stroke Research, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin  Berlin  GERMANY
G.Nieweler  Center for Stroke Research, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin  Berlin  GERMANY
G.J.Jungehulsing  Center for Stroke Research, Charité Universitätsmedizin Berlin,  Berlin  GERMANY
P.U.Heuschmann  Center for Stroke Research, Charité Universitätsmedizin Berlin  Berlin  GERMANY
H.J.Audebert  Center for Stroke Research, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin  Berlin  GERMANY
         
         
         
         
         
         
         
         

Topic: Vascular surgery and neurosurgery/interventional neuroradiology
Oral Session :   
Poster Session: Poster Session Red
Date: Wednesday 26 May 2010
Time: 12:30 - 14:00
Room: Exhibition Hall

 
MECHANICAL THROMBECTOMY WITH THE SOLITAIRE™ AB DEVICE IN LARGE ARTERY OCCLUSIONS OF THE ANTERIOR CIRCULATION. A PILOT STUDY
Background and Purpose: This pilot study describes the safety and effectiveness of a self-expanding and fully retrievable stent (SolitaireTM AB) in revascularization of patients with ischemic stroke secondary to large artery occlusion. Methods: In a prospective, single-center study we enrolled 20 consecutive patients with and acute ischemic stroke of less than 8 hours duration from symptoms onset (median [quartiles] National Institutes of Health Stroke Scale, 19 [16,23]) and an angiographic proved artery occlusion of the anterior circulation. The occluded artery at baseline was middle cerebral artery (MCA) in 12 patients, proximal internal carotid artery (ICA)/MCA tandem occlusion in 3 patients and terminal ICA in 5 patients. Thrombectomy was used as a rescue therapy in 2 patients who were refractory to intraarterial plasminogen activator and in 3 who did not achieved successful recanalization with MERCI retriever. Results: Postprocedure, successful revascularization (TICI IIb or III) was observed in 90% of treated vessels, and 45% of patients showed good functional outcome at 3 months (modified Rankin Scale score ≤ 2). Symptomatic intracranial hemorrhage was found in 2 (10%) patients on 24-hours CT, and 4 (20%) patients were dead at 90 days (1 within the first week). The groin puncture-to-recanalization median time was 50 [38-71] minutes when the analysis was restricted to patients in whom the Solitaire was the first endovascular approach (n=15). Most patients achieved a very high rate of complete revascularization, including lenticulostriate arteries, and only one pass was needed to fully retrieve the clot in 13 cases (mean 1.4 passes). No serious procedural events were reported. Conclusions: These results suggest that the Solitaire™ AB device can safely and effectively retrieve clots from the MCA and TICA within 8 hours from symptoms onset.
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L.Dorado, Hospital Universitari Germans Trias i Pujol. , Badalona, SPAIN
C.Castaño   Hospital Universitari Germans Trias i Pujol.   Badalona  SPAIN
C.Guerrero  Hospital Universitari Germans Trias i Pujol.   Badalona  SPAIN
M.Millán  Hospital Universitari Germans Trias i Pujol.   Badalona  SPAIN
M.Gomis  Hospital Universitari Germans Trias i Pujol.  Badalona  SPAIN
N.Pérez de la Ossa  Hospital Universitari Germans Trias i Pujol.   Badalona  SPAIN
M.Castellanos  Hospital Doctor Josep Trueta   Girona  SPAIN
M.R.García  Hospital Universitari Germans Trias i Pujol.   Badalona  SPAIN
S.Domènech  Hospital Universitari Germans Trias i Pujol.   Badalona  SPAIN
A.Dávalos  Hospital Universitari Germans Trias i Pujol.   Badalona  SPAIN
         
         
         
         
         

Topic: Stroke prevention
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Salon Azur

 
Is it Possible to Develop a “Gold Standard” Rapid Access Neurovascular Clinic in a Rural Hospital at Little Cost?
Background The risk of stroke following a minor cerebrovascular event is well established (1). Up to 10% of untreated patients will develop a stroke within the first week and up to 30% in the first month (1). A recent study showed that this risk can be reduced by >80% by urgently managing patients in a rapid access clinic (2). The purpose of presenting this audit is to demonstrate that a committed small stroke team can provide a neurovascular service comparable to that demonstrated in the EXPRESS study at little cost. Methods A neurovascular clinic working from an Elderly Day Care Unit was started. Patients were referred by proforma including an ABCD2 risk score. Referrals were seen on an “ad hoc” basis shared between Senior Doctors (2 Consultants, 1 Associate Specialist and 1 Specialist Registrar) organised by the unit nurse. The recurrent cost incurred was £30,000 to fund Radiology and Radiography time. We aimed to see all patients with an ABCD2 score >5 within 24hrs of referral. Patients with an ABCD2 score <5 were to be reviewed in <72hrs. Results 238 patients were seen over a 12 month period from January 1st 2008. 160 had a confirmed neurovascular event. 10 were posterior circulation events. Of the anterior circulation strokes, all had immediate CT scanning and 95% had carotid doppler scans within 48hrs of being reviewed (with reasons for ‘not scanned’). Patients with symptomatic artery stenosis >70% were immediately referred to a rapid access Vascular Service. All patients with confirmed TIA received secondary prevention prescription at the clinic. Of 10 patients in atrial fibrillation, 9 were immediately anticoagulated. Of the 149 patients with a cerebrovascular event, only 2 had a minor recurrence within 30 days. Conclusion Our audit has demonstrated that, with a little investment plus commitment and dedication from staff, a service meeting the gold standard of the EXPRESS study can be provided in a small rural unit.
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B. N.BHASKARAN, Prince Philip Hospital, Llanelli Swansea, UNITED KINGDOM
R.Thomas   University of Cardiff  Cardiff  UNITED KINGDOM
S.Osman  Prince Philip Hospital  Llanelli Swansea  UNITED KINGDOM
T P. L. T.Thomas  Prince Philip Hospital  Llanelli Swansea  UNITED KINGDOM
G. C.Morris  Prince Philip Hospital  Llanelli Swansea  UNITED KINGDOM
         
         
         
         
         
         
         
         
         
         

Topic: Interesting and challenging cases
Oral Session :   
Poster Session: Poster Session Red
Date: Wednesday 26 May 2010
Time: 12:30 - 14:00
Room: Exhibition Hall

 
Emergency endovascular treatment of a bilateral spontaneous internal carotid arteries dissection
Background: Carotid artery dissection (CAD) is a major cause of ischemic stroke in young patients; bilateral CAD are rare but frequently related to a previous neck trauma or collagen diseases. Patients with spontaneous CAD are thought to have an underlying structural defect of the arterial wall. About 7% of acute ischemic strokes due to CAD are of hemodynamic origin with no specific therapeutic indication. Recently few anecdotic cases of endovascular recanalization of bilateral CAD are described. Case report: We report the case of a 40 years old woman admitted to Emergency Department with mild fluctuating left hemiparesis and confusion. Symptoms were preceded by transient blurred vision, postural instability and headache. CT scan was negative. Due to the mild symptoms and unclear time of onset, thrombolysis was not considered. The following day brain MRI was negative, but a carotid ultrasound showed signs of bilateral internal CAD. Findings were confirmed by CT angiogram. The patient was immediately transferred to the angio-suite. On arrival the patient was drowsy but arousable with minor stimulation, unable to answer questions, with mild left hemiparesis (NIHSS 5). The angiography showed symmetrical dissection and subocclusion of both the internal carotid arteries in the cervical tract, with marked delay of the cerebral anterior circulation. We performed bilateral stenting (Wallstent 7mm x 5cm) with complete recanalization of the vessels (TIMI 3) and good recovery of brain perfusion. Two days later MRI showed small and bilateral pallidal and subcortical ischemic lesions. The patient was discharged at home asymptomatic. One month CT angiography showed patency of the ICAs. Conclusion: According to previous reports, in patients with ongoing hemodynamic cerebral damage due to bilateral carotid artery dissections, treatment with stenting angioplasty could be a safe, feasible and effective option.
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S.Nappini, Azienda Ospedaliero Universitaria Careggi, Firenze, ITALY
M.Nesi   Azienda Ospedaliero Universitaria Careggi  Firenze  ITALY
F.Ricciardi  Azienda Ospedaliero Universitaria Careggi  Firenze  ITALY
V.Palumbo  Azienda Ospedaliero Universitaria Careggi  Firenze  ITALY
V.Saia  Azienda Ospedaliero Universitaria Careggi  Firenze  ITALY
A.Consoli  Azienda Ospedaliero Universitaria Careggi  Firenze  ITALY
D.Inzitari  Azienda Ospedaliero Universitaria Careggi  Firenze  ITALY
S.Mangiafico  Azienda Ospedaliero Universitaria Careggi  Firenze  ITALY
         
         
         
         
         
         
         

Topic: Acute stroke: emergency management, stroke units and complications
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Palau Level I

 
Thrombectomy in acute ischemic stroke: feasibility and results in a non-university hospital setting
Background: Case series of intraarterial interventions in the treatment of acute ischemic stroke are mainly reported from university-based stroke centers. We assessed the short-term outcomes of intraarterial thrombectomies in acute ischemic stroke of two non-university-based stroke units in collaboration with the same neuroradiology service. Methods: Patients with endovascular therapy for ischemic stroke were identified from the case records. Neurointerventions were performed in general anaesthesia via a transfemoral microcatheter approach. Local thrombectomy used different retriever devices, local fibrinolysis (rtPA) and stent-assisted angioplasty. We assessed the clinical severity of stroke by the modified Rankin scale (mRS) before intervention and at discharge, the vascular territories of ischemia, types and times of procedures. Results: From December 2008 to December 2009, 135 patients received single systemic thrombolysis. Of 21 patients (mean age 65 years) who underwent local thrombectomy, 16 had primary systemic rtPA, but persisting severe neurological deficits (mRS 4 or 5) in the presence of large vessel occlusions. Five patients had primary endovascular therapy due to onset of stroke > 3 hours or contraindications for i.v. rtPA. Twelve patients had a favourable outcome with an improvement to a mRS <=3 (11 patients improved by >=2 points). All but one had anterior circulation ischemia. Three patients with middle cerebral artery occlusion and one with basilar artery (BA) thrombosis died due to secondary cerebral hemorrhage and oedema. Four of 5 patients with BA ischemia had an unfavourable outcome; they had delayed clinical worsening before intervention. Conclusion: Neurointerventional therapy in acute stroke is feasible in settings where non-university-based stroke units have access to a regional neuroradiological service. Selected patients with large vessel occlusions may benefit from i.v. thrombolysis combined with local thrombectomy.
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J.C.Wöhrle, Katholisches Klinikum Koblenz, Department of Neurology / Stroke Unit, Koblenz, GERMANY
R.Werner   Katholisches Klinikum Koblenz, Department of Neurology / Stroke Unit  Koblenz  GERMANY
U.Lange  Rhein-Mosel-Fachklinik, Department of Neurology / Stroke Unit  Andernach  GERMANY
C.Bamberg  Rhein-Mosel-Fachklinik, Department of Neurology / Stroke Unit  Andernach  GERMANY
S.Felber  Evangelisches Stiftungsklinikum Mittelrhein, Department of Diagnostic and Interventional Radiology  Koblenz  GERMANY
         
         
         
         
         
         
         
         
         
         

Topic: Interesting and challenging cases
Oral Session :   
Poster Session: Poster Session Red
Date: Wednesday 26 May 2010
Time: 12:30 - 14:00
Room: Exhibition Hall

 
Thromboembolic events due to probable Cervical Artery Dissection in Patients with Polycythaemia Rubra Vera.
Polycythemia rubra vera (PRV) is a myeloproliferative disorder characterized by JAK2 gene mutation and frequently associated with arterial or venous thromboembolism. The reported prevalence of thrombosis at the time of presentation range from 34 to 39%, with ischaemic stroke and TIAs accounting for 70% of arterial thromboses. Although the exact pathogenesis of thrombosis has not been determined, it is believed to be due to a prothrombotic state resulting from increased haematocrit and slowed cerebral blood flow. We describe 2 cases with a possible alternate etiology. Methods and Results: Case 1: A 43 Year old man had a 13 month history of recurrent transient episodes of right upper limb motor sensory loss following neck injury sustained in a road traffic accident. He developed a persistent episode of upper limb monoparesis, was noted to be polycythaemic and tested positive for JAK2 PRV. MRI with DWI and Fat Saturation Sequences showed multiple areas of restricted diffusion within the left middle cerebral artery territory and a possible dissection of the Left Internal Carotid Artery. Formal Carotid Angiography confirmed a lesion in the petrous segment of the artery. Case 2: A 48 Year old Man with known JAK2 PRV was admitted with a 9 month history of worsening ataxia, dysarthria and right sided weakness. 3 MRI Brain scans showed progressing areas of infarction in the vertebrobasilar circulation. MR with Fat Saturation showed probable dissection of the right vertebral artery. Both subjects were successfully managed with dual anti-platelet and warfarin therapy. Conclusions: Both these subjects with PRV showed evidence of recurrent thromboembolism in a single vascular territory over a number of months and culprit lesions consistent with probable dissection were found in the supplying artery. We suggest clinicians look for evidence of cervical artery dissection lesions in subjects with PRV presenting with recurrent ischaemic events.
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M.Harmon, St James's Hospital, Dublin, IRELAND
B.NiBhuachalla   St James's Hospital  Dublin  IRELAND
S.O'Sullivan  St James's Hospital  Dublin  IRELAND
P.Browne  St James's Harbison  Dublin  IRELAND
J.Meaney  St James's Hospital  Dublin  IRELAND
J.A.Harbison  St James's Hospital  Dublin  IRELAND
         
         
         
         
         
         
         
         
         

Topic: Experimental studies
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Salon Azur

 
Autologous stem cell treatment of stroke: a study concept to reveal cell migration in vitro and in vivo.
Background Stroke treatment by mesenchymal stem cells (MSC) was efficient in various animal studies. However, there is limited knowledge about cell homing to the lesion. This study uses a sheep model of focal cerebral ischemia to (1) define an optimal labeling protocol for ovine (o)MSC by very small ironoxide particles (VSOP), (2) detect labeled autologous oMSC in the brain and (3) to track intravenously (i.v.) injected oMSC after stroke. Methods (1) oMSCs were incubated with VSOP (0.5; 1.5; 3 and 6mM, respectively). MSC vitality was assessed before, and 0, 4 and 24 h after labeling by trypan-blue staining. Cells were stained with Prussian blue (PB) to visualize VSOP uptake. Relaxometry measurements were performed with a Burker Minispec to determine transverse relaxation time (T2) alterations by labeled oMSC. In vitro imaging using 1.5 and 3T MRI (T2*, SWI) was performed in gel phantoms (50mL tubes) with layers containing from 100 to 100,000 oMSC. Blinded investigators determined minimum visible cell number. (2) Two subjects received medullary pilot injections of labeled oMSC (0; 1,000; 10,000; 100,000 cells). Brains were subsequently scanned at 3T MRI. (3) 6 sheep will be subjected to permanent MCAO and receive i.v. injection of labeled oMSC 24 h after MCAO. 3T-MRI (T2*, SWI) will be performed 48 h after MCAO to track labeled cells. Results (1) Labeling of oMSCs is feasible. PB staining shows uptake of the iron particles in viable oMSCs at all molarities. Relaxometry measurements demonstrated a molarity-dependent reduction of T2 of labeled oMSCs. Minimal visible oMSC number was 100,000 cells at 1.5T and 1,000 cells at 3T. (2) 1,000 oMSC were visible at 3T in vivo after medullary injection. (3) Transplantation studies are still ongoing. Conclusion VSOP labeling is save and effective in oMSC and allows cell tracking in vitro and in vivo. Visualization of i.v. injected oMSC is still ongoing. This is the first study showing in vivo cell tracking in the brain in large animals.
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A.Dreyer, Fraunhofer Institute of Cell Therapy and Immunology, Leipzig, GERMANY
B.Nitzsche   Fraunhofer Institute of Cell Therapy and Immunology  Leipzig  GERMANY
C.Pösel  Fraunhofer Institute of Cell Therapy and Immunology  Leipzig  GERMANY
V.Zeisig  Fraunhofer Institute of Cell Therapy and Immunology  Leipzig  GERMANY
T.von Geymüller  Fraunhofer Institute of Cell Therapy and Immunology  Leipzig  GERMANY
M.Findeisen  Institute of Analytical Chemistry, University Leipzig  Leipzig  GERMANY
D.Lobsien  Department of Neuroradiology, Universityhospital of Leipzig  Leipzig  GERMANY
K.T.Hoffmann  Department of Neuroradiology, Universityhospital of Leipzig  Leipzig  GERMANY
F.Emmrich  Fraunhofer Institute of Cell Therapy and Immunology  Leipzig  GERMANY
J.Boltze  Fraunhofer Institute of Cell Therapy and Immunology  Leipzig  GERMANY
         
         
         
         
         

Topic: Interesting and challenging cases
Oral Session :   
Poster Session: Poster Session Red
Date: Wednesday 26 May 2010
Time: 12:30 - 14:00
Room: Exhibition Hall

 
Reversible Cerebral Vasoconstriction Syndrome a rare cause of stroke
Background: Reversible cerebral vasoconstriction syndromes (RCVS) are a recently adopted novel diagnostic entity. They comprise a diverse group of disorders that present acutely with headache with or without neurological deficit resulting from reversible multifocal narrowing of the cerebral arteries. RCVS occur mainly in the young and in approximately 60% of the cases they are associated with the puerperium or exposure to vasoactive substances. Although typically self-limited, RCVS can be complicated by ischemic or hemorrhagic stroke Case report: We report the case of a female patient with RCVS who also developed posterior reversible leukoencephalopathy (PRL). The 28year-old patient in day 5 postpartum, presented to the emergency department with acute onset headache. Two hours later she developed cortical blindness and altered mental status and six hours later she had a seizure. Her past medical history was chronic headaches and one incomplete pregnancy. Computerized tomography (CT) showed hypointense lesions in the left occipital lobe. Magnetic resonance imaging (MRI) revealed multiple bilateral lesions in the fronto-parietal lobe, the left occipital lobe and the left cerebellar hemisphere involving the cortex and the subcortical white matter. Magnetic resonance angiography (MRA) showed a left vertebral artery with a narrowed lumen compared to the right vertebral artery and a stenotic distal part. Twenty days after, the patient was free of neurological deficit and repeat MRI revealed that most lesions had disappeared. Discussion: Current literature suggests that RCVS and PRL may coexist in 10% of cases. This case report corroborates this data and provides novel evidence of an association of PRL with the puerperial period. Furthermore, it indicates that the suggested pathophysiological mechanisms of RCVS (cerebral vasoconstriction and ischaemia) and PRL (cerebral edema) may operate concurrently to produce the clinical and radiological picture of RCVS and PRL.
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A.PLAFADELI, NEUROLOCICAL DEPARTMENT OF GENERAL HOSPITALOF ATHENS "EVAGELISMOS'', ATHENS, GREECE
E.ZAFEIROPOULOU   NEUROLOCICAL DEPARTMENT OF GENERAL HOSPITALOF ATHENS "EVAGELISMOS''  ATHENS  GREECE
D.PAPADOPOULOS  NEUROLOCICAL DEPARTMENT OF GENERAL HOSPITAL OF ATHENS "EVAGELISMOS''  ATHENS  GREECE
M.FILI  NEUROLOCICAL DEPARTMENT OF GENERAL HOSPITAL OF ATHENS "EVAGELISMOS''  ATHENS  GREECE
D.KRAVARITIS  NEUROLOCICAL DEPARTMENT OF GENERAL HOSPITAL OF ATHENS "EVAGELISMOS''  ATHENS  GREECE
A.TAVERNARAKIS  NEUROLOCICAL DEPARTMENT OF GENERAL HOSPITALOF ATHENS "EVAGELISMOS''  ATHENS  GREECE
         
         
         
         
         
         
         
         
         

Topic: Stroke prognosis
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Palau Level I Foyer

 
Is post-stroke a fatigue, an anxiety disorder?
Fatigue affects more than 60% of people following stroke. Associations with both depression and hypotension are reported but do not explain the full association. Clinical observation of patients with post-stroke fatigue led us to hypothesise that they display a high level of anxiety. We reviewed data from previous studies to see if an association existed. Methods: Data from prior studies where Fatigue Severity Scores (FSS) were performed on patients who had suffered stroke or TIA were reviewed. Those subjects who had depression and anxiety assessed using the Hospital Anxiety and Depression Scale (HADS) were identified and collated to determine if there was evidence of an association. Results: Results for 63 subjects, 33 (52%) male were identified. Mean FSS was 3.6, scores of >/=4 are consistent with severe fatigue. Mean Anxiety sub-score for the HADS (HADSA) was 6.76 and depression (HADSD) sub-score was 4.57. Sub-scores >7 are considered abnormal and >10 highly suggestive of either anxiety or depression. FSS correlated significantly with both the depression (r=0.62, p<0.0001) and anxiety (r=0.60, p<0.0001) components of the HADS. Mean HADSA for those with FSS <4 vs those >/=4 was 5.1 vs 9.4 (p<0.0003, t-test) For HADSD the difference was smaller (3.4 vs 6.4. p=0.002). 17 of 25 subjects (68%) of subjects with FSS>/=4 had a HADSA >7 compared to 8 of 38 subjects (21%) with FSS<4 (Chi-Square= 13.9, p=0.0002). Results for HADSD >7 were less pronounced although still significant (8/25 (32%)) vs (3/38 (8%)) Chi square 4.5, p=0.03). Differences for HADSA >10 were, FSS >/=4; (10/25 (40%)) vs FSS<4; (2/38 (5%) p=0.0009, Fisher’s exact) but were non-significant for HADSD (3/25 vs 2/38. p=0.3, Fishers exact). Conclusions: Post stroke fatigue correlates strongly with anxiety. More than 2/3 of patients with significant fatigue have abnormal HAD anxiety scores. Patients with significant post-stroke fatigue should be assessed for anxiety and for appropriate treatment of same.
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C.Maguire, St James's Hospital, Dublin, IRELAND
S.Walsh   St James's Hospital  Dublin  IRELAND
J.A.Harbison  St James's Hospital  Dublin  IRELAND
         
         
         
         
         
         
         
         
         
         
         
         

Topic: Stroke prognosis
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Palau Level I Foyer

 
Quantitative EEG in ischemic stroke: pdBSI independently predicts disability and DTABR independently predicts death and dependency after six months.
Background - Stroke is a major cause of adult onset disability and dependency. We investigated whether EEG parameters are of prognostic value for functional outcome six months after ischemic stroke. Methods – One-hundred and ten (110) patients presenting with acute ischemic stroke and persistent neurological deficits at EEG recording were incrementally included. Clinical characteristics, volume of ischemia and EEG parameters were correlated with functional outcome. Predictive values for disability, dependency and death were calculated using ROC analysis and logistic regression modeling. Results – Statistically significant non-parametric correlations at p < 0.0028 were obtained between modified Rankin Scale (mRS) score at month 6 and age of stroke onset, NIHSS, volume of ischemia, OPCS classification, the pairwise derived brain symmetry index (pdBSI) and the (delta+theta)/(alpha+beta) ratio (DTABR). NIHSS (OR 1.15, 95% CI 1.04-1.27, p = 0.005) and pdBSI (OR 4.07, 95% CI 1.32-12.58, p = 0.015) emerged as independent predictors for disability six months after stroke. Dependency was independently predicted by NIHSS (OR 1.22, 95% CI 1.09-1.37, p < 0.0005) and DTABR (OR 2.25, 95% CI 1.16-4.37, p = 0.016). Six month mortality was independently predicted by age at stroke onset (OR 1.18, 95% CI 1.05-1.32, p = 0.007), NIHSS (OR 1.11, 95% CI 1.03-1.21, p = 0.009) and DTABR (OR 2.04, 95% CI 1.08-3.85, p = 0.028). Conclusions - EEG in the subacute setting of ischemic stroke may be of prognostic value for disability, dependency and death after 6 months. These findings may have an impact on stroke rehabilitation.
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R.V.A.Sheorajpanday, ZNA Middelheim, Antwerp, BELGIUM
G.Nagels   ZNA Middelheim  Antwerp  BELGIUM
A.J.T.M.Weeren  University of Antwerp  Antwerp  BELGIUM
P.P. De Deyn  University of Antwerp  Antwerp  BELGIUM
         
         
         
         
         
         
         
         
         
         
         

Topic: Etiology of stroke and risk factors
Oral Session :  B
Poster Session:  
Date: Thursday 27 May 2010
Time: 11:50 - 12:00
Room: F

18
The Prevalence of Adverse Prognostic Blood Pressure Characteristics and their association with Antihypertensive Agents in subjects with TIA and Stroke
Introduction: Hypertension is a risk factor for first and recurrent stroke. Increase, reduction or reversal of the normal 10-20 mmHg nocturnal dip in night-time blood pressure are also associated with an increase in relative risk of cardiovascular events in non-stroke patients. We previously reported a high prevalence of such characteristics on ambulatory blood pressure monitoring (AMBP) in patients following stroke or TIA but it is unclear if this is influenced by concomitant antihypertensive therapy. Methods: Data from subjects attending a secondary prevention clinic for subjects with TIA and stroke were reviewed. AMBP measurements were performed on all subjects using standard protocols and BHS approved monitors. Readings were taken at 30 minute intervals during daytime, and hourly from 23:00 to 07:00. Results were then categorised against details of antihypertensive medications prescribed. Results: Data on 170 subjects (Mean age 68 years, and 99 (58%)female) were included. 51 (30%) were on no antihypertensive medication at the time of measurement; 85 (50%) on 1 agent, 24 (14%) on 2 agents, while 10 patients (6%) were on 3 or more agents. Commonest agents used were ACE Inhibitors (35%) A2 Antagonists (17%) and Diuretics (14%). No class of agent was associated with a significantly lowered rate of adverse characteristics. In relation to blood pressure (BP) variation (the difference between mean day and night systolic BP), 63 patients (37%) recorded a dip of >20mmHg (extreme dippers). 33 patients (19.5%) showed elevated BP nocturnally (reverse dippers). Of the 51 patients on no medications, 18 (35%) were extreme dippers and 8 (16%) were reverse dippers. In comparison, of the 119 on treatment 45 (38%) (Chi sq 0.02, p=0.88) were extreme dippers and 25 (21%) were reverse dippers (Chi sq 0.35, p=0.55). Conclusion: Adverse prognostic blood pressure characteristics are prevalent among patients with stroke or TIA, regardless of antihypertensive medication used.
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K. ABillington, St James's Hospital , Dublin, IRELAND
SWalsh   St James's Hospital  Dublin  IRELAND
S.J.Hassan  St James's Hospital  Dublin  IRELAND
J.A.Harbison  Trinity College Institute or Neurosciences  St James's Hospital  IRELAND
         
         
         
         
         
         
         
         
         
         
         

Topic: Behavioral disorders and post-stroke dementia
Oral Session :   
Poster Session:  
Date: Thursday 27 May 2010
Time: 15:20 - 15:30
Room: H3

3
EEG in silent small vessel disease: sLORETA mapping reveals cortical sources of vascular cognitive impairment no dementia in the default mode network
Background – Vascular cognitive impairment, no dementia (vCIND) is a prevalent and potentially preventable disorder. Clinical presentation of the small-vessel subcortical subtype may be insidious and difficult to diagnose in the initial stage. We investigated electro-encephalographic sources of subcortical vCIND in comparison to amnestic multi-domain mild cognitive impairment (amdMCI) and cerebrovascular impairment without cognitive decline. Methods - Community residing patients with an uneventful central neurological history and presentation of cognitive decline without dementia were included. Cognitive healthy control participants, deliberately recruited from a cerebrovascular impaired cohort, experienced a fully recovered first ever transient ischemic attack without clinical or MRI evidence of stroke. From standard EEGs, the difference in sLORETA sources between vCIND and control, and between vCIND and amdMCI were determined for the discrete frequency ranges 1-4 (delta), 4-8 (theta), 8-10.5 (alpha1), 10.5-13 (alpha2), 13-22 (beta1) and 22-30 (beta2) Hz. Results – In vCIND, a statistically significant decrease in parieto-occipital alpha1 source activity compared to cognitive normal cerebrovascular impaired controls and MCI patients was found. There was a significant decrease in frontal and parieto-occipital beta1 source activity in vCIND compared to cerebrovascular impaired controls. We found a significant increase in (pre)frontal delta sources in vCIND compared to amdMCI. In amdMCI, delta sources were significantly increased in the core limbic system compared to cognitive normal controls. Conclusions – Cortical sources of abnormal EEG activity in regions implicated in the default mode network are revealed by sLORETA at an early stage in vascular cognitive impairment. Mapping of parieto-occipital alpha1, fronto-parieto-occipital beta1 and (pre)frontal delta loci in vCIND may reflect early executive and visuospatial dysfunction in this cohort. Our data indicate that standard EEG with sLORETA mapping might be an additional, non-invasive and cost-effective tool in patients presenting with cognitive decline. These findings may have an impact on memory care.
Graphic: http://www.esc-archive.eu/barcelona10/graphics_barcelona/aid_1031.html
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R.V.A.Sheorajpanday, ZNA Middelheim, Antwerp, BELGIUM
P.Marien   ZNA Middelheim  Antwerp  BELGIUM
G.Nagels  ZNA Middelheim  Antwerp  BELGIUM
A.J.T.M.Weeren  University of Antwerp  Antwerp  BELGIUM
J.Saerens  ZNA Middelheim  Antwerp  BELGIUM
M.J.A.M.van Putten  University of Twente  Enschede  THE NETHERLANDS
P.P.De Deyn  University of Antwerp  Antwerp  BELGIUM
         
         
         
         
         
         
         
         

Topic: Small vessel stroke and white matter disease
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Palau Level I Foyer

 
Cerebrovascular L-arginine reactivity in leukoaraiosis
Radiological findings of diffuse, confluent white matter abnormality known as leukoaraiosis have been described in the context of normal ageing, vascular dementia and »pure« Alzheimer's disease. Pathological equivalents of leukoaraiosis are myelin pallor, enlargement of perivascular spaces, gliosis and axonal loss. Associated clinical features are cognitive impairment, gait disturbance and falls. The precise mechanism of leukoaraiosis is not known. One of the possible mechanisms is endothelial dysfunction and resultant malfunction of the blood-brain barrier. We hypothesised that patients with leukoaraisosis have impaired endothelial function. Patients and methods: Cerebrovascular reactivity to L-arginine, which reveals the function of the cerebral endothelium, was investigated in patients with leukoaraiosis (14 patients, 5 male and 9 female, aged 62.5 ± 9.3years) and 19 age- and gender-matched healthy controls. The mean arterial velocity (vm) in both middle cerebral arteries was measured by transcranial Doppler sonography during a 15-minute baseline period, a 30-minute intravenous infusion of L-arginine and a 15-minute interval after L-arginine infusion. Arterial blood pressure, heart rate and CO2 were measured continuously. Results: The measured vm increase during L-arginine infusion in the patients with leucoaraiosis (19.0 % ± 8.1 %) was lower compared to the healthy controls (22.5 % ± 7.2 %), however it did not reach statistical significance (p=0,09). Conclusions: Although our results did not reach statistical significance we showed that cerebrovascular reactivity to L-arginine, which demonstrates cerebral endothelial function, is probably impaired in patients with leucoaraiosis.
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M.SOSTARIC-PODLESNIK, Department of Neurology, Celje General Hospital, Oblakova 5, 3000 Celje, Celje, SLOVENIA
J.PRETNAR-OBLAK   Department of Neurology, Ljubljana Medical Centre, Zaloška 7, 1000 Ljubljana  Ljubljana  SLOVENIA
B.ZVAN  Department of Neurology, Ljubljana Medical Centre, Zaloška 7, 1000 Ljubljana  Ljubljana  SLOVENIA
M.ZALETEL  Department of Neurology, Ljubljana Medical Centre, Zaloška 7, 1000 Ljubljana  Ljubljana  SLOVENIA
         
         
         
         
         
         
         
         
         
         
         

Topic: Etiology of stroke and risk factors
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Exhibition Hall

 
NEUROPSYCHOLOGICAL PERFORMANCE AND CEREBROVASCULAR REACTIVITY IN NON-TREATED HYPERTENSIVE PATIENTS
Background: High blood pressure is a risk factor for mild cognitive deterioration, therefore hypertensive patients are at higher risk of cognitive decline compared. We assessesd the neuropsychological performance and cerebrovascular reactivity in symptom-free, non-treated hypertensive patients. Methods: 173 persons were investigated. All hypertensives (N=79, 43.3+/-10.2 yrs) were recently diagnosed, symptom-free, non-treated, without target organ damage, had no diabetes and all of them had a normal cranial CT scan. In the control group 94 persons were included (44.0+/-9.4 yrs). Eleven neuropsychological tests were performed in both groups and through these tests reaction time, attention and memory skills, anxiety and depression states were determined. During head-up tilt table testing (HUTT) continuous, non-invasive and simultaneous monitoring of cardiac and cerebral hemodynamical parameters were recorded. Results: Significant differences were seen in those tests, which evaluated the short term memory, attention and psychomotor speed: Rey Auditory Verbal Learning Test p=0.0173, WAIS Digit Span Test p=0.0000, WAIS Digit Symbol Test p=0.0544. While there was a significant higher rate of anxiety in the hypertensive group (p=0.006), non significant difference was seen in depression rate. During HUTT the absolute values of the hemodynamical parameters were significantly higher in the hypertensive group (blood pressure p=0.0000, heart rate p=0.0000, total peripheral resistance p=0.0005). After tilting up non significant percentage changes of these parameters were seen between the groups. By monitoring the cerebral blood flow velocity non-significant differences were seen in the absolute values and percentual changes. Conclusion: Significant differences could be detected in the cognitive performance of hypertensive patients compared to controls. Therefore early and correct treatment is very important in preventing further impairment and cognitive deterioration.
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L.Csiba, Department of Neurology, Debrecen, HUNGARY
K.R.Kovacs   Department of Neurology  Debrecen  HUNGARY
Cs.Szekeres  Department of Neurology  Targu Mures  ROMANIA
Z.Bajkó  Department of Neurology  Targu Mures  ROMANIA
A.Bojtor  Department of Neurology  Debrecen  HUNGARY
         
         
         
         
         
         
         
         
         
         

Topic: Acute stroke: clinical patterns and practice
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Palau Level I

 
Clinical Feature and Localization of Intractable Hiccup in Patients with Acute Lateral Medullary Infarction
Background: Intractable hiccups are defined as hiccup persisting for more than 48 hours. The relationship between lesion location of lateral medullary infarction (LMI) and intractable hiccup is rarely reported. This study was designed to investigate the clinical characteristics and topographic patterns of intractable hiccups in the LMI. Methods: We identified 9 patients with intractable hiccups by medical record, telephone interview and brain MRI between 1998 and 2003. LMI was diagnosed by clinical findings and brain MRI. MRI lesions were classified vertically as upper, middle and lower level and horizontally. Results: All patients with intractable hiccups were men. The onset time of intractable hiccups was 3.8±2.7 days (range, 1~7 days). The duration of intractable hiccups was 15.1±8.9 days (range, 4~31 days). Vertically, three patients had lesions in the upper medulla, two patients had lesions in the upper and middle medulla, two patients had lesions in the all levels of the medulla, one patient had lesions in the middle medulla, and one patient had lesions in the middle and lower medulla. Horizontally, dorsolateral and/or midlateral lesions were always involved. All patients with LMI with intractable hiccup had vertigo/dizziness, nausea/vomiting and dysphagia. Conclusion: These results demonstrate that intractable hiccups are frequent in men and related to the dorsolateral region of the middle and/or upper levels of medulla. We suggest that involvement of the nucleus ambiguous may be responsible for intractable hiccups.
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B.G.Yoo, Department of Neurology Kosin University College of Medicine, Busan, SOUTH KOREA
J.H.Lee   Department of Neurology Kosin University College of Medicine  Busan  SOUTH KOREA
S.Y.Huh  Department of Neurology Kosin University College of Medicine  Busan  SOUTH KOREA
         
         
         
         
         
         
         
         
         
         
         
         

Topic: Stroke prognosis
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Palau Level I Foyer

 
Early spermine levels predict stroke severity at 28 days.
Background: Biomarkers which can help to identify stroke early or correlate with outcome may be useful in clinical practice and in clinical trials. The polyamine pathway is involved in apoptosis, and following acute stroke in animal models the metabolism of polyamines are altered . We aimed to evaluate levels of spermine and established markers of neuronal damage (neurone specific enolase, S100B and GFAP) in patients with acute ischaemic stroke. Methods: 60 patients with stroke were recruited as soon as possible after admission (90% within 24 hours). Bloods and clinical assessments using National Institute of Stroke Scale (NIHSS) for stroke severity/neurological deficit, and Barthel Index (BI)/modified Rankin Score (mRS) for functional outcome were performed at intervals from admission to 28 days. Spermine levels from erythrocytes were measured by HPLC. Serum NSE, GFAP and S100B were measured using ELISA. Pearson’s correlations were determined using SPSS. Results: Spermine levels peaked at 24hours (10.5nmol/ml RBC). Baseline spermine significantly correlates (inversely) with mRS (R= -0.4; p< 0.05) and BI (R=0.48, p< 0.05) at 7days. 18 h spermine levels strongly correlate with NIHSS from 18 h to 28 d (R= -0.58 to -0.94; p< 0.05) as well as BI at 14 d (R=0.62; p< 0.05). 24 h spermine levels also show association with 7 d NIHSS, mRS and BI (R= -0.52, -0.61 and 0.64 respectively; p< 0.05). NSE peaked at 14 days, while S100B peaked at 72 hours after stroke onset. On multiple logistical regression with age, sex, BP and stroke subtype, NSE was not correlated with outcome at 28 days, while 72h S100B correlated with NIHSS at day 28 (CI: 0.006 to 0.017, p value 0.001, R2: 0.77). GFAP levels were only detectable in one patient. Conclusions: Spermine may be a useful biomarker of stroke diagnosis and severity. Further studies in larger patient numbers with imaging parameters to correlate with final infarct size will be necessary to confirm this.
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P.Acheampong, University of Aberdeen, Aberdeen, UNITED KINGDOM
H.M.Wallace   University of Aberdeen  Aberdeen  UNITED KINGDOM
M.J.Macleod  University of Aberdeen  Aberdeen  UNITED KINGDOM
         
         
         
         
         
         
         
         
         
         
         
         

Topic: Heart and brain
Oral Session :   
Poster Session: Poster Session Red
Date: Wednesday 26 May 2010
Time: 12:30 - 14:00
Room: Palau Level I

 
The presence of supraventricular tachycardia may be a marker of paroxysmal atrial fibrillation in acute ischemic stroke and TIA patients
Background: Atrial fibrillation (AF) is a major risk factor for ischemic stroke and may explain a substantial proportion of otherwise cryptogenic strokes. However, detection of paroxysmal AF in acute ischemic stroke (AIS) and TIA patients is challenging and dependent on duration and modality of cardiac monitoring. Supraventricular tachycardia (SVT) is known to be associated with development of AF. We sought to identify the rate of SVT in patients with AIS and TIA who were monitored with Holter and continuous cardiac telemetry (CCT). Methods: One hundred and thirty-three consecutive patients were admitted to an academic institution for AIS or TIA and had concurrent inpatient CCT and Holter monitoring. Those with known AF were excluded. The modified Wald approach was used to determine 95% confidence intervals (CI) for detection rates of AF and SVT by each modality. Detection rates for AF and SVT were compared using the McNemar paired proportion test. Results: Among 133 patients, 8 (6.0%) were diagnosed with new onset AF during inpatient evaluation. Risk factors for new AF included age (P = 0.001), coronary artery disease (P = 0.020), SVT (P = 0.017), and embolic pattern on neuroimaging (P = 0.041). The overall detection rate of AF was higher for Holter monitoring (6.0%, 95% CI 2.9-11.6) compared with CCT (0, 95% CI 0-3.4), (P = 0.008). Supraventricular tachycardia was detected in 41.4% (95% CI 33.3-49.9) on Holter compared to 4.5% (95% CI 1.9-9.7) on CCT (P < 0.001). Six of the 8 (75%) patients with new AF also had SVT on Holter monitoring. Furthermore, 2 patients with SVT but no AF on initial Holter monitoring subsequently developed AF. Conclusions: Supraventricular tachycardia is a marker for atrial fibrillation that may warrant further long-term cardiac monitoring in patients with acute ischemic stroke or TIA. Holter monitoring offers a higher detection rate for SVT when compared to CCT.
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M.A.Lazzaro, Rush University Medical Center, Chicago, USA
K.Krishnan   Rush University Medical Center  Chicago  USA
S.Prabhakaran  Rush University Medical Center  Chicago  USA
         
         
         
         
         
         
         
         
         
         
         
         

Topic: Acute stroke: new treatment concepts
Oral Session :   
Poster Session: Poster Session Red
Date: Wednesday 26 May 2010
Time: 12:30 - 14:00
Room: Palau Level I

 
Prolonged low-dose intravenous rtPA thrombolysis of subacute infratentorial strokes.
Background and Purpose: Prognosis of infratentorial ischemic strokes is very difficult to establish. The posterior circulation symptoms are often gradual or stuttering with episodes of worsening and risk of sudden death. The purpose of our study was to analyze the results of prolonged low-dose rtPA thrombolysis (LDT) in patients with subacute infratentorial strokes. Methods: 34 patients with subacute infratentorial strokes have been treated with 20mg IV rtPA in prolonged 48 hours infusion (0.125–0.150mg/kg/h). LDT was started either at the admission when the symptoms lasted more than 3 hours or at the time of clinical worsening during hospitalization period. NIHSS evaluation was performed at admission, at the start of the infusion and at 24 h, 48 h and 72 h after start of therapy. Early clinical result has been classified as stabilized (deltaNIHSS=0), improved (deltaNIHSS≤1) or worsened (deltaNIHSS≥1) at the end of NDT. Modified Rankin scale was evaluated at 3 months after stroke. Results: Therapeutic interval for LDT was 4.5–144.0 hours (mean 38.7 +/- 39.5 hours). 19 pts (55.9%) have started LDT immediately after admission. Their initial NIHSS was in the range between 2–15 (mean = 7.9 +/- 4.7). 15 pts (44.1%) worsened during hospitalization; their NIHSS before start of LDT was in the range 3–35 NIHSS (mean 13.6 +/- 9.9), mean deltaNIHSS = + 6). During LDT therapy have been 12 of 34 pts (35.3%) stabilizied; 17 pts (50.0%) improved; 5 pts worsened (11.8%. 3 months after discharge the mRS was: mRS 0 = 9 pts (26.5%), mRS 1 = 3 pts (29.4%), mRS 2 = 8 pts (23.5%), mRS 3 = 5 pts (11.8%), mRS 4 = 2 pts (5.9%), mRS 5 = 0 pt (0.0%), mRS 6 = 7 pts (20.6%). Independence at 3 months (mRS = 0–2) have achieved 58.8% of all pts (20 of 34). We have not observed any intracranial hemorrhagic transformation neither local or systemic hemorrhagic complication. We have not detected any significant changes of hemocoagulation parameters. Conclusions: Prolonged low-dose intravenous rtPA thrombolysis seems to be effective and safe therapy of subacute infratentorial ischemic strokes with gradual or stuttering course of posterior circulation symptoms.
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M.BROZMAN, Neurology Clinic, University Hospital Nitra, Constantin the Philosopher University of Nitra, Nitra, SLOVAKIA
A.PETROVIČOVÁ   Neurology Clinic, University Hospital Nitra, Constantin the Philosopher University of Nitra  Nitra  SLOVAKIA
D.VISZLAYOVÁ  Neurology Clinic, University Hospital Nitra, Constantin the Philosopher University of Nitra  Nitra  SLOVAKIA
T.GOBO  Neurology Clinic, University Hospital Nitra, Constantin the Philosopher University of Nitra  Nitra  SLOVAKIA
A.FRIŠOVÁ  Neurology Clinic, University Hospital Nitra, Constantin the Philosopher University of Nitra  Nitra  SLOVAKIA
G.HAJAŠ  Neurology Clinic, University Hospital Nitra, Constantin the Philosopher University of Nitra  Nitra  SLOVAKIA
K.KROČKOVÁ  Neurology Clinic, University Hospital Nitra, Constantin the Philosopher University of Nitra  Nitra  SLOVAKIA
R.FELEDIOVÁ  Neurology Clinic, University Hospital Nitra, Constantin the Philosopher University of Nitra  Nitra  SLOVAKIA
S.KOVÁČOVÁ  Neurology Clinic, University Hospital Nitra, Constantin the Philosopher University of Nitra  Nitra  SLOVAKIA
M.HALAJ  Jessenius,s.r.o., Nitra  Nitra  SLOVAKIA
J.STRAUSS  Jessenius,s.r.o., Nitra  Nitra  SLOVAKIA
B.VESELÝ  Neurology Clinic, University Hospital Nitra, Constantin the Philosopher University of Nitra  Nitra  SLOVAKIA
         
         
         

Topic: Heart and brain
Oral Session :   
Poster Session: Poster Session Red
Date: Wednesday 26 May 2010
Time: 12:30 - 14:00
Room: Palau Level I

 
Cognitive impairment in congestive heart failure Versus Atrial Fibrillation in the elderly Stroke-Free Patients
Objectives: Congestive heart failure (CHF) has been proposed as a possible cause of cognitive dysfunction. Can atrial fibrillation (AF) in stroke-free patients lead to impaired cognition? Aim of the study was to compare the cognitive patterns of non-stroke patients with CHF, AF without CHF and patients having cardiovascular diseases, other than AF, uncomplicated by CHF. Methods: In an observational case control study, we studied 162 hospitalized elderly CHF patients in the Egyptian National Institute of Heart and Mataryia Teaching Hospital class II (CHFm, m: moderate), 134 CHF patients in class III–IV (CHFs, s: severe), 138 stroke-free individuals with AF and 434 no-CHF, no-AF patients. Subjects underwent MRI to exclude stroke. Subjects with stroke, dementia, or depression were excluded. Cognitive function was assessed by Stanford Binnet test battery version 4 (Arabic version) covering the domains attention, visual-spatial intelligence, verbal attainment, verbal and visual-spatial memory. Results: Neuropsychological performances of groups were compared by multivariate analysis. Correlates of an abnormal performance on at least three neuropsychological tests were assessed by logistic regression analysis. CHFs performed worse than no-CHF, no-AF patients and AF, which was worse than no-CHF, no-AF patients. The largest difference being in tests of attention, verbal learning and visual-spatial memory (p < 0.001). Prevalence of abnormal performance on at least 3 tests was 57.9 % in CHFs, 53.2% in AF, 43% in CHFm and 34.3 % in no-CHF groups (chi square = 17.3, p < 0.0001). Conclusion: Cognitive impairment is common among CHF and AF patients and seems to be causally related to CHF severity, and probable hypoxia resulted from unstable cardiac output. The cognitive dysfunction also characterizes a relevant fraction of patients with cardiovascular diseases uncomplicated by CHF. Also, cognition should be considered in the evaluation of patients with AF and any suggested treatments.
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N.Kitchener, Egyptian General Organization for Teaching Hospitals and Institutes, Cairo, EGYPT
B.E.Fouad   Egyptian General Organization for Teaching Hospitals and Institutes , Heart National Institute  Cairo  EGYPT
M.Abdalla  Egyptian General Organization for Teaching Hospitals and Institutes  Cairo  EGYPT
A.Abdelkarim  Egyptian General Organization for Teaching Hospitals and Institutes   Cairo  EGYPT
M.A.M.Ghoraba  Egyptian General Organization for Teaching Hospitals and Institutes  Cairo  EGYPT
         
         
         
         
         
         
         
         
         
         

Topic: Interesting and challenging cases
Oral Session :   
Poster Session: Poster Session Red
Date: Wednesday 26 May 2010
Time: 12:30 - 14:00
Room: Exhibition Hall

 
Should it be called ischemic stroke or transient ischemic attack?
Background- Acute ischemic stroke(AIS) due to vertebro-basilar(VB) thrombosis is associated with high mortality & prolonged disability. Therapeutic route & time window for thrombolysis in acute settings remain debatable. Methods- We describe a case of severe AIS due to VB occlusion in whom intravenous tissue plasminogen activator(IV-TPA) and transcranial Doppler(TCD) monitoring, started 5hours after symptom-onset resulted in rapid recanalization & clinical recovery. Results- A 57year old lady was brought with history of rapid deterioration of consciousness during past 4.5hours. She didn’t suffer from any significant illness in past. Upon arrival, she was stuporous with Glasgow coma scale of 6points (no eye opening, incomprehensible sounds and flexion of limbs to pain). She was afebrile, blood pressure 146/85mmHg, regular pulse(82/minute) & normal blood sugar. Her pupils reacted sluggishly. National Institute of Health Stroke Scale Score was 30points. Blood urea, creatinine, electrolytes & liver enzymes were normal. Computerized tomography (CT) of brain done at 285minutes from symptom-onset was normal. CT angiography(CTA) showed no contrast opacification in entire VB system. IV-TPA was started at 300minutes from onset. No flow signals were obtained from VB arteries on pre-TPA bolus TCD. 22minutes after IV-tPA bolus, TCD showed sudden & complete recanalization of entire VB system. Complete clinical recovery followed during next 25minutes. CTA performed at 390minutes from symptom-onset showed complete recanalization of VB system. No areas of restricted diffusion were noted on magnetic resonance imaging(MRI) of brain, performed at 8hours from the symptom-onset. She was discharged on day 2. Conclusion- Our patient favors thrombolysis in extended therapeutic window for acute VB thrombosis, even with severe neurological deficits. Perhaps, TCD exposure through transforaminal window delivered higher energy to clot and helped in faster recanalization. IV-TPA was justified for prolonged & severe deficits with complete VB occlusion. However, absence of any acute infarction on MRI opens an interesting debate about final diagnosis- AIS or transient ischemic attack?
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A.Ahmad, National University Hospital, Singapore, SINGAPORE
H.L.Teoh   National University Hospital  Singapore  SINGAPORE
B.P.L.Chan  National University Hospital  Singapore  SINGAPORE
V.K.Sharma  National University Hospital  Singapore  SINGAPORE
         
         
         
         
         
         
         
         
         
         
         

Topic: Acute stroke: emergency management, stroke units and complications
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Palau Level I

 
ANESTHETIC CONSIDERATIONS AND THE ROLE OF BLOOD PRESSURE MANAGEMENT IN THE ENDOVASCULAR TREATMENT OF ACUTE ISCHEMIC STROKE
INTRODUCTION: Increasingly used in North America, endovascular thrombolysis for ischemic stroke results in high recanalization rates without a comparable increase in good clinical outcomes. Many neurointerventionalists prefer general anesthesia to keep patients still. The purpose of this study is to identify the role of anesthesia and any other associated peri-procedural factors in determining clinical outcomes in patients undergoing endovascular procedures for acute ischemic stroke. METHODS: We retrospectively studied patients who underwent open label IA procedures for stroke from 2003-2009 in our IA database. Data were collected from chart reviews and automated anesthesia records. We used the Houston Intra-arterial Therapy(HIAT) score (1 point for age >75 years; 1 for NIHSS score >18, and 1 point for glucose >150 mg/dL) for adjusting for baseline differences. The primary clinical outcome was mRS 0-2 at 3 months. RESULTS: 96 patients (67 males, median age 65) with median NIHSS 17(Range 12-20) were included in the study. The distribution of type of anesthesia was as follows: 48/96 general anesthesia, 44/96 conscious sedation (14) or local anesthesia only (30) and 4/96 undetermined. 7/48(15%) in the GA group had good clinical outcome when compared to 29/44(66%) in the local anesthesia/conscious sedation group (RR 0.22 95% CI 0.11-0.45). After adjusting for HIAT score and the presence or absence of any major anesthetic co-morbidities, the GA group had significantly worse clinical outcome (p value 0.001). Lower blood pressure correlated with poorer clinical outcomes in both anesthesia groups. The lowest mean systolic blood pressure in the GA group was 104 mm Hg compared to 135 mm Hg in the local anesthesia/conscious sedation group (p value 0.0001). CONCLUSION: The use of GA during endovascular procedures in acute ischemic strokes is associated with poorer clinical outcomes at 3 months. This could be because of lower peri-procedural blood pressures.
Graphic: http://www.esc-archive.eu/barcelona10/graphics_barcelona/aid_1494.html
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B.K.MENON, UNIVERSITY OF CALGARY, CALGARY, CANADA
M.DAVIS   UNIVERSITY OF CALGARY  CALGARY  CANADA
L.BAGHHIRZADA  UNIVERSITY OF CALGARY  CALGARY  CANADA
C.HERRERA  UNIVERSITY OF CALGARY  CALGARY  CANADA
M.EESA  UNIVERSITY OF CALGARY  CALGARY  CANADA
A.M.DEMCHUK  UNIVERSITY OF CALGARY  CALGARY  CANADA
M.GOYAL  UNIVERSITY OF CALGARY  CALGARY  CANADA
D.P.ARCHER  UNIVERSITY OF CALGARY  CALGARY  CANADA
M.D.HILL  UNIVERSITY OF CALGARY  CALGARY  CANADA
         
         
         
         
         
         

Topic: Management and economics
Oral Session :   
Poster Session: Poster Session Red
Date: Wednesday 26 May 2010
Time: 12:30 - 14:00
Room: Palau Level I

 
A cost-utility analysis of intra-arterial treatment for acute ischemic stroke
Background and Purpose: Preliminary evidence suggests that for patients with acute ischemic stroke caused by a proximal intracranial arterial occlusion intra-arterial (IA) thrombolysis could be a more effective treatment than intravenous (IV) thrombolysis. This cost-utility analysis compares four treatment strategies: 1) conservative treatment for all, 2) IV thrombolysis for all, 3) direct IA thrombolysis for those with an intracranial arterial occlusion and IV for all others, and 4) IV thrombolysis followed by IA (IV-IA) thrombolysis for those with IA occlusion. Methods: A health economic model was developed to compare the treatment strategies. The target population consisted of patients with ischemic stroke, admitted within 4.5 hours from onset who did not have contra-indications for IV and/or IA thrombolysis. A decision tree and life-table were used to assess 6 month and lifetime costs (Euros) and effects (quality-adjusted life years/QALYs) for all treatments. Results for intra-arterial treatment strategies were expressed as an incremental cost-effectiveness ratio compared with conservative treatment. A literature search provided the estimates used in the decision tree and data from the EDISSE and PRACTISE trials were used for cost estimates. Results: Lifetime cost-effectiveness for IV thrombolysis was a savings of €5,885 per QALY gained as compared to conservative treatment. IA thrombolysis was dominated by IV-IA thrombolysis, with savings of €1151 per QALY. However, Monte Carlo simulation (Fig 1) indicated significant uncertainty about the cost-effectiveness of IV-IA thrombolysis. Conclusions: This study suggests that endovascular treatment of ischemic stroke patients is potentially cost-effective from a health care perspective. However, more randomized clinical trials are necessary in order to reduce the considerable amount of uncertainty concerning the costs and effects of endovascular treatment for acute ischemic stroke.
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J.Bouvy, Institute for Medical Technology Assessment, Department of Health Policy and Management (iBMG), Erasmus MC Rotterdam, , Rotterdam, THE NETHERLANDS
P.S.S.Fransen   Department of Neurology, Erasmus MC Rotterdam,   Rotterdam  THE NETHERLANDS
MKoopmanschap  Institute for Medical Technology Assessment, Department of Health Policy and Management (iBMG), Erasmus MC Rotterdam,   Rotterdam  THE NETHERLANDS
L. Niessen  Institute for Medical Technology Assessment, Department of Health Policy and Management (iBMG), Erasmus MC Rotterdam, Rotterdam, the Netherlands  Rotterdam  THE NETHERLANDS
S.Baeten  Institute for Medical Technology Assessment, Department of Health Policy and Management (iBMG),  Rotterdam  THE NETHERLANDS
D.W.J.Dippel  Department of Neurology, Erasmus MC Rotterdam  Rotterdam  THE NETHERLANDS
         
         
         
         
         
         
         
         
         

Topic: Vascular surgery and neurosurgery/interventional neuroradiology
Oral Session :   
Poster Session: Poster Session Red
Date: Wednesday 26 May 2010
Time: 12:30 - 14:00
Room: Exhibition Hall

 
Possible effectiveness of extensive indirect cerebral revascularization surgery for the hemorrhagic event prevention in moymoya disease. (based on the radiological observation)
BACKGROUND: Although Indirect cerebral revascuarization has been known to be effective for improving cerebral ischemia, its role in the prevention of hemorrhagic event is still controversial. We performed this study to clear the sources of hemorrhagic events and to evaluate the possible effectiveness of revascularization for its prevention. METHODS: The authors reviewed a consecutive series of 128 patients with moyamoya syndrome. We analyzed their hemorrhagic or ischemic patterns and their angiographic characteristics as well. 67 cerebral revascularization surgeries (53 extensive indirect revascularization, 11 minimal indirect revascularization, 3 direct revascularization) has been performed in 44 patients (11 hemorrhagic type, 33 ischemic type). Postoperative angiography had been done in 38 sides of 24 patients. We analyzed postoperative change of moyamoya vessel in surgically treated patients. RESULTS: Thirty two patients had been presented with cerebral hemorrhage and 93 had been presented with cerebral ischemia. Three patients had been presented with both. Hemorrhage occurred mainly in the ventricle (14 patients), thalamus (9) and basal ganglia (6), where maximal hemodynamic loading existed. Cerebral infarction had been identified in 56 patients and they occurred mainly in the borderzone area (96.7% of patients), which suggested that infarction had developed hemodynamically. No cerebral infarction had been identified in the rest of ischemic type patients. There was no difference between hemorrhagic and ischemic type in the collateral development pattern on the DSA. Moyamoya vessels had been regressed in all of extensive indirect surgery group but did not disappeared completely in the minimal indirect surgery group and direct surgery group. CONCLUSION: Considering that most Hemorrhagic events had occurred around the maximal hemodynamic loading area such as the junction between ventripetal artery and ventrifugal dysplastic artery and such dysplatstic artery had been disappeared after extensive revascularization, extensive Cerebral revascularization could reduce hemorrhagic event through the reducing hemodynamic loading in such moyamoya vessels.
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H.S.PARK, Department of Neurosurgery, School of Medicine, Inha University, INCHEON, SOUTH KOREA
E.Y.KIM   Department of Neurosurgery, School of Medicine, Inha University  INCHEON  SOUTH KOREA
D.KHYUN  Department of Neurosurgery, School of Medicine, Inha University  INCHEON  SOUTH KOREA
         
         
         
         
         
         
         
         
         
         
         
         

Topic: Acute stroke: emergency management, stroke units and complications
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Palau Level I

 
Discovery of a panel of blood biomarkers to differentiate acute stroke from stroke-mimicking conditions
Background- At present, the absence of a widely available diagnostic test for acute cerebral ischemia remains a limitation in the management of stroke. The triaging stage is likely to have the highest rate of stroke mimicking conditions and being the best scenario for a quick, accurate diagnostic assay to send to reference hospitals all true strokes that might get therapeutically benefit. Methods- In front of stroke suspicion (<3h from symptom onset) blood samples were obtained at ED to test selected biomarkers and later on a complete diagnostic protocol allowed to decide the diagnosis of “true stroke” (stroke) or a “stroke mimicking condition”. 230 cases were studied [146 strokes, 61 mimics (seizures, tumours, migraine, hypoglycemia, syncope…) and 23 healthy controls]. From a screening in a large (>150) protein-antibody library, in a sub-group of cases, we identified 23 biomarkers useful to differentiate stroke from mimics (p<0.05). Those key biomarkers were combined in arrays and tested for validation in the whole study population by Search Light technology (Thermo Fisher Scientific). Results- The multivariate analysis identified IL-17 OR 114.7; BNGF OR 9.2; IGFBP-3 OR 34.5; TNFR1 OR 8.7; Hypertension OR 3.5; Atrial Fibrillation OR 26.7 and Dyslipidemia OR 8.1 (all p<0.009), as independent parameters to differentiate stroke from stroke-mimicking conditions. That allowed building up a model with great predictive value (AUC=0.93) adding significant information to both clinical data alone and biomarkers alone (p<0.05). Negative predictive value for stroke obtained by combinations of 3 biomarkers was 100% and some combinations of only 2 biomarkers had 100% positive predictive value. The test allowed correctly allocating 46.9% of the mimics and 98.6% of the strokes. Conclusions- Results of this extensive study identified biomarkers able to differentiate stroke from mimics that will permit rapid referral of stroke patients to hospitals were acute treatments are available.
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J.Montaner, Neurovascular Research Laboratory, Neurology Department, Vall d'Hebron Hospital., Barcelona, SPAIN
A.Penalba   Neurovascular Research Laboratory, Vall d'Hebron Hospital.  Barcelona  SPAIN
P.Chacón  Lipids Unit, Biochemical Department, Vall d'Hebron Hospital.  Barcelona  SPAIN
P.Delgado  Neurovascular Research Laboratory, Vall d'Hebron Hospital.  Barcelona  SPAIN
A.Rossell  Neurovascular Research Laboratory, Vall d'Hebron Hospital.  Barcelona  SPAIN
M.Ribó  Neurology Department, Vall d'Hebron Hospital.  Barcelona  SPAIN
D.Salat  Neurology Department, Vall d'Hebron Hospital.  Barcelona  SPAIN
D.Giralt  Neurovascular Research Laboratory, Vall d'Hebron Hospital.  Barcelona  SPAIN
M.Quintana  Neurology Department, Vall d'Hebron Hospital.  Barcelona  SPAIN
A.Flores  Neurology Department, Vall d'Hebron Hospital.  Barcelona  SPAIN
T.García-Berrocoso  Neurovascular Research Laboratory, Vall d'Hebron Hospital.  Barcelona  SPAIN
C.Molina  Neurology Department, Vall d'Hebron Hospital.  Barcelona  SPAIN
I.Fernández-Cadenas  Neurovascular Research Laboratory, Vall d'Hebron Hospital.  Barcelona  SPAIN
J.Alvarez-Sabín  Neurology Department, Vall d'Hebron Hospital.  Barcelona  SPAIN
         

Topic: Brain imaging
Oral Session :   
Poster Session: Poster Session Red
Date: Wednesday 26 May 2010
Time: 12:30 - 14:00
Room: Palau Level I

 
CEREBRAL PERFUSION CT PREDICTS FUNCTIONAL RECOVERY OF PATIENTS AFTER THROMBOLYTIC THERAPY FOR ACUTE ISCHEMIC STROKE.
Background: Combining perfusion CT (CTP) with CT angiography (CTA) and noncontrast CT provides information about acute stroke pathophysiology and can improve the patient selection for thombolysis, but we unknown what CTP findings have prognostic value after treatment with r-TPA. Methods: We evaluated what clinical and CTP findings at admission were associated to functional recovery (FR)(mRS <3 at 3 months) in 197 consecutive patients treated with iv r-TPA for ischemic stroke, according to SITS criteria, between December-2005 and October-2009. Demographics and vascular risk factors, previous treatments, biological parameters, treatment delay and NIHSS score were registered in all patients prior to treatment. CTP –maps of mean transit time (MTT), cerebral blood flow (CBF) and cerebral blood volume (CBV)- was performed to 82.2%, CTA to 75% and transcranial sonography to 59%. We made a multivariate analysis by using associated factors in the univariate study (p<0.05, Chi squared for categorical and U de Mann-Whitney for non parametric variables) by statistical program SPSS. Results: mRS score at 3 months was obtained in 179 patients. FR occurred in 112 (62.6%). Age (p=0.05), glucose level (p=0.003), initial NIHSS score (p=0.000), frequencies of hypertension (59.8% vs 74.8%, p=0.04) and changes in MTT (81.4% vs 100%, p=0.001), CBF (74.2 vs 98%, p=0.000) and CBV (29.8% vs 66.6%, p=0.000) were different in two groups. In a logistic regression model, only initial NIHSS score (p=0.000, OR=1.23, 95%CI=1.1-1.3) and no changes in CBV maps (p=0.02, OR=2.69, 95%CI=1.1-6.5) were independently associated to FR. In addition, early recanalization occurred in 65.2% (valid percentage). In multivariate analysis recanalization was also associated to FR (p=0.001, OR=14.9, 95%CI=3.1-71.6). Conclusion: Normal maps of CBV on perfusion CT predict functional recovery of patients treated with intravenous r-TPA and could help to select patients for combined endovascular therapy when recanalization was not achieved.
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D.Larrosa, Hospital Universitario Marques de Valdecilla and Fundacion Marques de Valdecilla (IFIMAV), Santander, SPAIN
M.Revilla   Hospital Universitario Marques de Valdecilla and Fundacion Marques de Valdecilla (IFIMAV)  Santander  SPAIN
E.Palacio  Hospital Universitario Marques de Valdecilla and Fundacion Marques de Valdecilla (IFIMAV)  Santander  SPAIN
M.Rebollo  Hospital Universitario Marques de Valdecilla and Fundacion Marques de Valdecilla (IFIMAV)  Santander  SPAIN
J.A.Berciano  Hospital Universitario Marques de Valdecilla and Fundacion Marques de Valdecilla (IFIMAV)  Santander  SPAIN
         
         
         
         
         
         
         
         
         
         

Topic: Stroke prognosis
Oral Session :  B
Poster Session:  
Date: Thursday 27 May 2010
Time: 17:10 - 17:20
Room: H3

14
Prediction of major vascular events in patients with a TIA or ischemic stroke. A comparison of 7 models.
Background: In patients with a recent TIA or minor stroke, prediction of long term risk of major vascular events is important, but difficult. A commonly recommended population-based prediction model, the Framingham risk score, has not been evaluated and compared with other prediction models. We studied the external validity of currently available prediction models. Methods: We validated predictions from 3 population-based models (Framingham, SCORE and INDIANA project) and 4 stroke-cohort-based models (SPI-II, Oxford TIA, Dutch TIA study, and the ABCD2 study) in an independent cohort of patients with a recent TIA or minor stroke.The validation cohort consisted of 592 patients with a TIA or minor stroke, with a mean follow-up of 2 years. The primary outcome was the two-year risk of the composite outcome event of non-fatal stroke, myocardial infarction or vascular death,. We used calibration graphs and c-statistics to evaluate the 7 models. Results: For the primary outcome event the two-year risk was 12%, for the secondary outcome event 9%. After adjustment for baseline risk and for prevalence of risk factors, calibration was adequate for the Dutch TIA, the ABCD2, and SPI-II models. Discrimination ranged from 0.61 to 0.64 for the population-based models and from 0.64 to 0.68 for stroke-cohort-based models. Conclusions: Discrimination was poor to reasonable for all currently available risk prediction models aimed at patients with a recent TIA or minor stroke. Overall, stroke-population based models performed better than population-based models. Clinical usefulness may be best for the ABCD2 model that has a limited number of easily obtainable variables, a reasonable c-statistic (0.64), and adequate calibration.
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A.D.Wijnhoud, Erasmus Medical Center, Rotterdam, THE NETHERLANDS
E.Maasland   Erasmus Medical Center  Rotterdam  THE NETHERLANDS
H.F.Lingsma  Erasmus Medical Center  Rotterdam  THE NETHERLANDS
E.W.Steyerberg  Erasmus Medical Center  Rotterdam  THE NETHERLANDS
P.J.Koudstaal  Erasmus Medical Center  Rotterdam  THE NETHERLANDS
D.W.J.Dippel  Erasmus Medical Center  Rotterdam  THE NETHERLANDS
         
         
         
         
         
         
         
         
         

Topic: Heart and brain
Oral Session :   
Poster Session: Poster Session Red
Date: Wednesday 26 May 2010
Time: 12:30 - 14:00
Room: Palau Level I

 
Effect of acute stroke on heart function
Background: There are contradictory data on how brain hemispheric localization/side influences the function of the heart. Our aim was to study the pathologic cardiological abnormalities in acute stroke patients without coronary heart disease or rhythm disturbances in the anamnesis. Methods: Between 1st of March, 2009 and 30th of September, 2009 at the Neurointensive Care Unit we monitorized 91 acute stroke patients’ parameters continuously for 24-36 hours: pulse, systolic, diastolic, mean blood pressure, 12 lead ECG. We were interested in the correlation of the above mentioned parameters and age, side and size of the cerebral lesion (by CT/MRI), type of stroke, mortality. Exclusion criteria were: fever, severe hyperglycemia, cardiac failure, myocardial infarct, pulmonary disorders, obstructive sleep apnoe, drug or metabolic caused rhythm disturbances, beta blocker usage. Results: The average age was 62,3+/-14,6 years. The left hemisphere was affected in 45%, the right in 38,5%, both hemispheres in 3,3%, and 13,2 % suffered from VB syndrome. Ischemic stroke was in 74,7%, hemorrhage 14,3%, SAH 3,3%, TIA 7,7%. In the group where no heart disorder was known at admission, altogether 18% had repolarization abnormalities (10 patients had ST depression, 7 ST elevation). In addition, especially during the night, by 33% of the patients supraventricular (SVES) and ventricular extrasystoles (VES) were detected. 35% of patients had tachycardy and 23% bradycardy, both were significantly higher in the right sided lesions (p<0.05). VES was more frequent in left hemispherical lesions and VB syndrome (p<0.05). Less than 90 mmHg systolic pressure could be detected in 27% of patients, this was remarkable at dawn. Nine patients died, in 2 patients fatal rhythm disturbance caused death. Conclusion: Both sided hemispheric lesions and VB syndromes can cause cardiological and ECG abnormalities. Intensive monitoring is essential in acute stroke at least for 36 hours.
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I.Fekete, University of Debrecen, Department of Neurology, Debrecen, HUNGARY
N.Deregi   University of Debrecen, Department of Neurology  Debrecen  HUNGARY
J.Aranyosi  University of Debrecen, Department of Neurology  Debrecen  HUNGARY
K.Fekete  University of Debrecen, Department of Neurology  Debrecen  HUNGARY
L.Csiba  University of Debrecen, Department of Neurology  Debrecen  HUNGARY
         
         
         
         
         
         
         
         
         
         

Topic: Acute stroke: new treatment concepts
Oral Session :   
Poster Session: Poster Session Red
Date: Wednesday 26 May 2010
Time: 12:30 - 14:00
Room: Palau Level I

 
Impact of combined intravenous thrombolysis and endovascular approach in elderly patients
Background: Intravenous (IV) alteplase is not currently recommended in octogenarian patients and the benefit-safety ratio of the endovascular therapy in this age group remains to be determined. The aim of this study was to determine the impact of combined IV–intra-arterial (IA) approach in octogenarian patients. 
 Methods: We report in a single-center observational study, age-specifics outcomes of patients treated by combined IV/IA thrombolytic approach. We used patients ≥ 80 years with documented arterial occlusion treated by IV thrombolysis alone at the same center as control groups to provide information on treatment benefice/risk ratio.
 Results: Among the 78 patients ≥ 80 years treated by IV-IA approach, early neurological improvement rate didn’t differ from younger counterparts, whereas the 90-day favourable outcome rate was significantly lower in octogenarian. 90-day mortality rate was higher in patients ≥ 80 years (adjusted odds ratio (OR), 3.45; 95% confidence interval (CI), 0.78 to 15.19). Octogenarian patients had a higher risk of haemorrhage complication with an adjusted OR of 4.63 (95%CI, 1.27-16.91). 
In comparison to the control group of patients ≥ 80 years treated by IV thrombolysis alone (n=26), patients ≥ 80 years treated by IV/IA approach had a higher recanalization rates (74% vs. 38%, p=0.01) but an increased risk of haemorrhage complications (61% vs. 19%, p=0.003) with no difference in clinical efficacy outcome. Conclusions : IV–IA approach was associated with higher mortality and asymptomatic hemorrhagic rates in patients ≥ 80 years compared to younger counterparts. In comparison with IV-treated octogenarian patients, IV–IA treated patients ≥ 80 years had no improved clinical outcomes and had a higher risk of haemorrhage complications
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M.M.Mazighi, Bichat Hospital University, Paris, FRANCE
E.M.Meseguer   Bichat Hospital University  Paris  FRANCE
J.L.Labreuche  Bichat Hospital University  Paris  FRANCE
J.M.Serfaty  Bichat Hospital University  Paris  FRANCE
J.P.Laissy  Bichat Hospital University  Paris  FRANCE
P.L.Lavallée  Bichat Hospital University  Paris  FRANCE
L.C.Cabrejo  Bichat Hospital University  Paris 
C.G.Guidoux  Bichat Hospital University  Paris  FRANCE
I.K.Klein  Bichat Hospital University  Paris  FRANCE
T.S.Slaoui  Bichat Hospital University  Paris  FRANCE
E.S.C.Schouman Claeys  Bichat Hospital University  Paris  FRANCE
P.A.Amarenco  Bichat Hospital University  Paris  FRANCE
         
         
         

Topic: Stroke prognosis
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Palau Level I Foyer

 
Uric acid in the first hours after acute ischaemic stroke
Background: The role of uric acid on stroke outcome and mortality is controversial. This study was aimed to evaluate the association of uric acid levels measured during the acute phase of ischaemic stroke with outcome and mortality. Methods: In a prospective study, we included 419 patients with ischemic stroke. Uric acid was measured on admission. Stroke severity on admission was measured with NIH stroke scale (NIHSS). Functional outcome on day seven was measured with modified Rankin Scale (mRS). Multiple logistic regression analysis was used to assess the independent association between variables and outcome. Survival was analysed by Cox regression analysis after adjusting for cardiovascular risk factors and factors known to influence uric acid level or acute stroke outcome. Results: The mean age (SD) of the patients was 69.3 (13.6) years. The median NIHSS (interquartile range) on admission was 4 (2-9) and the median mRS (interquartile range) on day seven was 2 (1-3). The median time (interquartile range) from symptoms onset to hospital admission and blood sample was 2.8 (1.4-6.6) hours. Seventy-one patients (16.7 %) died during a median follow–up period of 47 months. High uric acid was independently associated with a favourable outcome (OR 1.21, 95% CI 1.01-1.45, p=0.03). High uric acid level was associated with higher mortality (OR 2.77, 95% CI 1.37-5.56, p=0.01) but no significant association was found after adjusting for confounders (OR 1.88, 95% CI 0.83-4.27, p= 0.30). Conclusions: The current study indicates that high serum uric acid levels measured during the acute phase of ischaemic stroke are associated with favourable outcome and no increased mortality. High uric acid may be neuroprotective in ischaemic stroke in humans.
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N.Logallo, Haukeland University Hospital, Bergen, Norway, Bergen, NORWAY
H.Naess   Haukeland University Hospital, Bergen, Norway  Bergen 
T.Idicula  Haukeland University Hospital, Bergen, Norway  Bergen  NORWAY
J.Brogger  Haukeland University Hospital, Bergen, Norway  Bergen  NORWAY
U.Waje-Andreassen  Haukeland University Hospital, Bergen, Norway  Bergen  NORWAY
L.Thomassen  Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway  Bergen  NORWAY
         
         
         
         
         
         
         
         
         

Topic: Acute stroke: current treatment
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Palau Level I

 
Current guidelines regarding the management of blood pressure in acute ischemic stroke and the outcome of cardioembolic strokes
Background: Guidelines state that blood pressure (BP) should not be lowered in acute ischemic stroke unless it exceeds 220/120 mmHg. However, ischemic stroke is a heterogeneous disease and these rules may not apply to all subtypes. Material and methods: Of a consecutive series of 112 acute ischemic strokes admitted to our hospital, 24 cases (21,4%) were cardioembolic (CE) ones diagnosed in accordance with the TOAST criteria. Stroke severity and outcome was assessed by scoring the patients on stroke scales (NIHSS, SSS) and functional scales (Barthel index-BI) on admittance and 10 days after stroke onset. BP was monitored daily. Results: Of the CE stroke patients, 83.8% had associated hypertension. The mean BP on admission was 147,9 (standard deviation-SD 26) mmHg /90 (SD 16.6) mmHg. Patients with lower systolic (<140) and diastolic BP (<90) had significantly better outcomes than those with higher BP values (table 1). Similarly, lower mean systolic (S) and diastolic (D) BP (<140 and < 90 mm Hg) during the first 3 days after stroke onset were associated with better prognosis (table 1.) Conclusions: The difference in the outcome could have several explanations: higher BP values on admittance may be associated with larger infarctions and increased intracranial pressure, higher BP values in the first days of evolution may contribute to symptomatic hemorrhagic transformation. However, our findings suggest that the management of BP in acute ischemic stroke should be differentiated according to the presumed etiopathogenic subtype.
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Table: http://www.esc-archive.eu/barcelona10/graphics_barcelona/aid_237.html

 

A.Simion, University of Oradea, Faculty of Medicine and Pharmacy, Oradea, ROMANIA
A.Jurcau   University of Oradea, Faculty of Medicine and Pharmacy  Oradea  ROMANIA
R.Simion  University of Oradea, Faculty of Medicine and Pharmacy  Oradea  ROMANIA
         
         
         
         
         
         
         
         
         
         
         
         

Topic: Acute stroke: clinical patterns and practice
Oral Session :  A
Poster Session:  
Date: Thursday 27 May 2010
Time: 15:00 - 15:10
Room: H1

7
Thrombolysis has a low complication rate in patients with stroke mimics
BACKGROUND: The frequency of false-positive diagnosis of ischemic stroke (‘stroke mimic’) has been estimated at approximately 1-3%. Since decision making for thrombolysis in acute stroke settings is restricted to a limited time window and usually based on clinical assessment and CT findings only, thrombolysis is sometimes applied to patients with a final diagnosis other than stroke. We analyzed clinical characteristics and response to rtPA thrombolysis of patients with stroke mimics. METHODS: From a prospectively collected stroke and MRI data bank we identified 45 patients (mean age 66.2 y., median NIHSS 6) without evidence of acute brain infarction on MRI including negative diffusion-weighted images (DWI) who had been treated with rtPA. We analyzed clinical characteristics, rate of favorable response to thrombolysis, and complications. Furthermore, the most plausible pathophysiological diagnosis was selected in each based on all available data (imaging, EEG, laboratory findings, etc.). RESULTS: Stroke mimics included seizures (n=12), functional disorders (n=5), brain tumors (n=2), dementia (n=3), migraine (n=2), hypoglycemia, encephalitis, hypertensive encephalopathy and cervical radiculopathy (n=1 each). Best diagnosis after exclusion of others was TIA in the remaining 17 patients. Most patients presented with motor or sensorimotor hemiparesis (71%) and/or aphasia (49%); 24% had isolated aphasia. Clinical improvement after thrombolysis was observed in 87% with a median NIHSS of 1 at discharge. Mild complications related to rtPA (asymptomatic hemorrhagic transformation, reversible orolingual angioedema, epistaxis) occurred in 3 patients (6.6%). None of the patients deteriorated clinically and there was no symptomatic hemorrhage. DISCUSSION: Thrombolysis does not seem harmful in stroke mimics and prognosis is favorable. Stroke physicians should therefore not refrain from therapy for fear of misdiagnosis, provided that other contraindications are excluded.
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R.Kern, Dept. of Neurology, UniversitätsMedizin Mannheim, University of Heidelberg, Mannheim, GERMANY
A.Förster   Dept. of Neurology, UniversitätsMedizin Mannheim, University of Heidelberg  Mannheim  GERMANY
M.Griebe  Dept. of Neurology, UniversitätsMedizin Mannheim, University of Heidelberg  Mannheim  GERMANY
M.Wolf  Dept. of Neurology, UniversitätsMedizin Mannheim, University of Heidelberg  Mannheim  GERMANY
E.Hornberger  Dept. of Neurology, UniversitätsMedizin Mannheim, University of Heidelberg  Mannheim  GERMANY
K.Szabo  Dept. of Neurology, UniversitätsMedizin Mannheim, University of Heidelberg  Mannheim  GERMANY
M.G.Hennerici  Dept. of Neurology, UniversitätsMedizin Mannheim, University of Heidelberg  Mannheim  GERMANY
         
         
         
         
         
         
         
         

Topic: Intracerebral/subarachnoid haemorrhage and venous diseases
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Palau Level I Foyer

 
The prognostic significance of lipid levels in hyperacute Intracerebral Hemorrhage
BACKGROUND Recent studies found that lower cholesterol and triglyceride levels are associated with a higher mortality rate in patients with acute intracerebral hemorrhage (ICH). We aimed to investigate whether lipid levels were associated with death and dependency in patients with hyperacute ICH. METHODS We prospectively studied consecutive patients with spontaneous supratentorial ICH, within the first 6 hours after symptom onset. Immediately after CT diagnosis, we collected blood samples by venopuncture and plasma was frozen at -80 °C until used. We measured the levels of total cholesterol (tCh), LDL-Ch, HDL-Ch, VLDL-Ch, Ch/HDL, LDL-Ch/HDL-Ch and triglyceride. We also recorded age, hematoma volume and the Glasgow coma scale score (GCS) at admission. We assessed the functional outcome with the Rankin scale 3 months after stroke and we defined a favorable outcome as a Rankin scale score ≤ 2. We performed univariate and multivariate statistical analyses. RESULTS We included 70 patients; with a mean age of 71.7 +/- 10.8 years and 61% of them were men. Blood samples were obtained a mean of 199 +/- 293 minutes after the onset of symptoms. At the 3-month follow-up, mortality rate was 28%, and 73% of the patients were dead or dependent. In univariate analysis, higher age (p<0.0001), higher hematoma volume (p<0.0001) and lower GCS (p<0.0001) were associated with an unfavourable functional outcome. The logistic regression analysis showed that age (OR 0.87 per year, p=0.0002) and hematoma volume (OR 0.95 per ml, p=0.03) were independent predictors of functional outcome. None of the lipid levels measured showed a prognostic value in either univariate or multivariate analyses. CONCLUSION In patients with hyperacute intracerebral hemorrhage, the measurement of lipid concentrations does not add prognostic information to other well-known prognostic predictors.
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J.Martí-Fàbregas, Neurology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, SPAIN
R.Delgado-Mederos   Hospital de la Santa Creu i Sant Pau  Barcelona  SPAIN
S.Martínez-Ramírez  Hospital de la Santa Creu i Sant Pau  Barcelona  SPAIN
R.Marín  Hospital de la Santa Creu i Sant Pau  Barcelona  SPAIN
A.Alejaldre  Hospital de la Santa Creu i Sant Pau  Barcelona  SPAIN
J.Crespí  Hospital de la Santa Creu i Sant Pau  Barcelona  SPAIN
J.L.Martí-Vilalta  Hospital de la Santa Creu i Sant Pau  Barcelona  SPAIN
J.Ordóñez  Hospital de la Santa Creu i Sant Pau  Barcelona  SPAIN
         
         
         
         
         
         
         

Topic: Vascular imaging
Oral Session :   
Poster Session: Poster Session Red
Date: Wednesday 26 May 2010
Time: 12:30 - 14:00
Room: Palau Level I

 
Common anatomical variations of the Posterior Circle of Willis: A comparison of MR and neuropathological data sets.
Background: Variations in Posterior Circle of Willis anatomy are reported as associated with possible increased stroke risk. Previous studies of the posterior circulation using MRA have reported inconsistent findings of prevalence of variations. Neuropathological studies are more consistent but cannnot reflect influence of physiological function. We performed a study of to compare a large group of brain MRAs with published neuropathological (NP) data. Methods: 163 consecutive MRA studies performed on a Siemens 1.5T MR scanner were reviewed by Neurology and Radiology fellows using standard criteria. Variations of posterior circulation anatomy were noted and recorded. Results were compared with published findings of Riggs and Rupp’s large NP study. Comparison of data sets was performed by an independent researcher. Results: Unilateral hypoplastic or absent Posterior Communicating Artery (PComA) was evident in 37 of 163 (22.7%) of the MRA and 192 of 994 (20.9%) NP studies (Chi Square 0.81, p=0.36). MRA revealed bilateral hypoplasia / absence in 8 (4.9%), consistent with random occurrence of disease. In contrast, Riggs and Rupp reported hypoplastic/absent vessels bilaterally in 305 (30.7%). Hyperplastic PComAs were found in 24 of 163 MRAs (14.7%) compared with 160 of 994 NP cases (16.1%) (Chi-sq 0.11, p=0.74). Bilateral hyperplasia was found in 5 of 163 MRAs (3.1%), consistent with random occurrence, but 123 of 994 NP cases (12.4%). (Chi sq 11.4, p=0.07). All hyperplastic PComAs described neuropathologically were felt to be associated with a hypoplastic/absent P1 (‘fetal’ variant) compared to 17 of 29 on MRA (58.6%). Conclusions: Prevalence of unilateral anatomical variants are highly consistent between neuropathlogical data and MRA. Bilateral disease is reported more often in neuropathological specimens than is evident on MRA, MRA data being more consistent with random development of variants and neuropathological findings with a genetic or developmental tendency.
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S.Byrne, Trinity College Institute for Neurosciences, Dublin, IRELAND
R.Dunne   St James's Hospital  Dublin  IRELAND
J.Meaney  St James's Hospital  Dublin  IRELAND
J.A.Harbison  Trinity College Institute for Neurosciences  Dublin  IRELAND
         
         
         
         
         
         
         
         
         
         
         

Topic: Vascular surgery and neurosurgery/interventional neuroradiology
Oral Session :   
Poster Session: Poster Session Red
Date: Wednesday 26 May 2010
Time: 12:30 - 14:00
Room: Exhibition Hall

 
Surgical recanalization for chronic total occlusion of carotid artery
Background: Carotid artery total occlusion (CATO) is popular in clinical work. But the treatment of CATO is limited, although it’s important to symptomatic cases. We evaluated the different surgical methods in patients with CATO. Methods: From October 2007 to July 2009 patients who underwent surgical recanalizion for CATO were retrospectively evaluated. Patient data analyzed included sex, age, risk factors, operative methods, and long-term follow-up with clinical evaluation and carotid duplex scan. Neurologic status was evaluated with the Modified Rankin Scale (mRS) before the operation, immediately after the operation, and at 6-months’ follow-up. Results: Twenty-three patients underwent surgical recanalizion for symptomatic chronic CATO over the last 2 years. The average age of the patients was 63.7 ± 8.4 years, and 91.3% were men. Patient risk factors included hypertension (19, 82.6%), hyperlipidemia (17, 73.9%), diabetes (11 , 47.8%), and coronary artery disease (7,30.4%). All patients had ischemic symptom within 3 months before operation, including transient ischemic attack (14, 60.9%), stroke (5, 21.7%), and amaurosis fugax (4, 17.4%). All patients were diagnosised as CATO by cerebral angiography. In all 23 patients, occlusion of common carotid artery is 4 cases, other 19 cases were internal carotid artery occlusion. Recanalization was successfully established in 20(87.0%) of 23 patients and confirmed with angiography, CT angiography, or duplex sonography. Postoperative morbidity included 1 death (4.3%) because of malignant infarction 3 days after operation. Follow-up averaging 9.1 ± 1.3 months (range, 6-18 months) was obtained in all patients. At 6 months, 22 (95.7%) of 23 patients were absent of ischemic accident. 19(82.6%) patients remained antegrade flow in the carotid artery. Conclusion: Our data support surgical recanalization for CATO in carefully selected patients. Operation and intervention may be two important aspects to establish antegrade flow.
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L.Jiao, Department of Neurosurgery of Xuanwu Hospital, Beijing, CHINA
F.Ling   Department of Neurosurgery of Xuanwu Hospital  Beijing  CHINA
Y.Hua  Department of Vascular Sonography of Xuanwu Hospital  Beijing  CHINA
M.Ye  Department of Neurosurgery of Xuanwu Hospital  Beijing  CHINA
Y.Ma  Department of Neurosurgery of Xuanwu Hospital  Beijing  CHINA
         
         
         
         
         
         
         
         
         
         

Topic: Small vessel stroke and white matter disease
Oral Session :  A
Poster Session:  
Date: Thursday 27 May 2010
Time: 15:40 - 15:50
Room: F

11
Withdrawn!
withdrawn!
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R.P.W.Rouhl, Maastricht University Medical Centre, Maastricht, THE NETHERLANDS
R.J.van Oostenbrugge   Maastricht University Medical Centre  Maastricht  THE NETHERLANDS
J.G.M.C.Damoiseaux  Maastricht University Medical Centre  Maastricht  THE NETHERLANDS
R.O.M.F.I.H.Theunissen  Maastricht University Medical Centre  Maastricht  THE NETHERLANDS
I.L.H.Knottnerus  Maastricht University Medical Centre  Maastricht  THE NETHERLANDS
J.Staals  Maastricht University Medical Centre  Maastricht  THE NETHERLANDS
L.H.G.Henskens  Maastricht University Medical Centre  Maastricht  THE NETHERLANDS
A.A.Kroon  Maastricht University Medical Centre  Maastricht  THE NETHERLANDS
P.W.de Leeuw  Maastricht University Medical Centre  Maastricht  THE NETHERLANDS
J.W.Cohen Tervaert  Maastricht University Medical Centre  Maastricht  THE NETHERLANDS
J.Lodder  Maastricht University Medical Centre  Maastricht  THE NETHERLANDS
         
         
         
         

Topic: Management and economics
Oral Session :   
Poster Session: Poster Session Red
Date: Wednesday 26 May 2010
Time: 12:30 - 14:00
Room: Palau Level I

 
A pilot study to set up a model stroke unit in Sri Lanka- using the available infra structure within the public health system in Sri Lanka
Introduction: Sri Lanka is a developing country with a population of 20 million people. Stroke is the leading cause of adult disability in Sri Lanka. There was only one stroke unit in the whole country at the onset of this work. There is a strong need to set up stroke units in Sri Lanka, using the available infra structure within the Sri Lankan health system. Method: We had preliminary discussions with several physicians who are interested in improving stroke care in Sri Lanka. Three Sri Lankan senior physicians were invited to visit our stroke unit at Western hospital. We had discussions with the current stroke unit at National hospital of Sri Lanka, Colombo, Sri Lanka to obtain their help in the process of training stroke nurses and medical officers. In March 2008, we conducted a Stroke education campaign in Sri Lanka to improve awareness in this important health problem. A model stroke unit was established in Base Hospital, Kegalle to test the possibility of setting up further stroke units in other public hospitals in Sri Lanka. Conclusion: The education campaign was quite successful. First Author of this abstract spent a two week period in Sri Lanka during March 2008. Four different talks on stroke care were given in four different hospitals in Sri Lanka during this visit. A book on stroke care was published through the sponsorship of a leading news paper in Sri Lanka and 50,000 copies of this book were freely distributed throughout Sri Lanka. Five different interviews were conducted using the mass media to improve stroke care awareness among Sri Lankans (national news papers, national television). A 16 bed stroke unit was established at Base hospital, Kegalle using the currently available general medical beds in that hospital. Nurses and medical officers will go through a training program in stroke at the currently established stroke unit at National hospital, Colombo, Sri Lanka in the near future.
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K. M. T.Wijeratne, Western Health, Melbourne, AUSTRALIA
V. D. P.Wijeratne   Austin Health  Melbourne  AUSTRALIA
W. P .Dissanayake  Ministry of Health , Base Hospital, Kegalle  Kegalle   SRI LANKA
R.Kalupahana  Base Hospital  Kegalle  SRI LANKA
         
         
         
         
         
         
         
         
         
         
         

Topic: Small vessel stroke and white matter disease
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Palau Level I Foyer

 
Clinical predictors of lacunar syndrome not due to lacunar infarction
Background: Lacunar syndrome (LS) not due to lacunar infarct (LI) is poorly characterised. This single centre, retrospective study was conducted to describe the clinical characteristics of patients with LS not due to LI and to identify clinical predictors of this variant of lacunar stroke. Methods: A total of 146 patients with LS not due to LI were included in the “Sagrat Cor Hospital of Barcelona Stroke Registry” during a period of 19 years (1986–2004). The characteristics of these 146 patients with lacunar syndrome not due to lacunar infarct were compared with those of the 733 patients with lacunar infarction. Results: Lacunar syndrome not due to lacunar infarct accounted for 16.6% of all cases of lacunar stroke syndrome (n = 876). Stroke subtypes included atherothrombotic infarction in 37% of patients, cardioembolic infarction in 26%, intracerebral haemorrhage in 25.3%, spontaneous subdural haematoma in 2.7%, unusual aetiology in 1.4% and unknown cause in 7.5%. Subtypes of lacunar syndromes included pure motor stroke in 63 patients, sensorimotor stroke in 51, pure sensory stroke in 14, atypical lacunar syndrome in 9, ataxic hemiparesis in 5 and dysarthria-clumsy hand in 4. Valvular heart disease, atrial fibrillation, sudden onset, limb weakness and sensory symptoms were significantly more frequent among patients with lacunar syndrome not due to lacunar infarct than in those with lacunar infarction, whereas diabetes was less frequent. In the multivariate analysis, atrial fibrillation (OR = 4.62), sensorimotor stroke (OR = 4.05), limb weakness (OR = 2.09) and sudden onset (OR = 2.06) were independent predictors of lacunar syndrome not due to lacunar infarct. Conclusion: Although lacunar syndromes are highly suggestive of small deep cerebral infarctions, lacunar syndromes not due to lacunar infarcts are found in 16.6% of cases. The presence of sensorimotor stroke, limb weakness and sudden onset in a patient with atrial fibrillation should alert the clinician to the possibility of a lacunar syndrome not due to a lacunar infarct
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A.Arboix, Cerebrovascular Division, Barcelona, SPAIN
M.Grau-Olivares   Cerebrovascular Division. Sagrat Cor Hospital of Barcelona  Barcelona  SPAIN
L.Blanco  Cerebrovascular Division. Sagrat Cor Hospital of Barcelona  Barcelona  SPAIN
G.Arbe  Cerebrovascular Division. Sagrat Cor Hospital of Barcelona  Barcelona  SPAIN
E.Comes  Cerebrovascular Division. Sagrat Cor Hospital of Barcelona  Barcelona  SPAIN
L.Garcia-Eroles  Cerebrovascular Division. Sagrat Cor Hospital of Barcelona  Barcelona  SPAIN
C.Targa  Cerebrovascular Division. Sagrat Cor Hospital of Barcelona  Barcelona  SPAIN
J.Massons  Cerebrovascular Division. Sagrat Cor Hospital of Barcelona  Barcelona  SPAIN
         
         
         
         
         
         
         

Topic: Acute cerebrovascular events (ACE): TIA and minor strokes
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Palau Level I

 
Lipoprotein-associated Phospholipase A2 (Lp-PLA2) mass and activity may influence early vascular recurrence in transient ischemic attack patients.
Introduction: Lp-PLA2 has emerged as a novel biomarker in cardiovascular diseases due to its ability to predict both primary and recurrent stroke in population-based studies. Little is known about its role in the early prognosis of stroke patients. Therefore, we aimed to investigate Lp-PLA2 level and activity in transient ischemic attack (TIA) patients and to study their relationship with early outcome. Methods: Lp-PLA2 mass and activity were respectively measured by means of the PLAC test at an automated Olympus analyzer and by a colorimetric activity method (Diadexus), in 166 TIA patients and 144 controls. Vascular risk factors, clinical course and stroke etiology were assessed for the purpose of this study. Outcome was defined as the presence of stroke/TIA within 7 days and within 1 month after the index TIA. Results: Both Lp-PLA2 mass (347 vs 199 ng/mL, p<0.05) and activity (187 vs 160 nmol/mL/min, p<0.05) were higher in TIA patients than in controls. Lp-PLA2 mass and activity were decreased in patients with past medical history of dyslipemia and coronary heart disease, and in patients taking antiplatelet treatments before the TIA. During follow-up, nine (5.4%) strokes/TIA occurred within the first week and 23 (13.9%) within the first month. Among all factors associated with outcome, multivariate analyses (Cox regression) were performed to identify potential predictors of stroke/TIA within 7 days and within 1 month. An atherothrombotic stroke etiology (HR 3.28, p=0.011), together with the past medical history of dyslipemia (HR 3.68, p=0.008) and Lp-PLA2 activity higher than 207 nmol/mL/min (HR 2.7, p=0.042) were all significant predictors for recurrent stroke/TIA within the first month. However, when the outcome was considered very early (within the first week) only the atherothrombotic stroke etiology remained as significant predictor for Stroke/TIA (HR 9.3, p=0.008). Conclusions: Lp-PLA2 activity might add significant prognostic information in the early evaluation of TIA patients.
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P.Delgado, Neurovascular Research Laboratory. Research Institute Vall Hebron., Barcelona, SPAIN
A.Penalba   Neurovascular Research Laboratory. Research Institute Vall Hebron.  Barcelona  SPAIN
P.Chacon  Lipid Unit. Vall Hebron Hospital.  Barcelona  SPAIN
D.Pelegri  Clinical Biochemistry Unit. Vall Hebron Hospital.  Barcelona  SPAIN
T.Garcia-Berrocoso  Neurovascular Research Laboratory. Research Institute Vall Hebron.  Barcelona  SPAIN
D.Giralt  Neurovascular Research Laboratory. Research Institute Vall Hebron.  Barcelona  SPAIN
D.Salat  Stroke Unit. Neurology Department. Vall Hebron Hospital.  Barcelona  SPAIN
M.Rubiera  Stroke Unit. Neurology Department. Vall Hebron Hospital.  Barcelona  SPAIN
C.A.Molina  Stroke Unit. Neurology Department. Vall Hebron Hospital.  Barcelona  SPAIN
J.Alvarez-Sabin  Stroke Unit. Neurology Department. Vall Hebron Hospital.  Barcelona  SPAIN
A.Rosell  Neurovascular Research Laboratory. Research Institute Vall Hebron.  Barcelona  SPAIN
J.Montaner  Neurovascular Research Laboratory. Research Institute Vall Hebron.  Barcelona  SPAIN
         
         
         

Topic: Vascular surgery and neurosurgery/interventional neuroradiology
Oral Session :   
Poster Session: Poster Session Red
Date: Wednesday 26 May 2010
Time: 12:30 - 14:00
Room: Exhibition Hall

 
Prevention of stroke by superficial temporal artery to distal middle cerebral artery bypass surgery.
Background: Extracranial-to-intracranial (EC-IC) bypass surgery for the prevention of stroke in patients with symptomatic carotid artery occlusion has been criticized since the randomized trial. But it might benefit patients with compromised cerebrovascular hemodynamics. METHODS: We reviewed all patients underwent EC-IC bypass in our hospital from 2000-2009. Patient data were analyzed included sex, age, operative methods, postoperative angiography, and long-term follow-up with clinical evaluation and cerebral perfusion evaluation. Neurologic status was evaluated with the Modified Rankin Scale (mRS) before the operation, immediately after the operation, and at 6 and 12 months’ follow-up. RESULTS: 217 patients underwent EC-IC bypass in our hospital from 2000-2009. The average age of the patients was 42.1 ± 12.9 years, and 131 (60.4%) were men. All patients had ischemic symptom within 6 months before operation, including transient ischemic attack (117, 53.9%), DIND (37, 17.1%), and stroke (63, 29.0%). 62 (28.6%) patients were diagnosised as Moyamoya diseases, 72 (33.2%) cases were diagnosised as carotid artery occlusion, 57 (26.3%) cases were diagnosised as middle cerebral artery occlusion, and the other 26 (12.0%)were diagnosised as carotid or middle cerebral artery severe stenosis. EC-IC bypass was successfully finished in 205 (94.5%) of 217 patients and confirmed with angiography. Postoperative morbidity included 3 death (1.4%) and 9 (4.1%) cases of hematoma postoperatively. Follow-up averaging 37.8 ± 18.3 months was obtained in 172 patients. At 6 months, 168 (97.7%) of 181 patients were absent of ischemic accident, and 159 (92.4%) of 172 patients were absent of ischemic accident at the 12 months follow-up. CONCLUSION: STA-MCA bypass surgery can restore cerebrovascular reserve in high-risk patients with symptomatic patients. It’s still useful method to prevent stroke in certain population.
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Y.Chen, Department of Neurosurgery of Xuanwu Hospital, Beijing, CHINA
F.Ling   Department of Neurosurgery of Xuanwu Hospital  Beijing  CHINA
M.Li  Department of Neurosurgery of Xuanwu Hospital  Beijing  CHINA
Z.Zhang  Department of Neurosurgery of Xuanwu Hospital  Beijing  CHINA
         
         
         
         
         
         
         
         
         
         
         

Topic: Small vessel stroke and white matter disease
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Palau Level I Foyer

 
Angiogenic T-cells relate to lower endothelial progenitor cell number in hypertension related cerebral small vessel disease
BACKGROUND – Endothelial progenitor cells (EPC) are circulating immature cells which can restore endothelial damage. EPC vitality is impaired in cerebral small vessel disease (CSVD). Angiogenic T-cells (ang-T-cells) could promote EPC vitality. Therefore, we hypothesized that lower EPC numbers and vitality in patients with CSVD relate to lower angiogenic T-cell numbers. METHODS – 31 essential hypertensive patients with CSVD (white matter lesions and/or asymptomatic lacunar infarcts) were compared to 30 age- and sex-matched hypertensive controls without CSVD. We assessed signs of CSVD (lacunar infarcts, white matter lesions, Virchow Robin spaces at basal ganglia level (VRS)) using MRI. We determined EPC numbers (CD34/KDR) and ang-T-cell numbers (CD3/CD31/CD184) with flow cytometry, and EPC vitality (cluster formation) with cultures. RESULTS – EPC number correlated with ang-T-cell number (R=0.244; p<0.01). The only significant predictor for EPC vitality was the ang-T-cell number (p=0.04), independent of blood pressure values. Furthermore, both ang-T-cell numbers as well as EPC numbers showed a negative correlation with white matter lesion volumes (mainly periventricular: -0.238; p<0.01 and -0.225; p=0.01 respectively), and number of VRS (-0.325; p=0.001; -0.22; p=.04 respectively). After correction for age, blood pressure values, and sex, ang-T-cell number only related independently to VRS (p=0.008), and EPC number only related to lacunar infarcts (p=0.01) as well as to VRS (p=0.05). CONCLUSION – Angiogenic T-cell numbers relate to EPC numbers and vitality, as well as to MRI parameters of cerebral small vessel disease in hypertensive patients. Our data suggest that the role of EPC in cerebral small vessel disease could be mediated by angiogenic T-cells.
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R.P.W.Rouhl, Maastricht University Medical Centre, Maastricht, THE NETHERLANDS
A.Mertens   Maastricht University Medical Centre  Maastricht  THE NETHERLANDS
R.J.van Oostenbrugge  Maastricht University Medical Centre  Maastricht  THE NETHERLANDS
J.G.M.C.Damoiseaux  Maastricht University Medical Centre  Maastricht  THE NETHERLANDS
L.L.Debrus-Palmans  Maastricht University Medical Centre  Maastricht  THE NETHERLANDS
L.H.G.Henskens  Maastricht University Medical Centre  Maastricht  THE NETHERLANDS
A.A.Kroon  Maastricht University Medical Centre  Maastricht  THE NETHERLANDS
P.W.de Leeuw  Maastricht University Medical Centre  Maastricht  THE NETHERLANDS
J.Lodder  Maastricht University Medical Centre  Maastricht  THE NETHERLANDS
J.W.Cohen Tervaert  Maastricht University Medical Centre  Maastricht  THE NETHERLANDS
         
         
         
         
         

Topic: Small vessel stroke and white matter disease
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Palau Level I Foyer

 
COMPARATIVE STUDY OF THE COGNITIVE PROFILE OF PATIENTS WITH A FIRST-EVER LACUNAR INFARCT WITH AND WITHOUT SILENT BRAIN INFARCTS.
BACKGROUND:Cerebral infarction of lacunar type (LI) are an ischemic infarction of less than 20 mm of diameter, located in the territory of cerebral penetrating arteriole and represent the 25% of ischemic stroke. LI have been frequently associated with hypertension and diabetes mellitus. Several studies have suggested that the presence of a single LI and multiple LI are two different entities, because single LI have been associated with the presence of microatheromatosis whereas multiple LI have been related more frequently with lipohyalinosis. The aim of the study is compare the cognitive profile of patients with a single LI from patients with a first LI with silent brain infarcts associated. METHODS:83 patients were admitted consecutively in the Departament of Neurology of our hospital presenting as a first-ever single LI manifestated as one of classical lacunar syndromes according to Miller-Fisher (pure motor hemiparesis, pure sensory syndrome, sensoriomotor syndrome, dysarthria clumsy-hand, ataxic hemiparesis or atypical lacunar syndrome). The patients were classified into two groups according the presence of one or multiple LI objectived by magnetic resonance imaging. All the patients underwent a comprehensive neuropsychological assessment. RESULTS:The patients with single LI (37,3%) and multiple LI (43,4%) presented high blood pressure in the 67,7% and 76% respectively. MMSE score was 27,90±2.27 for the group with a single LI and 27.92±2.06 for the group with multiple LI. There were no statistical significant differences between groups in gender, age and education. The group with multiple LI showed a poorer performance in semantic fluency (11,26± 4,66;p=0.002) and a short-delay verbal memory (3,48± 1,889;p=0.012). CONCLUSION:Even to present similar general cognition scores (MMSE), the group with multiple LI showed a poorer neuropsychological performance, specially in excutive functions (semantic fluency) and in short-delay verbal memory. Those impairments may be justified for the interruption of fronto-subcortical circuits for the multiple LI. Thus those patients might have a mid/long-term worse prognosis and higher risk to develop vascular dementia.
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L.BLANCO-ROJAS, HOSPITAL UNIVERSITARI SAGRAT COR, BARCELONA, SPAIN
M.GRAU-OLIVERES   HOSPITAL UNIVERSITARI SAGRAT COR  BARCELONA  SPAIN
A.ARBOIX  HOSPITAL UNIVERSITARI SAGRAT COR  BARCELONA  SPAIN
J.MASSONS  HOSPITAL UNIVERSITARI SAGRAT COR  BARCELONA  SPAIN
M.OLIVERES  HOSPITAL UNIVERSITARI SAGRAT COR  BARCELONA  SPAIN
         
         
         
         
         
         
         
         
         
         

Topic: Etiology of stroke and risk factors
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Exhibition Hall

 
Visceral Obesity Predicts Incident Carotid Atherosclerotic Plaque Formation Independently from Body Mass Index (General Obesity). Longitudinal Results from the Study of Health in Pomerania (SHIP)
Background: There is general consent that visceral obesity contains more cardio- and cerebrovascular risk than peripheral obesity. However, longitudinal data on the predictive value of visceral obesity with respect to progression of subclinical markers for atherosclerosis are limited. Thus, the role of visceral, as opposed to peripheral, obesity in the atherosclerotic process is still unclear. Methods: We investigated the predictive value of waist-to-hip ratio (WHR) for incident carotid plaque (CP) formation in a population-based longitudinal study of 1907 subjects (aged 46-81y), who underwent ultrasonography of both carotid arteries and received vascular risk factor assessment at baseline and after 5 years. CP was defined as any focal thickening of the intima-media complex protruding into the vessel lumen. Incident CP formation during follow-up was defined as the appearance of at least one CP in a previously plaque-free arterial segment (i.e., right and left common, internal and external carotid arteries and carotid bifurcations). The number of segments with incident CP formation served as dependent variable in regression models. Results: CP prevalence at baseline was 67%. Among the 627 subjects without CP at baseline, 414 (66%) had at least one incident CP during follow-up. In negative binominal regression models adjusted for age, sex and quartiles of the body mass index (BMI), the number of arterial segments with incident CP was 1.5fold higher (risk ratio=exp(beta)) for subjects in the highest quartile of the WHR distribution (regression coefficient beta = 0.41; CI: 0.14-0.68; p<0.01) and 1.3fold higher for subjects in the second highest quartile (beta = 0.28; CI: 0.03-0.52; p<0.05) compared to those in the lowest quartile. These associations remained significant after further adjustment for the Framingham risk score. Conclusions: The WHR predict incident CP formation independently from BMI indicating a key role of visceral obesity in the atherosclerotic process.
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B.von Sarnowski, Department of Neurology, Ernst-Moritz-Arndt-University of Greifswald, Greifswald, GERMANY
J.Lüdemann   Institute of Clinical Chemistry and Laboratory Medicine, Ernst-Moritz-Arndt-University of Greifswald  Greifswald  GERMANY
H.Völzke  Institute of Community Medicine, Ernst-Moritz-Arndt-University of Greifswald  Greifswald  GERMANY
H.Wallaschofski  Institute of Clinical Chemistry and Laboratory Medicine, Ernst-Moritz-Arndt-University of Greifswald  Greifswald  GERMANY
M. Dörr  Department of Cardiology, Ernst-Moritz-Arndt-University of Greifswald  Greifswald  GERMANY
C. Kessler  Department of Neurology, Ernst-Moritz-Arndt-University of Greifswald  Greifswald  GERMANY
U. Schminke  Department of Neurology, Ernst-Moritz-Arndt-University of Greifswald  Greifswald  GERMANY
         
         
         
         
         
         
         
         

Topic: Acute stroke: new treatment concepts
Oral Session :  A
Poster Session:  
Date: Wednesday 26 May 2010
Time: 9:20 - 9:30
Room: H1

6
Bringing Forward Reperfusion with Oxygenated Blood Perfusion Beyond Arterial Occlusion During Endovascular Procedures in Acute Ischemic Stroke Patients
Recanalization achieved with endovascular (EV) procedures is not always accompanied by clinical improvement. Most EV procedures are time consuming implying a delayed reperfusion of the penumbra despite the capacity of earlier microcatheter access to the ischemic tissue beyond the clot. We aim to explore safety and feasibility of microcatheter driven oxygenated blood perfusion (MOB) beyond the clot. Methods We studied consecutive stroke patients undergoing EV procedures. Timing of all procedural steps was recorded. We then explored safety and feasibility of repeated MOB with femoral artery blood. MOB was injected beyond the occlusion every time the clot was crossed. Pre and post occlusion flow was continuously monitored with transcranial Doppler (TCD). Results We studied 60 patients(age 70±11; NIHSS:20 IR:18-21), MCA occlusion(63.3%), ICA(36.6%). Time from symptom onset(TFSO) to arterial puncture was 193±77min. Clot was successfully crossed with microcatheter in 46 patients (76,6%) in mean TFSO: 228±82min. Recanalization was achieved in 44 cases(73.2%) in a mean TFSO of 328±144 min. The mean time from first clot-crossing to recanalization was 122±59 min. Repeated manual injections of MOB were performed in 17 patients. Patients with/without MOB presented similar baseline characteristics. Median number of MOB injections was 2(IR:2-3) and the median injected blood volume was 40ml (IR:27.5-50). Mean time from first MOB to arterial recanalization was 136±86 min. During MOB a non-pulsatile flow appeared in previously non visible distal branches on TCD. Rate of symptomatic hemorrhage was similar: MOB 5.9% Vs 4.7%(p=0.93). Recanalization (MOB 87.5% Vs 67.5%;p=0.06) was achieved in a similar TFSO (MOB: 350±49 min. Vs 316±177; p=0.066) Conclusions MOB perfusion beyond the occluding clot seems a safe procedure feasible in more than 3/4 of stroke patients undergoing EV procedures. MOB may intermittently advance reperfusion up to 2 hours before final recanalization is achieved.
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M.Marc, Hospital Vall d'Hebron, Barcelona, SPAIN
M.Rubiera   Hospital Vall d'Hebron   Barcelona  SPAIN
J.PAGOLA  Hospital Vall d'Hebron   Barcelona  SPAIN
P.Meler  Hospital Vall d'Hebron   Barcelona  SPAIN
A.Flores  Hospital Vall d'Hebron  Barcelona  SPAIN
D.Rodriguez  Hospital Vall d'Hebron   Barcelona  SPAIN
J.Alvarez-Sabin  Hospital Vall d'Hebron   Barcelona  SPAIN
C.Molina  Hospital Vall d'Hebron   Barcelona  SPAIN
         
         
         
         
         
         
         

Topic: Stroke prevention
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Salon Azur

 
Lack of use of antithrombotic treatment in primary and secondary stroke prevention.
Introduction: Besides appropiate control of vascular risk factors and life-style changes, current clinical guidelines recommend antithrombotic therapy in selected cases in primary and secondary stroke prevention. We aimed to retrospectively study whether or not these guidelines were correctly followed before the event regarding antithrombotic treatment in a cohort on consecutive acute ischemic stroke patients. Methods: Medical records of 530 consecutive acute stroke patients were reviewed to assess the presence of vascular risk factors, previous established vascular diseases and treatments prior to the stroke. Risk stratification in patients with no previous vascular diseases was stablished according to the SCORE, REGICOR and Framingham-D’Agostino systems. Results: 338 patients had full available data for the study. Although 142 (42%) of them had already history of vascular diseases (29% were previous stroke), 22% were not taking any antithrombotic treatment as secondary prevention. Among patients without history of vascular diseases, 27% were considered as high-risk patients according to the risk classification systems and the majority of them (77%) were not taking antithrombotic treatment. Overall, 22.7% of our patients did not receive any antithrombotic treatment although it was recommended. Differences in risk according to the stratification system used and the factors related with the non-adherence to antithrombotic treatments will be discussed. Conclusions: A significant amount of stroke patients were not taking antithrombotic treatment according to the current guidelines in stroke prevention. An effort should be made for the correct implementation of the recommendations to prevent stroke.
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P.Delgado, Neurovascular Research Laboratory. Research Institute Vall Hebron., Barcelona, SPAIN
D.Giralt   Neurovascular Research Laboratory. Research Institute Vall Hebron.  Barcelona  SPAIN
CJarca  Neurovascular Research Laboratory. Research Institute Vall Hebron.  Barcelona  SPAIN
M.Quintana  Neurovascular Research Laboratory. Research Institute Vall Hebron.  Barcelona  SPAIN
A.Flores  Neurology Department. Vall Hebron Hospital.  Barcelona  SPAIN
J.Dura  Neurology Department. Vall Hebron Hospital.  Barcelona  SPAIN
J.Montaner  Neurovascular Research Laboratory. Neurology Department. Vall Hebron Hospital.  Barcelona  SPAIN
         
         
         
         
         
         
         
         

Topic: Acute stroke: clinical patterns and practice
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Palau Level I

 
Posterior cerebral artery infarcts: clinical study of 232 patients
Background: Clinical features, etiology and prognosis of patients with ischaemic stroke caused by infarction in the territory of the posterior cerebral artery (PCA) have not been studied as extensively as in other vascular territories. This single centre, retrospective study was conducted with the following objectives: a) to describe the clinical characteristics, etiology and short-term outcome of stroke patients with PCA infarction as compared with that of patients with ischaemic stroke due to middle cerebral artery (MCA) and anterior cerebral artery (ACA) infarctions, and b) to identify predictors of PCA stroke. Methods: A total of 232 patients with PCA stroke were included in the “Sagrat Cor Hospital of Barcelona Stroke Registry” during a 19-year period (1986–2004). The characteristics of these 232 patients with PCA stroke were compared with those of the 1,355 patients with MCA infarctions and 51 patients with ACA infarctions included in the registry. Results: Infarctions of the PCA accounted for 6.8% of all cases of stroke (n = 3808) and 9.6% of cerebral infarctions (n = 2704). Stroke subtypes included lacunar infarct in 34.5% of cases, atherothrombotic in 29.3%, cardioembolic in 21.6%, infarct of unknown cause in 8.6%, and infarction of unusual aetiology in 6%. In-hospital mortality was 3.9% (n = 9). Symptom-free at hospital discharge was documented in 45 patients (19.4%). Hemianopia (odds ratio [OR] = 6.43), lacunar etiology (OR = 2.18), symptom-free at discharge (OR = 1.92), limb weakness (OR = 0.10), speech disorders (OR = 0.33), and cardioembolism (OR=0.65) were independent variables of PCA stroke in comparison with MCA infarction, whereas sensory deficit (OR = 2.36), limb weakness (OR = 0.11) and cardioembolism as stroke mechanism (OR = 0.43) were independent variables of PCA stroke in comparison with ACA infarction. Conclusion: Lacunar stroke is the main subtype of brain infarction in the territory of the PCA. Several clinical features are more frequent in stroke patients with PCA infarction than in patients with ischaemic
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A.Arboix, Cerebrovascular Division. Sagrat Cor Hospital, Barcelona, SPAIN
G.Arbe   Cerebrovascular Division. Sagrat Cor Hospital   Barcelona  SPAIN
L.Garcia-Eroles  Cerebrovascular Division. Sagrat Cor Hospital   Barcelona  SPAIN
M. Oliveres  Cerebrovascular Division. Sagrat Cor Hospital   Barcelona  SPAIN
E.Comes  Cerebrovascular Division. Sagrat Cor Hospital  Barcelona  SPAIN
M.Balcells  Cerebrovascular Division. Sagrat Cor Hospital   Barcelona  SPAIN
M.Grau-Olivares  Cerebrovascular Division. Sagrat Cor Hospital   Barcelona  SPAIN
J. Massons  Cerebrovascular Division. Sagrat Cor Hospital   Barcelona  SPAIN
          SPAIN
         
         
         
         
         
         

Topic: Stroke prognosis
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Palau Level I Foyer

 
Efficacy and hemorrhagic side effects of 0.6mg/kg of intravenous rt-PA treatment for the aged patients.
<Background> Since the approval of 0.6mg/kg of intravenous (i.v.) rt-PA treatment for acute ischemic stroke in October, 2005 in Japan, more than 8000 patients were treated. However, this therapy did not widely applied for the aged patients, particularly aged at 75 years old or more because of the Japanese guidelines of which statements were mainly based on the clinical trials with rt-PA dosage of 0.9mg/kg. We analyzed the efficacy and hemorrhagic side effects of this lower dosage on the aged patients. <Methods> We analyzed 65 consecutive patients with ischemic stroke treated with 0.6mg/kg of i.v. rt-PA from October, 2005 to September, 2009 (mean 71.7+/-13.4 years old) in the single hospital. Patients were divided into two groups; patients aged at 75 years old or more (= G group, n=31) and patients aged under 75 years old (=L group, n=34). Hemorrhagic transformation was evaluated by CT/MRI during 14 days after treatment by three observers blinded the age of the patients. Stroke subtype, co morbidity, National Institutes of Health Stroke Scale (NIHSS) score, and modified Rankin Scale (mRS) were recorded. <Results> Frequency of Stroke subtypes were similar between the two groups. Frequency of hypertension was higher in G group than L group, 80.6 and 47.1%, respectively. Frequency of diabetes, dyslipidemia, and atrial fibrillation were similar between the two groups. Free radical scavenger, edarabone, was administrated in 83.9% in G group and 91.2% in L group. NIHSS score before rt-PA therapy in G and L groups were 12.1 and 13.4, respectively, 9.5 and 9.8 at 24 hours after treatment, 6.5 and 7.3 at Day-7, 5.7 and 4.9 at discharge. Patients with mRS0-1 were 6(19.4%) and 9(26.5%) at discharge, 8(25.8%) and 9(26.5%) at 3 months. Frequency of intracranial hemorrhage (ICH) within 36 hours after the rt-PA injection was 29.0 and 29.4%, and symptomatic ICH was 3.2 and 5.9%, respectively. <Conclusion> There was no significant difference in the number of symptomatic ICH, in the improvement of NIHSS score, and in the mRS score between the two groups. Effectiveness of i.v. rt-PA with the dosage of 0.6mg/kg in the aged patients (≥75 years old) should not be underestimated.
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H.Akiyama, Department of Neurology, St. Marianna University School of Medicine., Kawasaki, JAPAN
T.Kato   Department of Neurology, St. Marianna University School of Medicine.  Kawasaki 
Y.Hasegawa  Department of Neurology, St. Marianna University School of Medicine.  Kawasaki 
         
         
         
         
         
         
         
         
         
         
         
         

Topic: Small vessel stroke and white matter disease
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Palau Level I Foyer

 
Direct thrombus imaging in lacunar infarction using ultra high field magnetic resonance imaging: rationale and design of the 7-MILES study
Background In cerebral small vessel disease (SVD), small ischemic lesions, i.e. lacunar infarcts (LI’s), are located in the supplying areas of the small perforating arteries in the basal ganglia or the deep white matter. It is unclear whether LI’s are caused by microthrombi, or whether they are caused by obstruction due to other processes, such as arteriolosclerosis or lipohyalinosis. The aim of this explorative diagnostic study is to visualize the possible presence of microthrombi in the small perforating arteries in the acute phase of LI using ultra high field 7T MRI. Methods Twenty patients with acute LI will be included within 96 hours after onset of symptoms. After 6 months, a follow-up scan is performed to differentiate acute from permanent changes. In addition, a healthy control group is scanned. The MRI-protocol includes T1, T2, and diffusion-weighted images (DWI), 3D FLAIR, and 3D Time of flight (TOF) combined with multiple echo gradient susceptibility weighted imaging (SWI). Due to the very short T2-relaxation time of iron-containing thrombus at 7T, thrombus appears dark in the TOF-scan, while flowing blood is bright. This allows direct visualization of microthombi in the small perforating arteries. Combining these images with the DWI and FLAIR images allows for precise localization of the thrombus in relation to the ischemic lesion. Results Enrolment has started in December 2009. Pilot results of the first 2 patients show hypo-intense lesions close to the ischemic lesions, consistent with iron-containing masses in the arteries. This suggests the presence of microthrombi at the time of the LI. However, SWI phase images have yet to be analysed to exclude calcium as the source of the lesions and follow-up MRI has yet to be performed. Conclusion 7T MRI appears a feasible technique to visualize possible microthrombi in the small perforating arteries in the acute phase of LI. This study could provide further insights in the underlying pathofysiological processes in SVD.
Graphic: http://www.esc-archive.eu/barcelona10/graphics_barcelona/aid_1052.html
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R.P.Kloppenborg, Academic Medical Center, Amsterdam, THE NETHERLANDS
J.J.M.Zwanenburg   Image Sciences Centre  Utrecht  THE NETHERLANDS
M.M. Conijn  Image Sciences Institute, University Medical Centre  Utrecht  THE NETHERLANDS
W. P. TH. M. Mali  University Medical Centre  Utrecht  THE NETHERLANDS
M.I.Geerlings  Julius Center, University Medical Centre  Utrecht  THE NETHERLANDS
P.R.Luijten  Image Sciences Institute, University Medical Centre  Utrecht  THE NETHERLANDS
L.J.Kappelle  University Medical Centre  Utrecht  THE NETHERLANDS
P.J.Nederkoorn  Academic Medical Center  Amsterdam  THE NETHERLANDS
         
         
         
         
         
         
         

Topic: Etiology of stroke and risk factors
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Exhibition Hall

 
Risk factors for stroke differ in the very old.
Background: Risk factor modification is an important strategy in patients who suffered a stroke. It has been shown that efficacy of preventive treatment (carotid entarterectomy, statins, antihypertensives etc.) can be expected at any age, however, risk factor in the very old are not well known. The aim of the present study was to compare the distribution of risk factors in + 80 year old patients and younger patients with ischemic stroke. Methods: Data was prospectively collected from consecutive patient dischargees with a diagnosis of ischemic stroke from 1 st February 1998 to October 2001 at a large Copenhagen community hospital. Recognized risk factors, demographical factors, stroke characteristics and outcome were recorded. The analysis was based on 757 admissions with CT-verified ischemic stroke, 279 of whom were 80 years or older (36,9 %). Results: The very old stroke patients are predominantly female( 65 % women 42 % women in the younger group (p<0,001)). Atrial fibrillation was present in 39,1 % of the very old vs. 23,0 % in younger patients, p<0.001. Diabetes type 1 in 10,6 % vs. 18,0 % in younger patients, p=0.009. Hyperhomocysteinemia was present in 32,9 % of the very old vs. 24,0 %, p=0.017. Hypercholesterolemia in 36,8 % of the very old vs. 47,3 %, p=0.012. A history of angina or myocardial infarction in 32,2 % vs. 24,9 % p=0.035, of the very old 14,3 % were smokers vs. 44,8 % p<0.001. Conclusions: Risk factors vary with age in patients after stroke. This analysis reveals important distinctions of risk factors in the very old stroke patient. More research is needed to gain a better understanding of these differences and design age appropriate prevention strategies.
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L.M.Christensen, Copenhagen University Hospital, Bispebjerg , Copenhagen, DENMARK
D.W.Krieger   Copenhagen University Hospital, Bispebjerg   Copenhagen  DENMARK
H.Christensen  Copenhagen University Hospital, Bispebjerg   Copenhagen   DENMARK
         
         
         
         
         
         
         
         
         
         
         
         

Topic: Acute stroke: current treatment
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Palau Level I

 
Hemorrhagic Transformation Associated with Intravenous Low-Dose Recombinant Tissue Plasminogen Activator Therapy in Japanese Patients from the SAMURAI rt-PA Registry
[Background]Routine use of low-dose (0.6mg/kg alteplase) intravenous (iv) recombinant tissue plasminogen activator (rt-PA) was approved in Japan in year 2005 for the patients suffering from cerebral ischemia within three hours of stroke onset. We investigated hemorrhagic transformation (HT) associated with low-dose iv rt-PA therapy using the SAMURAI rt-PA Registry, a retrospective, multicenter, observational study. [Methods]Consecutive stroke patients, who were treated with iv rt-PA therapy in 10 Japanese stroke centers, were included. Clinical data and information on HT within 36-hour after iv rt-PA therapy were collected. Severity of HT was determined according to neuroradiological findings. [Results]A total of 600 patients (377 men, 223 women; 72 ± 12 years old) were studied. HT was detected in 119 patients (19.8%) of entire cases (HI1 and HI2 in 10.8% and PH1 and PH2 in 8.5%). Symptomatic intracerebral hemorrhage within 36 hours after iv rt-PA therapy with a ≧1-point increase from the baseline National Institutes of Health Stroke Scale (NIHSS) score developed in 23 patients (3.8%). Cardiogenic embolism was related to any HT (p<0.05), while other types of ischemic stroke were not. Lower Alberta Stroke Program Early CT Score on MRI-DWI were related with any HT (p<0.01). After multivariate adjustment, presence of iv antihypertensive therapy immediately before iv rt-PA therapy (OR 2.1, 95% CI 1.3-3.4), presence of heart diseases (OR 1.9, 95% CI 1.2-3.3), usage of more than two types of oral antiplatelet agents just before iv rt-PA therapy (OR 2.5, 95% CI 1.1-5.7) were also independently associated with any HT. Presence of any HT was related with poor functional outcome (NIHSS at 24-hour and modified Rankin Scale at 3-month) (p<0.01). [Conclusion]This retrospective multi-center observational study in Japan, investigating HT after iv rt-PA therapy in Japanese population, revealed various factors relating with HT after the low-dose iv rt-PA therapy.
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K.Nishiyama, Department of Neurology and Stroke Center, Kyorin University, Tokyo, JAPAN
Y.Shiokawa   Department of Neurosurgery and Stroke Center, Kyorin University  Tokyo  JAPAN
S.Yamada  Department of Neurology and Stroke Center, Kyorin University  Tokyo  JAPAN
M.Koga  Cerebrovascular Division, Department of Medicine, National Cardiovascular Center  Suita  JAPAN
H.Kurita  Department of Neurosurgery and Stroke Center, Kyorin University  Tokyo  JAPAN
J.Nakagawara  Department of Neurosurgery and Stroke Center, Nakamura Memorial Hospital  Sapporo  JAPAN
E.Furui  Department of Stroke Neurology, Kohnan Hospital  Sendai  JAPAN
K.Kimura  Department of Stroke Medicine, Kawasaki Medical School  Kurashiki  JAPAN
H.Yamagami  Department of Neurology, Stroke Center, Kobe City General Hospital  Kobe  JAPAN
Y.Okada  Department of Cerebrovascular Disease, National Hospital Organization Kyushu Medical Center  Fukuoka  JAPAN
Y.Hasegawa  Department of Neurology, St Marianna University School of Medicine  Kawasaki  JAPAN
K.Kario  Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine  Shimotsuke, Tochigi  JAPAN
S.Okuda  Department of Neurology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan  Nagoya  JAPAN
M.Naganuma  Cerebrovascular Division, Department of Medicine, National Cardiovascular Center  Suita  JAPAN
K.Toyoda  Cerebrovascular Division, Department of Medicine, National Cardiovascular Center  Suita  JAPAN

Topic: Behavioral disorders and post-stroke dementia
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Palau Level I Foyer

 
Reciprocal impact of depression on cognition and cognition profile in first ever subactute infarction
Background Depression and cognitive dysfunctioning are common after stroke and are independent predictors of recovery. The relations between depression and cognition have been reported in animal models and in other diseases. Their interaction has not yet been studied within the first weeks after stroke. We studied the reciprocal impact of depression on cognition out of the context of vascular cognitive impairment. Methods We prospectively included patients presenting within 1 month after first ever infarction assessed on MRI. Were excluded those with a MMSE < 23 or with any other condition preventing them to achieve a comprehensive neuropsychological battery exploring instrumental functions, memory, executive functions and working memory. Depression was assessed with the Beck depression inventory (BDI). Results We included 207 patients (127 males), with a mean age of 48.5 years (16.4 SD), median 12 days after stroke. Median BDI was 6, 28.6% (95%IC 22.6-35.3) were depressed (BDI>9). Median MMSE was 30 and 89% (95%IC 84-93%) had a cognitive dysfunctioning in 1 test at least. With ordinal logistic regression, each point increase of BDI carried an odd of 1.1 (95%CI 1.04-1.19) of changing to a worse category of cognition. After correction for multiple comparisons, all the cognitive domains were correlated to depression. Using multivariate negative binomial regression, the executive functions test tower of Hanoi (p=0.001) and the working memory test CANTAB (p=0.009) were the best descriptors of the depression – cognition relation, adjusted for demographic and stroke characteristics. Brain atrophy or leukoaraïosis had no impact on depression and cognition profile. Conclusion The rate of depression in our population was in the range of post stroke depression studies. Within the very first weeks after stroke, we observed a reciprocal interaction between depression and cognition. The executive functions and working memory tests were the best descriptors of this interaction.
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M.Hommel, 1. INSERM CIC 003; Université Joseph Fourier , Grenoble, FRANCE
L .Carey   2. Division of Neurorehabilitation and Recovery, National Stroke Research Institute  Heidelberg Heights, Melbourne  AUSTRALIA
A.Jaillard  3. INSERM IFR 1; University Hospital   Grenoble  FRANCE
         
         
         
         
         
         
         
         
         
         
         
         

Topic: Acute stroke: current treatment
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Palau Level I

 
Unexplained Stroke and anticoagulation in not so obvious (questionable) paroxysmal atrial fibrillation (PAF)
Introduction: Acute stroke patients’ particularly older people, who have well documented atrial fibrillation in ECG, are anticoagulated according to established guidelines. However, not infrequently (about 25% in our estimate in acute stroke unit setting), initial ECG would record sinus rhythm, and paroxysmal atrial fibrillation (PAF) is only demonstrated on repeat ECGs or 24-hour tape (Holter monitoring) subsequently. Cardiologists, very occasionally, would come across these patients, and vascular neurologists (stroke specialist) have only limited exposure with rhythm problem in the elderly. However, stroke physicians in UK are mostly general physician (internist) with a special interest in stroke medicine. Methods: The definition of PAF is not always clear cut in this setting. 12-lead ECG’s documenting PAF or 24 hr tape recording at least one (often multiple) episode of PAF lasting for ≥ 30 seconds is currently considered as acceptable evidence for PAF. However, there are many instances when 24 hr tape would record only a few beats of irregular supraventricular rhythm (SVR) which may be multiple, often associated with sinus node disease (brady or tachyarrhythmia, pause etc) and may not be symptomatic (palpitations or light-headedness). Results: The empirical criteria that we have been following in our institution are as follows: a. those with ≥ 5 irregular beats of SVR particularly when they are multiple and associated with several, small, cortical infarcts on CT-head, a decision is taken for anticoagulation; b. those with ≤ 4 irregular SVR particularly if they are single, they are simply observed or a 24 hr tape is repeated at a later date. Conclusion: Patients in category b, who would be in standard treatment including anti-platelet agents, did not have embolic stroke after one year follow-up. It would be a fitting achievement, if this abstract generates enough interest for an appropriate randomized control trial (RCT) to test the validity of the above criteria.
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M.MAMUN, Medway NHS Foundation Trust, Gillingham, UNITED KINGDOM
          
         
         
         
         
         
         
         
         
         
         
         
         
         

Topic: Stroke prevention
Oral Session :   
Poster Session:  
Date: Thursday 27 May 2010
Time: 11:00 - 11:10
Room: A&B

4
Cognitive effects of carotid endarterectomy or stenting and their relation with new cerebral ischaemic lesions: a randomised comparison
Background New ischaemic lesions on diffusion-weighted imaging (DWI) – mostly without focal neurological deficit - are found about three times as often after carotid artery stenting (CAS) than after endarterectomy (CEA), and may be associated with cognitive decline. We compared the effects of CEA and CAS on cognition, and related this to the occurrence of new ischaemia. Methods The present study is a substudy of the International Carotid Stenting Study (ICSS; ISRCTN25337470). Patients were subjected to a detailed neuropsychological examination, before the intervention and at 6 months follow-up. Ischaemic damage was assessed on DWI before and within two days after revascularization. Cognitive data were standardised into Z scores. The primary outcome measure was the change in composite cognitive function Z score between baseline and follow-up. The primary outcome measure was compared between both treatment groups, as well as between patients with or without new ischaemic lesions. Results Of the 140 included patients, 81% completed follow-up neuropsychological testing (55 CEA, 58 CAS). The difference in composite Z score between baseline and follow-up was -0.18 ± 0.49 in the CEA group and -0.21 ± 0.40 SD in the CAS group (difference between groups, 0.03; 95% CI, -0.14 to 0.21). New ischaemic lesions on DWI were found in 7 (23%) of 30 patients after CEA and in 17 (50%) of 34 patients after CAS (P = 0.025). In both treatment groups combined, the difference in composite Z score was -0.22 ± 0.39 SD in patients without and -0.13 ± 0.56 SD in patients with new lesions (difference between groups, -0.09; 95% CI, -0.37 to 0.18). Conclusion In patients with symptomatic carotid artery stenosis, there is no significant change in global cognitive function at 6 months after revascularisation by either CAS or CEA. The substantially higher rate of new ischaemic lesions on DWI after CAS than after CEA has no effect on composite cognitive function. Funding: Netherlands Heart Foundation (2005B027)
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A.Altinbas, University Medical Center Utrecht and Rudolf Magnus Institute of Neurscience, Utrecht, THE NETHERLANDS
L.J.Kappelle   University Medical Center Utrecht and Rudolf Magnus Institute of Neurscience  Utrecht  THE NETHERLANDS
M.J.van Zandvoort  University Medical Center Utrecht  Utrecht  THE NETHERLANDS
M.M.Brown  National Hospital for Neurology and Neurosurgery, Queen Square  London  UNITED KINGDOM
L.H.Bonati  National Hospital for Neurology and Neurosurgery, Queen Square,  London  UNITED KINGDOM
A.Algra  University Medical Center Utrecht  Utrecht  THE NETHERLANDS
F.L.Moll  University Medical Center Utrecht  Utrecht  THE NETHERLANDS
W.P.Th.M.Mali  University Medical Center Utrecht  Utrecht  THE NETHERLANDS
P.J.Nederkoorn  Academic Medical Center Amsterdam  Amsterdam  THE NETHERLANDS
L.Jongen  University Medical Center Utrecht  Utrecht  THE NETHERLANDS
H.B.van der Worp  University Medical Center Utrecht and Rudolf Magnus Institute of Neurscience  Utrecht  THE NETHERLANDS
         
         
         
         

Topic: Management and economics
Oral Session :   
Poster Session: Poster Session Red
Date: Wednesday 26 May 2010
Time: 12:30 - 14:00
Room: Palau Level I

 
Validity of routinely collected hospital discharge diagnostic data for stroke: a population-based study
Background: Planning of clinical services for stroke, studies of trends in disease incidence and screening for outcome events in some clinical trials are usually based on Hospital Episode Statistics (HES). However, the validity of these data is uncertain, particularly for identifying stroke subtypes. The aim of this study was to validate routinely collected ICD-10 HES diagnostic codes for hospitalised patients with stroke. Methods: The Oxford Vascular Study (OXVASC) is a prospective population-based study of all incident and recurrent strokes in a population of 90,542 in Oxfordshire, UK. Multiple sources of case-ascertainment were used, including daily identification and assessment of all potentially eligible hospital admissions. All hospitalised patients included in OXVASC with a diagnosis of stroke were included in this study. Primary and secondary ICD-10 diagnosis fields were matched with the relevant hospital admissions identified in OXVASC. Results: Of 576 hospitalised strokes identified in the first five years of OXVASC (2002-2007), 449 (78%) had a hospital discharge diagnostic code for cerebrovascular disease (ICD-10 I60-I69). A further 25 (4%) had ICD-10 codes for TIA and related syndromes (ICD-10 G45-G46). There was no mention of cerebrovascular disease in 102 (18%) cases. Of the stroke subtypes classified by OXVASC, ICD-10 codes agreed for primary intracerebral haemorrhage 38/71 (54%) cases, subarachnoid haemorrhage for 21/33 (64%) cases and ischaemic stroke for 147/472 (31%) cases. 186 (32%) cases were given a code for stoke, not specified as haemorrhage or infarction (ICD-10 I64). Conclusion: Screening of hospital discharge coding misses about a quarter of patients hospitalised with stroke, and provides reliable data in about half of cases.
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L.E.Silver, Stroke Prevention Research Unit, University of Oxford, Oxford, UNITED KINGDOM
P.M.Rothwell   Stroke Prevention Research Unit, University of Oxford  Oxford  UNITED KINGDOM
         
         
         
         
         
         
         
         
         
         
         
         
         

Topic: Etiology of stroke and risk factors
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Exhibition Hall

 
The Clinical Importance of Sleep Apnea Associated with Acute Ischemic Stroke during Sleep or on Awakening
Background: The association of acute ischemic stroke with sleep apnea has been suggested. However, the studies of the clinical implication of acute ischemic stroke developing during sleep or awakening were limited. We performed this study to identify the relation between sleep apnea and the onset of acute ischemic stroke during sleep or on awakening. Methods: One hundred sixteen patients with acute ischemic stroke or transient ischemic attack were consecutively enrolled in the present study. Acute ischemic stroke occurring during sleep or on awakening was defined as sleep-related stroke. SA was evaluated within 48 hours after the onset of stroke or TIA using a portable screening device, which allowed automated analysis of apnea, hypopnea, and snoring. Clinical and sleep-related variables, including body mass index (BMI), cardiovascular risk factors, Epworth sleep scale, Stanford sleepiness scale, Berlin questionnaire, stroke severity, and disability, were assessed. Results: The sleep-related stroke was found in 27 patients (23%). Patients with sleep-related stroke had significantly higher mean apnea-hypopnea index (AHI) compared with those without sleep-related stroke (20.8 vs 13.3, p=0.02). The severe SA (AHI≥20) was more commonly found in patients with sleep-related stroke than in those without (48.1% vs 19.1%, p<0.01) No other variables including BMI, cardiovascular risk factors, sleep-related scales, and stroke severity and disability, were associated with sleep-related stroke onset. Conclusion: Acute ischemic stroke during sleep or on awakening is associated with severe sleep apnea, and the screening the presence of sleep apnea early in acute ischemic stroke should be performed.
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S.Yu , Department of Neurology Korea University College of Medicine, Seoul, SOUTH KOREA
B.Joo   Department of Neurology Korea University College of Medicine  Seoul  SOUTH KOREA
M.Song  Department of Neurology SM Christianity Hospital  Pohang  SOUTH KOREA
K.Jung  Department of Neurology Korea University College of Medicine  Seoul  SOUTH KOREA
K.Park  Department of Neurology Korea University College of Medicine  Seoul  SOUTH KOREA
         
         
         
         
         
         
         
         
         
         

Topic: Acute stroke: new treatment concepts
Oral Session :   
Poster Session: Poster Session Red
Date: Wednesday 26 May 2010
Time: 12:30 - 14:00
Room: Palau Level I

 
Granulocyte colony-stimulating factor for acute ischemic stroke: a randomized controlled trial of safety and efficacy (STEMTHER)
Background. G-CSF as a neuroprotector and a stimulator of autologous bone marrow stem cell release can in theory improve the outcome of acute ischemic stroke. We sought to examine the safety and efficacy of using G-CSF (Leukostim) to treat acute ischemic stroke. Methods. We conducted a single-centre, unmasked, randomized controlled trial STEMTHER (NCT00901381) involving twenty adult patients with unilateral ischemic stroke in the carotid region who presented within forty-eight hours of onset. The experimental group (n=10) received subcutaneous G-CSF injections (10 mkg/kg per day) combined with conventional therapy for five days. The primary outcome was the degree of dependence in the daily activities measured with the modified Rankin Scale obtained at day 180. The safety was evaluated by frequency of hemorrhagic transformation of infarction and serious adverse events. Results. All of the patients in the experimental group completed the five-day course of treatment. Four of them (three – in the control and one – in the experimental group) were lost to follow-up. Analysis of the therapy efficacy included data on patients who had follow-up examination. Analysis of the therapy safety included data on all patients. The experimental and control groups showed no statistical difference in neurological impairment, degree of disability and dependence in the daily activities at day 180. Conclusion. Acute ischemic stroke therapy with G-CSF (10 mkg/kg per day) for five days is safe, but does not improve the outcome at 180 days after stroke onset. Further investigation of high-dose G-CSF efficacy is needed.
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A.M.Alasheev, Clinical Institute of the Brain, Ekaterinburg, RUSSIAN FEDERATION
A.A.Belkin   Clinical Institute of the Brain  Ekaterinburg  RUSSIAN FEDERATION
I.N.Leiderman  Clinical Institute of the Brain  Ekaterinburg  RUSSIAN FEDERATION
R.A.Ivanov  Institute of Medical Cells Technologies  Ekaterinburg  RUSSIAN FEDERATION
T.M.Isakova  City Clinical Hospital #40  Ekaterinburg  RUSSIAN FEDERATION
E.N.Rudnik  City Clinical Hospital #40  Ekaterinburg  RUSSIAN FEDERATION
D.YRogov  Institute of Medical Cells Technologies  Ekaterinburg  RUSSIAN FEDERATION
L.G.Fechina  Institute of Medical Cells Technologies  Ekaterinburg  RUSSIAN FEDERATION
A.M.Popov  Institute of Medical Cells Technologies  Ekaterinburg  RUSSIAN FEDERATION
T.Y.Verzhbitskaya  Institute of Medical Cells Technologies  Ekaterinburg  RUSSIAN FEDERATION
L.I.Savelyev  Institute of Medical Cells Technologies  Ekaterinburg  RUSSIAN FEDERATION
S.L.Leontiev  Institute of Medical Cells Technologies  Ekaterinburg  RUSSIAN FEDERATION
S.I.Spector  Institute of Medical Cells Technologies  Ekaterinburg  RUSSIAN FEDERATION
         
         

Topic: Acute stroke: emergency management, stroke units and complications
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Palau Level I

 
Avoiding in-hospital delays in early time windows: a standardized stroke thrombolysis workflow in a neurological emergency room
Background Intravenous thrombolysis for acute stroke is the more efficient the earlier treatment is initiated even within the approved 3 hour time window. In hospital delays account for a significant proportion of avoidable time loss until treatment is initiated. Paradoxically, studies have reported longer door-to-needle times the earlier patients arrive (“3-hour effect”). We hypothesized that a standardized thrombolysis procedure carried out in a specialized neurological emergency room can minimize in hospital delays and erase the “3-hour effect”. Methods Onset-to-door (OTD) and door-to-needle (DTN) times of 246 consecutive thrombolysis patients were analyzed. Patients were treated CT-based within 3 hours by a resident based stroke team within a neurological emergency room. A standardized protocol designed to minimize in hospital delays is applied. Correlation of OTD and DTN as well as dependence of DTN from time of treatment (daytime vs. night hours and weekend vs. weekday) were tested. Results Median DTN time was 25 min. DTN did not correlate with OTD time (Pearson r=-0.097; p=0.13) and patients arriving within 90 min from symptom onset showed comparable DTN times to patients arriving within 90-180 min. Neither treatment on weekends nor during night hours led to significant in hospital treatment delays. Conclusion Applying a standardized thrombolysis protocol carried out by specialized stroke team within a neurological emergency room, in hospital delays can be minimized. This allows improvement of door-to-needle times irrespectively of the time to arrival and treatment during off-hours.
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M.Köhrmann, University of Erlangen-Nuremberg; Dept. of Neurology, Erlangen, GERMANY
P.D.Schellinger   University of Erlangen-Nuremberg; Dept. of Neurology  Erlangen  GERMANY
L.Breuer  University of Erlangen-Nuremberg; Dept. of Neurology  Erlangen  GERMANY
M.Dohrn  University of Erlangen-Nuremberg; Dept. of Neurology  Erlangen  GERMANY
C.Blinzler  University of Erlangen-Nuremberg; Dept. of Neurology  Erlangen  GERMANY
S.Schwab  University of Erlangen-Nuremberg; Dept. of Neurology  Erlangen  GERMANY
H.B.Huttner  University of Erlangen-Nuremberg; Dept. of Neurology  Erlangen  GERMANY
         
         
         
         
         
         
         
         

Topic: Behavioral disorders and post-stroke dementia
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Palau Level I Foyer

 
STROKE RELATED DELUSIONAL MISIDENTIFICATION SYNDROME
Introduction Delusional misidentification syndromes (DMS) are rare and are characterised by inability to register the identity of a person. They are disorders iof information processing and well described in schizophrenia, traumatic brain injury and dementia. We present a patient who developed Capgras syndrome after right sided stroke. Case A 63 year old man who is left handed presented to stroke unit within an hour of developing dense left hemiplegia with global dysphasia. He was thrombolysed to good effect being independently mobile within 48 hours. His dysphasia improved gradually and he was able to communicate effectively within 4 weeks. Follow up CT scan of the brain showed infarction of the right basal ganglia complex including the internal and external capsule and in the right pre-central frontal lobe. At sixth week, it became apparent that the patient had difficulty accepting his 30 year old son as his ‘real’ son as he felt that his son has been replaced by an impostor. This belief was of delusional intensity and he also exhibited secondary delusions that his family are part of the scheme. There was no evidence of prosopagnosia clinically but scored 31 on the Benton face recognition test (<37 indicate severe impairment). Overall CAMCOG score was 59/104 (Language 24/30, Memory 11/27, executive function 15/28). He underwent autobiographical memory assessment which showed that his episodic memory was worse than factual memory at all periods of his life. Personal episode assessment using family album of photographs demonstrated that he could correctly identify his son as a six year old but not in recent pictures. Holes in the memory and difficulty in linking episodic memory along with his fixed visual memory of the son as 6 year old resulted in delusion belief of misrepresentation. Extensive cognitive therapy and brief course of mirtazapine, made no difference though the family are coping better. Conclusion DMS is very rare after stroke. Diagnostic work up in our patient demonstrate clear link with poor episodic memory and prosopagnosia. It can be resistant to treatment and family should be involved in therapy.
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R.Durairaj, University Hospital Aintree, Liverpool, UNITED KINGDOM
P.Fitzsimmons   University Hospital Aintree  Liverpool  UNITED KINGDOM
         
         
         
         
         
         
         
         
         
         
         
         
         

Topic: Small vessel stroke and white matter disease
Oral Session :  A
Poster Session:  
Date: Thursday 27 May 2010
Time: 15:50 - 16:00
Room: F

12
Hyperhomocysteinaemia is associated with cerebral small vessel disease in patients with clinically manifest atherosclerosis: the SMART-MR study
Background Homocystein is a known risk factor for lacunar infarction (LI) and white matter lesions (WML), as putative manifestations of cerebral small vessel disease (SVD), but also for atherosclerosis. It is unclear whether homocystein is independently associated with SVD, without confounding by background atherosclerosis. We evaluated the association between homocystein and LI’s and WML in a large cohort of patients with clinically manifest atherosclerosis, in order to examine the effect of homocystein on top of pre-existent atherosclerosis. Methods Within the SMART-MR study, a prospective cohort study of patients with clinically manifest atherosclerosis, we performed a cross-sectional analysis in 1040 patients (mean age 59 ± 10 years, 80% male). WML volume was measured on MRI scans with automated brain segmentation and expressed as a logarithmic transformed percentage of total brain volume. We analyzed the associations between both total plasma homocystein (tHcy) and hyperhomocysteinemia (HHcy, N=121), defined as > 16.3 µmol/L in women and 18.8 µmol/L in men and the total number of LI’s and WML volume. Results Linear regression analyses, adjusted for age, sex, vascular risk factors and renal function, showed that tHcy and HHcy were significantly associated with larger lnWML volumes (B=0.02: 95% CI 0.01 to 0.03, and B=0.42: 95% CI 0.24 to 0.60). An increase of tHCy was associated with an increased risk of LI (OR 1.4, 95% CI 1.08-1.84, per 10 µmol). Adjustment for brain volume or history of cerebrovascular disease did not alter the results. Conclusion In this cohort of patients with clinically manifest atherosclerosis, there was a significant association between homocystein levels and LI and WML, comparable with previous results in population-based studies of healthy people. Our findings suggest an additional effect of homocystein on the development of cerebral SVD on top of pre-existent large vessel atherosclerosis.
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R.P.Kloppenborg, Academic Medical Center, Amsterdam, THE NETHERLANDS
P.J.Nederkoorn   Academic Medical Center  Amsterdam  THE NETHERLANDS
Y.van der Graaf  Julius Center, University Medical Center Utrecht  Utrecht  THE NETHERLANDS
M.I.Geerlings  Julius Center, University Medical Center Utrecht  Utrecht  THE NETHERLANDS
         
         
         
         
         
         
         
         
         
         
         

Topic: Experimental studies
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Salon Azur

 
NON-INVASIVE CEREBROVASCULAR AUTOREGULATION REAL - TIME MONITORING
Aims of the study: to carry out continuous CA monitoring on ICU patients with severe TBI by using invasive ICP and ABP monitors together with non-invasive IBV wave monitor [1,2]. One hour CA monitoring sessions have been carried out on 13 patients (age mean/range 30.5/(18-64)). Data were collected from 87 sessions of simultaneous invasive and non-invasive B wave, respiratory wave and pulse wave monitoring and from 53 sessions of invasive and non-invasive CA monitoring [1, 2]. A mathematical model of CA (Ursino and Magosso, 2001) has been used for simulation of the ABP/ICP and ABP/ IBV wave phase shift frequency dependences in the cases of intact and impaired CA. It has been shown a good agreement between invasive and non-invasive moving correlation coefficient R individual variability during one hour invasive and non-invasive CA monitoring sessions. The correlation between ICP and IBV slow waves exceeded 0.9. Correlation of invasive and non-invasive CA monitoring data also exceeded 0.9 when the amplitudes of intermittent ICP B waves’ was above 3.0 mmHg and the amplitude of ABP slow waves’ was above 5.0 mmHg. The Bland Altman evaluation of invasive and non-invasive CA monitoring data also shows a good agreement (SD = 0.05, p<0.0001). It has been shown for the first time that the phase shift between permanent respiratory waves is statistically significantly different in the cases of intact CA and impaired CA. Mathematical simulation shows that the phase shift between permanent respiratory waves under intact CA and impaired CA conditions is from 26 degree to 73 degree in the range of pial artery reactivity [1.5 s; 10 s] and reactivity of arterioles [1.5 s; 2 s]. Phase shift changes of permanent respiratory ABP and IBV waves permit continuous non-invasive CA monitoring under ICU conditions without unnatural physical or pharmacological stimulations of CA system. 1. A.Ragauskas et al. US Patent application 20060094964. 2. A.Ragauskas et al. US Patent application 20090270734.
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A.Ragauskas, Kaunas University of Technology, Kaunas, LITHUANIA
E.Kalvaitis   Kaunas University of Technology  Kaunas  LITHUANIA
R.Chomskis  Kaunas University of Technology  Kaunas  LITHUANIA
V.Petkus  Kaunas University of Technology  Kaunas  LITHUANIA
A.Kalasauskienė  Lithuanian Academy of Physical Education  Kaunas  LITHUANIA
         
         
         
         
         
         
         
         
         
         

Topic: Acute stroke: emergency management, stroke units and complications
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Palau Level I

 
ENDOVASCULAR TREATMENT OF BASILAR THROMBOSIS: A TIME LIMIT FOR INVASIVE THERAPY.
BACKGROUND: Acute thromboembolic occlusion of the basilar artery accounts for 6% to 10% of large-vessel stroke in humans. Although outcomes continue to be poor, pharmacological and mechanical thrombolysis in endovascular therapy may increase the survival and limit the disability rate. Recanalization of the basilar artery is key to the successful treatment, but treatment as late as 12h hours after symptom onset has been related to high risk of hemorrhagic and unknown outcome and rate of recanalization. METHODS: We review all patients with basilar thrombosis diagnosis and treated by endovascular therapy during last 5 years (2004-2009) at Bellvitge University Hospital. We evaluate epidemiological aspects related to functional outcome and vessel recanalization. RESULTS: At baseline, the mean age was 56+/-14 years and the mean NIHSS score was 23+/-6. Of 23 patients who were analysed 14 were treated with only intraarterial trhombolysis; stent placement was performed in 2 patients and mechanichal thrombolysis in 9 patients. A recanalization to TICI 2 or 3 was achieved in 12 patients (53%). Mean time to onset treatment was 14 hours (4-48 h). There was a significant correlation between complete vessel recanalization and favorable outcome. At hospital discharge, 7 patients (33%) had an NIHSS improvement of >4; and six patients (25%) had an mRS score of <3 at 3 months. Mortality at 7 days was 27% (6 patients), one had developed symptomatic haemorrhage and extravasation of contrast. The all-cause mortality at 3 months was 39 %. Subanalysis of endovascular treatment time demonstrated efficacy when treatment was initiated whitin the first 12h of stroke onset; and bad outcome in the group with >12 h(mRs score>3: 92%). CONCLUSIONS: Complete recanalization by intraarterial thrombolsis, was strongly correlated with certainly good clinical outcome at 3 months, but this benefit appears when select patients with early basilar artery thrombosis (<12h onset of symptoms).
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P.Cardona , Bellvitge University Hospital, Hospitalet de Llobregat, SPAIN
H.Quesada   Bellvitge University Hospital  Hospitalet de Llobregat  SPAIN
A.Escrig  Sant Boi Hospital  Sant Boi  SPAIN
L.Cano  Bellvitge University Hospital  Hospitalet de Llobregat  SPAIN
P.Mora  Bellvitge University Hospital  Hospitalet de Llobregat  SPAIN
R.Cambra  Bellvitge University Hospital  Hospitalet de Llobregat  SPAIN
F. Rubio  Bellvitge University Hospital  HospitaleT de Llobregat  SPAIN
         
         
         
         
         
         
         
         

Topic: Experimental studies
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Salon Azur

 
NON-INVASIVE ABSOLUTE ICP MEASUREMENT TECHNOLOGY VALIDATION: NEUROLOGICAL PATIENTS STUDY
In the clinical study we compared the new absolute ICP (aICP) non-invasive measurement method (1) with invasive aICP measurement method showing that the systematic error of new method is negligible (2). The aICP non-invasive measurement method is based on a two-depth TCD technique for aICP and external absolute pressure aPe comparison. The intracranial segment of the ophthalmic artery (OA) is compressed by aICP. The extracranial segment of OA is compressed by the controlled extracranial pressure aPe. The blood flow parameters in both OA segments are approximately the same in the case of aPe=aICP. Special multichannel two-depth TCD device is used as an indicator of aPe=aICP. The study on healthy volunteers has been performed in supine and upright body positions in order to evaluate the accuracy of new two-depth TCD device and uncertainty of non-invasive aICP meter. The achieved agreement between mean aICP and standard deviation (SD) for the independently studied three groups of healthy volunteers is the evidence that phase contrast MRI method (3,4) and proposed ultrasonic method (1,2) of non-invasive absolute ICP measurement are free from systematic errors and do not need calibration of the system “individual patient - non-invasive aICP meter“. The results of neurological patients’ study showed at first time that it is possible to measure aICP non-invasible with high accuracy ( SD ≤ 2,2 mmHg; CI = 0,95). 1. A.Ragauskas et al. US Patents 5951477 and 7147605, European Patent 1018942. 2. A. Ragauskas et al. Acta Neurochir (2005) Suppl 95:357-361. 3. N. Alperin et al. Acta Neurochir (2005) Suppl 95:177-181. 4. N. Alperin et al. Radiology (2000) 217(3):877-885. This study was supported by UAB “Vittamed technologijos” and EU Structural Fund Project BPD04-ERPF-3.1.7-03-05/0020 and also by FP7 project “BRAINSAFE”.
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A.Ragauskas, Kaunas University of Technology, Kaunas, LITHUANIA
R.Sunokas   Kaunas University of Technology  Kaunas  LITHUANIA
R.Zakelis  Kaunas University of Technology  Kaunas  LITHUANIA
V.Matijosaitis  Kaunas University of Medicine  Kaunas  LITHUANIA
         
         
         
         
         
         
         
         
         
         
         

Topic: Intracerebral/subarachnoid haemorrhage and venous diseases
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Palau Level I Foyer

 
Relevance of very old age in spontaneous acute primary intraventricular haemorrhage
Background: Primary intraventricular hemorrhage, --bleeding in the ventricular system without a discernable parenchymal component--, is very rare. This single centre, retrospective study was conducted to describe the demographic, clinical and prognostic characteristics of patients with primary intraventricular haemorrhage as compared with those of patients with classical subcortical haemorrhage. Methods: Twelve patients with primary intraventricular haemorrhage were included in the “Sagrat Cor Hospital of Barcelona Stroke Registry” during a 19-year period. Data from stroke patients are entered in the stroke registry following a standardized protocol with 161 items regarding demographics, risk factors, clinical features, laboratory and neuroimaging data, complications and outcome. The region of the intraventricular haemorrhage was identified on CT scans and/or MRI studies of the brain. Results: Primary intraventricular haemorrhage accounted for 0.3% of all cases of stroke (n = 3,808) and 3.3% of intracerebral haemorrhage (n = 407). Five patients (41.7%) aged 85 years old or older. Very old age (odds ratio [OR] = 9.89), atrial fibrillation (OR = 8.92), headache (OR = 6.89) and altered consciousness (OR = 4.36) were independent predictors of primary intraventricular haemorrhage. A total of five patients died (in-hospital mortality rate 41.7%). Patients older than 85 years as compared with those younger than 85 years were more frequently females (100% vs 28.6%) and showed higher in-hospital mortality rate (60% vs 28.6%). Conclusions: A total of 3.3% of patients with acute intracerebral haemorrhage had a primary intraventricular haemorrhage. This is a severe clinical condition with an in-hospital mortality rate of 41.7%. Age (85 years or older) was the most important predictor of primary intraventricular haemorrhage.
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A.Arboix, Cerebrovascular Division. Sagrat Cor Hospital, Barcelona, SPAIN
A.Vicens   Cerebrovascular Division. Sagrat Cor Hospital  Barcelona  SPAIN
L.Garcia-Eroles  Cerebrovascular Division. Sagrat Cor Hospital  Barcelona  SPAIN
E.Comes  Cerebrovascular Division. Sagrat Cor Hospital  Barcelona  SPAIN
C. Targa  Cerebrovascular Division. Sagrat Cor Hospital  Barcelona  SPAIN
M.Balcells  Cerebrovascular Division. Sagrat Cor Hospital  Barcelona  SPAIN
M.Grau-Olivares  Cerebrovascular Division. Sagrat Cor Hospital  Barcelona  SPAIN
J.Massons  Cerebrovascular Division. Sagrat Cor Hospital  Barcelona  SPAIN
         
         
         
         
         
         
         

Topic: Acute stroke: new treatment concepts
Oral Session :   
Poster Session: Poster Session Red
Date: Wednesday 26 May 2010
Time: 12:30 - 14:00
Room: Palau Level I

 
Targeting small vessel knock signals (SVK) using Transcranial Doppler ultrasonography: a potential new ischaemic stroke treatment
Background “Small vessel knock”(SVK) signals are asymmetric high intensity signals found at the baseline of Transcranial doppler ultrasonography(TCD) spectra.1 They form part of a wider spectrum of knock signals found in stroke which include high intensity wall movement and emboli signals.2 SVK signals appear to represent the ultrasound signal from all sizes of occluded artery3 and are commonly found in association with minimal flow signals (TIBI 1). “SVK-like” signals have also been reproduced in vitro at the site of branch occlusion and are likely to result from red cell movement into and out of an occluded branch.4 However, both pathological SVK and physiological wall movement are found at the beginning and end of systole and SVK signals disappear when a TCD filter of >100Hz is used. 3 In order to allow the development of SVK targeting as a new stroke therapy pathological SVK signals need to be distinguished from physiological knock signals. Here the features that distinguish SVK from physiological knock will be presented including the important changes that occur to SVK associated with clinical recovery Methods Diagnostic power 2 MHz TCD (DWL Compumedics Doppler box) was performed on all cases targeting SVK in relevant arterial territories and depth. Results The following will be shown: Examples of SVK in different sizes of arterial occlusion; comparing SVK with wall movement and emboli; the effect of >100 Hz filtration; changes to SVK signals during insonation associated with clinical recovery; algorithm for SVK detection; video evidence of SVK-targeted recovery Conclusions SVK ultrasound targeting provides a potential new stroke therapy without side effects but requires distinction of physiological knock from SVK. This work illustrates how this can be done supporting future RCTs. 1. Syme PD. ACNR 2004;4(4):28-31 2. Tsivgoulis et al. Stroke. 2009;40:644-647 3. Syme PD. Stroke. 2009;40:e402-e404 4. Chung et al. Stroke.2009;40:648-651
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P.Syme, NHS Borders, University of Edinburgh, Edinburgh, UNITED KINGDOM
          
         
         
         
         
         
         
         
         
         
         
         
         
         

Topic: Rehabilitation and reorganisation after stroke
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Palau Level I Foyer

 
Robot-evaluation of upper limb spasticity after BoNTxA injection,.
Background: Despite the existence of several clinical scales, to obtain an objective measure of spasticity is still a difficult and uncertain task. Also difficult it is to ascertain the effectiveness of botulinum toxin(BoNTxA) on the upper limb after stroke. The ability to quantify subtle but potentially important changes in movement characteristics with robot device is a useful adjunct to more clinically oriented assessment procedures. In our study, the use of the InMotion2 robot enables the performance of repeated specific tasks and provides innovative measures to assess the changes in spasticity after BoNTxA. Methods: 12 children with spastic hemiplaegia post ischemic stroke, aged between 7 and 14, were recruited.The InMotion2 robot is equipped with sensitive-motor feedback and enables the measurement of the trajectory’s features through kinetic and cinematic variables. The measurements were performed before and one month after injection through the following indexes: Point Into Area (PIA), Average Speed, Average Jerk, Shoulder-elbow angular error. Clinical assessment accompaines through conventional scales such as MAS, Melbourne Scale and PROM. Results: Patients had a significantly reduction in spasticity which explains a upper limb function and quality movement improvement measured with the Melbourne Scale (p<0.01). These improvements is consistent with robot-based evaluation results that showed statistically significant changes (p<0.01) following BoNTxA injections. Conclusions: The exercise of the upper limb during the robot evaluation requires the active control of the shoulder, elbow and wrist joints and the trajectory measured by the robot during the exercise is useful to assess both qualitatively and quantitatively the changes induced by the botulinum toxin on pathological synergies. For this reason, we think that the InMotion2 robot can be considered as a valid tool for the assessment of the motor recovery and for rehabilitative training.
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G.Di Rosa, Pediatric Neuro-rehabilitation Division, Hospital Bambino Gesù, Rome, ITALY
F.Frascarelli   Pediatric Neuro-rehabilitation Division,Hospital Bambino Gesù  Rome  ITALY
L.Masia  Robotics Brain and Cognitive Science Department,Italian Institute of Technology  Genova  ITALY
M.Armando  Pediatric Neuro-rehabilitation Division,Hospital Bambino Gesù  Rome  ITALY
M.Petrarca  Pediatric Neuro-rehabilitation Division,Hospital Bambino Gesù  Rome  ITALY
E.Castelli  Pediatric Neuro-rehabilitation Division,Hospital Bambino Gesù  Rome  ITALY
         
         
         
         
         
         
         
         
         

Topic: Rehabilitation and reorganisation after stroke
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Palau Level I Foyer

 
RTMS as inhibitor factor of epileptic activity after stroke
Backround. Near twenty new antiepileptic medicines to XXI centuries were developed. Today the same physical factor applies to epilepsy treatment and attempt to use transcranial magnetic stimulation undertake too. Methods. We have studied particularities of EEG-mapping characteristics changing’s of 112 poststroke patients after complex rehabilitation: with (basic group) and without (control group) methodic of subthreshold 10 Hz rTMS with intensity 1.7 T and stimulus duration 250 msec. In all groups paroxysmal activities were estimated and parameters of frequencies, indexes, regularity of alfa- and betha-rhythms, betha-rhythms focusing were calculated by «Brainscan». We investigated evoked potentials (SSEPs, P300) too. Results. 8.2% of this cohort of patients had EEG paroxysmal activities what correlated with high evoked potentials amplitudes (р<0.05). After rTMS course numbers of paroxysmal activity patterns statistically certain reduced (-54.8%, p=0.01). Positive EEG dynamic consisted in decreasing frequency of alfa-rhythm inversion in early (р=0.027) and late (р=0.04) rehabilitation period, in decreasing of betha-index (p<0.04), betha-rhythm regularity (p<0.03) and betha-rhythm focusing (p<0.035). Conclusion. Thus, complex rehabilitation with methodic of subthreshold 10 Hz rTMS reduced paroxysmal activity patterns in patients with poststroke EEG epileptic activity and bring brain electric activity to normal function by correction of neuroplasticity. Received results prompted us to develop methodic of rTMS using to epilepsy treatment.
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V.V.Kistsen , Belarussian Medical Academy of Postgraduate Education, Neurology and Neurosurgery Dept., Minsk, BELARUS
V.V.Evstigneev    Belarussian Medical Academy of Postgraduate Education, Neurology and Neurosurgery Dept.  Minsk  BELARUS
N.S.Misuk  Belarussian sciencific-practical Center of Psychiatry  Minsk  BELARUS
         
         
         
         
         
         
         
         
         
         
         
         

Topic: Vascular imaging
Oral Session :   
Poster Session: Poster Session Red
Date: Wednesday 26 May 2010
Time: 12:30 - 14:00
Room: Palau Level I

 
CT-angiography of the aorta in patients with cryptogenic ischemic stroke: Useful in the routine stroke work-up?
Background: About one third of ischemic strokes remain cryptogenic, even after extensive work-up in specialized centers. Atherosclerotic plaques in the aorta can cause thromboembolic events, but are often overlooked, because routine examinations are usually not able to identify them properly. They can also elude detection by transesophageal echocardiography (TEE). Furthermore, some patients decline TEE because of its invasive and uncomfortable nature. CT-angiography (CTA) is a quick, safe method to detect aortic plaques and could be useful in cases where TEE is not capable to visualize every part of the aorta, if of validity to identify sources of embolism. Methods: We studied prospectively the results of ECG-triggered CTA of the aorta and TEE in so far 20 patients (10 men, 10 women, mean age 64 years), with cryptogenic stroke after exclusion of other mechanisms of stroke, including cadiogenic ones. Results: Of 20 patients with acute ischemic stroke, 8 (40%) had strokes in the anterior and 10 (50%) in the posterior circulation, while 2 patients (10%) had infarcts in territories of both the anterior and the posterior circulation. CTA revealed relevant atherosclerotic plaques in the aorta in 8 cases (40%). TEE showed aortic plaques in a total of 4 patients (20%), having 2 overlapping positive results with the CTA. In these cases, the strokes were no longer classified as cryptogenic. CTA was well tolerated and no side effects were reported. Conclusion: CTA of the aorta can help discover plaques that may be potential embolic sources if TEE fails to detect plaques or is unavailable or not applicable. The detection of such plaques in the CTA may influence stroke classification and secondary prevention. To establish CTA as a routine part of stroke work-up, more data is needed, particularly in conjunction with TEE results.
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A.Chatzikonstantinou, Department of Neurology, Universitätsmedizin Mannheim, Mannheim, GERMANY
A.Chatzikonstantinou   Institute of Clinical Radiology and Nuclear Medicine, Universitätsmedizin Mannheim  Mannheim  GERMANY
R.Krissak  Institute of Clinical Radiology and Nuclear Medicine, Universitätsmedizin Mannheim  Mannheim  GERMANY
D.Artemis  Institute of Clinical Radiology and Nuclear Medicine, Universitätsmedizin Mannheim  Mannheim  GERMANY
C.Fink  Institute of Clinical Radiology and Nuclear Medicine, Universitätsmedizin Mannheim  Mannheim  GERMANY
R.Kern  Institute of Clinical Radiology and Nuclear Medicine, Universitätsmedizin Mannheim  Mannheim  GERMANY
S.Schönberg  Institute of Clinical Radiology and Nuclear Medicine, Universitätsmedizin Mannheim  Mannheim  GERMANY
M.G.Hennerici  Department of Neurology, Universitätsmedizin Mannheim  Mannheim  GERMANY
         
         
         
         
         
         
         

Topic: Rehabilitation and reorganisation after stroke
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Palau Level I Foyer

 
The Adverse Effect of Post-stroke Spasticity on 3-month Functional Outcomes
Background: Spasticity’s impact on post-stroke outcomes remains controversial yet several devices and medications have been used to address it. Here, we report the effect of spasticity on functional outcomes at 3 months post-ischemic stroke. Design: In 2005, 460 ischemic stroke patients were interviewed in hospital and at 3 months. Based on this cohort, we previously published a validated multivariable regression model for predicting 3-month modified Rankin score (mRS) as an indicator of functional outcome. Here, we tested whether including spasticity improved model fit, and estimated the effect spasticity had on the outcome. Spasticity was defined by a positive response to the question “Did you have spasticity following your stroke?” on direct interview. Prior to soliciting responses the interviewers described spasticity using ist commonly occurring signs and symptoms. Patients who had expired by 90 days (n=30), or did not have spasticity data available (n=102) were excluded. Results: There were 328 ischemic stroke patients included in the analysis. Mean age was 67 (SD=14) years; 52% were male and 25% were black. At 3 months, 54 (16.5%, 95CI=12.7-21.0) reported spasticity. Patients reporting spasticity had a median 3 month mRS of 3.0, compared with patients without spasticity, who had a median 3 month mRS of 2.0 (p<0.01). Spasticity affected the 3-month functional status (β=0.420, 95CI= 0.194 to 0.645), after accounting for age, diabetes, leukoaraiosis, and retrospective NIHSS. Using spasticity as a covariable, the model’s R2 changed from 0.599 to 0.622. Conclusions: In our model, the presence of spasticity in the cohort was associated with a worsened 3-month mRS by an average of 0.4 after adjusting for known covariables. This significant adverse effect on functional outcomes adds predictive value beyond previously established factors. Furthermore, the effect of spasticity on post-stroke functional outcomes has not been reported before using population based methods.
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S.R.Belagaje, University of Cincinnati, Cincinnati, USA
C.Lindsell   University of Cincinnati  Cincinnati  USA
K.Alwell  University of Cincinnati  Cincinnati  USA
C.J.Moomaw  University of Cincinnati  Cincinnati  USA
K.Dunning  University of Cincinnati  Cincinnati  USA
D.Kleindorfer  University of Cincinnati  Cincinnati  USA
DWoo  University of Cincinnati  Cincinnati  USA
M.L.Flaherty  University of Cincinnati  Cincinnati  USA
O.Adeoye  University of Cincinnati  Cincinnati  USA
P.Khatri  University of Cincinnati  Cincinnati  USA
J.P.Broderick  University of Cincinnati  Cincinnati  USA
B.Kissela  University of Cincinnati  Cincinnati  USA
         
         
         

Topic: Etiology of stroke and risk factors
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Exhibition Hall

 
Frequency of cortical laminar necrosis in ischemic stroke
Background: Cortical spreading depolarization (CSD) is known as pathophysiological correlate of migraine aura. Animal experiments showed that the coupling between CSD and cerebral blood flow can be changed pharmacologically so that CSD induces spreading microaterial spasm and cortical spreading ischemia (CSI). Furthermore it was demonstrated experimentally that focal laminar cortical necrosis results from CSD/cortical spreading ischemia. The objective of this study was to investigate (i) the frequency of ischemic laminar cortical necrosis in consecutive unselected stroke patients and (ii) whether or not they are associated with migraine/migrainous aura. Method: Consecutive unselected ischemic stroke patients who were admitted to our stroke unit during a one year period were prospectively enrolled. Inclusion criteria were clinically defined acute stroke syndrome with a corresponding ischemic lesion on MRI or CT. The standardized clinical assessment included clinical syndrome, cerebrovascular risk factors and diagnosis of migraine according to the criteria of the International Headache Society. Results: 487 consecutive ischemic stroke patients were included. All patients received CT, 397 MRI. We concentrated on the patients with MRI: In 4 patients (1,0%) cortical laminar ischemic necrosis was found on brain scan. All patients (4/4) were female and 3/4 had a history of migraine. Conclusion: The results indicate that cortical laminar ischemic necrosis is rare. The data suggest a positive association with migraine.
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A.Ziegler, Department of Neurology, Charite - University Medicine Berlin, Germany, Berlin, GERMANY
J.P.Dreier   Department of Neurology, Charite - University Medicine Berlin, Germany  Berlin  GERMANY
F.Bode  Department of Neurosurgery, Charite - University Medicine Berlin, Germany  Berlin  GERMANY
H.Audebert  Department of Neurology, Charite - University Medicine Berlin, Germany  Berlin  GERMANY
S.Leistner  Department of Neurology, Charite - University Medicine Berlin, Germany  Berlin  GERMANY
         
         
         
         
         
         
         
         
         
         

Topic: Stroke prognosis
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Palau Level I Foyer

 
Improved outcome of thrombotic stroke in patients treated with HMG CoA reductase inhibitors may be linked to reduced oxidative stress
Background: Recent studies show that pretreatment with HMG CoA reductase inhibitors (statins) improves the outcome of subsequent ischemic strokes. Statins are given mainly to normalize lipid profile but have also pleiotropic effects. We evaluated whether the improved outcome of thrombotic stroke (MA) was linked to the antioxidant effects of statins. Methods: 100 patients with thrombotic stroke diagnosed according to the TOAST criteria were evaluated on stroke scales (NIHSS, SSS) and functional scales (BI) on admission and at discharge and had their previous treatment recorded. Cholesterol levels (total, HDL-, and LDL-cholesterol) were measured on admission and serum malondialdehyde (MDA) was measured on admission and on day 7. Results: The 30 patients on statin treatment had similar age and HDL-C levels, but lower total and LDL-cholesterol levels. The strokes of patients treated with statins were nonsignificantly less severe but had a significantly better outcome. The serum MDA as marker of oxidative stress was significantly lower in patients taking statins at stroke onset and lower throughout the first 7 days (table). Conclusions: The improved outcome of thrombotic strokes in patients taking statins may be due, at least partly, to a diminished oxidative stress, opening the perspective of prescribing these drugs not only according to the lipid profile, but also according to comorbidities linked with increased oxidative stress.
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Table: http://www.esc-archive.eu/barcelona10/graphics_barcelona/aid_1079.html

 

A. Jurcau, University of Oradea, Faculty of Medicine and Pharmacy, Oradea, ROMANIA
A. Simion   University of Oradea, Faculty of Medicine and Pharmacy  Oradea  ROMANIA
R. Simion  Faculty of Medicine and Pharmacy  Oradea  ROMANIA
         
         
         
         
         
         
         
         
         
         
         
         

Topic: Management and economics
Oral Session :   
Poster Session: Poster Session Red
Date: Wednesday 26 May 2010
Time: 12:30 - 14:00
Room: Palau Level I

 
Clinical predictors of prolonged hospitalization in first-ever stroke patients
Background: The length of stay is the main cost-determining factor during hospitalization. The length of stay may reflect the impact of the differences in health care system organization. However, prolonged hospitalization is a poorly characterized condition. This study describes the clinical predictors of very long stay after first-ever acute stroke based on data collected from a prospective hospital-based stroke registry. Methods: We studied all consecutive patients with acute stroke included in the “Sagrat Cor Hospital of Barcelona Stroke Registry” over a 17-year period. Prolonged hospitalization was defined as a length of stay greater than 12 days after admission. Demographic, risk factors, clinical, neuroimaging, and outcome variables were analyzed to identify predictors of prolonged hospitalization. Results: Among 3,112 acute stroke patients collected from the stroke registry, 1,534 (49.4%) were hospitalized for more than 12 days. Mean length hospital stay was 27.7 (SD= 24.8) days. Vascular complications (odds ratio [OR] = 2.68), urinary complications (OR = 2.56), limb weakness (OR = 1.79), infectious complications (OR = 1.78), and male sex (OR = 1.16) were significantly associated with prolonged hospitalization. Symptom-free at discharge (OR = 0.45) and lacunar infarct (OR = 0.43) were inversely associated with prolonged hospitalization. Conclusion: Medical complications (vascular, infectious and urinary) occurring during hospitalization in the acute phase of stroke can independently affect the length of hospital stay. This information can be useful to optimize planning and organization in relation of the health care system in acute stroke patients.
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A.Arboix, Cerebrovascular Division. Sagrat Cor Hospital, Barcelona, SPAIN
J.M.Vives   Cerebrovascular Division. Sagrat Cor Hospital  Barcelona  SPAIN
J.Massons  Cerebrovascular Division. Sagrat Cor Hospital  Barcelona  SPAIN
L.Garcia-Eroles  Cerebrovascular Division. Sagrat Cor Hospital  Barcelona  SPAIN
E.Comes  Cerebrovascular Division. Sagrat Cor Hospital  Barcelona  SPAIN
M.Oliveres  Cerebrovascular Division. Sagrat Cor Hospital  Barcelona  SPAIN
M.Grau-Olivares  Cerebrovascular Division. Sagrat Cor Hospital  Barcelona  SPAIN
M.Balcells  Cerebrovascular Division. Sagrat Cor Hospital  Barcelona  SPAIN
         
         
         
         
         
         
         

Topic: Stroke prevention
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Salon Azur

 
ENHANCING THE COMPLIANCE OF STROKE PATIENTS WITH EDUCATIONAL PROGRAM IN PRIMARY HEALTH CARE IN HUNGARY
Background: The aim of this study was to examine the effect of primary health care education in reaching the target blood pressure and normal metabolism makers of stroke patients. Methods: A pre- and post-test design was used in a follow up study to measure the blood pressure, BMI, metabolism blood markers (glucose, cholesterol, HDL, triglycerid) before and after the nurse led educational program. The program focused on enhancing patients’ compliance to keep the advices for medication and life style change in order to prevent a new stroke event. One GP registry was the basis of the sample selection using Framingham scores, too. Data were collected at home and in GP surgery with NIBPM. Laboratory tests were used as well. The data analysis was done with Chi-square and T tests using SPSS14.0. Results: In the sample 80 patients were involved (48 female and 32 male). The average age was 51,22 years. The patients after the education thought that they can improve their health more (38 vs 49; p=0,02). Although the average BMI was less after the education it was not significant (30,63 vs 29,65; p=0,29). The average BP (Hgmm) was less both in home and in surgery after the education 143/89-136/83 vs 149/91-139/85 (p=0,049). The most salient reduction were detectable in cholesterol, HDL level 15% vs 48%; 30% vs 40% (p=0,03). In glucose and triglycerid level there were not significant change. Discussion: Stroke patients’ compliance can be improved by appropriate educational program. The regular home control of BP can contribute to reach the target BP of stroke patients. The dietary advices may normalize pathological BMI and other blood parameters. Patient education is a good method to prevent stroke events at risk groups.
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I.Szogedi, University of Pecs Faculty of Health Sciences, Zalaegerszeg, HUNGARY
S.Komaromi   ALBA Family Practiconer Association  Szekesfehervar  HUNGARY
E.Pap  Zala County Teaching Hospital Department of Cardiology  Zalaegerszeg  HUNGARY
L.Vizvari  Institute for Basic and Continuing Education of Health Workers  Budapest  HUNGARY
E.Zsigmond  University of Pecs Faculty of Health Sciences  Zalaegerszeg  HUNGARY
J. Betlehem   University of Pecs Faculty of Health Sciences  Pecs  HUNGARY
         
         
         
         
         
         
         
         
         

Topic: Stroke prevention
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Salon Azur

 
Risk of recurrent cerebrovascular events in patients with cryptogenic stroke or transient ischemic attack and patent foramen ovale. The FORI (Foramen Ovale Registro Italiano) study
Background: The optimal management strategy in patients with cryptogenic stroke found to have a patent foramen ovale (PFO) remains unclear. The aims of this observational multi-centre study were to evaluate: 1) the risk of recurrent cerebrovascular events in patients with cryptogenic stroke or TIA and PFO who underwent either percutaneous PFO closure or medical treatment; 2) the risk factors associated to recurrent events. Methods: Consecutive patients (aged 55 years or less) with PFO and first-ever cryptogenic minor ischemic stroke or TIA were recruited in 13 Italian hospitals between January 2006 and September 2007 and followed-up for two years. Results: 238 patients were included in the study (mean age 42.2±10.0 years; 118 males); 117 patients received antithrombotic therapy while percutaneous PFO closure was performed in 121 patients. Stroke as an index event was more common in the medical treatment patients (p=0.01). Presence of ASA and the evidence of 20 bubbles or more on TCD were more common in the PFO closure group (p=0.002 and p=0.02). Eight patients (6.6%) experienced a complication during PFO closure. At 2 year follow-up, 17 recurrent events (TIA or stroke) (3.6% per year) were observed. Seven recurrent events (2.9% per year) were observed in the percutaneous PFO closure group while 10 recurrent events (4.2% per year) were observed in the medical treatment group. The risk of recurrent stroke was 0.4% per year in patients who underwent percutaneous closure (1 event) in comparison to 3.4% per year in patients receiving medical treatment (8 events). On multivariate analysis, percutaneous closure was not superior to antiplatelet therapy in preventing recurrent TIA or stroke (OR 0.1, 95% CI 0.02-1.5, p=0.1) while it was barely superior to antiplatelet therapy in preventing recurrent stroke (OR 0.1, 95% CI 0.0-1.0, p=0.053). Conclusions: In this observational non randomized study, PFO closure was superior to medical therapy in the prevention of recurrent stroke. Complication during PFO closure was the trade-off for this clinical benefit.
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for the Forame Ovale Registro Italiano (FORI) Investigators

M.Paciaroni, Stroke Unit - Division of Cardiovascular Medicine, University of Perugia, Perugia, ITALY
G.Agnelli   Stroke Unit - Division of Cardiovascular Medicine, University of Perugia  Perugia  ITALY
A.Pezzini  Neurology Clinic, University of Brescia  Brescia  ITALY
A.Padovani  Neurology Clinic, University of Brescia  Brescia  ITALY
P.Cerrato  Stroke Unit - University of Torino  Torino  ITALY
G.Silvestrelli  Poma Hospital  Mantova  ITALY
F.Corea  San Giovanni Battista Hospital  Foligno  ITALY
P.Chiocchi  Cardiology - San Giovanni Battista Hospital  Foligno  ITALY
F.Chiodo Grandi  Stroke Unit - Cattinara Hospital  Trieste  ITALY
R.Musolino  Neurological Division - University of Messina  Messina  ITALY
A.Bersano  Neurology Unit - University of Milano  Milano  ITALY
S.Sacco  Department of Neurology - University of L'Aquila  L'Aquila  ITALY
D.Giobbe  Neurology - Molinette Hospital  Torino  ITALY
A.Baldi  Stroke Unit   Portogruaro  ITALY
W.Ageno  University of Insubria  Varese  ITALY

Topic: Interesting and challenging cases
Oral Session :   
Poster Session: Poster Session Red
Date: Wednesday 26 May 2010
Time: 12:30 - 14:00
Room: Exhibition Hall

 
Late resolution of radiological findings in reversible cerebral vasoconstriction syndrome
A 50-year-old woman was referred to our clinic with a non analgesic response headache. 24 hours from the beginning she developed left hemianopsia. She had a history of migraine since adolescence, was a smoker (20 pack-year history), and had 2 normal gestations. She identified this headache as her usual migrane (pulsatile and located at the occipital regions and accompanied by nausea and vomiting) except it didn´t improve with medication (ibuprofen and tryptans) and was accompanied by visual alterations. Brain computed tomography (CT) showed an hematoma located in the right occipital hemisphere. CT angiography (CTA) and digital subtraction angiography (DSA) revealed multifocal segmental vasoconstriction in anterior and posterior circulation. Because of clinical characteristics, normal cerebrospinal fluid findings and absence of any other sign of vasculitys she was set on medication for probable reversible cerebral vasoconstriction (RCVS). The follow up CTA 10 days after disclosed no significant improvement, 3 months later there were still substantial narrowing lesions on CTA, desapearing only 8 months after the symptom commenced. Despite this we didn´t consider cerebral vasculitys as diagnosis in order to the bening clinical presentation. Conclusion: RCVS is used as a descriptive term for a group of syndromes in which patients have reversible vasoconstriction of the cerebral arteries usually with severe, recurrent headaches, and can be associated with other neurologic clinical findings. The most specific finding for RCVS is the resolution of the vascular abnormalities within days or weeks documented by vascular imaging, but in some cases this resolution can be delayed. We present a RCVS case with radiological findings that last longer that was describe in the literature before.
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J.F.BUENDÍA, HOSPITAL UNIVERSITARIO VIRGEN DE LA ARRIXACA, MURCIA, SPAIN
M.LOZANO   HOSPITAL UNIVERSITARIO VIRGEN DE LA ARRIXACA  MURCIA  SPAIN
A.MORALES  HOSPITAL UNIVERSITARIO VIRGEN DE LA ARRIXACA  MURCIA  SPAIN
G.PARRILLA  HOSPITAL UNIVERSITARIO VIRGEN DE LA ARRIXACA  MURCIA  SPAIN
J.ZAMARRO  HOSPITAL UNIVERSITARIO VIRGEN DE LA ARRIXACA  MURCIA  SPAIN
P.SANTOS  HOSPITAL UNIVERSITARIO VIRGEN DE LA ARRIXACA  MURCIA  SPAIN
         
         
         
         
         
         
         
         
         

Topic: Epidemiology of stroke
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Exhibition Hall

 
Need for a City-Wide Triage Program for Acute Stroke Patients in Chicago
Background: Chicago is the third largest city in the United States. We analyzed the number and distribution of stroke patients in Chicago, with the goal of identifying underserved areas and designing an organized stroke system of care to improve access to high-level acute stroke care city-wide. Methods/Results: The city of Chicago has more than 2.85 million residents in 227 square miles, with over 9 million in the entire metropolitan area. The racial makeup is 37.6% white, 35.0% black, and 28.1% Hispanic or Latino. The city is served by one integrated emergency medical services (EMS) system for the emergent transportation of stroke patients. Currently, stroke patients are taken to the nearest hospital. Based on the Illinois Hospital Association COMPdata® database, 8402 persons were discharged from 39 city hospitals with a principal diagnosis of acute cerebrovascular disease (ICD-9 codes 430-437) in 2006. The majority (69.2%) was admitted via the emergency department. Only 1635 (19.5%) patients were admitted to the 9 PSCs in 2006, approximately half via EMS. The geographic distribution of strokes indicated high density “stroke belts” in the northwest and south sides of Chicago (figure 1). Discharge procedure codes indicated that only 53 (0.63%) stroke patients received intravenous thrombolysis in 2006. As of January 2010, Chicago now has 16 PSCs in diverse geographic regions of the city. Analysis of ground transport times suggests that each resident of Chicago now lives within 20 minutes of at least 1 PSC (figure 2). Conclusions: The burden of stroke is high in Chicago with very low rates of PSC utilization and intravenous thrombolysis for acute stroke patients. An increase in the number of PSCs in Chicago now makes triage of acute stroke patients to the nearest PSC feasible, with the goal of improving acute care access, rates of thrombolysis, and clinical outcomes city-wide.
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on behalf of the Chicago Area Stroke Taskforce

S.Prabhakaran, Rush University Medical Center, Chicago, USA
M.J.Alberts   Northwestern University  Chicago  USA
         
         
         
         
         
         
         
         
         
         
         
         
         

Topic: Management and economics
Oral Session :   
Poster Session: Poster Session Red
Date: Wednesday 26 May 2010
Time: 12:30 - 14:00
Room: Palau Level I

 
From “traditional” to “comprehensive stroke unit” models: Optimization of economic ressources.
Background: The introduction of the diagnosis related groups (DRG) system in Germany and its modification into a case-based lump sum system has radically influenced the organization of in-hospital patient treatment. Since the financial reward depends mainly on the case-mix-index, discharge management has a crucial influence on economic figures. Duration of treatment in a Stroke Unit (SU) plays a central role. Our SU started 1998 with 5 beds and was gradually extended to the current 13-bed intensive care monitoring capacity. The “Stroke Competence Center”, with a total capacity of 29 patients, including additional 16 beds for early post-stroke management and treatment, follows the concept of a “comprehensive stroke unit”. This has positive effects on both treatment and prognosis of stroke patients, but here we will concentrate on the economic aspects. Methods: Data from stroke patients treated on our SU since the introduction of the OPS codes 8-981.x (2005-2009) was analyzed. Data from 2009 was extrapolated whenever possible. We analyzed the number of treated stroke patients, number of thrombolytic treatments (as a measure of quality of stroke treatment), the number of cases coded with OPS 8-981.x and the ratio of OPS 8-981.0 (24-72 hours on SU) to the higher remunerated OPS 8-981.1 (>72 hours on SU). Results: The number of treated patients on SU increased by 48% (807 in 2005, 1197 in 2008). The number of thrombolyses per year has nearly doubled (82; 10% in 2005, 177; 15% in 2008). The introduction of the comprehensive stroke unit concept lead to a great increase in the ratio of the higher rewarded OPS 8-981.1 (1.5 in 2005, 4.53 in 2008). Conclusions: Our data demonstrates that the comprehensive stroke unit concept leads to a significant optimization of the financial potential, in addition to the medical advantages concerning more effective stroke treatment and work-up as well as to the improved flow of information and an enhanced doctor-patient relationship.
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A.Chatzikonstantinou, Department of Neurology, Universitätsmedizin Mannheim, Mannheim, GERMANY
H.Bäzner   Department of Neurology, Universitätsmedizin Mannheim  Mannheim  GERMANY
M.G.Hennerici  Department of Neurology, Universitätsmedizin Mannheim  Mannheim  GERMANY
         
         
         
         
         
         
         
         
         
         
         
         

Topic: Brain imaging
Oral Session :  A
Poster Session:  
Date: Wednesday 26 May 2010
Time: 9:20 - 9:30
Room: A&B

6
Fully automatic delineation of hypoperfused tissue in perfusion MRI compared to a semi-automated approach results in considerable discrepancies in perfusion deficit volumes
Background Using MRI several methods are available to assess the hypoperfused areas in patients with acute ischemic stroke (AIS). Previously, studies dealing with volumes of hypoperfused tissue used either a manual approach to lesion delineation or an automated approach with predefined thresholds. We compared volumes obtained through a partially manual method, based on combining thresholds with human judgement, to those calculated by a fully automated method. Methods We retrospectively included 145 AIS patients who had perfusion MRI performed within 24 hours of AIS. Using Stroketool we calculated perfusion maps of 3 parameters (MTT, CBF and Tmax), with three different thresholds for each parameter. The 9 resulting maps were then post-processed using two different procedures. In the manual procedure, a human rater roughly drew a region of interest around the areas where hypoperfusion was credible and measured the resulting volume. In the automated procedure, CSF areas were excluded from thresholded maps in a fully automatic step and the remaining volumes were calculated. The level of agreement between these two methods was assessed using Bland-Altman plots. Results Volumes calculated by the automatic method were in 98,6% of cases larger than those derived with human input and the mean difference in the volumes between the two methods ranged from 24ml to 205ml. Of all the calculated maps the Tmax map (threshold at 8s) showed the lowest level of discrepancies (Figure 1.) with the mean difference in volumes at 24ml and the biggest outlier at 184ml. Conclusions Statistical analysis showed that there were considerable discrepancies between the two methods for all of the 9 created maps and that the degree of agreement is not acceptable. The fully automated procedure for calculating volumes of hypoperfused tissue greatly overshoots the volumes calculated with human input showing that automated protocols still require substantial refinement in order to produce credible results.
Graphic: http://www.esc-archive.eu/barcelona10/graphics_barcelona/aid_1085.html
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I.Galinovic, Center for Stroke Research Berlin, Berlin, GERMANY
A.C.Ostwaldt   International Graduate Program Medical Neurosciences  Berlin  GERMANY
B.Hotter  Center for Stroke Research Berlin  Berlin  GERMANY
P.Brunecker  Center for Stroke Research Berlin  Berlin  GERMANY
W.Schmidt  Center for Stroke Research Berlin  Berlin  GERMANY
J.B.Fiebach  Center for Stroke Research Berlin  Berlin  GERMANY
         
         
         
         
         
         
         
         
         

Topic: Stroke prevention
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Salon Azur

 
Precision of pharmacogenetics algorithms for estimation of warfarin daily dose
Background: Warfarin is the first choice in oral anticoagulation, despite its safety profile and difficulties to initiate and maintain the therapeutic anticoagulation due to the wide individual variability in daily dose. Individual genetic profile (mainly CYP2C9, VKORC1 genes) explains up to 60% of dose variability and could help us to estimate daily dose before the initiation of treatment using pharmacogenetics algorithms. There is no consensus on one algorithm; therefore, different formulas are available. Accuracy of prediction of respective algorithms can be expressed in the value of coefficient of determination (R2, value from 0 to 100%). Objective: To compare empirically determined warfarin daily dose with dose predicted by three published algorithms [1-3] in our cohort of patients divided by age. Methods: We selected patients from our database with empirically determined stable warfarin dose (dose constant at least 3 months with 3 consecutive INR in therapeutic range). All patients were genotyped for polymorphisms of CYP2C9 (*1, *2, *3) and VKORC1 (haplotypes A, B) genes. Warfarin dose was predicted using three algorithms [1-3] for each patient, R2 were calculated for each algorithm. Results: 131 patients with stable anticoagulation were included - median time from last dose change 6 (3 – 84) months, median time of treatment 22,5 (4 – 276) months. The values of R2 for respective algorithms were 63,58% [1], 37,59% [2] and 33,82% [3]. In 21 patients aged 39 or younger: 15,38% [1], 6,12% [2] and 10,42% [3]. In 109 patients older than 40 years: 73,29% [1], 34,22% [2] and 48,88% [3]. Conclusion: Pharmacogenetic prediction is clinicaly useful in patients older than 40 years, the most precise was algorithm [1]. References: 1] Sconce E et al. Blood 2005;106:2329-33. 2] Carlquist JF et al. J Thromb Thrombolysis 2006;22:191-7. 3] Gage B et al. Clin Pharmacol Ther 2008;84:326-31.
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A.Tomek, Department of Neurology, Charles University, 2nd Faculty of Medicine , Praha, CZECH REPUBLIC
V.Maťoška   DNA Laboratory, Department of Clinical Biochemistry, Hematology and Immunology, Hospital Na Homolce  Praha  CZECH REPUBLIC
T.Kumstýřová  DNA Laboratory, Department of Clinical Biochemistry, Hematology and Immunology, Hospital Na Homolce  Praha  CZECH REPUBLIC
Z.Lacinová  DNA Laboratory, Department of Clinical Biochemistry, Hematology and Immunology, Hospital Na Homolce  Praha  CZECH REPUBLIC
L.Táborský  DNA Laboratory, Department of Clinical Biochemistry, Hematology and Immunology, Hospital Na Homolce  Praha  CZECH REPUBLIC
M.Bojar  Department of Neurology, Charles University, 2nd Faculty of Medicine   Praha  CZECH REPUBLIC
         
         
         
         
         
         
         
         
         

Topic: Acute cerebrovascular events (ACE): TIA and minor strokes
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Palau Level I

 
Should Transient Ischemic Attack Patients Be Hospitalized Or Referred To A Same-Day Specialty Clinic? – A Decision Analysis
Background: Previous community-based studies suggested that the stroke risk following transient ischemic attack (TIA) was 11% at 90 days with half of the risk within 2 days. Hospitalization has been recommended on the basis of increased access to standards of care including tissue plasminogen activator (tPA) and carotid endarterectomy (CEA) among eligible patients. Recent same-day clinic-based studies, however, have demonstrated that urgent assessment and immediate initiation of secondary prevention measures can decrease stroke risk by 80%.We aimed to compare two approaches of acute TIA management (hospitalization versus same-day clinic) using a Markov transition state decision analysis model. Methods: The Markov model was developed to simulate a cohort population of 1000 TIA patients, with cycle length of 30 days, stratified by the initial decision of hospitalization vs. appointment to a same-day specialty clinic. We used PubMed to search for relevant data from English language literature. We assumed a 2-day stroke risk of 0.12% in both groups based on the EXPRESS and SOS-TIA experiences but increased utilization of CEA (13.3 vs. 4.7%) and tPA(53.3 vs. 8.0%) among hospitalized versus clinic-evaluated patients, respectively. Outcomes were expressed in terms of the expected number of quality-adjusted life years (QALYs). Results: For acute TIA patients, the expected QALYs were 16.3316 for the hospitalized group and 16.3485 for the same-day clinic group. The threshold at which acute hospitalization was preferred was reached only when the 2-day stroke risk was >2% or nearly 20-fold greater than recent same-day clinic-based studies suggest (figure). Conclusion: Despite the potential to increase access to tPA and early CEA, hospitalization of all TIA patients may no longer be routinely justified. Only patients with 2-day stroke risk >2% may benefit from hospitalization. Further study regarding cost-effectiveness is warranted in this high-risk cohort.
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J.K.Joshi, Rush University Medical Center, Chicago, USA
B.Ouyang   Rush University Medical Center  Chicago  USA
S.Prabhakaran  Rush University Medical Center  Chicago  USA
         
         
         
         
         
         
         
         
         
         
         
         

Topic: Vascular surgery and neurosurgery/interventional neuroradiology
Oral Session :   
Poster Session: Poster Session Red
Date: Wednesday 26 May 2010
Time: 12:30 - 14:00
Room: Exhibition Hall

 
Suction thrombectomy for recanalization of large vessel occlusion
Background Intra-arterial approach includes rt-PA alone or in combination with mechanical devices. Recently, new aspiration devices such as Penumbra System (PS) or Distal Access Catheter (DAC) have been developed. We report our experience of one year using these devices in difficult recanalization patient comparing with a similar group in the year before. Methods Retrospective analysis of acute stroke patients with large vessel occlusion treated by endovascular procedure in the last two years in the University of Pittsburgh Medical Center Stroke Institute was performed. Two groups were considered, non aspiration group (NAG) and aspiration group (AG). The cut-of point was the first use of an aspiration device in November 2008. Results We gave 208 endovascular procedures but by inclusion criteria, 43 patients in NAG and 54 in AG were selected. Demographic data and mean NIHSS were similar in both groups, 16.82 vs 16.67 (p=0.143). Time of procedure was 18 minutes less (p=0.095) and the rt-PA dosis was 2.5 mg lower (p=0.013) in AG. Mean number of Merci pases was 3.4 vs 1.8 in NAG and AG respectively (p<0.001). Recanalization rate was 71.1% in NAG vs 86.4% in AG (p=0.048). There was a trend to better outcome (29.5% vs 35.8%) and lower mortality (40.9% vs 34.0%) in the aspiration group. Conclusions Difficult recanalization patients need lower dosis of rt-PA, less Merci pases with higher recanalization rate using aspiration devices. There was a trend to shorter time of procedure, better outcome and lower mortality in this group.
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G.RUIZ-ARES, UNIVERSITY HOSPITAL LA PAZ - IdiPaz, MADRID, SPAIN
R.LIN   UNIVERSITY OF PITTSBURGH MEDICAL CENTER - STROKE INSTITUTE  PITTSBURGH  USA
A.ALEU  UNIVERSITY OF PITTSBURGH MEDICAL CENTER - STROKE INSTITUTE  PITTSBURGH  USA
M.JUMMA  UNIVERSITY OF PITTSBURGH MEDICAL CENTER - STROKE INSTITUTE  PITTSBURGH  USA
J.OAKLEY  UNIVERSITY OF PITTSBURGH MEDICAL CENTER - STROKE INSTITUTE  PITTSBURGH  USA
T.JOVIN  UNIVERSITY OF PITTSBURGH MEDICAL CENTER - STROKE INSTITUTE  PITTSBURGH  USA
         
         
         
         
         
         
         
         
         

Topic: Stroke prognosis
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Palau Level I Foyer

 
Pretreatment with statins improves outcome in patients with first-ever ischaemic stroke
Objective: Data from different studies suggest a favourable association between pretreatment with statins and outcome after ischaemic stroke. We examined whether there were differences in in-hospital mortality according to the presence or absence of statin therapy in a large population of first-ever ischaemic stroke patients and assessed the influence of statins upon early death and spontaneous neurological recovery. Methods: In 2,082 consecutive patients with first-ever ischaemic stroke collected from a prospective hospital-based stroke registry, statin use was documented in 381 and early neurological recovery in 382. Results: Outcome was better in the presence of statin therapy, with significant differences in in-hospital mortality (6% vs 13.3%, P=0.001) and symptom-free (22% vs 17.5%, P=0.025) and severe functional limitation (6.6% vs 11.5%, P=0.002) at hospital discharge, as well as lower rates of infectious respiratory complications during hospitalization. In the logistic regression model, statin therapy was the only variable inversely associated with in-hospital death (odds ratio 0.57) and directly associated with early neurological recovery (odds ratio 1.32). Conclusion: Use of statins before first-ever ischaemic stroke was associated with reduced mortality and neurological disability and with a higher chance for good outcome, suggesting that statins may be protective in the setting of cerebral ischaemia.
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A.Arboix, Cerebrovascular Division. Sagrat Cor Hospital, Barcelona, SPAIN
M.Grau-Olivares   Cerebrovascular Division. Sagrat Cor Hospital  Barcelona  SPAIN
L.Garcia-Eroles  Cerebrovascular Division. Sagrat Cor Hospital  Barcelona  SPAIN
M.Oliveres  Cerebrovascular Division. Sagrat Cor Hospital  Barcelona  SPAIN
C.Targa  Cerebrovascular Division. Sagrat Cor Hospital  Barcelona  SPAIN
M.Balcells  Cerebrovascular Division. Sagrat Cor Hospital  Barcelona  SPAIN
E.Comes  Cerebrovascular Division. Sagrat Cor Hospital  Barcelona  SPAIN
J.Massons  Cerebrovascular Division. Sagrat Cor Hospital  Barcelona  SPAIN
         
         
         
         
         
         
         

Topic: Brain imaging
Oral Session :   
Poster Session: Poster Session Red
Date: Wednesday 26 May 2010
Time: 12:30 - 14:00
Room: Palau Level I

 
Brain perfusion imaging in severe carotid artery stenosis - Comparison between transcranial ultrasound perfusion imaging and perfusion-weighted MRI
Background: Severe internal carotid artery stenosis can cause constriction of cerebral perfusion. Different techniques are currently available to measure brain perfusion. Ultrasound perfusion imaging (UPI) has been shown to be capable to differentiate hypoperfused and non-perfused cerebral tissue. Aim of the study is to compare the value of UPI and perfusion-weighted magnetic resonance imaging (pw-MRI) on the evaluation of cerebral perfusion in patients with severe internal carotid artery stenosis. Methods: Ten patients with severe internal carotid artery stenosis were included. UPI was performed with Phase-Inversion-Harmonic-Imaging and bolus application of contrast media for semi-quantitative analysis of time intensity curves. Time-to-peak intensity (TPI) values were compared to the Mean-Transit-Time of pw- MRI examinations in predefined Regions-of-Interest (ROI). Further, a comparison of pre- and postoperative UPI data was performed in some cases. Results: Seven of 10 patients could be evaluated. 80 ROIs were used for the comparison of UPI and pw-MRI and 37 ROIs for pre- and postoperative comparison of UPI data. There was no delay in any MRI ROI. In UPI, there were relevant delays in 15% of ROIs preand in 12.5% post-operatively. 54.5% of these ROIs were in the inner border zone. In comparison to the established pw-MRI technique, UPI described subtle perfusion delays mainly of the inner border zone. Conclusion: These preliminary results provide indication for the diagnostic power of UPI and of a possible non-invasive tool for the detection of hemodynamic relevance of severe internal carotid artery stenosis.
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C.Krogias, Dept. of Neurology, St. Josef-Hospital, Ruhr University Bochum, Bochum, GERMANY
C. Henneböhl   Dept. of Neurology, St. Josef-Hospital, Ruhr University Bochum  Bochum  GERMANY
B.Geier  Dept. of Vascular Surgery, St. Josef-Hospital, Ruhr University Bochum  Bochum  GERMANY
C.Hansen  Institute of High Frequency Engineering, Ruhr University Bochum  Bochum  GERMANY
T.Hummel  Dept. of Vascular Surgery, St. Josef-Hospital, Ruhr University Bochum  Bochum  GERMANY
S.Meves  Dept. of Neurology, St. Josef-Hospital, Ruhr University Bochum  Bochum  GERMANY
J.Eyding  Dept. of Neurology, St. Josef-Hospital, Ruhr University Bochum  Bochum  GERMANY
         
         
         
         
         
         
         
         

Topic: Acute stroke: clinical patterns and practice
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Palau Level I

 
The coordinator coordinator of the overall operational stroke of the Hospital of Caserta: leader of a multidisciplinary team and the centrality of a program of care pathways and a draft neuroriablitativo early post-stroke.
Stroke Unit at the Hospital of Caserta was built a project based on the therapy: pharmacological and neurorehabilitation, involving implementation by multiple professionals. The project is based on a planning neuroriabilitaziojne early post-stroke, which is coordinated by a single person and involves not only the patient, family members or caregiver. The nurse coordinator is the central figure, which is related with the doctors, nurses, physiotherapists, patients and their families: the figure of reference, which has clarity of roles and responsibilities, and willingness to devote time and effort faclitare in communication between team members, patients and family members, and to inform patients about their medical conditions and their destiny care. Results of the implementation of the process: 1) execution of neroriabilitazione detection; 2) incentive to increase productivity and optimize the quality of care for patients with stroke; 3) rationalize the use of hospital resources, including staff nurses, respecting the criteria of appropriateness; 4) containing the results of brain damage, with zero mortality rate. Conclusion: the coordinator, on the advice of doctors, enforces four objectives: 1) standardizing the behavior of acceptance of the patient by the nursing staff, 2) garantireal specific patient monitoring and life support; 3) implement all the preventive measures based on cardiovascular risks; 4) give valuable support to the family of the patient by giving information on the type and length of stay in the ward.
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M.Quarantiello, Hospital Sant'Anna and San Sebastiano, Caserta, ITALY
F.P.   hospital Sant'Anna and San Sebastiano  Caserta  ITALY
         
         
         
         
         
         
         
         
         
         
         
         
         

Topic: Acute stroke: clinical patterns and practice
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Palau Level I

 
Is there something wrong with Intravenous Thrombolysis in Belgium? The Belgian data of the Safe Implementation of Thrombolysis in Stroke Study.
Background: We report the Belgian experience of the Safe Implementation of Thrombolysis study. This prospective observational register evaluates safety and efficacy of intravenous recombinant tissue-type plasminogen activator in routine use for ischaemic stroke. Methods: We compared demographic and baseline characteristics, rate of symptomatic intracerebral hemorrhages, functional outcome at 90 days and treatment delay between patients enrolled in centres in Belgium and non-Belgian SITS-registry population. We performed a multivariate analysis to adjust for differences in demographic and baseline characteristics. Results: 743 patients were enrolled in 42 centers between December 2002 and December 2007. At baseline, Belgian patients had more severe strokes (median NIHSS 14 vs. 12). They were older (71 vs. 67y), had more history of hyperlipidemia (42 vs. 34%, p<0.01) and atrial fibrillation (30 vs. 26%, p<0.01). Before stroke, more Belgian patients were disabled (20 vs. 8%, p<0.01). Median stroke onset-to-treatment delay was 140 vs. 145 min, with median door-to-needle time of 75 vs. 66 min. Mortality at 3 months was higher (23% vs. 14% (p<0.01)). Functional independence at 3 months (modified Rankin Scale 0-2) was attained by only 43% vs. 53% (p<0.01). Slight increase of SICH as per SITS protocol was observed (2,4 vs. 1,6%, p=0.15). In multivariate analysis functional independence at 3 months (OR 0.95, p=0.31) was not different from non-Belgian patients. However mortality at 3 months was still higher (OR 1.15, p=0.02), although there was no statistical difference in SICH rates (OR 1.15, p= 0,33). Conclusion: When corrected for baseline characteristics in a multivariate analysis, we found no major differences in functional outcome nor rate of symptomatic intracerebral hemorrhage compared to patients registered outside of Belgium. Difference in 3 months mortality remains unexplained, but is in line with mortality observed in randomized clinical trials. Despite this remark, intravenous thrombolysis for ischemic stroke is safe and effective in routine clinical use in Belgium.
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P.Vanacker, AZ Sint-Jan Brugge-Oostende, Brugge, BELGIUM
V.Thijs   University Hospitals  Leuven  BELGIUM
A.Peeters  CHU Saint-Luc  Brussels  BELGIUM
B.Bruneel  AZ Groeninghe  Kortrijk  BELGIUM
P.Laloux  CHU Mont-Godinne  Yvoir  BELGIUM
P.Druwé  AZ Sint-Vincentius  Antwerp  BELGIUM
P.De Deyn  AZ Middelheim  Antwerp  BELGIUM
N.Ahmed  Karolinska University Hospital  Stockholm  SWEDEN
N.Wahlgren  Karolinska University Hospital  Stockholm  SWEDEN
G.Vanhooren  AZ Sint-Jan Brugge-Oostende  Brugge  BELGIUM
         
         
         
         
         

Topic: Small vessel stroke and white matter disease
Oral Session :  A
Poster Session:  
Date: Thursday 27 May 2010
Time: 15:00 - 15:10
Room: F

7
White matter hyperintensities and blood brain barrier permeability as predictors of white matter hyperintensity progression following minor stroke
Background: White matter hyperintensities (WMH) on MR are common and associated with dementia, lacunar stroke and depression. The cause of WMH is uncertain although they may be associated with increased blood brain barrier (BBB) permeability. We investigated whether baseline BBB permeability predated WMH progression after minor stroke. Methods: We recruited patients presenting with ischaemic lacunar or minor cortical stroke diagnosed by a panel of experts with brain MRI at presentation. We measured deep and periventricular WMH scores on FLAIR (Fazekas score) and BBB permeability with gadolinium (Gd) enhanced MRI 4 weeks after the stroke. We followed up patients with brain MR FLAIR and T2 at three years and recorded WMH change (Prins score). Results: We recruited 97 patients at inception (mean age 66 years, SD 10); 48 were alive and able to have follow-up MR, at median 39 (IQR 30-45) months. With univariate binary logistic regression, there were strong associations between baseline deep and periventricular WMH and increasing deep and periventricular WMH (OR 10.4, 95% CI 2.2-49.6, p=0.003 and OR 3.4, 1.3-8.6, p=0.01 respectively). Associations with baseline permeability were variable, eg increased deep grey matter permeability predicted increased deep WMH at follow-up (OR 3.5, 1.2 to 11.5, p=0.01) but decreased baseline Gd leak into the CSF predicted increased WMH at follow-up in some regions (eg frontal periventricular WMH OR 0.7, 0.5 to 0.9, p=0.02, temporal deep WMH OR 0.6, 0.4 to 0.9, p=0.005). Age did not predict WMH progression. Conclusions: Baseline WMH are strong predictors of WMH progression. Associations with baseline BBB permeability are more variable, and more data are needed to determine the role of BBB permeability in small vessel disease, but as BBB changes are very subtle, future studies will require large sample sizes to account for multiple inter-related factors.
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F.N.Doubal, Unviversity of Edinburgh, Edinburgh, UNITED KINGDOM
P.A.Armitage   Unviversity of Edinburgh  Edinburgh  UNITED KINGDOM
E.M.Sandeman  Unviversity of Edinburgh  Edinburgh  UNITED KINGDOM
K.Shuler  Unviversity of Edinburgh  Edinburgh  UNITED KINGDOM
M.S.Dennis  Unviversity of Edinburgh  Edinburgh  UNITED KINGDOM
J.M.Wardlaw  Unviversity of Edinburgh  Edinburgh  UNITED KINGDOM
         
         
         
         
         
         
         
         
         

Topic: Management and economics
Oral Session :   
Poster Session: Poster Session Red
Date: Wednesday 26 May 2010
Time: 12:30 - 14:00
Room: Palau Level I

 
Impact of a quality improvement programme on TIA clinic delays and driving compliance
Background: A TIA or minor stroke is a medical emergency for which intervention may prevent a major stroke. In the UK the Driving and Vehicle Licensing Authority (DVLA) recommend a car driving restriction of one month following a single TIA or a minor stroke. Objective: To evaluate the impact of a multi-modal quality improvement program on waiting times and compliance with driving restrictions at a neurovascular clinic in a general hospital. Methods: Diagnostic and demographic data were prospectively recorded and compared before (Phase 1) and after (Phase 2) implementation of a quality improvement program. A stroke nurse specialist co-ordinated a twice weekly neurovascular clinic, a weekly joint neurologist-stroke physician clinic was implemented, and prior to assessment patients were advised of DVLA driving restrictions for suspected TIA/minor stroke. Delays to assessment and driving compliance were compared before and after implementation of the quality-improvement program. Results: In the Phase 1 study 298 consecutive patients were identified, 146 men and 152 women, mean age 58.2 (SD 16) years. In the first 3 months of the quality improvement program (Phase 2) 80 patients, 29 men and 51 women, mean age 59.5 (SD 15) years were assessed. 143 patients (48%) were diagnosed with TIA/stoke in the Phase 1 study compared to 29 of 80 patients (36%) in the Phase 2 study, p=NS. Delays from symptom onset to clinic assessment were reduced from a mean of 38 days to 16 days in the Phase 2 study, p<0.001. The proportion of patients who drove to the clinic was reduced from 48% to 10%, p<0.001 after implementation of the quality improvement program. Conclusions: A stroke nurse specialist can help decrease delays for patients attending neurovascular clinics. Shorter delays decrease inconveniences for patients including driving restrictions and help reinforce appropriate driving guidelines. However, despite a dramatic reduction in waiting times for our neurovascular clinic, the delay from symptom onset to assessment remains unacceptable. Daily clinics with access to investigations and treatment are required to facilitate timely neurovascular assessments.
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J.McKee, Altnagelvin Hospital, Londonderry, UNITED KINGDOM
P.Gordon   Altnagelvin Hospital  Derry  UNITED KINGDOM
M.O.McCarron  Altnagelvin Hospital  Derry  UNITED KINGDOM
         
         
         
         
         
         
         
         
         
         
         
         

Topic: Epidemiology of stroke
Oral Session :   
Poster Session:  
Date: Thursday 27 May 2010
Time: 15:50 - 16:00
Room: A&B

12
Fatal Cerebral Strokes and Coronary Deaths in a Norwegian Cohort Followed for 40 Years: Diagnostic Validity of Mortality Statistics.
Background — Routinely collected national health statistics on stroke mortality and death from ischemic heart disease represent an important source for case ascertainment and endpoints in epidemiologic studies. The validity of such information in Norwegian national data and agreement with other sources are unknown. The present study was initiated to determine the accuracy of death certification due to cerebral stroke and ischemic heart disease in the Norwegian national death registry. Methods — 6811 randomly selected men and women living in Bergen, Norway who in 1965 were invited to The Clinical Bergen Blood Pressure Study form the basis for this analysis. Information on fatal strokes and coronary deaths was collected from mortality statistics and from autopsy records. Results — After 40 years of follow up 4387 eligible subjects had died and 1163 had undergone a post mortem examination. 548 (12%) had died from cerebral stroke and 1120 (24%) from ischemic heart disease according to the mortality statistics, compared to 113 (10%) strokes and 323 (28%) coronary events registered in local necropsy records. The sensitivity and positive predictive value of fatal cerebral strokes and coronary deaths in mortality statistics were 0.75, 95% confidence interval (CI) [0.66, 0.83] and 0.86 [0.77, 0.92], and 0.87 [0.83, 0.91] and 0.84 [0.80, 0.88] respectively. The Cohen’s Kappa coefficients were 0.78 and 0.80 respectively. Death from cerebral stroke was a negative predictor of autopsy (Odds ratio (OR) 0.69, 95% confidence interval (CI) 0.54, 0.87, p 0.002), whereas death from coronary heart disease was not (OR 1,14, 95%CI 0.97, 1,33, p 0.104), both adjusted to gender and age at death (quartiles). Conclusion — There was a substantial agreement between mortality statistics and autopsy findings for both fatal strokes and coronary deaths. Post mortem examinations were associated to age, gender and cause of death.
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A.K.Gulsvik, Department of Geriatric Medicine, Oslo University Hospital, Ullevaal, University of Oslo, Oslo, NORWAY
A.Gulsvik   Department of Thoracic Medicine, Institute of Medicine, University of Bergen  Bergen  NORWAY
E.Svendsen  Department of Pathology, The Gade Institute, Haukeland University Hospital, University of Bergen  Bergen  NORWAY
B.Maehle  Department of Pathology, The Gade Institute, Haukeland University Hospital, University of Bergen  Bergen  NORWAY
D.S.Thelle  Department of Biostatistics, Institute of Basic Medical Sciences, University of Oslo  Oslo  NORWAY
T.B.Wyller  Department of Geriatric Medicine, Ullevaal University Hospital, University of Oslo  Oslo  NORWAY
         
         
         
         
         
         
         
         
         

Topic: Stroke prognosis
Oral Session :   
Poster Session: Poster Session Blue
Date: Thursday 27 May 2010
Time: 12:30 - 14:00
Room: Palau Level I Foyer

 
Predictors of all-cause and cardiovascular mortality following acute stroke: a cohort study with 12 years of follow-up
Background Identification of predictors of mortality after stroke may contribute to the reduction of deaths through better management strategies for patients at high risk. The knowledge of which predictors are important in long-term mortality is scarce. This study investigated predictors for long-term all-cause mortality and cardiovascular mortality in a cohort of patients hospitalized for acute stroke. Methods We prospectively followed 550 patients aged > 60 years, who were consecutively admitted within 24 hours of an acute stroke. Patients were followed for 12 years or until death. Multivariate Cox regression models were used to analyze predictors of all-cause and cardiovascular mortality. The following independent variables were used: age, gender, living alone, previous stroke, ischemic heart disease, atrial fibrillation, hypertension, diabetes, cancer, current smoker, hemorrhagic stroke, right hemisphere stroke andseverity measured with the Scandinavian stroke scale. Results The 12-year mortality rate was 86.5%. In multivariate models, all-cause mortality was associated with the following hazard ratios, HR (95% CI): age 1.08 (1.07-1.10), severity of stroke 2.13 (1.75-2.56), male gender 1.61 (1.33-1.96), diabetes 1.72 (1.35-2.22), hemorrhagic stroke 1.61 (1.21-2.13), ischemic heart disease 1.28 (1.01-1.64) and previous stroke 1.25 (1.01-1.54). Cardiovascular mortality was associated with age 1.06 (1.04-1.08), severity of stroke 2.78 (2.13-3.57), male gender 1.69 (1.31-2.17), diabetes 1.85 (1.37-2.50), hemorrhagic stroke 2.0 (1.43-2.78), ischemic heart disease 1.56 (1.16-2.13) and right hemisphere stroke 1.49 (1.16-1.89). Conclusion Age, severity of stroke, male gender, diabetes, hemorrhagic stroke and ischemic heart disease were all independently associated with a higher risk of all-cause and cardiovascular mortality over 12 years following stroke. Previous stroke increased the risk of all-cause mortality and right hemisphere stroke increased the risk of cardiovascular mortality.
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O.M.Ronning, Akershus University Hospital, Akershus, NORWAY
K.Stavem   Akershus University Hospital  Akershus  NORWAY
         
         
         
         
         
         
         
         
         
         
         
         
         

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